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1 |
SHAPING IMMUNIZATION
PROGRAMMES IN THE CURRENT
DECADE
Thomas Cherian
2 |
40 YEARS OF EPI: DID IT MEET
EXPECTATIONS?
Small pox eradication and the birth of EPI
3 |
0
10
20
30
40
50
60
70
80
90
100
Year
Global High-Income countries Low Income countries
Third dose coverage form DTP containing vaccines,
1980-2013, by Income
Source: WHO/UNICEF coverage estimates 2013 revision. July 2014 and Country Income Categories (World Bank)
as of July 2014 (2013 GNI per capita). Income classification not available for: Cook Islands, Niue and Nauru
Immunization Vaccines and Biologicals, (IVB), World Health Organization.
194 WHO Member States. Date of slide: 29 July 2014.
High-income
countries
Global
Low-income
countries
96%
84%
79%
4 |
Global coverage estimates, 1980-2013DTP 1 & 3, Measles 1 & 2, HepB 3, Hib3, PCV3 and Rota (last dose)
0
10
20
30
40
50
60
70
80
90
10019
80
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
% c
ove
rag
e
dtp3 hepb3 hib3 mcv mcv2 mcv2x2 pcv3 pol3 rotac
Source: WHO/UNICEF coverage estimates 2013 revision. July 2014
Immunization Vaccines and Biologicals, (IVB), World Health Organization.
194 WHO Member States.
5 |
9 years4 years
6 |
Polio eradication:
the end in sight?
1988:
> 350,000 cases
> 125 endemic countries
2014:
342 cases
3 endemic countries
6 re-infected countries
0
200
400
600
800
1 000
1 200
1000s
Reduction in estimated measles deaths, 1985 - 2013
7
Source: WER 2014; in press
87% drop from
1985-2013
75% drop from
2000-2013
8 |
Impact of new vaccines: Hib meningitis in
The Gambia
Oluwalana et al J Pediatr 2013;163:S4-7
9 |
Source: http://www.kemri-wellcome.org/index.php/en/studies_inner/75
10 |
Impact of RV on diarrhoea mortality in
Mexico and Brazil
Richardson et al. NEJM 2010; 362:299; do Carmo GM et al. PLoS Med 2011; 8(4):e1001024
In Mexico and Brazil 35% and 22%
reductions in diarrhoea-related mortality,
respectively, were observed in children
under 5 years, following the introduction
of rotavirus vaccine
11 |
MenAfriVac roll-out 2010 – 2014(Early achievements 2010-2012)
No reported case of NmA among the vaccinated
12 |
"The mission of the Decade of
Vaccines is to extend, by 2020
and beyond, the full benefits of
immunization to all people,
regardless of where they are
born, who they are, or where they
live."
“We envision a world in which
all individuals and communities
enjoy lives free from vaccine-
preventable diseases".
13 |
Goals of the Global Vaccine Action Plan
14 |
Monitoring Framework
Independent review
Assessment of progress
16 |
– DTP3: All countries >90% national coverage, and >80% in every district by end 2015
– Polio: transmission stopped by end 2014
– Maternal and neonatal tetanus: eliminated by 2015
– Measles: eliminated in 4 regions by end-2015
– Rubella: eliminated in 2 regions by end-2015
– Introduction of under-utilized vaccines: At least 90 low or middle income countries to have introduced one
or more such vaccines by 2015
GVAP mid-point targets
17 |
Polio eradication
1988:
> 350,000 cases
> 125 endemic countries
2014:
342 cases
3 endemic countries
6 re-infected countries
No WPV3 cases
WPV in endemic countries– Only 6 cases in Nigeria, none
reported in past 4 months
– Increase in cases in Pakistan and Afghanistan
Spread to previously polio-free countries
– Substantial reduction in number of cases, particularly in Somalia & Syria
Insecurity and attacks of health workers
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! ! ! !! ! ! !! ! ! !
! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !
! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !! ! ! ! ! ! !
! ! ! ! ! ! ! !! ! ! ! ! ! ! !! ! ! ! ! ! ! !! ! ! ! ! ! ! !
! ! !! ! !! ! !
<1 (86 countries or 44%)
≥1 - <5 (28 countries or 14%)
≥5 - <10 (11 countries or 6%)
≥10 - <50 (33 countries or 20%)
≥50 (15 countries or 8%)
No data reported to
WHO HQ
Not applicable
Measles Incidence Rate* 2013
*Rate per 1'000'000 population
Outbreaks represent cases
reported to WHO through end
Dec 2013 except where noted †:• DRC through 18 Feb 2014
• Pakistan through end May 2013
• Somalia through 31 Dec 2013
Data in WHO HQ as of 10 February 2014
The boundaries and names shown and the designations used on this map do not imply the
expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement. ©WHO 2014. All
rights reserved.
Ukraine: 12,744 in 20123,308 in 2013
Somalia†: 9,983 in 20122,848 in 2013
Nigeria: 6,447 in 201255,335 in 2013
Romania: 7,452 in 20121,074 in 2013
Angola: 4,458 in 20126,505 in 2013
Dem Rep Congo†: 72,029 in 201289,108 in 2013
Ethiopia: 4,347 in 20123,982 in 2013
Pakistan†: 14,984 in 2012>25,000 in 2013
Indonesia: 15,489 in 20128,147 in 2013
Thailand: 5,197 in 20121,825 in 2013
Georgia: 31 in 20127,830 in 2013
Sudan: 8,523 in 20122,679 in 2013
India: 18,668 in 2012
China: 6,183 in 201227,825 in 2013
Turkey: 57 in 20127,371 in 2013
18(15 countries or 8%)
Reported Measles Cases in 15 Large Outbreaks since Jan 2012
19 |
20 |
Not for the first time…
21 |
ARE WE ON TRACK TO REACH OUR
COVERAGE GOALS ?
0
20
40
60
80
10019
80
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
%
co
ve
rag
e
Global African American Eastern Mediterranean European South East Asian Western Pacific
Source: WHO/UNICEF coverage estimates 2012 revision. July 2013
Immunization Vaccines and Biologicals, (IVB), World Health Organization.
194 WHO Member States. Date of slide: 17 July 2013.
Global
immunization
coverage has
stagnated in past 5
years
22 |
What are the challenges and
possible solutions?
THE NEW “REALITY” OF EPI: THE CHANGING PARADIGM
Source: BMGF/WHO24
25 |
The current challenges
• Trained human resources
• Vaccine supply chains
• Information systems
Inadequate systems
• Availability
• Financing
• Pricing & procurement
Vaccine supply & price
• Unregistered & migrant populations
• Failure of integration: missed opportunities
• Conflicts and crisis
• Hesitancy and refusals
Reaching the “5th
child”
The immunization information system
INPUTS PROCESS OUTCOMES IMPACT
• Finances• Commodities• Human
resources
• Session monitoring
• Programme reviews
• EVM• Data quality &
surveillance assessments
• Immunization coverage
• Mortality & morbidity reduction
• Economic impact
1. EVM (Effective Vaccine Management) Assessments in low and lower-middle income countries Source: WHO, 2014
Efficiently managing stocks of
vaccines in the country
Sufficient storage
capacity for existing vaccines
Maintaining vaccines in the correct
temperature ranges
Respecting vaccine
management policies and
practise
Reliable distribution
and transport system up to the last mile
Best practise for
international vaccine
arrival in country
Reaching standard
Not reaching standard% of countries that reach 80% target on relevant supply chain WHO standards1
Country immunisation supply chains do not meet WHO standards
Weak immunisation supply chains systems are another bottleneck to achieving immunization goals
28 |
The future is bright if we take advantage of
opportunities
Key supply chain challenges and bottlenecks have been diagnosed
Awareness of these challenges has been raised at highest levels and importance acknowledged
Technical solutions exist and ready for widespread implementation. Leveraging thermostability of vaccines by using them in a controlled temperature
chain (CTC)
Reducing storage volume by addressing presentation and packaging
Extending the reach of the cold chain to areas with no reliable energy source with solar equipment or long lasting passive vaccine containers
Improving stock management using mobile technologies for real time track and tracing of vaccines
Global strategies and funds mobilised to address to challenges have been developed (Gavi/Gates)
Implementation framework established through the joint WHO/UNICEF Immunization Supply Chain Hub
29 |
Vaccine supply
2013 2012 2011 2010
Number of countries reporting stock-outs 39 34 35 43
% countries reporting stock-outs 43% 37% 38% 47%
Number of stock-out events 2, 3 69 56 63 74
BCG vaccine 35 30 29 38
DTP containing vaccines 10 8 11 18
Measles containing vaccines 11 7 12 7
OPV/IPV vaccines 13 11 11 11
Average number of stock-out events 3 1.8 1.7 1.8 1.7
Average duration of a stock-out event (days) 3 36.7 28.2 30.5 45.3
Source: WHO/UNICEF JRF
12th MR LabNet
Tight supply situation for measles and MR vaccines
• High demand between
June and October 2014
• Both measles and MR
vaccines supplied from
the same manufacturer
• Possible to meet
overall demand
requirements but not in
terms of timing.
MV
MR
Data from UNICEF SD as of 19/05/2014
Rota HPV
WHO vaccine schedule data (as of Dec 2013). Counted countries with introduction in entire country and part of country (# countries introduced / total countries). In November 2014, EMRO confirmed all countries have introduced Hib (e.g. Egypt and Iran. No new introductions after Dec 2013 are added to this analysis. However, new introductions are logged elsewhere.
Are Low and Middle Income Countries Lagging Behind
with Introduction of New Vaccines?
1/20/2015 31
Percent of countries with vaccine in schedule by income group (2000-2013)
Hib PCV3
UMIC
LMIC
LIC
HIC
Sustainable access to vaccines in middle income countries
0
20
40
60
80
100
2000 2002 2004 2006 2008 2010 2012 20140
20
40
60
80
100
2000 2002 2004 2006 2008 2010 2012 2014
0
20
40
60
80
100
2000 2002 2004 2006 2008 2010 2012 2014
0
20
40
60
80
100
2000 2002 2004 2006 2008 2010 2012 2014
Percentage
Countries without Hib:LIC: NoneLMIC: Egypt, South SudanUMIC: China, Iran, and Thailand
Small UMIC lag for PCV
1. Sentinel countries chosen for deeper dive analyses include: Philippines, Egypt, Cape Verde, South Africa, Thailand, Ecuador,Indonesia and Angola selected for high absolute burden, high VPD rate, or other special characteristics
Description of need
Access to affordable vaccine supply
• Greater access to information on pricing/contracts and capacity to use this information
• Greater/easier participation in pooled procurement• More/faster entry PQ vaccines into global markets
Prioritization of national immunization financing
• Mobilization of domestic resources to cover NUVI costs, without jeopardizing other critical spending
Informed decision-making regarding new vaccine
introductions
• Effective and efficient evidence-based decision-making process
• NITAG functionality• Availability of and ability to analyze evidence
Strengthening regulatory & procurement systems
• Harmonization of regulations concerning registration of PQ vaccines
• Access to revolving funds• Capacity to issue tenders• Capacity to forecast demand
1
2
3
4
The MIC Task Force has prioritized the
following areas for action:
1/20/2015 32Sustainable access to vaccines in middle income countries
Access to vaccine price information: the V3P
project
http://www.who.int/immunization/programmes_systems/procurement/v3p/platform/AnalysesSpread/en/
~400,000 High Risk Areas identified by Polio Programme
~ 256,000 Migrant
sites
Migrant sites High risk areas in
settled population
~ 166,000 HR areas in settled
population
= 10 Migrant sites = 10 HR sites
Source: SIA coverage data
Insecurity and epidemics are affecting coverage in some
countries:# children vaccinated with DTP3 in the 3 most Ebola affected countries
MMR coverage at two and five years of age, England 1997/8-2011/12
Distribution of confirmed measles cases in England by year of birth, Q1 2013
05
10152025303540
Tailoring Immunization Programmes: Addressing Vaccine Hesitancy
39 |
Conclusions
The 40 years of EPI have seen great progress
The full potential of immunization is still untapped
The evolution of EPI has led to increasing complexity, exposing the fragility of the health systems
The last miles are the most difficult; issues are complex and solutions are not simple
The GVAP offers solutions, but implementation required a greater country ownership and the concerted effort of all stakeholders
http://www.who.int/immunization/global_vaccine_action_plan/en/
Together we can make it happen!