Implications of beneficial off-target effects for upcoming eradication campaigns (measles and polio) Ane Bærent Fisker, MD, PhD Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Denmark and Bandim Health Project, Guinea-Bissau
Elimination targets
Strategies Routine vaccinations Birth 6w 10w 14w 9 months BCG+ 3*DTP+ 3* Measles vaccine Campaigns >1,000,000,000 doses of Measles Vaccine >10,000,000,000 doses of Oral Polio Vaccine
Purpose and Evaluation Campaigns conducted to Achieve high vaccination coverage To reach children not reached by the routine programme Monitored by Coverage: Doses given / estimated target population Specific disease protection / incidence
Targeted effects Reported measles cases by year WHO: Global measles and rubella strategic plan: 2012-2020
Estimated impact on mortality Small Measles mortality has been reduced by 75% since 2000 Polio infections have been reduced by 99% since 1988 Source: WHO But with non-specific /off-targeted effects -> campaigns could have much wider effects.
Bandim Health Project A platform for testing real-life effects of health interventions Guinea-Bissau Rural Guinea-Bissau Regular home visits Rural Guinea-Bissau Urban Guinea-Bissau Rural Guinea-Bissau > 100,000 individuals in 6 suburban districts > 100,000 individuals in 182 village clusters
Guinea-Bissau 2001-2014: 19 Campaigns with Oral Polio Vaccine 3 Campaigns with Measles Vaccine 10 Campaigns with Vitamin A 1 Campaign with H1N1 2001 2002 2003 missing vaccine 2004 Dec 2005 May 2006 May 2007 June 2008 July 2009 Mar May H1N1 Mar 2011 2011 July 2012 Dec 2012 Aug 2014 Dec 2014 2001 2002 2004 2005 2006 2007 Jan 2009 Jan April Dec April 2011 Mar 2012 May 2013 2013 2014, no vaccines Other vaccines
Measles vaccination campaign 2006 29-05-2004 29-05-2005 29-05-2006 15-05-2005 15-05-2006 15-05-2007 May2006, no vaccines Other vaccines
Measles vaccination campaign 2006 29-05-2004 29-05-2005 29-05-2006 15-05-2005 15-05-2006 15-05-2007 Results removed
Boosting with measles vaccine in previous studies 4½-8 mo 9 mo Follow-up Observational study 1980-83: MRR=0.41 (0.19-0.85) Randomised trial 2003-2009: MRR=0.71 (0.5-1.0) Aaby, BMJ, 1993 and Aaby, BMJ,
Conclusion Measles vaccination campaign Prevent measles and mortality from other causes than measles Especially among those previously vaccinated
Oral Polio Vaccine
Off-Target Effects of Oral Polio Vaccine First campaign in Bissau 1998: Mortality March-Dec 1998 campaign in 1998 age groups Mortality rate ratio vs. No 0-5 months 0.56 (0.3-1.0) 0-4 years 0.67 (0.5-0.9) Aaby, Vaccine, 2005
vaccination campaigns in Guinea-Bissau 2002-14 Urban Bissau Trials 2003 missing vaccine, no vaccines Other vaccines 2001 2001 2002 2002 2004 2004 2005 Dec 2005 May 2006 2006 2007 May 2007 Jan 2009 June 2008 Jan July 2009 Mar April May H1N1 Dec Mar 2011 April 2011 2011 Mar 2012 July 2012 Dec 2012 2013 May 2013 Aug 2014 2014 Dec 2014
Urban Bissau Trials 2003 missing vaccine, no vaccines Other vaccines 2001 2001 2002 2002 2004 2004 2005 Dec 2005 May 2006 2006 2007 May 2007 Jan 2009 June 2008 Jan July 2009 Mar April May H1N1 Dec Mar 2011 April 2011 2011 Mar 2012 July 2012 Dec 2012 2013 May 2013 Aug 2014 2014 Dec 2014 vaccination campaigns in Guinea-Bissau 2002-14
0 50 Urban Bissau: Under 5-years mortality 100 150 200 250 300 350 400 450 Campaigns 1980 1985 1990 1995 2000 2005 2015 Year MDG4 reached: 68% reduction from 1990-2013 236/1000 to 68/1000
to be replaced by IPV
IPV Effects Birth IPV 4-6 mo IPV 9 mo Four trials in Guinea-Bissau 1985-2003 IPV as a control vaccine Aaby, PIDJ, 2007
IPV Effects Female / Male Mortality Rate Ratio Birth 4-6 mo IPV 9 mo 1.52 (1.02-2.28) 0.88 (0.68-1.14) P=0.025 Aaby, PIDJ, 2007
Conclusion Purpose of campaigns Reach those not reached Eliminate measles and polio
0 50 Conclusion Purpose of campaigns Reach those not reached Eliminate measles and polio Little effect expected on mortality Real life observation Lower Mortality Especially among previously vaccinated children 100 150 200 250 300 350 400 450 1980 1985 1990 1995 2000 2005 2015 Year
Bandim Health Project and Research Center for Vitamins and Vaccines (CVIVA)