Download - What's New in Immunization_
What’s new in immunization and where
do PVOs fit in?
Presented to CORE Group Meeting
by Rebecca Fields and Robert Steinglass, MCHIP
October 12, 2012
Outline of presentation
What is new in the field of immunization Findings from ARISE with particular
relevance for PVOs New vaccine introduction
Pneumonia other12% Pneumoccocal
diseases*6%
Hib*2% Pertussis
2%Tetanus
1%Measles1%
Rotavirus*5%
Diarrhoea other10%HIV
2%Malaria9%
Perinatal32%
Other18%
Global U5 Mortality: Role of Vaccine Preventable Diseases (2008 data)
8.8 million under five deaths
17% (1.5 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 estimates
The cause of 1.5 million deaths globally among children that are preventable by routine vaccination, 2008
Pneumoccocal diseases*
32%
Rotavirus*30%
Hib*13%
Pertussis13%
Measles8%
Tetanus4%
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 estimates
What’s new in immunization?
Global Vaccine Action Plan (Decade of Vaccine) Many new entrants into immunization arena Need to move from RED to REC Role for CSOs recognized (RED modules, MLM
module on partnering with communities) Mechanisms to engage CSOs (e.g. GAVI
constituency) Inequity now recognized as key challenge BMGF strategy for routine imm being designed Polio erad. declared public health emergency New vaccines exposing cracks in RI system
Source: Optimize
1. Varies by nat'l schedule; represents maximum.1980: Diphtheria, pertussis, tetanus, measles, polio and tuberculosis; 2010 add'l vx: PCV, Rota, HepB, Hib, Yellow Fever, Rubella, JE, MenA. 2. Represents maximum; 1980: 1 BCG, 3 DTP, 3 OPV, 1 measles; 2010: based on 2012 WHO immun. position papers. 3. Based on projected vol. per immun. child for 20 countries according to introduction plans; compares 2001 vol. for tradt'l vx with 2020 expected vol.; growth driven by penta, PCV, Rotavirus, HPV. 4. Based on 2008 projections. Source: WHO Bulletin, 62 (5):729 -736 (1984); Optimize Vaccine Supply Chains, Optimize (2009); State of the world’s vaccines and immunization, WHO (2009); Vaccine volume calculator, S. Kone, WHO (2011); Immunization position papers, WHO (2012). Historical analysis of cMYPs in GAVI eligible countries, L. Brenzel and C. Politi (2012)
Diseases vaccinated against1
Vaccine volume per fully immunized child (cm3)3
Immunization cost per child ($) [including
delivery costs] 4 ~6x
4x
2.5x
2010+$30+
1980s realities 2010 and beyond realities
20050
1980$5
2008$17
Increased stress on
the RI system
Age groups targeted for immunization
Vaccine doses per child (#) [assuming
receives vx listed above] 2 ~3x
System requirements continue to grow
Across life
course
Routine Immunization System
Life Cycle
Vaccination
Polio Eradication
NUVI
Measles Elimination
Support other health
interventions
Tetanus
Eliminatio
nFamily
Planning
• RED is intended to be a flexible approach
• the idea is for countries/districts to tailor it to fit their situation
• so the intensity of implementing each component will vary from country to country
The five overlapping components of the Reaching Every District (RED) approach
Planning and managementof resources
Reaching the target populations
Linking services with communities
Supportive supervision
Monitoring for action
Source: ARISE/JSI, 2012
JSI’s ARISE ProjectAfrica Routine Immunization System Essentials (funded by BMGF)
Strengthen the evidence base to improve understanding of the drivers of RI system performance and exploring investment options.
What drives routine immunization performance in Africa?Why did coverage improve in some countries? Why did coverage improve in some districts and not others? (within the same country: Ethiopia, Ghana, Cameroon)
Visit us at arise.jsi.com
ARISE Project: A pathway to improving routine immunization coverage at district level in Africa
Take vaccination into heart of the
community
More workers,
build trust, local support,
vaccine supply.
Raised awareness, improved access,
increased use
Cadre of Community-centered Health Workers
Effect
Mechanism
Transformational step
Joint planning,
awareness- raising,
Performance review, Resource pooling
Shared Shared sense of sense of
purpose & purpose & accountabiliaccountabili
ty, ty, credibilitycredibility
Ensured service
availability,
decreased dropout rates
Partnership between the Health System and the Community
Effect
Mechanism
Transformational step
Gather information
on preferences;
choose appropriate
sites for outreach,
adapt servicesPersonal links, use
appropriate avenues, trust and credibility
of health workers and
service Increased physical and
social access;
increased acceptance,
improved completion
of vaccination
schedule
Tailor Immunization Services to Community Needs
Effect
Mechanism
Transformational step
CSHGP Historic Level of Effortsby Intervention
Role of PVOs/NGOs
Engage on global immunization issues Assure immunization is a core component of all
health programs Play a role at national and sub-national levels
(Inter-agency Coordinating Committee, plans) Staff need to stay technically up-to-date Make sure immunization doesn’t get lost amid so
many other objectives/initiatives
Why does civil society (e.g., PVOs) often NOT participate in routine immunization?
Feel unwelcome on ICC Uneasy relationship with
Government/MOH Increasing demand can
betray trust, if services don’t follow
Community work not valued
Immunization is too vertical, broader objectives
Looking for financial support
“New” vaccines – new opportunities
yellow fever rubella hepatitis B HPV (human papillomavirus virus) Hib (haemophilus influenzae type b) pneumococcal (conjugate) rotavirus meningococcal A (conjugate) typhoid JE (Japanese encephalitis) oral cholera
New vaccines bring new challenges
Increase in number of vaccines (6 12 -15) Difficult age restrictions (Rotavirus vaccine) New target age groups (HPV) New messages (disease syndromes, partial
protection) Integrated approaches to disease control Cold chain and logistics challenges (volume,
waste) Cost of new vaccines
Framework: Protection, prevention and treatment strategies for pneumonia & diarrhoea
Reduce Reduce pneumonia pneumonia
and and diarrhoea diarrhoea morbidity morbidity
and and mortalitymortality
PREVENTPREVENT
PROTECTPROTECT
TREATTREAT
24
Contribution of healthy actions for pneumonia and diarrhea interventions - examples
PROTECTPROTECT PREVENTPREVENT TREATTREAT
Exclusive breastfeeding for 6 months
Vaccines against measles, pertussis, Hib , rotavirus,
and pneumococcus
Home management of dehydration (ORS and
zinc)
Adequate nutrition Vitamin A supplementation
Community Case Management (CCM)
Hand-washing with soap Prevention of HIV in children
Case management in health facilities
Community-wide sanitation promotion
Cotrimoxazole prophylaxis for HIV exposed and
infected children
Case management at hospitals
Treatment and safe storage of household
water
Zinc supplementation for children with diarrhea
Example of BCC materials, Kenya
PCV 10 Poster – Global Action Plan Against Pneumonia
Poster during “Malezi Bora” child health week (linked with Africa Vaccination Week)
Challenges and opportunities with new vaccines – role for PVOs?
Resource mobilization for new vaccine introduction
High demand for the vaccine – real danger of stock outs
Community perceptions on multiple antigen vaccinations
Communication about disease syndromes when only some is vaccine-preventable
Real opportunity to achieve MDG 4
Renewed government/ partners interest in immunization
Renewed community interest in immunization
Training opportunity for health workers
Create momentum for GAPP implementation
Challenges Opportunities
Opportunities for PVOs to engage
1) Policies and plans exist – need to strengthen communication and community involvement for pneumo and DD prevention/ implementation; develop strategies for migrant and urban populations
2) National and local media – develop partnerships for positive messaging and supportive articles/programs
3) Technical Advisory Groups – integrate case management and prevention with behavior change interventions
4) Link with initiatives (World Pneumonia Day, World Handwashing Day, 2012 Year of RI Intensification)
5) Community mobilizers in place – improve/focus their support in high risk areas (mapping, due lists, referral)
Immunization has a role to play in your portfolio:
MCH IMCI/CCM Nutrition Safe Motherhood Infectious Diseases Child Health Child Survival PHC
Vaccinated, Immunized
& Protected!
Thank You
Every child should be a VIP…
Thank you!
www.mchip.net
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Extra slides
Global Vaccine Action Plan’s strategic objectives
• All countries commit to immunization as a priority• Individuals and communities understand value of vaccines
and demand immunization as both their right and responsibility
• Benefits of immunization are equitably extended to all people
• Strong immunization systems are an integral part of a well-functioning health system
• Immunization programs have sustainable access to predictable funding, quality supply and innovative technologies
• Country, regional and global research and development innovations maximize the benefits of immunization
MCHIP immunization strategies
Increase capacity for sustainable immunization coverage with all appropriate vaccines to reach unreached and reduce child mortalitySupport effective and sustainable introduction of safe, high-quality, life-saving new vaccinesEngage in disease control priority programs with focus to enhance positive effects on strengthening RI platformInfluence global and regional levels with program learning from the field
Sustainable Routine Immunization System
Policies
PracticesFinancing
CommunityAction
Advocacy &Communications
Monitoring &
Surveillance
Supportive Supervision
Supplies &
Logistics
Training
Management
Introduction of new vaccines are challenging the immunization system• Good planning, partnership and adequate resources • Effective commitment of Government, partners and community• Good coordination between MOH and ICC partners and close follow-up for the
introduction process• Additional storage capacity to accommodate new vaccine• Increased number of vaccines at the vaccination site level• Increased immunization waste to manage and dispose• More training for health workers and community volunteers• Revised technical guidelines, recording and reporting tools, IEC materials, etc.• Good communication with parents to address concerns• Good surveillance system prior to and after NV introduction• Extra financial resources required to buy vaccines
•
National Actions
Global Actions
Program Implementation
Preparation(3-6 months before
launch)Vaccine Launch
Post-Introduction
M&E
Initiate discussion and reach consensus to introduce a vaccine
and the type of product
Conduct nationwide cold Chain storage space assessment
Update/prepare cMYP and costing tables
Ensure it is incorporated into the national health sector
plan
Develop an introduction plan
Initiate surveillance to establish baseline
Prepare and/or amend application and submit
on time
Solicit ICC endorsement and commitment for implementation
Obtain ministerial signatures on the
application to GAVI
Country re-/submits application
IRC makes a recommendation to the GAVI Board
GAVI Secretariat prioritizes
applications for approval
Upgrade cold chain
Advocate for vaccine introduction
support
Conduct registration of the vaccine, review
vaccine supply distribution system, upgrade as needed
Revise, print and distribute EPI
management tools
Develop learning materials, conduct technical training
Make improvements to
waste management system, as needed
IEC/demand creation for new
vaccine
Initiate AEFI surveillance for the NV and strengthen AEFI
reporting system
Develop communications
strategies and key messages to address caregiver/ provider
concern(s)
PR events held to launch the
vaccine
Monitor and respond to any
reported adverse events
Conduct post-introduction evaluation
assessment a year following vaccine launch
Document lessons learned
Reduced morbidity
and mortality due to the targeted vaccine
preventable disease
Asses the magnitude of the problem: morbidity and
mortality due to the target disease with the
new vaccine
Scale Up Map for New Vaccine Introduction
Conduct impact
assessment
Source: MCHIP 2011
What do some country bilaterals say about ICC and
immunization?• ICC agenda is too
narrow, confining• Important ICC
decisions made beforehand
• Their technical assistance not valued
Potential country roles for NGOs in routine immunization
• Directly immunize• Support district MOH staff (capacity
building)• Mobilize communities and create
demand• Use birth and service registers to reduce
left-outs and drop-outs• Plan and monitor with communities• Advocacy
So why does Civil Society participate on campaigns?
• High-level request• Clear role• Credit/Recognition• Funding• Supply/services assured
“But they won’t participate for the long-run.”
So why do NGOs love to participate in “Child Health”/CCM/c-IMCI?
• Credit/recognition (appreciation from communities)
• Supply assured • Clear role• Funding
Promotion of “Healthy Actions”
•Motivate individuals, households, and communities to: Adopt “healthy actions” Engage in the fight
against leading child-killers
Increase demand for health services
Identify danger signs and seek treatment
• Improve knowledge, attitudes, norms and practices
• Motivate others to use immunization and other PHC services• Arrange a clean outreach site (school, community meeting room, etc.)• Transport vaccines and health workers, particularly for outreach sessions• Inform other community members when a health worker/team arrives at the outreach site• Provide a meal to the health worker when they are on outreach visits• Register patients, control crowds and make waiting areas more comfortable on the day of a fixed or outreach session • Deliver appropriate messages, including dispelling rumours about immunization• Assist with newborn and defaulter tracking• Arrange home visits when children are behind schedule, to explain immunization and to motivate caregivers• Provide equipment and even financial support
Understanding reasons for low coverage is easier when district and health facility staff establish rapport with the community and involve community members in planning, promoting, implementing and monitoring services
Illustrative community linkages with immunization