GlobalImmunizationStrategiesProgressPotential__ThomasCherian

8/9/2019 GlobalImmunizationStrategiesProgressPotential__ThomasCherian

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Global Immunization Overview:progress and potential

(including an update on the H1N1

response)

Global Immunization Overview:progress and potential

(including an update on the H1N1

response)

Thomas CherianExpanded Programme on ImmunizationWHO, Geneva


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GOTC-CME | Charlotte June 20102 |

pneumococcus (30%)

measles (16%)

rotavirus (21%)

Hib

(15%)

pertussis (10%)tetanus (6%)

76% 24%

other (


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77

28

32

38

40

43

43

48

49

53

62

69

78

80

81

8185

0 20 40 60 80 100

IPTpformalariaChildrensleepingunderITNs

ExclusivebreastfeedingAntibioticsforpneumonia

DiarrhoeatreatmentMalariatreatment

Earlyinitiation

of

breastfeeding

ImprovedsanitationfacilitiesCareseekingforpneumonia

4+antenatalcarevisitsSkilledattendantatdeliveryComplementary

feeding

(6

9

ImproveddrinkingwaterVitaminAsupplementation(2

MeaslesimmunizationDPT3immunization

NeonataltetanusprotectionHib3immunization

Only vaccinations

reaching 80%

coverage

Interventions able

to be scheduled

routinely have highercoverage than those

needing functional

health systems and

24-hour availability

Median national coverage levels for 18 Countdown interventions and approaches, 68 priority countries,most recent estimate.

Source: WHO CAH department

Uneven Coverage Patterns Across InterventionsUneven Coverage Patterns Across Interventions


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Projected Changes in Under-5 yr mortality dueto VPDs

Projected Changes in Under-5 yr mortality dueto VPDs

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

M

illions

Preventable if coverage

is scaled up to 90%,impact of campaigns andwidespread use of new

vaccines

Not preventable by 2015

60%-70%reduction in

rate

Preventable with current pace of

progress with coverage improvements


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The Global Immunization Vision & StrategyReaching the world's children with life-saving vaccines

The Global Immunization Vision & StrategyReaching the world's children with life-saving vaccines

Four strategic areas

- Reaching more people

- Introducing new vaccines &technologies

- Synergies with otherinterventions in healthsystems context

- Global interdependence


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Progress & setbacks withthe "traditional" EPI vaccines


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Are we on track to reach our coverage goals?

Global DTP3 Coverage 1980-2008 and projections 2009-2010

0

20

40

60

80

100

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

2010

%

coverage

Global African American

Eastern Mediterranean European South East Asian

Western Pacific

Source: WHO/UNICEF coverage estimates 1980-2008, July 2009

193 WHO Member States.


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Globally, in 2008,23.5 million infants not receiving DTP3

Globally, in 2008,23.5 million infants not receiving DTP3

0 2 4 6 8 10

India

Nigeria

Pakistan

Indonesia

Democratic Republic of the Congo

Ethiopia

China

Uganda

Chad

Iraq

2008

2007

2006

Source: WHO/UNICEF coverage estimates 1980-2008, July 2009 193 WHO Member States. Date of slide: 27 July 2009


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Over 75% of unvaccinated children in India live in 7states

Unvaccinated children (in millions)

Over 75% of unvaccinated children in India live in 7states

Unvaccinated children (in millions)6.4 1.82 3.27

0.3

0.40.4

0.5

0.5

0.6

0.7

0.8

1.2

1.3

2.4

0 2 4 6 8 10 12

Sudan

Niger

Angola

Bangladesh

Philippines

DR Congo

Pakistan

Ethiopia

China

Indonesia

Nigeria

India

Bihar Uttar PradeshRest India

Source: WHO-UNICEF Estimates

WB, 5%

Orissa, 3%

Jharkhand,

5%

UP, 29%

Rest India,23%

Bihar, 16%Rajasthan,

10%

MP, 9%

India: State wise proportion ofun-immunized children


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"Global Measles Deaths Drop by 78% butResurgence likely"

"Global Measles Deaths Drop by 78% butResurgence likely"

0

200000

400000

600000

800000

1000000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

No.ofdeaths

Estimates* Projected worst case Projected status quo

Estimated number of measles deaths worldwide,20002008 and projections of possible resurgencein measles deaths worldwide, 20092013

Worst case: MCV1 level, no follow-up SIAs in 47 priority countriesStatus quo: MCV1 increases and follow-up SIAs continue, no SIAs in India

Wkly Epid Rec, 4 december 2009No. 49, 2009, 84, 505516


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Measles outbreaks in Africa 2009-10Measles outbreaks in Africa 2009-10

Outbreak reports as of June 16, 2010: Outbreaks reported in 30 African countries

Over 79,000 cases and 1127 deaths reported Major resurgence in southern Africa after > 10 years of very

low incidence as a result of intensified immunization activities

Reasons: Weak "routine" deliver and dependence on campaigns Inflated coverage estimates for campaigns

Delays in conducting campaigns due to lack of political supportand financial commitment

Cross-border spread, and religious (and other) objectors


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Introducing New vaccines

further expanding EPI


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50% coverage**

ADIPs focus on faster uptake for the worldspoorest children

ADIPs focus on faster uptake for the worldspoorest children

Years from availability

Million doses

0

50

100

150

200 HepB 75lowestincomecountries

Hib - 75lowestincomecountries

1 3 5 7 9 11 13 15 17 19 21 23

33% coverage**

ESTIMATE

10% coverage**

50% coverage**


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Turning a Vicious Cycle into a VirtuousCycle

Turning a Vicious Cycle into a VirtuousCycle

HigherpricesUncertain

demand

Limited supply

LowerpricesPredictabl

e demand

Increasedproduction

capacity


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Accelerating the Development and Introduction ofNew Vaccines: establishing, communicating, &

delivering the value of vaccination

Accelerating the Development and Introduction ofNew Vaccines: establishing, communicating, &

delivering the value of vaccination

Deliver value

Reliable supply of

affordablevaccine andassured financing

Communicate value

Generate political

will to prioritizedisease preventionand vaccineintroduction

Establish value

Disease burden &

vaccine impact arewell defined atcountry level

SurveillanceResearch

Cost-effectiveness

Audience researchKey messages

Media relations

Demand forecast/roll-outsFinancing

Target product profiles


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Countries Using Hib Vaccines in 2009and Status of GAVI Approval

Countries Using Hib Vaccines in 2009and Status of GAVI Approval

The boundaries and names shown and the designations used on this map do not imply the expression ofany opinion whatsoever on the part of the World Health Organization concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries. Dotted lines on maps represent approximate border lines for which there may not yet be fullagreement. WHO 2010. All rights reserved

No (32 countries or 16%)

Yes (154 countries or 80%)

Yes part of the country (3 countries or 2%)

GAVI approved (4 countries or 2%)

Source: WHO/IVB database, 193 WHO Member States. Data as of January 2010193 WHO Member States. Date of slide: 28 January 2010 Provisional Data

Hib Vaccine now

introduced in 157countries (81%)

Introductions in 2009:3 non-GAVI and 18GAVI-eligible

countries

GAVI applications:

4 countries approved2 countries submittedin Sept 2009


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Countries Using Pneumococcal Vaccines in 2009and Status of GAVI Approval

Countries Using Pneumococcal Vaccines in 2009and Status of GAVI Approval



Yes (32 countries or 16%)

Yes part of the country (3 countries or2%)GAVI approved (11 countries or 6%)


PCV now introduced in35 countries plus 3

partial introductions

Introductions in 2009: 2non-GAVI and 2 GAVI-eligible countries

GAVI applications:

11 countries approvedin 2008

14 countries submittedin Sep 2009


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Countries Using Rotavirus Vaccines in 2009and Status of GAVI Approval

Countries Using Rotavirus Vaccines in 2009and Status of GAVI Approval



Yes (22 countries or 11.5%)

GAVI Approved (1 country or 0.5%)


RV now introduced in 22countries

Introductions in 2009: 4non-GAVI and 1 GAVI-eligible country

GAVI applications:

1 country approved

8 countries submitted inSep 2009


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Accelerating the introduction ofpneumococcal vaccines

Accelerating the introduction ofpneumococcal vaccines


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Prevention of epidemic meningococcal meningitis inAfrica through vaccination

Prevention of epidemic meningococcal meningitis inAfrica through vaccination

African meningitis belt 2008-09 largest epidemic since 1996:80,000 cases; 5,000 deaths

Men A conjugate vaccine developed through private public

partnership with an Indian Manufacturer and available at costof $ 0.40

Vaccine licensed in India in 2010 and WHO prequalificationexpected soon

First vaccine introductions expected in 2010 in Burkina Faso,Mali and Niger

Definition of immunization strategy to induce rapid protectionand herd immunity

Single dose mass campaigns targeted at 1-29 year olds EPI schedule, follow-up campaigns in 1-4 year olds Evaluation of the effect on transmission (African

Meningococcal Carriage Consortium)


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Norms and Standards

CountryDecision-Making

Monitoring andSurveillance

Planning,Financing &Procurement

Vaccine Delivery

Children &Adolescents

Surveillance & Lab NetworksCommon Platforms

Programme performance PIEsPost-Marketing, AEFI cMYPsDemand and Supply ForecastingPooled ProcurementHealthy Vaccine Market

Delivery Systems, Equitable AccessVaccine Management

HR DevelopmentCommunicationOperational Research

Vaccine Product CharacteristicsPrequalificationNRA StrengtheningClinical Research

Policy guidelinesDataNITAGsAdvocacy

Cancer Control

Pneumoniacontrol

DiarrhoeaControl


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Sentinel site surveillance for InvasiveBacterial Diseases and Rotavirus Diarrhoea

Yes (46 Member States or 24%)Data collected from WHO Regions

Slide date: 13 November 2009

The boundaries and names shown and the designations used on this map do not implythe expression of any opinion whatsoever on the part of the World Health Organizationconcerning the legal status of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries. Dotted lines on mapsrepresent approximate border lines for which there may not yet be full agreement.WHO 2009. All rights reserved


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Formalize Rota & IBD Laboratory Networks, 2010Formalize Rota & IBD Laboratory Networks, 2010

WHO Regional Reference Laboratories

WHO Global Reference Laboratories

Global:

IBD & Rota

Regional: IBD

IBD

IBD & Rota

Rota

IBD

IBD

IBD & Rota

IBDRota

Rota

Rota

IBD


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GOTC-CME | Charlotte June 201027 |27

The Advance Market Commitment forPneumococcal Vaccines

AMC

PriceperDose

AMCPeriod Tail Period

AMC subsidy

GAVIfunding

Country Co-pay ( $0.10 - $0.30 per doseinitially) *

$7

$3.50

$0

Tail price cap

1stEligibleVaccine available

suppliers shareof AMC funds

depleted

10 Years2 64 8

Supply CommitmentFulfilled

* Co-financing levels will be in line with the applicable GAVI co-financing policy.


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Response to the H1N1pandemic..the ongoing

controversy


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Pandemic Influenza H1N1 OverviewPandemic Influenza H1N1 Overview

April 2009

First infections reported to WHO

25 April WHO declares public health emergency of international concern

End of May

Confirmed infections in >48 countries & territories

11 June

WHO declares pandemic (phase 6)

1 July

120 countries & territories with confirmed infections


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Pandemic Update(31 May 2010)

Pandemic Update(31 May 2010)

As of 30 May, worldwide more than 214 countries havereported laboratory confirmed cases of pandemic

influenza H1N1 2009, including a cumulative reported18,138 deaths.

Overall, influenza activity at low level globally The most active areas of pandemic influenza virus transmissioncurrently are in parts of the Caribbean and Southeast Asia

In temperate zones, in between seasons; sporadic detection of

H1N1 pandemic strain Among influenza strains detected in May 2010, influenza B

predominates; pandemic H1N1 still predominant influenza A strain,though H3N2 is now predominant in parts of Africa.


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Majority of cases have uncomplicated influenza illness that resolveswithout antiviral treatment

Majority of deaths caused by severe viral pneumonia

Renal failure / multiple organ failure, hypotension and shock Bacterial co-infection at presentation and nosocomial

50-80% of severe cases have underlying conditions

Varies by country and by definition of 'underlying condition' Average about 55% with underlying conditions Pregnancy, asthma or other lung disorders, cardiovascular, diabetes,

immunosuppression, neurologic disorders

Obesity may be newly recognized risk factor but needs more study

Severe cases and deaths have occurred in young and previouslyhealthy adults and less often children

Summary of clinical featuresSummary of clinical features


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Use of vaccine during the pandemicUse of vaccine during the pandemic

Made in a period of uncertainty about full impact ofpandemic and of data on vaccine effectiveness and

doses required

With the knowledge of insufficient supply for global use,but recognizing the need for global equity in vaccine

distribution

Mortality and morbidity reduction considered main goal

Recommended prioritization of health workers andgroups at high risk for mortality

P d i V i E iP d i V i E i


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Pandemic Vaccine ExperienceIndustrialized countries

Pandemic Vaccine ExperienceIndustrialized countries

More than 265 M doses distributed from September2009 through Feb 2010

Estimated 175 M doses administered

Vaccination coverage varies between less than 10% to45 % of the population

No unusual safety issues reported


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Vaccine Deployment in Developing Countries

(as of 10/6/10)

Vaccine Deployment in Developing Countries

(as of 10/6/10)

99 Countries have requestedvaccine donation and 86 have

signed letters of agreements

68 National vaccine deploymentand vaccination plans approved;10 more expected to be approved

by mid-June

34.2 million doses of vaccinedelivered to 53 countries

Planned delivery in June 10-30:32.4 million doses in 21 countries

272,000

1,933,600

8,385,800 8,139,500

12,595,000

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

January February March April May

Number of doses

Number of Countries

45

18

5

1110 10 8

4 3

9

64

97

4

1716 16

0

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

4 5

5 0

AF RO AM R O EM R O EUR O SEA R O W PRO

Countries requested donated vaccine

NDPs approved

Vaccine delivered by WHO

L l t th i tiL l t th i ti


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Lessons learnt: the communicationschallenge

Lessons learnt: the communicationschallenge

Explaining virus instability and uncertainty regarding futureevolution of the pandemic

The "pandemic" label: science, public perception and socialconsequences

Changing public perception: panic to complacence and suspicion

Fear of adverse events exceeded fear of disease over the courseof the pandemic

Targeted vaccination of risk groups led to allegations of being usedas "guinea pigs"

Anti vaccine groups and new communication channels throughinternet , blogs etc., made control of information difficult


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Lessons learnt : use of vaccineLessons learnt : use of vaccine

Decisions need to be made with limited data in hand formounting an appropriate response.

Safety, effectiveness and number of doses required Difficulty at national level to adapt pandemic preparedness plans

(One dose /2 doses, new risk groups)

Contracts with manufacturers even beforerecommendations on vaccine use were available Need for more flexible contracts with manufacturers

Importance of strengthening existing surveillance systems Global Influenza Surveillance Network; expand beyond strainmonitoring and include developing countries

V i t il bl t llV i t il bl t ll


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Vaccine was not available to allcountries at the same time

Vaccine was not available to allcountries at the same time

Introduction in high income countries preceded by morethan 4 months any introduction in developing countries

Started inSeptemberAustralia,China,

Hungary,Oman

Countries startingcampaignsin Jan/Feb 2010:

,Azerbaijan

, Iran,AfghanistanMongolia

Started in NovemberBahrain, Cyprus,Denmark, Ireland, Israel,Jordan, Kuwait,

Netherlands, Qatar,Romania, Russia, SaudiArabia, Singapore,Spain, Switzerland,Turkey, UAE

Started in OctoberAustria, Belgium, Canada,Finland, France, Germany,Japan, Mexico, Norway,

Portugal, Republic ofKoreaSwedenUnited KingdomUSA


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To summarizeTo summarize

Vaccines can and have been delivered successfully with highcoverage even in the most challenging situations

With the availability and use of newer vaccines, there is a hugepotential to make a big impact on child mortality

Opportunity to eliminate additional diseases, e.g. measles,congenital rubella & epidemic meningococcal meningitis

Significant challenges in achieving the potential of vaccines

Weak systems and financial sustainability in developing countries

Fears, suspicion, misinformation, and media hype in industrialized(and also some developing) countries (Wakefield, H1N1, PIL litigationin India)


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GOTC-CME | CharlotteJune201041 |

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