1 |

SHAPING IMMUNIZATION

PROGRAMMES IN THE CURRENT

DECADE

Thomas Cherian

2 |

40 YEARS OF EPI: DID IT MEET

EXPECTATIONS?

Small pox eradication and the birth of EPI

3 |

0

10

20

30

40

50

60

70

80

90

100

Year

Global High-Income countries Low Income countries

Third dose coverage form DTP containing vaccines,

1980-2013, by Income

Source: WHO/UNICEF coverage estimates 2013 revision. July 2014 and Country Income Categories (World Bank)

as of July 2014 (2013 GNI per capita). Income classification not available for: Cook Islands, Niue and Nauru

Immunization Vaccines and Biologicals, (IVB), World Health Organization.

194 WHO Member States. Date of slide: 29 July 2014.

High-income

countries

Global

Low-income

countries

96%

84%

79%

4 |

Global coverage estimates, 1980-2013DTP 1 & 3, Measles 1 & 2, HepB 3, Hib3, PCV3 and Rota (last dose)

0

10

20

30

40

50

60

70

80

90

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

2010

2011

2012

2013

% c

ove

rag

e

dtp3 hepb3 hib3 mcv mcv2 mcv2x2 pcv3 pol3 rotac

Source: WHO/UNICEF coverage estimates 2013 revision. July 2014

Immunization Vaccines and Biologicals, (IVB), World Health Organization.

194 WHO Member States.

5 |

9 years4 years

6 |

Polio eradication:

the end in sight?

1988:

> 350,000 cases

> 125 endemic countries

2014:

342 cases

3 endemic countries

6 re-infected countries

0

200

400

600

800

1 000

1 200

1000s

Reduction in estimated measles deaths, 1985 - 2013

7

Source: WER 2014; in press

87% drop from

1985-2013

75% drop from

2000-2013

8 |

Impact of new vaccines: Hib meningitis in

The Gambia

Oluwalana et al J Pediatr 2013;163:S4-7

9 |

Source: http://www.kemri-wellcome.org/index.php/en/studies_inner/75

10 |

Impact of RV on diarrhoea mortality in

Mexico and Brazil

Richardson et al. NEJM 2010; 362:299; do Carmo GM et al. PLoS Med 2011; 8(4):e1001024

In Mexico and Brazil 35% and 22%

reductions in diarrhoea-related mortality,

respectively, were observed in children

under 5 years, following the introduction

of rotavirus vaccine

11 |

MenAfriVac roll-out 2010 – 2014(Early achievements 2010-2012)

No reported case of NmA among the vaccinated

12 |

"The mission of the Decade of

Vaccines is to extend, by 2020

and beyond, the full benefits of

immunization to all people,

regardless of where they are

born, who they are, or where they

live."

“We envision a world in which

all individuals and communities

enjoy lives free from vaccine-

preventable diseases".

13 |

Goals of the Global Vaccine Action Plan

14 |

Monitoring Framework

Independent review

Assessment of progress

16 |

– DTP3: All countries >90% national coverage, and >80% in every district by end 2015

– Polio: transmission stopped by end 2014

– Maternal and neonatal tetanus: eliminated by 2015

– Measles: eliminated in 4 regions by end-2015

– Rubella: eliminated in 2 regions by end-2015

– Introduction of under-utilized vaccines: At least 90 low or middle income countries to have introduced one

or more such vaccines by 2015

GVAP mid-point targets

17 |

Polio eradication

1988:

> 350,000 cases

> 125 endemic countries

2014:

342 cases

3 endemic countries

6 re-infected countries

No WPV3 cases

WPV in endemic countries– Only 6 cases in Nigeria, none

reported in past 4 months

– Increase in cases in Pakistan and Afghanistan

Spread to previously polio-free countries

– Substantial reduction in number of cases, particularly in Somalia & Syria

Insecurity and attacks of health workers

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! ! ! ! ! ! ! !! ! ! ! ! ! ! !! ! ! ! ! ! ! !! ! ! ! ! ! ! !

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<1 (86 countries or 44%)

≥1 - <5 (28 countries or 14%)

≥5 - <10 (11 countries or 6%)

≥10 - <50 (33 countries or 20%)

≥50 (15 countries or 8%)

No data reported to

WHO HQ

Not applicable

Measles Incidence Rate* 2013

*Rate per 1'000'000 population

Outbreaks represent cases

reported to WHO through end

Dec 2013 except where noted †:• DRC through 18 Feb 2014

• Pakistan through end May 2013

• Somalia through 31 Dec 2013

Data in WHO HQ as of 10 February 2014

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 2014. All

rights reserved.

Ukraine: 12,744 in 20123,308 in 2013

Somalia†: 9,983 in 20122,848 in 2013

Nigeria: 6,447 in 201255,335 in 2013

Romania: 7,452 in 20121,074 in 2013

Angola: 4,458 in 20126,505 in 2013

Dem Rep Congo†: 72,029 in 201289,108 in 2013

Ethiopia: 4,347 in 20123,982 in 2013

Pakistan†: 14,984 in 2012>25,000 in 2013

Indonesia: 15,489 in 20128,147 in 2013

Thailand: 5,197 in 20121,825 in 2013

Georgia: 31 in 20127,830 in 2013

Sudan: 8,523 in 20122,679 in 2013

India: 18,668 in 2012

China: 6,183 in 201227,825 in 2013

Turkey: 57 in 20127,371 in 2013

18(15 countries or 8%)

Reported Measles Cases in 15 Large Outbreaks since Jan 2012

19 |

20 |

Not for the first time…

21 |

ARE WE ON TRACK TO REACH OUR

COVERAGE GOALS ?

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

2010

2011

2012

2013

2014

2015

%

co

ve

rag

e

Global African American Eastern Mediterranean European South East Asian Western Pacific

Source: WHO/UNICEF coverage estimates 2012 revision. July 2013

Immunization Vaccines and Biologicals, (IVB), World Health Organization.

194 WHO Member States. Date of slide: 17 July 2013.

Global

immunization

coverage has

stagnated in past 5

years

22 |

What are the challenges and

possible solutions?

THE NEW “REALITY” OF EPI: THE CHANGING PARADIGM

Source: BMGF/WHO24

25 |

The current challenges

• Trained human resources

• Vaccine supply chains

• Information systems

Inadequate systems

• Availability

• Financing

• Pricing & procurement

Vaccine supply & price

• Unregistered & migrant populations

• Failure of integration: missed opportunities

• Conflicts and crisis

• Hesitancy and refusals

Reaching the “5th

child”

The immunization information system

INPUTS PROCESS OUTCOMES IMPACT

• Finances• Commodities• Human

resources

• Session monitoring

• Programme reviews

• EVM• Data quality &

surveillance assessments

• Immunization coverage

• Mortality & morbidity reduction

• Economic impact

1. EVM (Effective Vaccine Management) Assessments in low and lower-middle income countries Source: WHO, 2014

Efficiently managing stocks of

vaccines in the country

Sufficient storage

capacity for existing vaccines

Maintaining vaccines in the correct

temperature ranges

Respecting vaccine

management policies and

practise

Reliable distribution

and transport system up to the last mile

Best practise for

international vaccine

arrival in country

Reaching standard

Not reaching standard% of countries that reach 80% target on relevant supply chain WHO standards1

Country immunisation supply chains do not meet WHO standards

Weak immunisation supply chains systems are another bottleneck to achieving immunization goals

28 |

The future is bright if we take advantage of

opportunities

Key supply chain challenges and bottlenecks have been diagnosed

Awareness of these challenges has been raised at highest levels and importance acknowledged

Technical solutions exist and ready for widespread implementation. Leveraging thermostability of vaccines by using them in a controlled temperature

chain (CTC)

Reducing storage volume by addressing presentation and packaging

Extending the reach of the cold chain to areas with no reliable energy source with solar equipment or long lasting passive vaccine containers

Improving stock management using mobile technologies for real time track and tracing of vaccines

Global strategies and funds mobilised to address to challenges have been developed (Gavi/Gates)

Implementation framework established through the joint WHO/UNICEF Immunization Supply Chain Hub

29 |

Vaccine supply

2013 2012 2011 2010

Number of countries reporting stock-outs 39 34 35 43

% countries reporting stock-outs 43% 37% 38% 47%

Number of stock-out events 2, 3 69 56 63 74

BCG vaccine 35 30 29 38

DTP containing vaccines 10 8 11 18

Measles containing vaccines 11 7 12 7

OPV/IPV vaccines 13 11 11 11

Average number of stock-out events 3 1.8 1.7 1.8 1.7

Average duration of a stock-out event (days) 3 36.7 28.2 30.5 45.3

Source: WHO/UNICEF JRF

12th MR LabNet

Tight supply situation for measles and MR vaccines

• High demand between

June and October 2014

• Both measles and MR

vaccines supplied from

the same manufacturer

• Possible to meet

overall demand

requirements but not in

terms of timing.

MV

MR

Data from UNICEF SD as of 19/05/2014

Rota HPV

WHO vaccine schedule data (as of Dec 2013). Counted countries with introduction in entire country and part of country (# countries introduced / total countries). In November 2014, EMRO confirmed all countries have introduced Hib (e.g. Egypt and Iran. No new introductions after Dec 2013 are added to this analysis. However, new introductions are logged elsewhere.

Are Low and Middle Income Countries Lagging Behind

with Introduction of New Vaccines?

1/20/2015 31

Percent of countries with vaccine in schedule by income group (2000-2013)

Hib PCV3

UMIC

LMIC

LIC

HIC

Sustainable access to vaccines in middle income countries

0

20

40

60

80

100

2000 2002 2004 2006 2008 2010 2012 20140

20

40

60

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2000 2002 2004 2006 2008 2010 2012 2014

0

20

40

60

80

100

2000 2002 2004 2006 2008 2010 2012 2014

0

20

40

60

80

100

2000 2002 2004 2006 2008 2010 2012 2014

Percentage

Countries without Hib:LIC: NoneLMIC: Egypt, South SudanUMIC: China, Iran, and Thailand

Small UMIC lag for PCV

1. Sentinel countries chosen for deeper dive analyses include: Philippines, Egypt, Cape Verde, South Africa, Thailand, Ecuador,Indonesia and Angola selected for high absolute burden, high VPD rate, or other special characteristics

Description of need

Access to affordable vaccine supply

• Greater access to information on pricing/contracts and capacity to use this information

• Greater/easier participation in pooled procurement• More/faster entry PQ vaccines into global markets

Prioritization of national immunization financing

• Mobilization of domestic resources to cover NUVI costs, without jeopardizing other critical spending

Informed decision-making regarding new vaccine

introductions

• Effective and efficient evidence-based decision-making process

• NITAG functionality• Availability of and ability to analyze evidence

Strengthening regulatory & procurement systems

• Harmonization of regulations concerning registration of PQ vaccines

• Access to revolving funds• Capacity to issue tenders• Capacity to forecast demand

1

2

3

4

The MIC Task Force has prioritized the

following areas for action:

1/20/2015 32Sustainable access to vaccines in middle income countries

Access to vaccine price information: the V3P

project

http://www.who.int/immunization/programmes_systems/procurement/v3p/platform/AnalysesSpread/en/

~400,000 High Risk Areas identified by Polio Programme

~ 256,000 Migrant

sites

Migrant sites High risk areas in

settled population

~ 166,000 HR areas in settled

population

= 10 Migrant sites = 10 HR sites

Source: SIA coverage data

Insecurity and epidemics are affecting coverage in some

countries:# children vaccinated with DTP3 in the 3 most Ebola affected countries

MMR coverage at two and five years of age, England 1997/8-2011/12

Distribution of confirmed measles cases in England by year of birth, Q1 2013

05

10152025303540

Tailoring Immunization Programmes: Addressing Vaccine Hesitancy

39 |

Conclusions

The 40 years of EPI have seen great progress

The full potential of immunization is still untapped

The evolution of EPI has led to increasing complexity, exposing the fragility of the health systems

The last miles are the most difficult; issues are complex and solutions are not simple

The GVAP offers solutions, but implementation required a greater country ownership and the concerted effort of all stakeholders

http://www.who.int/immunization/global_vaccine_action_plan/en/

Together we can make it happen!