the expanding role of immunization in saving lives · opv3, penta3 (dpt, hep b*, hib), pcv3,...
TRANSCRIPT
The expanding role of immunization in saving lives
Asnakew Tsega
Immunization Technical officer Maternal and Child Health Integrated Program (MCHIP)
Presented at the Mini-University George Washington University Center for Global Health
14 September 2012
Outline of the presentation
Burden of vaccine preventable diseases Vaccines and the current global coverage Global initiatives Vaccine delivery strategies and challenges New vaccines introduction and challenges Required actions
The Maternal and Child Health Integrated Program (MCHIP)
USAID Bureau for Global Health’s flagship for maternal, newborn and child health program
Working in well over 40 countries worldwide MCHIP supports programming and opportunities
for integration in: Maternal, Newborn and Child Health Immunization, Family Planning, Malaria, HIV/AIDS Water/Sanitation, Urban Health, Health Systems
Strengthening
Burden of vaccine preventable diseases
Global Causes of Under-Five Deaths in 2010
Global, regional and national causes of child mortality in 2010: a systematic analysis by CHERG (published in The Lancet, 375 (9730): 1969-1987.
7.6 million deaths in children < 5 years every year (14 children every minute)
64% (4.9 million) of deaths were from infectious diseases
Pneumonia 18% 1.40 million Diarrhea 10% 0.80 million Malaria 7% 0.56 million 40% (3.1 million) of deaths occurred in neonates
PTB Complications 14% 1.08 million Intrapartum-related complications
9% 0.72 million
Sepsis or meningitis 5% 0.39 million Pneumonia 4% 0.33 million
Summary of Global Estimates in 2010
1.5 million deaths among children from vaccine preventable disease by WHO regions, 2008
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
Vaccines and the current coverage
WHO Recommended Immunization Schedule Age of Contact Vaccine
Birth BCG, OPV-0, Hep B*
6 weeks OPV1, Penta1 (DPT, Hep B*, Hib), PCV1, Rota1
10 weeks OPV2, Penta2 (DPT, Hep B*, Hib), PCV2, Rota2
14 weeks OPV3, penta3 (DPT, Hep B*, Hib), PCV3, rota3**
9 months Measles, Hep B*, YF
12-15 months Measles 2nd dose and Rubella
Adolescent girls (13 years) HPV (3 injections 4 and 12 weeks apart) *total of 3 doses with timing dependent upon local epidemiology **depending on the type of vaccine (rotarix 2 doses and rotateq 3 doses)
Typhoid, meningococcal, japanese encephalitis, mumps vaccines are also available
Source: WHO/UNICEF coverage estimates 1980-2010
Global immunization DPT3 coverage, 1980-2010
Africa SE Asia
2011: global = 83% from 85% AFR= 71% AMR= 92% EMR = 85% Europe = 94% SEAR = 75% WPR = 96%
“Developing”* countries with all districts achieving at least 80% DTP3 coverage, 2008
* 155 developing countries and economies in transition per UN World Economic & Social Survey, 2008 classification
Yes (41 countries or 26%)
No data (24 countries or 16%) (DTP3 estimated coverage for 2007 16 countries > 90%; 8 countries< 90)
No (90 countries or 58%)
Not applicable (38 countries)
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 2009. All rights reserved
Source: WHO/UNICEF estimates and WHO/IVB database, July 2009,193 WHO Member States
Source: WHO/UNICEF coverage estimates 1980-2010
Challenges facing immunization
Increase/sustain coverage (beyond 80%) and quality with existing and new vaccines across wider age groups
Sustain reduced mortality from all vaccine-preventable diseases (and eradicate polio, measles control, etc)
Assure immunization continues to work in context of integration, decentralization, and privatization
Use immunization as a platform for other population-based interventions for mothers and children (e.g. routine integrated outreach) and for building health systems
Mobilize sustained national financing
Routine Immunization System
Support other health
interventions
Global commitments and targets: Decade Of Vaccine (DOV)
Global Vaccine Action Plan (GVAP) Child Survival Call to Action
The DoV is about taking action to achieve ambitious goals
Achieve a world free
of polio
Meet global and regional
elimination targets
Develop and introduce new and improved
vaccines and technologies
Avert hundreds of millions of cases and millions of future deaths Gain billions of dollars of economic productivity
Contribute to exceeding MDG 4 target for reduction in child mortality
Meet vaccination coverage targets in
every region, country and community
The GVAP identifies measurable targets for each goal
Achieve a world free of polio
Meet global and
regional elimination
targets
Meet vaccination coverage targets in
every region, country and community
Develop and introduce new and improved vaccines and technologies
• By 2015: Interrupt wild polio virus transmission
• By 2020:Certification of poliomyelitis eradication
• By 2015: Neo-natal tetanus eliminated in all WHO regions, Measles eliminated in at least 4, Rubella in at least 2
• By 2020:Measles and rubella eliminated in 5 WHO regions
• By 2015: 80+ LICs and MICs have introduced 1+ new or underutilized vaccine to their immunization (vs 2011)
• By 2020: 90% national coverage , 80% in every district for all vaccines in immunization programmes
• By 2020: Licensure, launch of vaccine(s) against one or more major non-VPDs
• By 2020: Licensure, launch of 1+ new platform delivery technology
How do we deliver the service in developing countries?
1. Planning and management of resources Better manage human and financial resources 2. Reaching the target populations Improve access to and use of services through a mix of service delivery strategies (fixed, outreach, mobile, etc.) 3. Linking services with the community Engage with communities to ensure health services are meeting their needs 4. Supportive supervision Regular on-site teaching, feedback, and follow-up with health staff 5. Monitoring and use of data for action Promote use of data especially during review meetings, use data tools for self-monitoring (e.g. charting of doses), map population in each health facility
“Reaching Every District” RED’s Five Operational Components
Planning and management of resources
Reaching the target
populations
Linking services with communities
Supportive supervision
Monitoring for action
• Flexible approach • Countries/districts to
tailor it to fit their situation
• Use of data, human and financial resources, capacity building, improved access & use of services
• Intensity of implementing each component varies from country to country
...the five components are not mutually exclusive
“Reaching Every District” (RED) - five operational components
• Identify service delivery strategies most appropriate to the needs of eligible populations (women and <1 children)
• Develop the right mix of strategies (fixed, outreach, mobile, etc), identifying where eligible groups are located, including hard to reach, the number of eligible groups by location, the reasons (if any) why they have been underserved or why they under-utilize services, and ways in which they can be reached
• Focus on increasing access and reducing drop-out rates and missed opportunities
Reaching the target population: What does this component of RED include?
Weak infrastructure poses a major challenge to achieving immunization goals
National Actions-Decision-
application
Global Actions- approval
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
Vac
cina
te a
ll el
igib
le p
eopl
e
Conduct impact
assessment
Source: MCHIP 2011
Comprehensive approach: Protection, prevention and treatment strategies
for pneumonia & diarrhoea
Reduce pneumonia
and diarrhoea morbidity and
mortality
Children becoming ill from pneumonia or diarrhoea
Vaccines: pertussis, measles, Hib, PCV and rotavirus
Cotrimoxazole prophylaxis for HIV-infected and exposedchildren
Zinc & Vitamin A supplementation
PREVENT Children by Providing Healthy Environment
Exclusive breastfeeding for 6 months
Adequate and complete nutrition
Hand washing with soap
Safe water and sanitation
Reduce indoor air pollution
Prevent low birth weight
PROTECT
Children who are ill with pneumonia and diarrhoea
Improved care seeking and referral
Case management at the health facility and community level
Supplies: Low osmolarity ORS, Zinc, antibiotics & oxygen
Continued feeding (including breastfeeding)
TREAT
Challenges in New Vaccines Introduction
Lack of epidemiologic evidence on disease burden in most countries Which vaccines to choose?
PCV? Rota? HPV? Or all at the same time? Which product? PCV10 vs PCV13?, rotarix vs Rotateq?
Practical introduction challenges (e.g., cold chain, logistics, more waste management, training, multiple injections to child on same day)
Sustainability questions Co-financing of the new vaccines What will happen after GAVI?
Vaccines out of the current routine vaccines schedule Need for new delivery systems(e.g., schools)
Most new vaccines require a well-functioning routine immunization program.
Required Actions by MOHs and Partners
Conduct high level advocacy to national governments Support countries to improve and sustain routine immunization
coverage Provide technical and financial support for the introduction of
new vaccines Expanding the cold storage space Building the capacity of managers and service providers
Conduct operation research on vaccine preventable diseases and immunization program and take appropriate actions
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