History & Future of the Expanded Programme on Immunization Supplier Meeting, Copenhagen, 3-4 April 2008 Dr Osman David Mansoor Senior Adviser EPI (New Vaccines) UNICEF New York
The Gates Challenge If we can find approaches that meet the needs of the poor in ways that generate profits for business and votes for politicians, we will have found a sustainable way to reduce inequity in the world. This task is openended. It can never be finished. But a conscious effort to answer this challenge will change the world. Bill Gates Commencement Address Harvard University Class of 2007
Expanded from what? Smallpox eradication Globally coordinated programme under WHO leadership Last case in 1977, eradication certified in 1979 Expanded Programme on Immunization EPI launched 1974 Build on smallpox infrastructure Six diseases (four vaccines) in Traditional EPI TB, Polio, Diphtheria, Tetanus, Pertussis, Measles EPI progressively adopted by all countries Universal by early 1980s
DTP3 coverage, 1980-2006 100 % coverage 80 60 40 20 63 68 56 52 49 44 38 24 26 20 UCI 75 71 70 70 73 73 72 72 72 71 73 73 73 75 77 78 79 GAVI support 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 Global African American Eastern Mediterranean European South East Asian Western Pacific
DTP3 unvaccinated infants, 2000-2006, projection 2010* number (millions) 40 35 30 25 20 15 10 5 0 33.6 32.4 32.5 31.0 29.4 28.4 26.3 GIVS goal: At least 90% coverage in all countries! 58%? 10.85 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 African American Eastern Mediterranean European South East Asian Western Pacific Source: WHO/UNICEF coverage estimates 1980-2006, August 2007
Original EPI infant schedule Vaccine/ Birth 6 weeks 10 weeks 14 weeks 9 months Age BCG BCG OPV OPV1 OPV2 OPV3 DTP DTP1 DTP2 DTP3 Measles Measles Tet. Tox to pregnant women Up to 5 doses, 2 in first preg, 1 in each subsequent
Additions to EPI GAVI-supported vaccines, phase 1, 2000-2005 Yellow fever in 1988 for endemic countries only: 33 in Africa, 11 in S.America Given with measles vaccine Hepatitis B in 1992 In high seroprevalence (>7%) countries by 1995 In all countries by 1997 Haemophilus influenzae type b (Hib) 1998: based on disease burden and capacity 2006: all countries. (Lack of data should not be obstacle)
The impact and potential of immunization (2002 data) 5,000,000 Traditional EPI Number of deaths 4,000,000 3,000,000 2,000,000 1,000,000 Deaths Old Deaths averted New 0 1 2 3 2,500,000 2,000,000 3.3 million prevented 1.1 million to be prevented 2,500,000 2,000,000 0.5 million prevented 2,500,000 1.0 million to be prevented 2,000,000 3 million to be prevented 1,500,000 1,500,000 1,500,000 1,000,000 1,000,000 1,000,000 500,000 500,000 500,000 0 Polio Diphtheria Tetanus Pertussis Measles Polio Dipht. N.Tet Pertus. Measles 0 Influenza YF Rubella JE Hepatitis B Hib Flu YF Rub. JE HepB Hib Slide from P. Zuber, WHO 0 Pneumo Rotavirus Meningo Dengue Cholera Typhoid HPV Pneumo Rota MenA Dengue Cholera Typhoid HPV
HepB and Hib GAVI supported vaccines since 2000 Enabled poorest countries to add to EPI DTPHepB and DTPHepBHib supported by GAVI Hib still a challenge for Middle Income countries WHO and UNICEF developing strategies Affordability expected to improve with more suppliers DTPHepBHib expected to replace DTP Impact on DTP and DTPHepB demand Birth dose of HepB still needed for perinatal transmission
Countries having introduced HepB vaccine and infant HepB3 coverage, 2006 164 countries introduced in national infant immunization schedule Source: WHO/UNICEF coverage estimates 1980-2006, August 2007 Date of slide: 20 August 2007 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 2007. All rights reserved HepB3 > 80% (131 countries or 68%) HepB3 < 80% (30 countries or 15% ) HepB vaccine introduced but no coverage data reported (3 countries or 2%) HepB* vaccine not introduced (29 countries or 15%) * 4 countries introduced HepB in adolescent immunization schedule
Hib in national immunization system, 1997 & 2008 2008 116 countries introduced* 28 countries to introduce in 2008 *2 countries have introduced part of the country 1997 26 countries introduced 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 2008. All rights reserved Source: WHO/IVB database, February 2008 193 WHO Member States. Accelerated uptake: new WHO position; GAVI support to 2015 co-finance incentive; Hib initiative;?peer pressure?asia in 2009
Global coverage estimates, 1980-2006 BCG, DTP1, DTP3, Polio3, Measles HepB3 and Hib 100 90 80 % coverage 70 60 50 40 30 20 10 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 GAVI support 2000 2001 2002 2003 2004 2005 2006 BCG DTP1 DTP3 Pol3 MCV HepB3 Hib3 Source: WHO/UNICEF coverage estimates 1980-2006, August 2007 Date of slide: 20 August 2007
BCG in HIV+ BCG is not used in richer countries Highest coverage vaccine in most countries BCG does not impact on TB overall Does prevent TB meningitis and other serious in infants Recent data showing benefits <risk for HIV+ SAGE recommendation not to use in HIV+ (2007) Programmes not yet clear how to implement
Future EPI schedule { GAVI-supported vaccines } Pneumococcal conjugate vaccine (PCV) Estimated ~800,000 deaths in under-five-year-olds 3 doses in infancy > 16% reduction in deaths in Gambia* Herd immunity/ single dose if age > 12 months potential for greater impact in campaigns Rotavirus vaccine (RV) Estimated ~500,000 deaths in under-two-year-olds Data from Africa and Asia on efficacy needed Intussusception and age (>32w) Regional/Special groups MeningA, Japanese Encephalitis, Typhoid Older age groups Booster doses of DTP/Td Human Papillomavirus (HPV) *Cutts FT et al. Lancet. 2005;365:1139-46
Implications for vaccine manufacturers Pace of implementation of new EPI uncertain Especially for lower mid-income countries Demand forecasting difficult More vaccines needed Coverage increasing, booster doses More combination vaccines needed Complex choices / Transitional vaccines (eg, DTPHepB) All liquid vaccines preferred Removes a step potential for errors Simplifies storage and use Optimal number of doses per vial Balance between cold chain and wastage Will price per dose vary for new vaccines?