Adolescent Immunization as part of a Life Course Approach:

Goals and experiences

Immunization in the Context of Adolescent Health

Dubai, 22-23 Oct 2017

Paul Bloem, Expanded Programme of Immunization/IVBWorld Health Organization

Overview

• Adolescent immunization, integration and life course approach - WHO policies

• Global practise in vaccinating adolescents & integration

• A zoom on HPV vaccines

• Country Examples of Adolescent Immunisation Programmes

• Challenges and way forward

Why is adolescent vaccination important?

1. Adolescence represents a critical phase of development between childhood and adulthood

2. Adolescents (10-19) in many LMIC represent up to 25% of the population

3. The health system has very limited interaction with this age group! Vaccination can be a key opportunity

PIA meeting, Barcelona, Spain, June 22-26, 2015

PIA meeting, Barcelona, Spain, June 22-26, 2015

Member States recommending vaccinationsin 9-15 year olds by WHO region

WHORegion

Total # of MS

HPV DT-containing

TT/Td-containing

Polio-containing

MCV Other vaccines

Worldwide 194 70 14 95 26 16 31

AFRO 47 10 1 6 2 0 0

PAHO 35 15 1 26 5 2 7

EMRO 21 1 1 9 3 2 3

EURO 53 29 9 35 14 11 15

SEARO 11 1 0 5 0 1 0

WPRO 27 14 2 14 2 0 6

Source: JRF June 2015

Countries recommending vaccines for the adolescent age group(9-15 years) ,by income group

Income Total # of MS

HPV DT-containing

TT/Td-containing

Polio-containing

MCV Other vaccines

Worldwide 194 70 36% 14 95 49% 26 16 31

Low 34 5 15% 0 3 22% 0 1 0

Middle 102 26 25% 2 50 49% 16 5 10

High 55 38 70% 12 22% 40 73% 10 18% 10 18% 21 38%

Not classified 3 1 0 2 0 0 0

Source: JRF June 2015

PIA meeting, Barcelona, Spain, June 22-26, 2015

The opportunity schools provideCompulsory school age range in GAVI-eligible countries

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Compulsory starting age Compulsory ending age

Source: UNESCO Institute for Statistics, 2012

Global practice of school based vaccinationAre any routine doses of vaccine given to children at school?

2009: 166 out the 187 (89%) member countries who completed a JRF responded to this question

2016: 191 out of the 194 (97%) member countries who completed a JRF responded to this question

Source: JRF (2010, 2017)

95

96

97

98

99

100

101

2016 2009

20162009

Routine, school based vaccination

Vertical program or Comprehenisive school program?

Comprehensive schoolhealth programVaccine delivery only

Source: JRF June 2015

any age/grade

School based vaccination Country Study (2009):- More vaccination in earlier grades

HPV (2017)

HPV in demo programme.

HPV (2010) HPV (2017)

Types of Health Services Provided to School Children with Vaccination

Services:

• Deworming

• General check up (vision, hearing, growth)

• Dental

• Screening (NCDs, nutritional status)

• Education, awareness, mental health

• Curative, referral

• Nutrition (supplements, food)

• Water & sanitation and hygiene

Other services delivered through SBI

0

5

10

15

20

25

30

35

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Num

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Source: JRF June 2015

Zoom in on HPV vaccines

WHO Position paper on HPV vaccine(WER May, 2017)

(www.who.int/immunization/documents/positionpapers/en/)

•Target: girls 9-13 years of age•)

•If the interval < 5 months, give an extra dose 6 months after the first one

WHO recommandations (May,2017):Target: Girls, 9 to 14 years of ageDoses: 2 doses Interval : 6 months minimum

No maximum interval (suggesteduntil 12-15 months after first dose)

@ introduction: vaccinate multi- agecohort 9-14 years old (or up to 18yrs) Immuno depressed or ≥15 years of age:

=> 3 doses

* Includes partial introduction

Data source: WHO/IVB Database, as of 09 August 2017Map production Immunization Vaccines and Biologicals (IVB),World Health Organization

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 2017. All rights reserved.

Introduced* to date (74 countries or 38.1%)

Not Available, Not Introduced/No Plans

(120 countries or 61.9%)

Not applicable

Global Progress in HPV introduction

1. Comprehensive Cervical Cancer Prevention & Control

2.ADO LESCENT

HEALTH

Integrating HPV vaccination with adolescent health interventions and programs

• An opportunity for reaching girls and boys with additional health interventions..

Broutet et al. JAH, 2013; Hindin et al. JAH, 2015

ADOLESCENT

HEALTH

PIA meeting, Barcelona, Spain, June 22-26, 2015

Country examples of adolescent immunization

Mexico: Home-based records across the life course

Case study HPV vaccination in New ZealandIntegrating school based programmes with general practice

• All New Zealand districts offer HPV as a school based programme, as well as in general practice

• Improved connection between school based programmes and GPs – GPs now recall incompletely immunised individuals at age 14

• Reminder Poster developed for GP practices

• Change HPV from grade 7 to Grade 6 to coincide with Tdap vaccination (co-delivery)

(HPV @ 13 years)

Malaysia: HPV vaccine as part of a school health package

South Africa: Integrated school health programmes includes HPV

• New integrated school health policy launched in 2012

• Package of services is provided according to age (grouped into educational phases)

– HIV Counseling and Testing and access to contraception required enabling legislation

• School activity booklet with health messages for girls and boys is delivered with HPV

• De-worming medication to be introduced in 2016 and administered by teachers whilst nurses are vaccinating at the school

Source: Presentation by South Africa at the Global Learning Meeting on HPV vaccine introduction, November 2015

Common practice in Western Pacific Region countries(2013)

13

14

Check of vaccination status at school entry?

Yes

No

Vaccination check up @ school entry

Source: JRF 2014

Consent• For infants, presence of mother at

the clinic is implied consent

• Redefine the consent process for

vaccinating adolescents not in parents' presence

Social mobilization even more important • Inform both caregivers and adolescents (and teachers and

stakeholders…)

• Non traditional stakeholders (eg .OBGYN)

• Vaccines targeting only girls predisposes to rumours (TT, HPV)

Challenges with vaccination of adolescents

Choice of strategy (Effort and cost considerations)• Health facilities or school-based?

• Community outreaches, Campaigns (eg. Child Health days)

• Balance of cost and coverage

• Coordination with the education and other sectors

How to reach vulnerable populations?• Out-of-school (non-enrolled/absent), Institutionalized, migrant,

farming communities

Reporting and monitoring of vaccination coverage• Challenge of denominators for this new age group

• Grade based/wide age range

Challenges with vaccination of adolescents

The way forward

Ever more vaccines target adolescents and school aged children. This holds potential to develop an adolescent vaccination "platform"

Adolescent vaccination can be integrated in and reinforce school health or adolescent health

Raise awareness and improve vaccination status through School-entry screening or medical check–up's (eg 12 yr old check up)

THANK YOU