Global Immunization Overview - WHO · Global Immunization Overview ... Vaccine supply stock outs – Supply chain management ... – Major resurgence in southern Africa after >10

Global Immunization OverviewGlobal Immunization Overview

Thomas CherianExpanded Programme on Immunization

WHO, Geneva

GHH seminar | June 15, 20112 |

Global U5 Mortality: Role of Vaccine Preventable Diseases (2008 data)

Global U5 Mortality: Role of Vaccine Preventable Diseases (2008 data)

Measles1%

Rotavirus**6%

HIV2%

Malaria8%

Perinatal33%

Other20%

Diarrhoea other9%

Pertussis2%

Hib*3%

Tetanus1%

Pneumoccocal diseases*

6%

Pneumonia other9%

8.8 million under five deaths

20% (1.7 million) from vaccine preventable diseases

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 provisional estimates based on Global Burden of Diseases estimates ** WHO/IVB estimates for 2004 based on Global Burden of Diseases estimates


Returns on investments in immunizationReturns 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.

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).

Source: Bloom & Channing 2004

Where do we stand with immunization programmes

globally


Global Immunization 1980-2009, DTP3 coverageglobal coverage at 82% in 2009

202325

3844

49525564

6875

71707073737272727374747475777980818182

0

20

40

60

80

10019

80

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

% c

over

age

Global African AmericanEastern Mediterranean European South East AsianWestern Pacific

Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 Date of slide: 13 July 2010

UCI


Countries with most unvaccinated infants DTP3, 2007-2009 (in millions) and DTP3 coverage in 2009

Countries with most unvaccinated infants DTP3, 2007-2009 (in millions) and DTP3 coverage in 2009

0 2 4 6 8 10

India

Nigeria

China

Indonesia

Pakistan

Ethiopia

Democratic Republic of the Congo

Uganda

Chad

Kenya

200920082007

Source: WHO/UNICEF coverage estimates 1980-2009, July 2010 Date of slide: 14 July 2010

66%

42%

97%

82%

85%

79%

77%

64%

23%

75%


ChallengesChallenges

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


% based on 887 reasons abstracted from 209 relevant articles

28%

7%

44%

21%

Under-vaccinated

55%

6%

12%

27%

Unvaccinated

FamilyCharacter-istics

ImmunizationSystems

ParentalAttitudesAnd Knowledge

% based on 33 reasons abstracted from 12 articles on unvaccinated children

Review of published literature: Reasons for being un-/under-vaccinated

Review of published literature: Reasons for being un-/under-vaccinated

Progress with measles control


Scaling-up 2nd Dose StrategiesScaling-up 2nd Dose Strategies

Number of doses of measles vaccine administered, by delivery strategy, 2000-2009

Measles Initiative

1st routine dose: WHO/UNICEF coverage estimates, The World Population Prospects - the 2008 revision. New York, 2009. 2nd 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)

0

50

100

150

200

250

300

350

400

450

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber o

f MC

V do

ses

(in m

illio

ns)

1st routine dose 2nd routine dose SIA


Impact of Accelerated ActivitiesImpact of Accelerated Activities

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber o

f rep

orte

d ca

ses

AFR AMR EMR EUR SEAR WPR

Number of reported measles cases by WHO Region, 2000-2009*

Number of estimated measles deaths, by WHO Region, 2000-2008

Source: Cases from annual Joint Reporting FormDeaths from Wkly Epid Rec Dec 4, 2009

*2009 case data incomplete

67% decrease

-

200,000

400,000

600,000

800,000

1,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008

Estim

ated

mea

sles

dea

ths

78% decrease

High-low bars indicate uncertainty


Expanding Measles Outbreaks in Africa, 2009-2010

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


World Health Assembly, May 2010

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

Introducing New vaccines …


50% coverage**

ADIPs focus on faster uptake for the world’s poorest children

ADIPs focus on faster uptake for the world’s poorest children

Years from availability

Million doses

0

50

100

150

200 HepB – 75 lowest income countries

Hib - 75 lowest income countries

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

33% coverage**

ESTIMATE

10% coverage**

50% coverage**


Turning a Vicious Cycle into a “Virtuous Cycle”

Turning a Vicious Cycle into a “Virtuous Cycle”

Higher pricesUncertain

demand

Limited supply

Lower pricesPredictable

demand

Increased production

capacity


Accelerating the Development and Introduction of New Vaccines: establishing, communicating, &

delivering the value of vaccination

Accelerating the Development and Introduction of New Vaccines: establishing, communicating, &

delivering the value of vaccination

Deliver value

Reliable supply of affordable vaccine and assured financing

Communicate value

Generate political will to prioritize disease prevention and vaccine introduction

Establish value

Disease burden & vaccine impact are well defined at country level

SurveillanceVaccine efficacy/safetyCost-effectiveness

Audience researchKey messagesMedia relations

Demand forecast/roll-outsFinancingTarget product profiles


Countries Using Hib containing Vaccine in National Immunization Schedule

Countries Using Hib containing Vaccine in National Immunization Schedule

Source: WHO/IVB database, 193 WHO Member States. Data as of June 2011Date of slide: 14 June 2011

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

No (13 countries or 7%)

Yes (170 countries or 88%)

Yes (Part of the country) (2 countries or 1%)

GAVI Approved not yet introduced (2 countries or 1%)GAVI Applied (6 countries or 3%)


Countries Using Pneumococcal Conjugate Vaccine in National Immunization

Schedule

Countries Using Pneumococcal Conjugate Vaccine in National Immunization

Schedule





Yes (Part of the country) (2 countries or 1%)

GAVI Approved not yet introduced (9 countries or 5%)GAVI Applied (28 countries or 15%)


Accelerating the introduction of pneumococcal vaccines

Accelerating the introduction of pneumococcal vaccines


Countries Using Rotavirus Vaccine in National Immunization Schedule

Countries Using Rotavirus Vaccine in National Immunization Schedule





GAVI Approved not yet introduced(2 countries or 1%)

GAVI Applied (6 countries or 3%)


Challenges of new vaccine introductionChallenges 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


Addressing vaccine pricingAddressing 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

GHH seminar | June 15, 201124 | 24

The Advance Market Commitment for Pneumococcal Vaccines

AM

C P

rice

per D

ose

AMC Period Tail Period

AMC subsidy

GAVIfunding

Country Co-pay ( $0.10 - $0.30 per dose initially) *

$7

$3.50

$0

Tail price cap

1stEligible Vaccine available

supplier’s share of AMC funds

depleted

10 Years2 64 8Supply Commitment

Fulfilled

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


Integrated Approaches to Disease ControlIntegrated 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

Monitoring & surveillance: the basis of well-performing

immunization programmes


Type of surveillance needs to be aligned to surveillance objectives

Type of surveillance needs to be aligned to surveillance objectives

ExampleObjectiveType

Polio, measlesDocument eradication/elimination -find all chains of transmission; certification

Country-wide, active, with lab confirmation of all cases

Syndromic surveillance, avian influenza

Routine monitoring; outbreak detection investigation

Country-wide passive, aggregate reporting, with selective investigation

Meningitis, Invasive bacterial diseases, rotavirus

Networks of sentinel sites providing representative data for the population

Sentinel site surveillance

Hepatitis B; disease incidence based on regular home visits

Obtain epidemiological informationEpidemiologic studies (detailed, labour intensive) and sero-surveys


Yes (173 countries or 90%) No (20 countries or 10%)

Countries Implementing Case-based Measles Surveillance, 2008

Countries Implementing Case-based Measles Surveillance, 2008

Source: WHO/IVB database, February 2009


Global VPD Laboratory Network, N> 700 Labs Global VPD Laboratory Network, N> 700 Labs

Polio and measles/rubella (109)Measles/rubella only (531)

Measles/rubella and yellow fever (14)Polio, Measles/rubella and yellow fever (13)

Labs/Institutes testing for:

+ 154 Sub-National Labs Polio only (23)

+ 331 (Prefecture Labs)

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 Types of sentinel surveillance

Bridging to get more comprehensive data

Facility-basedMeningitis

Facility-based;All invasive bacterial diseases

Population- based

Vaccine clinical trials (probe)

Surveillance Research


Sentinel site surveillance for Invasive Bacterial 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 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

2009 Global Surveillance Bulletins Communication: Rotavirus and Invasive Bacterial Diseases

http://www.who.int/nuvi/surveillance/

What's the future


OpportunitiesOpportunities

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


Decade of VaccinesDecade of VaccinesDecade of Vaccines

DAVOS 29 January 2010DAVOS 29 January 2010Bill and Melinda Gates Pledge $10 Bill and Melinda Gates Pledge $10 Billion in Call for Decade of Vaccines Billion in Call for Decade of Vaccines to support research, production and to support research, production and delivery of lifedelivery of life--saving vaccines to saving vaccines to children in developing countrieschildren in developing countries

World Health Assembly May 2010 World Health Assembly May 2010 ""…….Vaccines are one of the best life.Vaccines are one of the best life--saving saving buys on offer, preventing an estimated 2 to buys on offer, preventing an estimated 2 to 3 million deaths each year. WHO and 3 million deaths each year. WHO and UNICEF, in close collaboration with the UNICEF, in close collaboration with the Gates Foundation, countries, and partners, Gates Foundation, countries, and partners, are initiating a process to define the are initiating a process to define the ambitions and scope of this Decade of ambitions and scope of this Decade of Vaccines."....Vaccines."....

A shared vision and global partnership for realising the potential of vaccines and immunization


The Decade of Vaccines, 2011-2020: a comprehensive venture to advance immunization

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


DoV Work StreamsDoV 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 vaccine- preventable 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.


Proposal for Delivery GoalProposal for Delivery GoalThe 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.


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Global Immunization Overview - WHO · Global Immunization Overview ... Vaccine supply stock outs – Supply chain management ... – Major resurgence in southern Africa after >10