Dengvaxia: Lessons learned, public health imperatives


ENDEAVOR

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From 2011 to 2016, the Department of Health (DOH) grappled with the complexities of dengue fever, which has long plagued tropical countries like ours. Under the stewardship of Secretaries Enrique Ona and Janette Garin, the government implemented both preventive and curative measures, yet these efforts came under intense scrutiny as controversies unfolded. Early into the Duterte administration, a number of citizens brought suit against Secretary Garin. The other day, the Department of Justice (DOJ) announced the withdrawal of these cases for sheer lack of evidence.


As a first-hand witness to all these events, I wish to share with readers some perspectives into forward pathways.


Dengue fever has been endemic to the Philippines, with children often the most vulnerable to severe forms of the disease. The DOH’s initial efforts focused on traditional methods of prevention, including vector control programs such as community-based clean-up drives to eliminate mosquito breeding sites, use of insecticide-treated nets, and raising public awareness about protective measures. At ground level, local government units’ education campaigns urged households to participate actively in the 4S strategy: Search and destroy breeding sites; Secure self-protection; Seek early consultation; and Support fogging in hotspot areas.
Curative measures relied heavily on hospital capacity-building. Enhanced clinical management of dengue hemorrhagic fever and the establishment of dengue express lanes in public hospitals helped save lives. However, these initiatives were reactive and constrained by limited resources. The recurring outbreaks exposed the need for a more proactive and comprehensive strategy.


By the latter part of the Aquino administration, amid a significant upsurge in dengue cases among young children, Sanofi Pasteur, a French pharmaceutical giant, offered Dengvaxia, the first vaccine for dengue which had undergone years of clinical trials and was already being approved in other countries. Secretary Garin, who succeeded Ona in 2015, viewed this breakthrough as a potential game-changer.


Under Garin’s leadership, the DOH launched a school-based dengue immunization program targeting Grade 4 students in selected regions with high dengue prevalence. The move was hailed as pioneering, marking the Philippines as the first Asian country to roll out Dengvaxia. The program aimed to immunize over one million children and was supported by an allocation of approximately ₱3.5 billion from the government.


However, the implementation was marred by controversy. Critics questioned the program’s rapid rollout, citing concerns over insufficient public consultation and the lack of a complete risk-benefit analysis. When Sanofi later disclosed that Dengvaxia posed potential risks for individuals who had never been previously infected with dengue, panic ensued. Allegations of negligence and corruption were leveled against Garin and her team, culminating in lawsuits spearheaded by the Public Attorney’s Office (PAO).


The Dengvaxia controversy polarized public opinion. Many parents, grieving over the loss of children who were vaccinated, believed their deaths were linked to the program. On the other hand, medical experts and epidemiologists argued that while the vaccine’s introduction had flaws, its benefits outweighed the risks when administered under the right conditions.


Cases were filed against Secretary Garin and other officials, alleging criminal negligence. Only the other day, Justice Secretary directed DOJ prosecutors to move for the dismissal of these cases, citing lack of evidence to prove a direct causal link between Dengvaxia and the deaths in question. The ruling emphasized that the accusations were speculative and unsupported by scientific findings; hence, these were likely to be dismissed.


While this decision provides vindication for Secretary Garin, the damage to public trust in vaccines remains profound. Vaccine hesitancy surged in the aftermath of the controversy, leading to declines in immunization coverage for other diseases like measles and polio. Ironically, this coincided with the COVID-19 pandemic’s deadly onslaught  a few years ago. This hesitancy has had devastating consequences, with outbreaks of vaccine-preventable diseases.


The Dengvaxia episode underscores the urgent need for reforms in public health policy, particularly in the areas of risk communication, evidence-based decision-making, and program implementation. Here are some key recommendations for moving forward:


First: Strengthen transparency and public engagement.


The controversy revealed the importance of transparent communication between government agencies and the public. When introducing new medical interventions, policymakers must ensure that the public is well-informed about both the benefits and risks. Public consultations, stakeholder engagement, and open disclosure of clinical trial data can help build trust.


Second: Invest in local research and development.


Through synergy with the Research Institute for Tropical Medicine (RITM), the DOH can accelerate the pace of vaccine research and development. By investing in local scientists and partnering with international institutions, the country can reduce reliance on foreign manufacturers and ensure that vaccines are tailored to the specific needs of the population.


Third: Rebuild confidence in vaccines.


Rebuilding trust in the national immunization program is critical. This can be achieved through sustained education campaigns that emphasize the safety and efficacy of vaccines, coupled with grassroots efforts to address vaccine hesitancy in communities. Partnerships with schools, religious organizations, and community leaders will be essential.


Fourth: Improve surveillance and health systems.


Strengthening disease surveillance systems will enable early detection and containment of outbreaks. Investments in healthcare infrastructure, particularly in rural areas, will also ensure that patients receive timely and adequate care.


Fifth: Ensure accountability and ethical governance


To prevent similar controversies, the government must establish mechanisms for accountability and ethical oversight. This includes rigorous procurement processes, adherence to international safety standards, and regular audits of health programs. Proactive communication will preempt idle, baseless speculations that trigger panic reactions and erode public confidence in government.
In retrospect, it is evident that while the introduction of the vaccine was a bold step, its actual rollout was impeded by irresponsible rabble-rousing.


In December 2019, former President Benigno ‘Noynoy’ Aquino attended a fact-finding hearing at the Senate to shed light on the anti-dengue prevention and vaccination program implemented by the DOH. Providing context, he recalled similar concern over the possible outbreak of SARS in 2014 that he dealt with, too, with a clear sense of urgency, and was promptly contained. He said that as President, he needed to act expeditiously, after exercising due diligence, and to move forward with confidence, resilience and unity.


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