Global Immunization Overview Thomas Cherian Expanded Programme on Immunization WHO, Geneva
Global U5 Mortality: Role of Vaccine Preventable Diseases (2008 data) 8.8 million under five deaths Other 20% Pneumonia other 9% Pneumoccocal diseases* 6% Hib* 3% Pertussis 2% Tetanus 1% Measles 1% Rotavirus** 6% 20% (1.7 million) from vaccine preventable diseases Perinatal 33% HIV 2% Malaria 8% Diarrhoea other 9% 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 2 provisional estimates based on Global Burden of Diseases estimates ** WHO/IVB estimates GHH seminar for 2004 based June on 15, Global 2011 Burden of Diseases estimates
Returns on investments in immunization The rate of return to investment in the GAVI-supported immunization activities is conservatively estimated at 12% in 2005, rising to 18% in 2020. Source: Bloom & Channing 2004 These figures are comparable to average rates of return to investments in schooling (based on a survey of 98 country studies during 1960-97): primary: 19% secondary: 13% higher: 11% Source: G. Psacharopoulos and H. Patrinos, Returns to Investment in Education: A Further Update, World Bank Policy Research Working Paper 2881, September 2002 (social rates of return from Table 1). 3
Where do we stand with immunization programmes globally
Global Immunization 1980-2009, DTP3 coverage global coverage at 82% in 2009 % coverage 100 80 60 40 UCI 55 44 4952 38 75 71 64 68 7070 7373 7272 727374747475 7779 80818182 20 20 2325 0 1980 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 Global African American Eastern Mediterranean European South East Asian Western Pacific Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 Date of slide: 13 July 2010 5
Countries with most unvaccinated infants DTP3, 2007-2009 (in millions) and DTP3 coverage in 2009 0 2 4 6 8 10 India 66% Nigeria 42% China Indonesia Pakistan Ethiopia Democratic Republic of the Congo Uganda 97% 82% 85% 79% 77% 64% 2009 2008 2007 23% Chad 75% Kenya Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 Date of slide: 14 July 2010 6
Challenges Uninformed population or fearful population Programme management Human resources: number, training & motivation Immunization delivery services (hard to reach populations) Issues with data quality Capturing and reporting data on VPDs through administrative systems (numerator and denominator problems) Wide variation between administrative and survey data Low use of data for planning and corrective action Vaccine supply stock outs Supply chain management (forecasting, procurement and distribution) Storage and transportation in the cold chain 7
Review of published literature: Reasons for being un-/under-vaccinated Under-vaccinated Unvaccinated 28% 21% 27% 7% Immunization Systems 55% Parental Attitudes And Knowledge Family Characteristics 12% 44% 6% % based on 887 reasons abstracted from 209 relevant articles % based on 33 reasons abstracted from 12 articles on unvaccinated children 8
Progress with measles control
Scaling-up 2 nd Dose Strategies Number of doses of measles vaccine administered, by delivery strategy, 2000-2009 500 Number of MCV doses (in millions) 450 400 350 300 250 200 150 100 50 Measles Initiative 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 1st routine dose 2nd routine dose SIA 10 1 st routine dose: WHO/UNICEF coverage estimates, The World Population Prospects - the 2008 revision. New York, 2009. 2 nd routine dose: WHO/UNICEF Joint reporting form (no reports from Canada, Finland, Ireland, Italy, Luxemburg, Monaco, New Zealand, USA, Uruguay, SIA dose;: WHO SIA database, July 2010 (Provisional data)
Impact of Accelerated Activities Number of reported measles cases by WHO Region, 2000-2009* Number of estimated measles deaths, by WHO Region, 2000-2008 900000 1,000,000 Number of reported cases 800000 700000 600000 500000 400000 300000 200000 100000 0 67% decrease 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 AFR AMR EMR EUR SEAR WPR Estimated measles deaths 800,000 600,000 400,000 200,000-78% decrease 2000 2001 2002 2003 2004 2005 2006 2007 2008 High-low bars indicate uncertainty 11 Source: Cases from annual Joint Reporting Form Deaths from Wkly Epid Rec Dec 4, 2009 GHH *2009 seminar case data June incomplete 15, 2011
Expanding Measles Outbreaks in Africa, 2009-2010 As of 16 June 2010: Outbreaks in 30 African countries Over 79,000 cases and 1,127 deaths reported Major resurgence in southern Africa after >10 years of very low incidence following accelerated control efforts Reasons: Weak routine delivery Gaps in campaign coverage SIAs delayed due to inflated coverage estimates Limited target age range due to shortage of funds Cross border spread (migrants/nomads) and religious objectors 12
World Health Assembly, May 2010 Report A63/18: Global Eradication of Measles 19 Member States made interventions Eradication is a worthy public health goal that can be achieved A major obstacle in many countries is inadequate routine immunization systems which must be strengthened as an essential building block for achieving and maintaining regional measles elimination. 2015 targets as a milestone towards eradication GIVS coverage goals (90% routine coverage) 95% mortality reduction vs 2000 Incidence <5 per million 13
Introducing New vaccines
ADIPs focus on faster uptake for the world s poorest children ESTIMATE Million doses 200 HepB 75 lowest 50% coverage** income 50% coverage** 150 countries 100 33% coverage** 50 0 10% coverage** 1 3 5 7 9 11 13 15 17 19 21 23 Hib - 75 lowest income countries 15 Years from availability
Turning a Vicious Cycle into a Virtuous Cycle Uncertain demand Limited supply Higher prices Increased production capacity Predictable demand Lower prices 16
Accelerating the Development and Introduction of New Vaccines: establishing, communicating, & delivering the value of vaccination Establish value Communicate value Deliver value Surveillance Vaccine efficacy/safety Cost-effectiveness Audience research Key messages Media relations Demand forecast/roll-outs Financing Target product profiles Disease burden & vaccine impact are well defined at country level Generate political will to prioritize disease prevention and vaccine introduction Reliable supply of affordable vaccine and assured financing 17
Countries Using Hib containing Vaccine in National Immunization Schedule No (13 countries or 7%) Yes (170 countries or 88%) Source: WHO/IVB database, 193 WHO Member States. Data as of June 2011 Date of slide: 14 June 2011 Yes (Part of the country) (2 countries or 1%) GAVI Approved not yet introduced (2 countries or 1%) GAVI Applied (6 countries or 3%) 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 2011. All rights reserved 18
Countries Using Pneumococcal Conjugate Vaccine in National Immunization Schedule No (90 countries or 47%) Yes (64 countries or 33%) Source: WHO/IVB database, 193 WHO Member States. Data as of June 2011 Date of slide: 14 June 2011 Yes (Part of the country) (2 countries or 1%) GAVI Approved not yet introduced (9 countries or 5%) GAVI Applied (28 countries or 15%) 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 2011. All rights reserved 19
Accelerating the introduction of pneumococcal vaccines 20
Countries Using Rotavirus Vaccine in National Immunization Schedule No (13 countries or 7%) Yes (170 countries or 88%) Source: WHO/IVB database, 193 WHO Member States. Data as of June 2011 Date of slide: 14 June 2011 GAVI Applied (6 countries or 3%) GAVI Approved not yet introduced (2 countries or 1%) 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 2011. All rights reserved 21
Challenges of new vaccine introduction Uncertainty or scepticism about disease burden Weak immunization systems Knowledge and practice of immunization staff Cold chain, logistics, waste management Financial sustainability in resource constrained environment Surveillance systems Country ownership and investments in surveillance Adverse events surveillance & appropriate response Concerns about vaccine safety Fears, perceptions and misinformation about new vaccines 22
Addressing vaccine pricing Transparency in vaccine pricing Pooled procurement mechanisms PAHO vaccine revolving fund Technology transfer for vaccine production in countries with emerging economies Other innovative mechanisms Advanced market commitment 23
The Advance Market Commitment for Pneumococcal Vaccines $7 AMC Price per Dose $3.50 AMC subsidy GAVI funding Tail price cap Country Co-pay ( $0.10 - $0.30 per dose initially) * $0 1 st Eligible Vaccine available AMC Period 2 4 6 8 supplier s share of AMC funds depleted Tail Period 10 Years Supply Commitment Fulfilled * Co-financing levels will be in line with the applicable GAVI co-financing policy. 24 24
Integrated Approaches to Disease Control Global Action Plan for Prevention and Control of Pneumonia launched in November 2009 WHA resolution on Pneumonia Prevention and Treatment passed in May 2010 Comprehensive WHO/UNICEF Diarrhoea Control Strategy launched in Nov 2009 Comprehensive Cervical Cancer Control Strategy updated including immunization, reproductive health, cancer screening and control programmes, and adolescent health services 25
Monitoring & surveillance: the basis of well-performing immunization programmes
Type of surveillance needs to be aligned to surveillance objectives Type Objective Example Country-wide, active, with lab confirmation of all cases Document eradication/elimination -find all chains of transmission; certification Polio, measles Country-wide passive, aggregate reporting, with selective investigation Sentinel site surveillance Epidemiologic studies (detailed, labour intensive) and sero-surveys Routine monitoring; outbreak detection investigation Networks of sentinel sites providing representative data for the population Obtain epidemiological information Syndromic surveillance, avian influenza Meningitis, Invasive bacterial diseases, rotavirus Hepatitis B; disease incidence based on regular home visits 27
Countries Implementing Case-based Measles Surveillance, 2008 Yes (173 countries or 90%) No (20 countries or 10%) Source: 28 WHO/IVB database, February 2009
Global VPD Laboratory Network, N> 700 Labs + 331 (Prefecture Labs) + 154 Sub-National Labs Labs/Institutes testing for: Polio only (23) Measles/rubella only (531) Polio and measles/rubella (109) Measles/rubella and yellow fever (14) Polio, Measles/rubella and yellow fever (13) 29 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
Types of sentinel surveillance Bridging to get more comprehensive data Facility-based Meningitis Facility-based; All invasive bacterial diseases Populationbased Vaccine clinical trials (probe) Surveillance Research 30
Sentinel site surveillance for Invasive Bacterial Diseases and Rotavirus Diarrhoea Data collected from WHO Regions Slide date: 13 November 2009 31 Yes (46 Member States or 24%) 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
2009 Global Surveillance Bulletins Communication: Rotavirus and Invasive Bacterial Diseases http://www.who.int/nuvi/surveillance/ 32
What's the future
Opportunities Mandate from the WHO governing bodies WHA report on GIVS 2005 with report back in 2011 WHA resolution on measles control WHA resolution on pneumonia prevention and treatment Visible impact of vaccination on mortality and morbidity Pneumococcal and rotavirus vaccines in high and middle-income countries Data from developing countries through ongoing impact monitoring Strengthening of national policy & decision making processes Decade of vaccines Partnership to communicate the value of vaccination and increase investments in disease prevention through vaccination 34
Decade of Vaccines A shared vision and global partnership for realising the potential of vaccines and immunization DAVOS 29 January 2010 Bill and Melinda Gates Pledge $10 Billion in Call for Decade of Vaccines to support research, production and delivery of life-saving vaccines to children in developing countries World Health Assembly May 2010 ".Vaccines are one of the best life-saving buys on offer, preventing an estimated 2 to 3 million deaths each year. WHO and UNICEF, in close collaboration with the Gates Foundation, countries, and partners, are initiating a process to define the ambitions and scope of this Decade of Vaccines."... 35
The Decade of Vaccines, 2011-2020: a comprehensive venture to advance immunization The Decade of Vaccines (DoV) envisions a world where children, families, and communities enjoy lives free of the fear of vaccine preventable diseases. The goal of the DoV is to extend the full benefits of immunization to all people, regardless of where they live. This goal reflects the perspective that access to safe and effective vaccines is a human right that is not currently enjoyed by all people, particularly in low and middle income countries. Will require full engagement of the diverse stakeholders needed to facilitate vaccine discovery, development and delivery 36
DoV Work Streams Establishing and sustaining broad public and political support for the use of vaccines and the financing of immunization services. Strengthening the equitable delivery of immunization services to achieve universal coverage of safe and effective vaccines by 2020 in order to prevent, control, eliminate or eradicate vaccinepreventable diseases. Cultivating a robust scientific enterprise to produce innovation in the discovery and development of new and improved vaccines and associated technologies for high priority disease targets. Creating the right market incentives to ensure an adequate and reliable supply of affordable vaccines. 37
Proposal for Delivery Goal The goal of the Delivery stream of the Decade of Vaccine is, throughout the life-course, to achieve equity in the delivery of effective and safe immunization along with other essential primary health care interventions in order to prevent, control, eliminate or eradicate vaccine-preventable diseases. To strengthen country capacities to deliver immunization services to all people, following five guiding principles: 1. National ownership, responsibility and accountability in extending safe and effective immunization to their target populations; 2. Greater equity and equality in access to immunization both within and across countries, with a particular focus on populations in greatest need; 3. Ready and rapid access to new vaccines, technologies and products to meet national, regional and global disease burden reduction; 4. Alignment of immunization with other primary health care interventions; and 5. Preparedness and response to special needs created by unusual events, including humanitarian emergency action and the emergence of epidemics. 38
THANK YOU 39