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Perspectives for Vaccines Outside High-income Countries:
From Experience at Gavi, The Vaccine AllianceMugen UJIIE M.D. M.T.M
Chief of Travel Clinic / Director of Vaccination Support Center
Disease Control and Prevention Center
National Center for Global Health and Medicine
15:30-16:10 Dec 13th, 2019
Email: [email protected]
Twitter: @carpe_diem0820
https://www.sciencemag.org/news/2017/04/here-s-visual-proof-why-vaccines-do-more-good-harm
Characteristics of Vaccine
Vaccinee can not recognize the diseases prevented with vaccines, so the effectivenss of vaccination must be scientifically evaluated and understood as knowledge.
On the other hand, an adverse event that occurred after vaccination may be evaluated as a side effect as only healthy people receive immunization for prevention.
• Vaccines are one of the greatest achievements of biomedical science and public health.
Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children -- United States, 1990-1998
Impact of immunization on the Number of Annual Cases of Disease in The USA
Vaccine Fact Book 2012, PhRMA
Immunization currently prevents 2-3 million deaths every year• Immunization prevents deaths every year in all age groups
from diseases like diphtheria, tetanus, pertussis (whooping cough), influenza and measles. It is one of the most successful and cost-effective public health interventions. An additional 1.5 million deaths could be avoided, however, if global vaccination coverage improves.
WHO Facts,Detail, Immunizationshttps://www.who.int/news-room/facts-in-pictures/detail/immunization
Gavi, The Vaccine Alliance(Gavi)
• A global partnership organization established in 2000 at the annual meeting of the World Economic Forum (Davos Conference)
• To aim at increasing the fairness of children's right to vaccination and improving the vaccine gap in the world by linking the stakeholders such as low-income countries with many children who die of preventable infectious diseases, funding countries for immunization , WHO, UNICEF, World Bank, Bill & Melinda Gates Foundation, the vaccine industry, research and technical institutions, civil society organizations, etc.
• Since 2000, Gavi's support activities have estimated that more than 760 million children have received vaccinations, and it has saved more than 13 million lives between 2000 and 2018 (Progress Report 2018).
• Japan plans to invest a total of US $ 148.5 million from 2011 to 2020
Gavi in May 2016 - April 2017:
• Senior Programme Manager, Vaccine Implementation at Gavi, the Vaccine Alliance (on Secondment), Geneva, Switzerland
• PCV Programme
The world before vaccines
Flu pandemic
1918-1920
> 50-100 million deaths worldwide
Smallpox
epidemic
INDIA
1974
15,000 deaths
Yellow fever
PHILADELPHIA
1793
>5,000 deaths
Cholera
pandemic
EUROPE
1829-1851
>200,000 deaths
Polio
NEW YORK
1916
6,000 deaths
Examples of major disease outbreaks
Smallpox1798 Rabies
1885
Typhoid1886
Cholera1896
Plague1897
Tuberculosis(Bacille Calmette-Guérin)
1927 Typhus1938
Tetanus toxoid
Pertussis1926
Diphtheriatoxoid
1923
Influenza1936
YellowFever1935
Polio (injected inactivated)(1955) Mumps, live
(1967)
Anthrax, secreted proteins (1970)
Pneumococcus polysaccharides (1977)
Hepatitis B (plasma derived) (1981)Tick-borne encephalitis (1981)
Hepatitis B surface antigen recombinant (1986)
Typhoid (salmonella Ty21a), Live (1989)
13 valent pneumococcal conjugates (2010)
Zoster, live (2006)Rotavirus (attenuated and new reassortants (2006)Human papillomavirus recombinant quadrivalent (2006)
Cold-Adapted Influenza (2003)
Rotavirus reassortants (1999)Meningococcal conjugate* (group C) (1999)
Acellar pertussis, various (1996)Hepatitis A, inactivated (1996)
Cholera, live attenuated (1994)Typhoid (Vi) polysaccharide (1994)
Japanese encephalitis, inactivated (1992)
Polio (oral live) (1963)Measles, live (1963)
Rubella, live (1969)
Meningococcal polysaccharides (1974)
Adenovirus (1980)Rabies, cell culture (1980)
H. influenza type B polysaccharide (1985)
H. influenzae conjugate* (1987)
Varicella (1995)
Cholera (recombinant Toxin B) # (1993)
Cholera (WC-rBC) (1991)
Lyme OspA, protein (1998)
Pneumococcal conjugate, heptavalent* (2000)
Japanese encephalitis (Vera-cell) (2009)Cholera (WC only) (2009)Human papillomavirus recombinant bivalent (2009)
Meningococcal quadrivalent conjugates* (2005)
Quadrivalent influenza vaccines (2012)Meningococcal C and Y and Haemophilus influenza type b (2012)
Meningococcal B (2013)Influenza vaccine (baculovirus) (2013)
Human papillomavirus, 9-valent (2014)
Enterovirus (2015)Dengue (2015)
Cu
mu
lative
nu
mb
er
of va
ccin
es
Acceleration in vaccine development
Sources: timeline as of the end of 2010: Plotkin SA, Plotkin SL. The development of vaccines: how the
past led to the future. Nature Reviews Microbiology, AOP, 2011, 1–5. 2011-2015: US Food and Drug
Administration (FDA)
50+ licensed vaccines1798–2015
Fully protecting children with vaccines
1. Bacillus Calmette Guerin (BCG) (1 dose)
2. Diphtheria (3 doses)
3. Tetanus (3 doses)
4. Pertussis (3 doses)
5. Hepatitis B (3–4 doses)
6. Hib (3 doses)
7. Pneumococcal (3 doses)
8. Polio* (OPV and/or IPV, 3–4 doses)
9. Rotavirus (2–3 doses)
10. Measles (2 doses)
11. Rubella (1 dose)
12. HPV (2 doses) (adolescent girls)
Recommended for children in all countries
About vaccines
1980
2017
Vaccines have changed our lives
Note: shows reduction in the number of reported cases. Source: WHO: Global and regional immunization profile, July 2017.
Available at: http://www.who.int/immunization/monitoring_surveillance/data/gs_gloprofile.pdf
Tetanus Diphtheria Pertussis Measles Polio
~ 90% reduction in common
vaccine-preventable
diseases
in lower-income
countries
by increasing
equitable use of
vaccines
and protecting
people’s health
Saving
children’s
lives
Gavi’s mission
Vaccine Alliance partners
IMPLEMENTING
COUNTRY
GOVERNMENTS
DONOR COUNTRY
GOVERNMENTS
CIVIL SOCIETY
ORGANISATIONS
VACCINE
MANUFACTURERS
PRIVATE
SECTOR PARTNERS
RESEARCH
AGENCIES
Why Gavi was launched: creating equal access to vaccines
• In 2000
Note: Only countries with universal national programmes are included. World Bank 2017 country classification has been applied to the whole time series.
Source: The International Vaccine Access Center (IVAC) VIMS database. Data as of 31 December 2017.
High-income countries
Low-income countries
% countries with national Hib vaccine programmes
72%
3%
100% 100%
In 2017
How Gavi supports countriesAbout Gavi
Health system strengthening
support
Tailored technical
support
Vaccine
support
About vaccines Healthy communities Closing the immunisation gap
There are currently 64 Gavi-supported countries (2017)9 countries have started fully self-financing their vaccine programmes introduced with Gavi support
DONOR CONTRIBUTIONS AND PLEDGES
• 2016–2020 donor contributions and pledges to Gavi*
• (US$ billion)
16#vaccineswork
• *Comprised of total contributions received and outstanding pledges to GAVI as of 30 June 2016. Total figures above do not include in-kind contributions.
• Source: Gavi, the Vaccine Alliance data as of 30 June 2016.
Continued
support
The Gavi business model: reinventing aid
Country
Country
Country
Country
Country
Country
Pooling demand of
poorest countries
Strengthening vaccine
delivery platforms
Long-term
funding
Donor base
Co-financing
Market shaping
Shaping
markets
Supply Demand
Accelerating
access to vaccines
Sustaining
immunisation
Transition
out of
support
Gavi’s resource mobilisation model: a three-pronged approach
US$ 330m
US$
696m
US$
1,676m
$
US$ 32m
US$ 133m
2000 2010 2016
growing
donor
contributions
1
increasing
country
co-financing
3
MORE SECURE VACCINE SUPPLY
• 2001: 5 suppliers from 5 countries of production
2001
Belgium 1
France 1
Switzerland 1
Senegal 1
Republic of Korea 1
Source: UNICEF Supply Division, 2016.
19 #vaccineswork
Republic of Korea 1
MORE SECURE VACCINE SUPPLY
2015
Senegal 1
Belgium 1
France 1
* Includes 15 Gavi suppliers and 1 manufacturers of prequalified Gavi vaccines.
** One US manufacturer also produces in the Netherlands.
Note: Country of production represents country of national regulatory agency responsible for vaccine lot release.
Netherlands 1
United States 2**
India 4
Indonesia 1
China 1
Russian Federation 1
Republic of Korea 2
Brazil 1
Sources: UNICEF Supply Division; WHO list of pre-qualified vaccines, 2016
20 #vaccineswork
• 2015: 16 manufacturers* from 11 countries of production
Accelerating access: our vaccine portfolioYear of first
introduction/
use of stockpile
PNEUMO-COCCAL
MULTIVALENT MENINGITIS
INACTIVATED POLIO
JAPANESE ENCEPHALITIS
ORAL CHOLERA
HPV (CERVICAL CANCER)
MEASLES-RUBELLAMENINGITIS A
YELLOW FEVER
HEPATITIS B
PENTAVALENT
HIB
2001 2002 2007 2008 2010 2013 2015 20172009 20142003 2004 2005 2006 2011 2012 2016 2018 2019
Gavi 1.0 Gavi 2.0 Gavi 3.0 Gavi 4.0
>430introductions
and
campaigns
since 2000EBOLA TYPHOID
MEASLES2ND DOSE
ROTAVIRUS
Affordable and sustainable vaccine prices
Cost to immunise a child
with a full course of:
Approx.
USA price:
US$ 950US$ 35(28~)
HEPATITIS B
PENTAVALENT
HIB
ROTAVIRUS
PNEUMOCOCCAL
INACTIVATED POLIO
MEASLES
RUBELLA
HPV (CERVICAL CANCER)
DTP
Available pneumococcal vaccines supported by Gavi, either WHO prequalified, or expected to be prequalified
Price/dose $ 3.50 $2.00 $3.30 $2.90 $3.05
0
20
40
60
80
100Im
mu
nis
atio
n c
ove
rag
e r
ate
(%
)
1980 1985 1990 1995 2000 2005 2010 2018
Immunisation coverage: closing the gap
.
Note: Includes DTP-containing vaccines, such as pentavalent vaccine.
Source: WHO/UNICEF Estimates of National Immunization Coverage, 2016
Expanded Programme
on Immunization takes off
Stagnating immunisation
coverageGavi support to world’s
poorest countries
High-income countries
Globalaverage
96%
86%81%
Launch of Gavi
Post-Gavi
increase
2000-2018
21% points
Lowest-income countries Gavi-supported countries
Elias Zerthouni,2019, Cell
GAVI’S CO-FINANCING POLICY•Country ownership and steps to sustainability
Gav
i/2
012
/Sal
aLe
wis
Initial self
financing
Preparatory
transition
Accelerated
transition
Fully self financing
100% of vaccine cost
variable duration variable duration 5 years 5 years(manufacturer price
commitments)
years
End of Gavi financing
Low-income country threshold
Eligibility threshold
Increasing GNI per capita
HOW THE CO-FINANCING POLICY WORKS
• Purpose: To enhance ownership and put countries on a trajectory towards financial sustainability to prepare for phasing out of Gavi support
Source: Gavi, the Vaccine Alliance, 2016
Improving health systems: key ingredients
Integrated
service
delivery
Health
service
workforce
Health
information
systems
Demand
promotion &
community
engagement
Management
&
coordination
Vaccine
supply chain
Gavi catalyses new partnerships and innovation
Immunisation cold chainVaccine innovation Data and technology
Rwanda launches world's first national drone delivery service powered by Zipline
Rwanda launches world's first national drone delivery service powered by ZiplineIn photos: how vaccines reach the most remote places on earth
Japanese company’s contribution
• Gavi, NEC, and Simprints to deploy world's first scalable child fingerprint identification solution to boost immunisation in developing countries
https://www.gavi.org/gavi-nec-and-simprints-to-deploy-world-s-first-scalable-child-fingerprint-identification-solution-to-boost-immunisation-in-developing-countries
Vaccines: saving lives and boosting economies
Reduced sickness
Improved
learning
Reduced burden
on families
Healthcare savings
Increased
productivity
Increased economic &
political stability
Healthy communities, healthy economies: Gavi’s impact
• Gavi-supported countries, 2000–2018
>760million
children immunised
keep people healthy
>13million
future deaths averted
vaccines save lives
>150 billion US$
costs averted
related to illness
stronger economies
~20countries
set to transition out of
Gavi support by 2020
sustainable future
Economic losses avoided by immunization
Vaccinations in 73 countries between 2001 and 2020 avoid more than 20 million deaths and save an estimated US $ 350 billion in illness costs.The estimated full economic and social value is USD 820 billion.
Bull World Health Organ. 2017
Pre-school
education
Community
health workers
Calculating immunisation’s return on investment
Public
infrastructur
e
Immunisatio
n
3x7x 9x 18x
(cost of illness)
48x(full income
approach)
The Economic Benefits of Public Infrastructure Spending in
Canada.
The Centre for Spatial Economics, September 2015
The rate of return to the HighScope Perry Preschool
Program.
Department of Economics, University of Chicago, April 2009
Strengthening primary health care through community health workers…
Dessalegn H, Chambers R, Clinton C, Phumaphi J, Sirleaf J, Evans T, et al. 2015
Return on investment from childhood
immunizations in low- and middle-income
countries, 2011-20.
Health Affairs. 35(2):199-207. Ozawa S, Clark S,
Portnoy A, Grewal S, Brenzel L, Walker D. 2016
• In Gavi-supported countries, 2011–2020
Estimates for vaccination’s ROI for the next decade 2021-2030: Taking into account the broader benefits of people living longer, healthier lives, the return on investment rises to US$ 54 per US$ 1 spent.
The immunisation gap
• 19.9million
are not fully protected with basicvaccines
~140
millionchildren born
every year
~80%are in Gavi-supported
countries
India
Nigeria
Pakistan
Indonesia
Other Gavi
Rest of
world
Number of children globally not receiving the third dose of DTP-containing vaccine, 2015.
Source: WHO/UNICEF Estimates of National Immunization Coverage, 2016
1 in 5 children
in Gavi-supported
countries do not get
a full course of
basic vaccines
Increase domestic
resources for immunisation
Improve data quality
Optimise supply chains
Strengthen country leadership
Shape markets
Accelerate vaccines
Gavi’s strategy for closing the gap
STRATEGIC GOALS
FOCUS AREAS: EXAMPLES
Strengthen immunisation delivery
Improve sustainability
Focus on
vaccine coverage and
overcoming inequity to
reach every child
2000–2020: ever accelerating impact
Future deaths
prevented
1 million
+4million
+3million
+5-6million
13-14
million
90 million
+280million
+200million
+300million
~900
millionChildren
immunised
2001-
2005
2006-
2010
2011-
2015
2016-
2020
Gavi’s strategic periods
2001-
2005
2006-
2010
2011-
2015
2016-
2020
Sources: Gavi strategic demand forecasts 9 and 10,
Investing together for a healthy future: the 2016–2020 investment opportunity
Kenya introduces cervical cancer vaccine nationally• APPROXIMATELY 800,000 GIRLS TO BE PROTECTED
ANNUALLY THROUGH INTRODUCTION OF HPV VACCINE INTO ROUTINE IMMUNISATION PROGRAMME
Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis
• The estimated number of patients with cervical cancer in the world in 2018 is approximately 570,000, and 311,000 people died. Estimated age-standardized incidence is 13.1 per 100,000 women worldwide, but varies widely by country, ranging from 2 to 75
Marc A, et al. LancetGlob Health 2019
• sa
New Ebola and Malaria vaccine programme
• Gavi will open a new funding window, with estimated investment of US$ 178 million between now and 2025 for the new Ebola vaccine programme.
• The Gavi Board approved US$ 11.6 million in further funding to support the RTS,S malaria vaccine implementation programme for 2021-2023.
Typhoid Conjugate Vaccine
• Pakistan became the first country in the world to introduce the World Health Organization (WHO)-recommended typhoid conjugate vaccine (TCV) into its routine immunization program.
• It is the first typhoid vaccine that can be given to children as young as 6 months of age and confers longer term protection against typhoid.
Transition from Gavi support
STAR, 22 Jan 2019Daily Trust, 17 Dec 2019
www.gavi.org
Thank you