Sustaining Immunization in Developing Countries: The Future We Make

Sustaining Immunization in Developing Countries: The Future We Make Global Health Summit Denver, CO 29 April 211 Jon Kim Andrus, MD Deputy Director

Umbrella of protection in the Americas Measles eradication Polio Eradication Confirmed cases (thousands) 3, 25, 2, 15, 1, 5, Catch-up campaigns Follow-up campaigns 8 81 82 83 84 85 86 87 88 89 9 91 92 93 94 95 96 97 98 99 1 2 3 4 5 6 7 8 Cases Coverage 1 8 6 4 2 Routine infant vaccination coverage (%) Number of cases 7 6 5 4 3 2 1 Cases Coverage 7 71 72 73 74 75 76 77 78 79 8 81 82 83 84 85 86 87 88 89 9 91 92 93 94 95 96 97 98 99 1 2 3 4 5 6 7 8 Type 1 vaccine derived virus in 2 and 21: 21 cases 1 9 8 7 6 5 4 3 2 1 Coverage (%) Neonatal Tetanus Elimination Diphtheria and Pertussis Number of Cases 18 16 14 12 1 8 6 4 2 25 2 15 1 5 Latin America minus Haiti 1999 2 21 22 23 24 25 26 27 28 1985 1987 1989 1991 1993 1995 1997 1999 21 23 25 27 Source: Country reports Year Countries with cases in the last 3 years: Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru and Venezuela Haiti Year Number of Cases 14 12 1 8 6 4 2 Pertussis Diphtheria Coverage 78 79 8 81 82 83 84 85 86 87 88 89 9 91 92 93 94 95 96 97 98 99 1 2 3 4 5 6 7 8 1 8 6 4 2 Coverage (%)

19 Number of childhood vaccines routinely used industrialized countries and in Latin America and the Caribbean, 1975-21 17 15 13 11 Industrialized countries Latin America and the Caribbean Current GAP HPV Varicela Hepatitis A Meningococcal Seasonal flu - 26 Rotavirus - 26 Pneumococcal- 26 9 7 5 Measles, DPT Poliomyelitis, BCG 1975 198 1985 199 1991-1995 Haemophilus Influenzae b Rubella Mumps Hepatitis B** 1996-2 21-25 26-21

Accelerating Policy

Priorities HPV vaccine and cervical cancer AGE SPECIFIC MORTALITY RATES 12 1 8 6 4 2 Cervical Cancer Disease N. America Burden Taking advantage of new Cen. America technologies while Caribbean enhancing approaches to So. America screening to reduce 77, new cases per year mortality of this disease of 33, deaths per year poverty Reducing the developing country uptake time lag >2 decades -14 15-44 45-54 55-64 65+ AGE GROUP [years] Source: IARC 24 estimates

47th Directing Council, September 26 Urged Member States to: Expand legal and fiscal space and identify new revenue sources to sustainably finance the introduction of new vaccines against rotavirus, pneumococcus, influenza, and human papillomavirus; Support the mortality reduction targets, consistent with GIVS and the MDGs, for HPV, RV, influenza, and pneumo associated disease; Utilize the PAHO Revolving Fund for Vaccine procurement to purchase new and underutilized vaccines

ProVac Policy Framework Technical criteria Programmatic criteria Financial criteria www. paho.org/immunization Andrus et al. Public Health Reports 27;122(6):811-19

Priorities HPV vaccine and cervical cancer AGE SPECIFIC MORTALITY RATES 12 1 8 6 4 2 Cervical Cancer Disease N. America Burden Taking advantage of new Cen. America technologies while Caribbean enhancing approaches to So. America screening to reduce 77, new cases per year mortality of this disease of 33, deaths per year poverty Reducing the developing country uptake time lag >2 decades -14 15-44 45-54 55-64 65+ AGE GROUP [years] Source: IARC 24 estimates

Tools for Economic Analysis Vaccine Intro Costs Tool Burden of Disease Tools Costs Health Gains Cost Effectiveness Studies HPV Cost Effectiveness Studies Influenza Economic Analysis Cost Effectiveness Studies Rotavirus Cost Effectiveness Studies Pneumococcus

Cost Effectiveness and Affordability Cost effectiveness attempts to define the value of an intervention Affordability refers to the implications on the actual budget Example (Goldie et al, Vaccine 28): Price per dose Cost effectiveness Budget* $ 5. < $4 to avert DALY $36 million $12.25 < $8 $811 million $19.5 <$1,4 $1.26 billion *Financial cost to vaccinate 7% of 5 consecutive birth cohorts Pan American Health Organization

Number of Countries with Seasonal Influenza Vaccination Programs in the Americas, 1975-28 42 Countries Number of countries 45 4 35 3 25 2 15 1 5 1975 198 1985 199 1995 2 25 27 28 29

Accelerating Deployment

Congenital Rubella Syndrome Pro-Vac Workshop, September 26

Strategies Strategies always rely on: Immunizing susceptible population Conducting effective surveillance Sustaining the gains

Rubella Vaccination Coverage in Selected Countries of the Americas,1997-26 1 98 98 99 99 97 99 99 99 99 98 99 96 Coverage (%) 8 6 4 82 2 CAR COR HON ELS PAR COL NIC BOL PER DOR ARG* CHI BRA Vaccination of men and women * Vaccination of women only Source: Country reports Andrus JK, et al. Vaccine 28

Rubella elimination and primary health care PAHO. Changing lives: The EHDI experience in Costa Rica. EPI Newsletter August 27;29(4):1. Castillo-Solorzano C, Andrus JK. Rubella elimination and improving health care for women. Emerging Infectious Diseases 24;1(11):17-21.

Rubella and Measles Elimination, The Americas, 198 29 3, 25, Measles Elimination Number 2, 15, Accelerated rubella control 1, 5, Rubella Measles Rubella Elimination 198 1982 1984 1986 1988 199 1992 1994 1996 1998 2 22 24 26 28 Source: Country reports 17

Future Challenges

What s at stake? Child mortality was reduced from 54 per 1 live births in 199 to 36 in 2 To achieve MDG4 by 215, the 2 child mortality rate level of 36 per 1 live births will require another 5% reduction to 18 per 1 Immunization can only account for 1/3 of the reduction if RV and pneumococcal vaccines are introduced Such new vaccine introductions double and triple the national budget for vaccine purchases, respectively. Perinatal mortality will also require subtantial support Andrus et al. Health Affairs, 28; 27(2): 487-493

Vaccine Funding Source for National Immunization Programs in LAC, 1987-28 18 2 15 12 $ in millions 9 6 3 114 431 57 74 654 667 55 886 166 1987-91 1992-96 1997-1 22-6 27-8 National External

Financial Requirements for Vaccines, Latin America and the Caribbean, 27 Vaccine Cost Vaccine Budget Basic Vaccines (per fully immunized child) Under-Utilized Vaccines Supplementary Immunization BCG $.1 OPV $.66 Penta+Booster $12.37 Total $15.93 X Cohort MMR $2.8 TOTAL $15.93 Pediatric Yellow Fever $.65 1 doses Dose X Cost X Children 1 yr Yellow Fever $.65 1 dose Cost X High Risk Adults Pediatric Seasonal Influenza $1.2 2 doses Doses $21.93 X Cost X Children < 1 yr Adult Seasonal Influenza $3.5 1 dose Cost X High Risk Adults TOTAL $6. Rubella Elimination $.43 1 dose Cost X Women (15-39 yr) New Vaccines Pre-qualified Rotavirus (Oral Vaccine) $7.2 2 doses Doses $36.33 X Cost X Cohort New Vaccines Pneumococcus $53. 4 doses Doses X Cost X Cohort HPV $12. 3 doses Doses X Cost X Cohort Hepatitis A 8. 2 doses Doses $624.33 X Cost X Cohort TOTAL $588. Current Estimated Prices; Rubella elimination listed but not included in sum total of costs Source: PAHO s Immunization Unit & the PAHO Revolving Fund

Uptake of Pentavalent Vaccine in the Americas 35 3 $7.2 31 Countries, 1.5 million Doses $8 $7 Number of Countries 25 2 15 1 4 Countries, 3.9 million Doses $3.94 $6 $5 $4 $3 $2 Price ($) 5 $1 Pan American Health Organization 1998 1999 2 21 22 23 24 25 26 27 Year Pro-Vac Workshop, September 26 Countries Purchasing Price per dose $ 22

Urban cluster of yellow fever cases in Paraguay, 28 A urban cluster of human YF cases, Asunción Metropolitan area*. 1 deaths Median of age: 24 years (11-39) Female: 55% Infestation Index by Ae. Aegypti: 23% *Laurelty, Central Department

In summary, there is no magic bullet to ensuring equitable and sustainable introduction of new vaccines into developing countries. Ultimately, the solution requires a strategic vision grounded in long-term goals, not shortterm fixes. www. paho.org/immunization Pan American Health Organization