Making sure Rotavirus Vaccines actually get delivered to those

who need them most

Dr. Craig Burgess, JSI Research and Training Institute Inc.Rotavirus 2018 Symposium, Minsk, 31 August, 2018

Overview1. Global trends

2. Increasing access and utilization

GRISPRED / REC principles and evolutionData issuesCommunity engagementSupply chainsMissed opportunities

3. Some thoughts for the future

Global coverage estimates, 1980-2017BCG, DTP 1st and 3rd, Measles 1st and 2nd, Rubella 1st, HepBbirth and 3rd, Hib3, Pol3, YFV, PCV3 and Rota (last dose)

Source: WHO/UNICEF coverage estimates 2017 revision, July 2018.Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of Slide: 15 July 2018.

RVV on different growth

trajectory

Rotavirus vaccine introduced in 97* member states

• Global coverage for RVV is only 28%

• Rotavirus vaccine introduction is lagging in Middle Income Countries

* Includes 6 countries with partial introductionSource: WHO/UNICEF coverage estimates 2017 revision, July 2018. Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 15 July 2018.

5

Inequities in immunization

Source: WHO Global Health Observatory / Health Equity Monitor

To improve coverage in the countries with large numbers of unvaccinated, we need to identify under-vaccinated groups and find tailored strategies to serve them

RVV do not deliver themselves!

Vaccines do not deliver themselves!

Successful, equitable introduction needs strong underlying systems: 6 building blocks + 1

Services that are:• Accessible• Available• Acceptable• Affordable• Affable

Financing

Service Delivery

Vaccines, drugs, &

commodities

Information

Human Resources

Governance

People/ Communities

Key issues with delivering RVV

1. RVV introduction may exacerbate inequities without links to:

• pro-equity health & multi sector / PHC plans; • community participation (eg. using RED / REC)

2. Timing of RVV administration is important:• First dose >15 weeks, last dose < 32 weeks• NO catch up campaigns or PIRI: only through routine delivery• HWs and parents need to know this

Global Routine Immunization Strategy & Practices

Reach Every District (RED) strategy

• Strategy to achieve the goal of 80% immunization coverage in all districts and 90% nationally in all states

• Aims to fully immunize every infant with all vaccines included in national immunization schedules

• Build national capacity to maximize access and utilization of all vaccines, old and new

5 operational components:1. Re-establish outreach services2. Supportive supervision3. Linking services with communities4. Monitoring and use of data for action5. Planning and management of

resources

RED traditionally helps identify & prioritize underperforming districts

Low drop out(<10%)

High dropout(>10%)

High Coverage with DPT1

Low dropout(<10%)

High dropout(>10%)

Low coverage with DPT1

Access to immunisation services

Interpretation

Category 1Good accessGood utilization.

Category 2Good accessPoor utilization.

Category 3Poor accessGood utilization.

Category 4Poor accessPoor utilization.

Shift to identify & prioritize under served communities

1. Fragile: displaced or living with conflict or natural disasters

2. Urban poor:either living in slums or integrated

3. Rural remote / poor

Tailored strategies addressing social barriers, life course, more integrated & increasing use of NGOs / private sector to deliver

Equity Assessment: identify & prioritize High Risk populations at province, district and health facility levels. Better understand the social barriers to access and utilization

Map and list of static and outreach RI service delivery points

Convene groups who know the geography and populations,

Assign villages to service delivery points

Draft micro-map and plan: HF staff and Village Teams discuss and draft schedule for location, date, and times of RI services.

Identify and map all communities affected by inequities

Examples from Uganda and Cambodia

Delivery strategiesType Definition Areas served Av. frequency

Fixed Delivery of services ina Health Facility (HF)

Serves community within easy access to the

Health Facility

Twice a week or everyday

Outreach Delivery of services in an 'outreach site'

Area around the HF that the staff can visit in one

day

Once a month or once in

two/three months

Mobile teams

Delivery of services beyond the 'outreach

area'

Areas, not possible to cover in one day,

requires overnight stay

Once in 4-6 months –

challenge for timely RVV

delivery

X km

10 km

5 km

Fixed strategy

Outreach strategy

Mobile strategy

Health Center

Pop 500

Pop 221

Pop 654

Pop 1125

Pop 688

Pop 211

Pop 400

Pop 339

Pop 99

Pop 675

Pop 1898

Pop 312

Pop 89

Pop 187

Data issuesBalance use of real / admin / survey data

Political incentives to over-report numerator

Denominator accuracy

Higher coverage estimates are more sensitive to errors in target population estimates. Example of 10% error:

Community engagementGiving voice to the ultimate customer

Joint responsibility to plan, promote and implement services to increase accountability, appropriateness, quality and sustainability of services.

Community Engagement is not just…

Communication Demand Generation Top-Down Planning One way activities

But a shift towards… Community Conversations Intersection of Supply and

Demand Partnering A dialogue

Community engagementChallenges Illustrative examples

Unclear rolesDistrust (especially vulnerable popns.)Not monitored and not remuneratedAccountabilityRepresentation (power dynamics)Quasi-legal nature of some communities

Strategic communication: interpersonal, advocacy, dispel rumoursContribute: outreach planning food, transport, crowd controlCommunity meetingsPeer educationIdentify community mobilizers announcing servicesAnalysis left outs and drop outsCase detection

Logistics & supply chains, distribution capacity

~4x ~6x

~5x ~2x

Growing volume (cm³) to vaccinate per child

Increasing number of doses

2010 2020 Introduction of more expensive vaccines

Increase in stock keeping units

Note: All figures relate to GAVI-funded vaccines1. UNICEF Supply 2012 Financial report, WHO data for Pneumo and Rota vaccines, and HPV (only for girls); 2. 2010: GAVI Shipment Data; 2020; GAVI SDF Forecast; Including volume for GAVI future graduated countries; 3. Comparison based on 2013 Price; 2020 Vaccines include: Rota, Pneumo; HPV; 2010' vaccines include:YF, Measles, DPT, OPV (UNICEF SD); 4. GAVI Background SDF Information; 2010": estimates based on 2009 data; 2020: estimates based on 2013 forecast

2010 2020

Source: Gavi Immunization Supply Chain Strategy, developed 2015

Missed opportunities for vaccination (MoV)Estimated global prevalence of MoV = 32%

“Any contact with a health service that did not result in an eligible child or woman receiving a needed vaccine”

Source: Sodha and Dietz et. Al. and WHO

Causes: vaccine stock-outs, lack of integration, concern about wastage or multiple injections, health care workers’ misunderstandings about vaccine contraindications, lack of vaccine cards, transport or cold chain failure, staff absences

MoV training in Kinshasa -West (Dec 2017) ledto in number of DTP3 doses

5,089 additional doses in 2018, compared to same period in 2017

Source- initial WHO research Kinshasa West 2017-2018 post MoV training

2030 SDGs and GVAP 2.0: Partnerships, UHC / PHC, life cycle approaches, integration (Supply chains, inter-sector & inter-program)

The future

$ Domestic resource allocation: national priority setting and affordability; increasing need for political commitment

UHC 3 dimensions: i) essential health packages, ii) funding decisions and iii) scaling up access

Equity: Tailor RED / REC approaches for fragile, urban / rural poor communities, engage civil society (demand, accountability & appropriate services), MoV, # dose per vial, TSE, technology.

Thank you

Acknowledgements: Robert Steinglass and Wendy Prosser (JSI), Jan Grevendonk, Marta Gacic-Dono, Ike Udo (WHO), RAVIN partnership (IVAC, CDC, BMGF, JSI)

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References used for equity and coverage

Resources to use 1. Reaching Every District (RED) - A guide to increasing coverage and equity in all communities in the African Region https://www.afro.who.int/publications/reaching-every-district-red-guide-increasing-coverage-and-equity-all-communities2. Country decision making: introducing a new vaccine: http://www.who.int/immunization/programmes_systems/policies_strategies/decision_making/en/3. Missed Opportunities for Vaccination (MOV) Strategy http://www.who.int/immunization/programmes_systems/policies_strategies/MOV/en/4. Establishing and strengthening immunization in the second year of life: Practices for immunization beyond infancy http://www.who.int/immunization/documents/WHO_IVB_ISBN9789241513678/en/5. Reaching Every District strategy (WHO) http://www.who.int/immunization/programmes_systems/service_delivery/red/en/6. WHO principles and considerations when adding a new vaccine http://apps.who.int/iris/bitstream/10665/111548/1/9789241506892_eng.pdf?ua=17. Bottleneck and breakthroughs: lessons learned from new vaccine introductions in low-resource countries 2008-2013 (USAID / MCHIP) – table 7 pages 35-36http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=15580&lid=3 8. WHO SAGE, April 2012, review of NVI on health systemshttp://www.who.int/immunization/sage/meetings/2012/april/presentations_background_docs/en/ 9. Scale up map for new vaccine introduction (JSI / MCHIP / USAID) http://www.mchip.net/files/mchip-event-documents/230348766-Scale-Up-Map-for-New-Vaccine-Introduction-in-GAVI-Supported-Countries-1.pdf 10. Explorations of inequality. Childhood immunization http://www.who.int/gho/health_equity/report_2018_immunization/en11. Global Routine Immunization Strategies and Practices (GRISP) http://www.who.int/immunization/programmes_systems/policies_strategies/GRISP/en/