The expanding role of immunization in saving lives

Asnakew Tsega

Immunization Technical officer Maternal and Child Health Integrated Program (MCHIP)

Presented at the Mini-University George Washington University Center for Global Health

14 September 2012

Outline of the presentation

Burden of vaccine preventable diseases Vaccines and the current global coverage Global initiatives Vaccine delivery strategies and challenges New vaccines introduction and challenges Required actions

The Maternal and Child Health Integrated Program (MCHIP)

USAID Bureau for Global Health’s flagship for maternal, newborn and child health program

Working in well over 40 countries worldwide MCHIP supports programming and opportunities

for integration in: Maternal, Newborn and Child Health Immunization, Family Planning, Malaria, HIV/AIDS Water/Sanitation, Urban Health, Health Systems

Strengthening

Burden of vaccine preventable diseases

Global Causes of Under-Five Deaths in 2010

Global, regional and national causes of child mortality in 2010: a systematic analysis by CHERG (published in The Lancet, 375 (9730): 1969-1987.

7.6 million deaths in children < 5 years every year (14 children every minute)

64% (4.9 million) of deaths were from infectious diseases

Pneumonia 18% 1.40 million Diarrhea 10% 0.80 million Malaria 7% 0.56 million 40% (3.1 million) of deaths occurred in neonates

PTB Complications 14% 1.08 million Intrapartum-related complications

9% 0.72 million

Sepsis or meningitis 5% 0.39 million Pneumonia 4% 0.33 million

Summary of Global Estimates in 2010

1.5 million deaths among children from vaccine preventable disease by WHO regions, 2008

Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis, Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11. * WHO/IVB estimates

Vaccines and the current coverage

WHO Recommended Immunization Schedule Age of Contact Vaccine

Birth BCG, OPV-0, Hep B*

6 weeks OPV1, Penta1 (DPT, Hep B*, Hib), PCV1, Rota1

10 weeks OPV2, Penta2 (DPT, Hep B*, Hib), PCV2, Rota2

14 weeks OPV3, penta3 (DPT, Hep B*, Hib), PCV3, rota3**

9 months Measles, Hep B*, YF

12-15 months Measles 2nd dose and Rubella

Adolescent girls (13 years) HPV (3 injections 4 and 12 weeks apart) *total of 3 doses with timing dependent upon local epidemiology **depending on the type of vaccine (rotarix 2 doses and rotateq 3 doses)

Typhoid, meningococcal, japanese encephalitis, mumps vaccines are also available

Source: WHO/UNICEF coverage estimates 1980-2010

Global immunization DPT3 coverage, 1980-2010

Africa SE Asia

2011: global = 83% from 85% AFR= 71% AMR= 92% EMR = 85% Europe = 94% SEAR = 75% WPR = 96%

“Developing”* countries with all districts achieving at least 80% DTP3 coverage, 2008

* 155 developing countries and economies in transition per UN World Economic & Social Survey, 2008 classification

Yes (41 countries or 26%)

No data (24 countries or 16%) (DTP3 estimated coverage for 2007 16 countries > 90%; 8 countries< 90)

No (90 countries or 58%)

Not applicable (38 countries)

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 2009. All rights reserved

Source: WHO/UNICEF estimates and WHO/IVB database, July 2009,193 WHO Member States

Source: WHO/UNICEF coverage estimates 1980-2010

Challenges facing immunization

Increase/sustain coverage (beyond 80%) and quality with existing and new vaccines across wider age groups

Sustain reduced mortality from all vaccine-preventable diseases (and eradicate polio, measles control, etc)

Assure immunization continues to work in context of integration, decentralization, and privatization

Use immunization as a platform for other population-based interventions for mothers and children (e.g. routine integrated outreach) and for building health systems

Mobilize sustained national financing

Routine Immunization System

Support other health

interventions

Global commitments and targets: Decade Of Vaccine (DOV)

Global Vaccine Action Plan (GVAP) Child Survival Call to Action

The DoV is about taking action to achieve ambitious goals

Achieve a world free

of polio

Meet global and regional

elimination targets

Develop and introduce new and improved

vaccines and technologies

Avert hundreds of millions of cases and millions of future deaths Gain billions of dollars of economic productivity

Contribute to exceeding MDG 4 target for reduction in child mortality

Meet vaccination coverage targets in

every region, country and community

The GVAP identifies measurable targets for each goal

Achieve a world free of polio

Meet global and

regional elimination

targets

Meet vaccination coverage targets in

every region, country and community

Develop and introduce new and improved vaccines and technologies

• By 2015: Interrupt wild polio virus transmission

• By 2020:Certification of poliomyelitis eradication

• By 2015: Neo-natal tetanus eliminated in all WHO regions, Measles eliminated in at least 4, Rubella in at least 2

• By 2020:Measles and rubella eliminated in 5 WHO regions

• By 2015: 80+ LICs and MICs have introduced 1+ new or underutilized vaccine to their immunization (vs 2011)

• By 2020: 90% national coverage , 80% in every district for all vaccines in immunization programmes

• By 2020: Licensure, launch of vaccine(s) against one or more major non-VPDs

• By 2020: Licensure, launch of 1+ new platform delivery technology

How do we deliver the service in developing countries?

1. Planning and management of resources Better manage human and financial resources 2. Reaching the target populations Improve access to and use of services through a mix of service delivery strategies (fixed, outreach, mobile, etc.) 3. Linking services with the community Engage with communities to ensure health services are meeting their needs 4. Supportive supervision Regular on-site teaching, feedback, and follow-up with health staff 5. Monitoring and use of data for action Promote use of data especially during review meetings, use data tools for self-monitoring (e.g. charting of doses), map population in each health facility

“Reaching Every District” RED’s Five Operational Components

Planning and management of resources

Reaching the target

populations

Linking services with communities

Supportive supervision

Monitoring for action

• Flexible approach • Countries/districts to

tailor it to fit their situation

• Use of data, human and financial resources, capacity building, improved access & use of services

• Intensity of implementing each component varies from country to country

...the five components are not mutually exclusive

“Reaching Every District” (RED) - five operational components

• Identify service delivery strategies most appropriate to the needs of eligible populations (women and <1 children)

• Develop the right mix of strategies (fixed, outreach, mobile, etc), identifying where eligible groups are located, including hard to reach, the number of eligible groups by location, the reasons (if any) why they have been underserved or why they under-utilize services, and ways in which they can be reached

• Focus on increasing access and reducing drop-out rates and missed opportunities

Reaching the target population: What does this component of RED include?

Weak infrastructure poses a major challenge to achieving immunization goals

National Actions-Decision-

application

Global Actions- approval

Program Implementation

Preparation (3-6 months before

launch) Vaccine Launch Post-Introduction

M&E

Initiate discussion and reach consensus to

introduce a vaccine and the type of product

Conduct nationwide cold Chain storage space

assessment

Update/prepare cMYP and costing tables

Ensure it is incorporated into the national health

sector plan

Develop an introduction plan

Initiate surveillance to establish baseline

Prepare and/or amend application and submit on

time

Solicit ICC endorsement and commitment for

implementation

Obtain ministerial signatures on the

application to GAVI

Country re-/submits

application

IRC makes a recommendation

to the GAVI Board

GAVI Secretariat prioritizes

applications for approval

Upgrade cold chain

Advocate for vaccine introduction support

Conduct registration of the vaccine, review vaccine

supply distribution system, upgrade as needed

Revise, print and distribute EPI

management tools

Develop learning materials, conduct technical training

Make improvements to waste management system, as needed

IEC/demand creation for new vaccine

Initiate AEFI surveillance for the NV and strengthen

AEFI reporting system

Develop communications strategies and key

messages to address caregiver/ provider

concern(s)

PR events held to launch the vaccine

Monitor and respond to any

reported adverse events

Conduct post-introduction evaluation

assessment a year following vaccine launch

Document lessons learned

Reduced morbidity and mortality due

to the targeted vaccine

preventable disease

Asses the magnitude of the problem: morbidity and mortality due to the target

disease with the new vaccine

Scale Up Map for New Vaccine Introduction

Vac

cina

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ll el

igib

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eopl

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Conduct impact

assessment

Source: MCHIP 2011

Comprehensive approach: Protection, prevention and treatment strategies

for pneumonia & diarrhoea

Reduce pneumonia

and diarrhoea morbidity and

mortality

Children becoming ill from pneumonia or diarrhoea

Vaccines: pertussis, measles, Hib, PCV and rotavirus

Cotrimoxazole prophylaxis for HIV-infected and exposedchildren

Zinc & Vitamin A supplementation

PREVENT Children by Providing Healthy Environment

Exclusive breastfeeding for 6 months

Adequate and complete nutrition

Hand washing with soap

Safe water and sanitation

Reduce indoor air pollution

Prevent low birth weight

PROTECT

Children who are ill with pneumonia and diarrhoea

Improved care seeking and referral

Case management at the health facility and community level

Supplies: Low osmolarity ORS, Zinc, antibiotics & oxygen

Continued feeding (including breastfeeding)

TREAT

Challenges in New Vaccines Introduction

Lack of epidemiologic evidence on disease burden in most countries Which vaccines to choose?

PCV? Rota? HPV? Or all at the same time? Which product? PCV10 vs PCV13?, rotarix vs Rotateq?

Practical introduction challenges (e.g., cold chain, logistics, more waste management, training, multiple injections to child on same day)

Sustainability questions Co-financing of the new vaccines What will happen after GAVI?

Vaccines out of the current routine vaccines schedule Need for new delivery systems(e.g., schools)

Most new vaccines require a well-functioning routine immunization program.

Required Actions by MOHs and Partners

Conduct high level advocacy to national governments Support countries to improve and sustain routine immunization

coverage Provide technical and financial support for the introduction of

new vaccines Expanding the cold storage space Building the capacity of managers and service providers

Conduct operation research on vaccine preventable diseases and immunization program and take appropriate actions

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