40 years of childhood vaccination programmes in Africa. Mind the gap

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1 40 years of childhood vaccination programmes in Africa Mind the gap Charles Shey Umaru Wiysonge MD, MPhil, PhD, MASSAf Centre for Evidence-based Health Care, Stellenbosch University, South Africa charlesw@sun.ac.za 5th Infection Control African Network Conference Meikles Hotel, Harare, Zimbabwe, 05 November 2014

2 Potential conflicts of interest Deputy Director (past), Expanded Programme on Immunisation, Cameroon Member, WHO African Task Force on Immunisation Member, Global Alliance for Vaccines and Immunisation (GAVI) Independent Review Committee Member(appointed), Strategic Advisory Group of Experts on Immunisation (SAGE)

3 3 It all started with smallpox

4 Estimated crude birth and death rates per 1,000 for England, (source: Mercer A.J. Population Studies 1985; 39: ) Prevention of Smallpox

5 The basis of modern vaccination was laid in Dr Edward Jenner (England) Collection of the University of Michigan Health System, gift of Pfizer Inc. 5

6 Natural infection vs vaccination Pathogen Infection Toxins Disease Immune response Cure and protection Specific memory Vaccine - live attenuated - toxoid - inactivated - subunit Immune response Protection 6

7 1789 Smallpox 1885 Rabies 1896 Typhoid 1896 Cholera 1987 Plague Timeline for licensure of human vaccines

8 Public health achievements of the 20 th century

9 Annual global VPD deaths in children under-5, 2004 WHO 2008

10 Causes of under-five deaths (Global) in 2008 Black RE et al., Global, regional and national causes of child deaths in Lancet 2010.

11 Expanded Programme on Immunisation WHO developed a standard EPI schedule in basic antigens for infants Tuberculosis (Bacille Calmette-Guerin: BCG) Polio Diphtheria, tetanus, pertussis (DTP) Measles Proportion of children who receive 3 doses of DTP (DTP3) before 1yr is a standard measure of EPI performance

12 National DTP3 coverage in Africa from 1980 to 2010 Machingaidze S, Wiysonge CS, Hussey GD. PLoS Med 2013

13 In 2005 District coverage data in Africa 16 (30%) countries reported 80% DTP3 coverage in at least 80% of their districts In (30%) countries reported 80% DTP3 coverage in at least 80% of their districts Machingaidze S, Wiysonge CS, Hussey GD. PLoS Med 2013

14 Comprehensive and relevant evidence-based information is needed to equip African countries with the arsenal to take well-informed actions on improving childhood immunisation coverage. 14

15 Study design & data sources Study design Cross-sectional study Data sources Demographic Health Surveys Comparable variables Between World Bank data WHO/UNICEF immunisation data 15

16 Determinants Individual Child s age, sex, birth order Mother s age, education, employment, media access, health seeking behaviours No U5C, polygamous family, wealth index Community Neighbourhood poverty Illiteracy rate Unemployment rate Media access Average household size Female-headed households Residential mobility Place of residence Ethnic diversity Societal Fertility rate Gross domestic product Expenditure on health Adult illiteracy rate 16

17 Statistical analysis Multilevel modeling Takes into account the hierarchical structure of data Potentially avoids atomistic and ecological fallacy Enables the partitioning of variation between levels. Level 3: Country Source population Level 2: Community Level1: Individuals 17

18 Clustering effects Children in the same neighbourhood are subject to common contextual influences. There is some evidence for a possible neighbourhood and country contextual phenomenon shaping a common risk of un-immunisation 18

19 Risk of having an un-immunised child Factors OR (95% CI) Mother s age: versus 35 or older 1.18 ( ) Wealth index (with richest quintile as reference) Poorest 1.36 ( ) Poorer 1.30 ( ) Middle 1.21 ( ) Richer 1.15 ( ) Mother s education (with secondary or higher as reference) No formal education 1.35 ( ) Primary 1.26 ( ) Media access* 0.94 ( ) Health seeking behaviour* 0.56 ( ) Community level Urban (vs. rural) 1.12 ( ) Illiteracy rate 1.13 ( ) Country-level Fertility rate 4.43 ( ) Intra-cluster correlation (%) Country 21.1 Community 32.5

20 Health system environment Immunisation system components Health system building blocks Financing Operations 1. Vaccine supply & quality 2. Logistics 3. Services delivery 4. Surveillance 5. Communication Management Capacity building Individual and contextual factors were associated with childhood immunisation; Suggesting that public health programmes designed to improve uptake of childhood vaccines should address people, and the communities and societies in which they live.

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23 Factors associated with childhood immunisation research Univariable Multivariable Variable IRR (95% CI) p-value IRR (95% CI) p-value DPT3 coverage 0.40 (0.07, 2.36) * not included Gross domestic product 1.44 (1.24, 1.66) (0.74, 2.18) Adult literacy rate 1.16 (0.42, 3.18) not included Physicians/100,000 population 1.24 (0.96, 1.60) not included Total expenditure on health 3.21 (1.09, 9.41) (0.14, 3.11) Private expenditure on health 2.77 (1.61, 4.79) (1.29, 6.19) R & D expenditure 1.44 (1.22, 1.72) (0.61, 1.94) Human development index 2.37 (0.59, 9.51) not included * Is this an indication of lack of interactive communication between health decision-makers, programme managers, and researchers? Wiysonge CS et al, BMC Med 2013

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25 We envision a world in which all individuals and communities enjoy lives free from vaccinepreventable diseases". "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."

26 The Global Vaccine Action Plan Guiding Principles Strategic objectives of the Decade of Vaccines Goals Country ownership 1 All countries commit to immunisation as a priority 1. Achieve a world free of poliomyelitis Shared responsibility & partnership Equity Integration Sustainability Innovation 5 Immunisation programmes have sustainable access to predictable funding, quality supply and innovative technologies Strong immunisation systems are an integral part of a well-functioning health system The benefits of immunisation are equitable extended to all people 6 Country, regional and global research and development innovations maximize the benefits of immunisation 2 Individuals and communities understand the value of vaccines and demand immunisation as both their right and responsibility Meet global and regional elimination targets 3. Meet vaccination coverage targets in every region, country and community 4. Develop and introduce new and improved vaccines and technologies 5. Exceed the Millennium Development Goal 4 target for reducing child mortality

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28 Meet vaccination coverage targets in every region, country and community Target 1: reach 90% national coverage and 80% in every district with DTP3 by 2015

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31 Where DTP3 un-immunized children are located 80% located in 10 countries 1 dot = 200 unvaccinated children Source: Country reported data JRF

32 Inequitable access DTP 3 coverage in highest (blue) and lowest (red) wealth quintiles 13/24 countries have 10% difference in DTP3 between highest and lowest wealth quintiles 10 of the 13 are in Africa

33 Weak delivery systems 36 countries have dropout rates 10%; with 11 20%. DTP1-DTP3 dropout rate (2012) 50% of these countries are in Africa CAR; Cameroon; DRC; Ethiopia; Guinea; Guinea-Bissau; Equatorial Guinea, Liberia; Lesotho, Madagascar, Mali, Mozambique, Mauritania, Nigeria, Sierra Leone, Chad, Togo, Uganda < 10% (158 countries) 10-19% (25 countries) 20% (11 countries) 0 1,700 3, Kilometers

34 Poor data quality DTP3 WUENIC and Country reported data in AFR 37% countries with admin coverage> WHO/Unicef estimates DQS conducted in many countries but corrective actions are not always implemented There is a lack of validation mechanisms of coverage data, particularly at subnational level # district with DTP3 > 100% Inconsistency in denominator figures over years National census data outdated Lack of collaboration between EPI and national statistics offices

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36 Wild Poliovirus Cases 1, Previous 12 Months 2 Country Onset of most recent case Number of districts Total WPV (All type1) Cameroon 09-Jul Equatorial Guinea 03-May Ethiopia 05-Jan Nigeria 24-Jul AFR 24-Jul Poliovirus type 1 Endemic country Country with WPV case in previous 6 months Country with WPV case 6-12 months ago Afghanistan 18-Sep Iraq 07-Apr Pakistan 01-Oct Somalia 11-Aug Syria 21-Jan EMR 01-Oct Global 01-Oct Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance. 2 Onset of paralyses 29 October October 2014 Data in WHO HQ as of 28 October 2014

37 Wild Poliovirus Cases 1, Previous 6 Months 2 Country Onset of most recent case Number of districts Total WPV (All type 1) Cameroon 09-Jul Nigeria 24-Jul Equatorial Guinea 03-May AFR 24-Jul Afghanistan 18-Sep Poliovirus type 1 Endemic country Country with WPV case in previous 6 months Pakistan 01-Oct Somalia 11-Aug EMR 01-Oct Global 01-Oct Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance. 2 Onset of paralyses 29 April 28 October 2014 Data in WHO HQ as of 21 October 2014

38 Comparison of 2013 and 2014 Data Year to Date (01 January to 28 October) WHO region AFP Cases Wild Virus Polio Compatible Pending Final Classification >90 days Data received in HQ African as of 27 October Central South/East West American as of 25 October Eastern Mediterranean as of 27 October European as of 27 October South East Asian as of 27 October Western Pacific as of 28 October Global Total Data for 2013 as of 29 October 2013 and for 2014 as of 28 October 2014 Data in WHO HQ as of 28 October 2014

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40 Status of MNT elimination in AFR. Oct 2013 TT SIAs ongoing, and efforts to systematically use school health programs for TT provision Advocating with countries to change TT vaccine to DT/dT The validation of MNT elimination is expected to take place in 5 countries in 2014

41 Reduction in estimated measles deaths by WHO Region

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43 MCV2 introduction in AFR (as of April 2014 ) - MCV2 already in EPI in 15 countries - RWA, TAN to introduce in BFA, MOZ, MAL, SIL, SEN applied for ZIM to apply to GAVI in NAM: to consider in 2014

44 Hib introduction

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47 Penta, PCV and Rota roll out Penta PCV Cape Verde Rota STP Comoros Seychelles Cape Verde 46/47 Countries : South Sudan yet to introduce Mauritius STP Comoros Seychelles 29/47 Countries : Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Congo, Central Afr Rep, DRC, Ethiopia, Gambia, Mauritania, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Rwanda, STP, Senegal, Sierra Leone, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe In country EPI Not yet in country EPI Not AFR 16/47 Countries : Angola, Botswana, Burkina Faso, Burundi, Cameroon, Congo, Ethiopia, The Gambia, Ghana, Malawi, Mali, Rwanda, Sierra Leone, South Africa, Tanzania, Zambia Mauritius

48 South Africa: Rotavirus Surveillance Pre and Post Vaccine Introduction (Dr. George Mukhari Hospital) Declining trends in severe diarrhea Aug 2009 Vaccine Introduction Aug 2009 Source: LM Seheri et al Vaccine 2012

49 MenA conjugate vaccine roll out Cumulative number of vaccinated individuals 160,000, ,277, ,000, ,000, ,000, ,181,879 80,000,000 60,000,000 54,613,721 40,000,000 20,000,000 19,154, So far, no reported case of NmA among the vaccinated populations 2013 = Lowest ever reported number of suspect cases during an epidemic season

50 Countries plan to introduce IPV GAVI applications March round (5) May round (10) Sept round (21) Missing information (1) Non-eligible countries (9) Comoros Benin Angola Lesotho Algeria Ethiopia DR Congo Burkina Faso Botswana Liberia Kenya Burundi, Cape Verde Nigeria Madagascar Cameroon Equatorial Guinea Tanzania Malawi CAR Gabon Rwanda Chad Mauritius Senegal Congo Namibia Sierra Leone Cote d'ivoire Seychelles The Gambia Eritrea Swaziland Uganda Ghana Guinea Guinea Bissau Mali Mauritania Mozambique Niger Togo South Sudan Sao Tome & Principe Zambia Zimbabwe

51 Preparation for IPV introduction: IPV Introduction in AFRO Orientation provided to all EPI Managers and partners (one-day workshop organized during the 3 EPI Managers meetings in February/March 2014) Training of pool of consultants (73) to support countries: Anglophone (03-04 Apr) & Francophone (14-15 Apr) Plan to expand the AFR and ISTs capacities to support the accelerated introduction Coordination mechanisms with all partners in place Some challenges related to IPV introduction Accelerated introduction timeline (by end 2015) Issue of high cost of vaccines in GAVI non eligible countries Communication in the context of multiple injections (3 injections to the child at the same visit)

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54 Country ownership Data on immunization expenditures is inadequate to draw conclusions on trends NITAGs in 2012 The number of NITAGs meeting functionality criteria have increased significantly Only 3 Countries in Africa have a NITAG meeting all 6 WHO criteria of functionality Capacity strengthening required for NITAGs to collect, synthesize and use data and evidence for decisions NITAGs have important role in improving quality of national data and monitoring progress at national level 63 Countries meeting the 6 NITAG criteria ,700 3,400 Kilometers 99 Countries having a NITAG with administrative or legislative basis 104 Countries Reporting the Existence of a NITAG with ToRs 116 Countries Reporting the Existence of a NITAG

55 Surveillance systems High quality surveillance is essential for assessing whether immunization programmes are having the desired impact Surveillance quality and timely reporting is inadequate to meet national programme needs Inconsistencies noted in surveillance data from different sources, i.e. JRF versus surveillance reports Greater investments and technical assistance is required to strengthen systems

56 Trend of government funding vaccines ( ) Percentage Average, million $ 100% $2.5 90% $2.0 80% $2.0 70% $1.4 $1.4 $1.5 $1.5 60% 54% 55% $1.5 50% 58% 53% 40% $1.2 $1.1 30% 40% 35% 36% $1.0 20% $0.5 10% 0% $ Percentage of government funding vaccines (average % in selected countries) Percentage of government funding vaccines (average % in the region) Government funding vaccines in absolute values (average million $ in selected countries )

57 Trend of government funding routine immunization ( ) Percentage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Average, million $ $4.5 $3.9 $3.7 $4.0 $3.2 $3.3 $3.5 $2.9 $2.8 $3.0 $2.3 $2.5 52% 51% 52% 53% $2.0 48% 48% 48% $1.5 $1.0 $0.5 $ Percentage of government funding RI (average % in selected countries)

58 Conclusion 40 years of EPI in Africa

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60 I ACKNOWLEDGE WHO FOR MOST OF THE DATA PRESENTED IN THIS TALK THANK YOU MERCI GOD BLESS YOU Website : charlesw@sun.ac.za Twitter