Challenges to Sustaining National Immunization Programs in Developing Countries

Transcription

1 Challenges to Sustaining National Immunization Programs in Developing Countries III International Symposium of Immunobiology - Bio- Manguinhos / Maio 2016 Rio de Janeiro, Brasil Jon Kim Andrus, MD Executive Vice President, Sabin Vaccine Institute Director, Vaccine Advocacy and Education 1

2 Our Mission Sabin is a non-profit, 501(c)(3) organization. Its mission is to reduce needless human suffering from vaccine-preventable and neglected tropical diseases (NTDs) by developing new vaccines, advocating for increased use of existing vaccines, and promoting expanded access to affordable medical treatments. 2

3 Our Programs Vaccine Advocacy and Education Vaccine Development Global Network for Neglected Tropical Diseases Click to add text 3

4 Pro-Vac Workshop, September 2006

5 Measles

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7 Goals of the Global Vaccine Action Plan IAIM Inaugural Conference, March 3-4, 2015, Istanbul, Turkey

8 GVAP mid-point targets 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 IAIM Inaugural Conference, March 3-4, 2015, Istanbul, Turkey

9 19 Number of childhood vaccines routinely used industrialized countries and in Latin America and the Caribbean, Industrialized countries Latin America and the Caribbean Current GAP HPV Varicela Hepatitis A Meningococcal Seasonal flu Rotavirus Pneumococcal Measles, DPT Poliomyelitis, BCG Haemophilus Influenzae b Rubella Mumps Hepatitis B**

10 Framework for evidence-based Policy decisions Technical criteria Programmatic criteria Societal criteria Andrus et al. Public Health Reports 2007;122(6):811-6

11 ProVac s objectives Strengthen infrastructure for decisionmaking (National Immunization Technical Advisory Groups) Develop tools for economic analysis and provide training to national multidisciplinary teams Collect data, conduct analysis, and gather framework of evidence Advocate for evidence-based decisions Effectively plan for vaccine introduction when evidence supports it

12 Strengthening infrastructure and building capacity for evidence based decisions Countries have requested technical support from PAHO; to help integrate economic studies into the national decision-making process for immunization Directing Council resolution (CD47.R10) Ministry of Health ProVac Central Team (PAHO HQ) National IM Committee Surv. Officers Nat l Consultant EPI Manager ProVac Country Team Clinician PAHO Country Focal Point Health Economist ProVac Centers of Excellence National level Regional level 12

13 Vaccine and Immunization Investment Case For every dollar invested in national immunization programs: 15 dollars are saved in the cost of health services 44 dollars are saved when societal benefits are included 13

14 Rubella Elimination: Cost Savings Elimination of rubella and congenital rubella syndrome (CRS) costs 7% of what it would take the health systems of countries to care and provide rehabilitative services for babies born with CRS Not all immunization interventions are costsaving e.g. rotavirus vaccine at current prices Irons B, et al. AJPH 2000;90(10:

15 Congenital Rubella Syndrome Pro-Vac Workshop, September 2006

16 High mortality rationale for immunization interventions Conditions Vaccine-preventable deaths among children worldwide Measles 610,000 Haemophilus influenzae type B 450,000 Pertussis 285,000 Neonatal tetanus 200,000 Congenital rubella syndrome (1996) 110,000 Yellow fever 30,000 Diphtheria 5,450 Paralytic polio 1919 Source: WHO 2004; Cutts & Vynnycky, 1999

17 High morbidity rationale for immunization interventions Autistic boy Spastic, deaf Autistic Deaf-blind, retarded Rubella Project for Multihandicapped; Bellevue Hospital 1968 Courtesy Dr. L. Cooper

18 5/3/2016 Sabin Vaccine Institute 18

19 Strategies Strategies always rely on: Immunizing susceptible population Conducting effective surveillance Sustaining the gains Andrus, et al. Measles and rubella eradication in the Americas. Vaccine 2011;29S:DD91-D96.

20 High Political Commitment and Participation First Lady and Cabinet President launching campaign 20

21 Campaign Characteristics 1. Nontraditional groups vaccinated Adolescents and adults: men and women 2. Large proportion of population to be vaccinated 3. Broad and timely social mobilization 4. Detailed plans of action monitored in the field Range of 40-70%of total population Political commitment and partner participation at all levels Requires 100%coverage (total immunity) 5. Short time period Intense: 6 weeks 21

22 22 Rubella Vaccination Coverage in Selected Countries of the Americas, Coverage (%) CAR COR HON ELS PAR COL NIC BOL PER DOR ARG* CHI BRA Vaccination of men and women * Vaccination of women only Pro-Vac Workshop, Source: September Country 2006 reports Andrus JK, et al. Vaccine 2008 (In Print)

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24 5/3/2016 Sabin Vaccine Institute 24

25 Casos 600 Distribution of confirmed cases in Brazil, * N: N: Campanha Nac de Eliminação da Rubéola N: % Últimos casos SP/MT SE Source: SVS/MS * Preliminary data EW 40/

26 5/3/2016 Sabin Vaccine Institute 26

27 Rubella - Measles Reporting Network 30,000 reporting sites, target was to have at least one per 100,000 population integrated for measles and rubella surveillance 148 sub-national, national, and regional laboratories 14 PAHO field epidemiologists in priority countries Case-based community surveillance with data flow to Regional office MESS & ISIS computer software Andrus, et al. Strengthening surveillance: Confronting Infectious diseases in developing countries. Vaccine 2011;29S:D126-D

28 Rubella elimination and primary health care PAHO. Changing lives: The EHDI experience in Costa Rica. EPI Newsletter August 2007;29(4):1. Castillo-Solorzano C, Andrus JK. Rubella elimination and improving health care for women. Emerging Infectious Diseases 2004;10(11): Pro-Vac Workshop, September

29 Global Health Security www. Sabin.org

30 Internationally-supported GPEI Workforce (N=30,000+) is focused in endemic and transitioning countries Millions of vaccinators Tens of thousands of local social mobilizers Thousands of skilled technical staff Hundreds of highly skilled technical managers/leaders Includes social mobilizers. Does not include vaccinators or regional/headquarters personnel. >1000 personnel >100 personnel >40 personnel >10 personnel 1+ personnel 30

31 Polio-funded staff can and already do achieve more than stopping polio (2 nd BCG survey Feb 2015) 100% 75% 50% 25% BCG survey: staff time allocation (self-reported) 5% 5% 5% 6% 7% 4% 1% 7% 7% 4% 5% 6% 5% 16% 16% 5% 2% 9% 4% 7% 11% 11% 4% 9% 21% 7% 18% 5% 8% 14% 13% 7% 18% 9% 32% 28% 22% 23% 17% 22% 14% 26% 74% 64% 15% 54% 40% 39% 44% 44% 46% 37% 29% 27% ~46% time spent on RI-related activities 0% Afghanistan Angola Chad DRC Ethiopia India Nigeria Pakistan Somalia South Sudan Overall Polio eradication Routine Immunization Measles and rubella New vaccine introduction Child health days or weeks Maternal, newborn, and child health and nutrition Health systems strengthening Natural disasters and humanitarian crises Sanitation and hygiene Other diseases or program areas

32 Building on the Polio Laboratory & Surveillance Network (>700 labs) 32

33 Countries have learned many lessons on the road towards eradication Accessing insecure and hard-to-reach areas Accountability Communications Social mobilization/community engagement Working in a complex global partnership Achieving and maintaining political commitment Global disease surveillance networks How can these lessons be used for greater benefit?

34 What is Expected of Countries? The goal in the next 12 months is for 14 countries, nine of which are in Africa, to develop polio transition plans by end-2016 (+ PAK and AFG by end-2017) Plans will provide roadmap for transition of essential polio functions, resources and lessons learned during Plans should include budget commitments from governments and donors to enable implementation starting in 2017 GPEI Legacy Planning

35 Legacy Planning: Outcome Legacy Planning: Overall, what would a successful outcome look like? National & Institutional legacy plans developed, building on the strengths of the GPEI (e.g. access) to benefit generations to come, including: Essential polio functions mainstreamed into ongoing national and institutional structures (e.g. immunization) Resources, lessons and knowledge documented and transitioned to other health priorities as appropriate Goal: To ensure, that these are the outcomes of the Legacy Planning process, and that we all plan a rational future together.

36 Most Obvious Candidates for Transitioning of Polio Assets Immunization system strengthening Measles and rubella elimination

37 Why It Makes Sense to Pivot from Polio Eradication to Measles-Rubella Elimination 1. Strategies are similar Surveillance and lab network Outbreak preparedness and response Importance of achieving/maintaining high routine coverage Need for periodic SIAs to reach inaccessible children Use of communications/social mobilization network 2. Polio infrastructure concentrated in the lowest-performing countries with highest measles-rubella disease burden 3. Polio and measles-rubella already working together and interconnected including human resources 4. Measles still major cause of <5 child deaths 5. Rubella is the leading infectious cause of birth defects

38 EPI Financing and Vaccine Legislation in the Americas, EPI Expenditures (millions) % 94% 90% 92% 79% Number of Laws External funding source National funding source Vaccine Laws Pro-Vac Workshop, September 2006Pan American*Includes financing data from all countries in the region; same data will be disaggregated Health and analyzed for only the countries included in the study. Organization

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40 Partnerships EUROPEAN UNION

41 In summary, there is no magic bullet to tackling the challenges to sustaining national immunization programs. Ultimately, the solution requires a strategic vision grounded in long-term goals, not short-term fixes, that will ultimately lead to national ownership and capacity development. www. Sabin.org

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43 Vaccine Advocacy and Education Reducing the burden of preventable diseases by bringing together key stakeholders and leaders in government, private sector and civil society in order to foster cooperation, share information and best practices, and develop improved vaccine policy and access. 43

44 Vaccine Advocacy and Education (VAE) Our VAE programs: The Coalition against Typhoid The International Association of Immunization Managers The Sustainable Immunization Financing Program Special Projects 44

45 Special Projects The Dengue Vaccine Initiative Rotavirus Rubella Meningococcal, Pneumococcal and Pertussis A consortium working to lay the groundwork for dengue vaccine decision-making and introduction in endemic areas. Sabin hosts bi-annual international symposia, bringing together stakeholders to share new data and relevant research. Sabin is also part of The ROTA Council. Sabin carries out advocacy activities to support the global elimination of measles and rubella. Sabin works to improve disease estimates and surveillance, and raise awareness of these vaccinepreventable diseases. 45

46 Special Projects The Vaccine Advocacy and Education program also increases knowledge among journalists, immunology stakeholders, policy makers and others through: Journalist information sessions The Ciro de Quadros Vaccinology Course Symposia and workshops 46