Shaping Immunization Programmes in the Current Decade

SHAPING IMMUNIZATION PROGRAMMES IN THE CURRENT DECADE

Thomas Cherian

1 | 40 YEARS OF EPI: DID IT MEET EXPECTATIONS?

Small pox eradication and the birth of EPI

2 | Third dose coverage form DTP containing vaccines, 1980-2013, by Income

100 96% 90 High-income 84% countries 80 79%

70 Global 60

40 Low-income 30 countries 20

Year

Global High-Income countries Low Income countries

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.

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

100 90 80 70 60 50 40

30 % coverage % 20 10

2004 2005 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2006 2007 2008 2009 2010 2011 2012 2013

dtp3 hepb3 hib3 mcv mcv2 mcv2x2 pcv3 pol3 rotac

Source: WHO/UNICEF| coverage estimates 2013 revision. July 2014 Immunization4 Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. 4 years 9 years

5 | Polio eradication: the end in sight?

1988: > 350,000 cases 2014: > 125 endemic countries 342 cases 3 endemic countries 6 re-infected countries

6 | Reduction in estimated measles deaths, 1985 - 2013

1 200 87% drop from

1 000 1985-2013 1000s

800 75% drop from 2000-2013 600

400

200

Source: WER 2014; in press

7 Impact of new vaccines: Hib meningitis in The Gambia

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

8 | Source: http://www.kemri-wellcome.org/index.php/en/studies_inner/75 9 | Impact of RV on diarrhoea mortality in Mexico and Brazil

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

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

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

No reported case of NmA among the vaccinated

11 | “We envision a world in which all individuals and communities enjoy lives free from vaccine- preventable diseases".

"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."

12 | Goals of the Global Vaccine Action Plan

13 | Monitoring Framework

Independent review

14 | Assessment of progress GVAP mid-point targets

– 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

16 | Polio eradication

 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 & 1988Syria: 2014: > 350,000 cases 342 cases  Insecurity> 125 endemic and attackscountries of health 3 endemic countries workers 6 re-infected countries

17 | Measles Incidence Rate* 2013 Reported Measles Cases in 15 Large Outbreaks since Jan 2012

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Ukraine: 12,744 in 2012! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Georgia: 31 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 3,308 in 2013! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 7,830 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Romania: 7,452 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 1,074 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Pakistan†: 14,984 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! >25,000 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Turkey: 57 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 7,371 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !China:! 6,183 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 27,825 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Sudan: 8,523 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 2,679 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Thailand: 5,197 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 1,825 in 2013 ! ! ! ! ! Nigeria: 6,447 in 2012 ! ! ! ! ! ! ! ! 55,335 in 2013 ! ! !

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Dem Rep Congo†: 72,029 in 2012 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 89,108 in 2013 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Ethiopia: 4,347 in 2012 Angola: 4,458 in 2012 3,982 in 2013 6,505 in 2013 Indonesia: 15,489 in 2012 <1 (86 countries or 44%) 8,147 in 2013 *Rate per 1'000'000 population ≥1 - <5 (28 countries or 14%) Outbreaks represent cases India: 18,668 in 2012 ≥5 - <10 (11 countries or 6%) reported to WHO through end ≥10 - <50 (33 countries or 20%) Somalia†: 9,983 in 2012 Dec 2013 except where noted †: ≥50 (15 countries or 8%) 2,848 in 2013 • DRC through 18 Feb 2014 18 • Pakistan through end May 2013 No data reported to (15 countries or 8%) • Somalia through 31 Dec 2013 WHO HQ The boundaries and names shown and the designations used on this map do not imply the Not applicable 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 Data in WHO HQ as of 10 February 2014 rights reserved. 19 | Not for the first time…

20 | ARE WE ON TRACK TO REACH OUR COVERAGE GOALS ?

100

60 Global 40 immunization

% coverage % coverage has 20 stagnated in past 5 years

1984 2005 1980 1981 1982 1983 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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.

21 | 22 | What are the challenges and possible solutions? THE NEW “REALITY” OF EPI: THE CHANGING PARADIGM

24 Source: BMGF/WHO The current challenges

Inadequate • Trained human resources • Vaccine supply chains systems • Information systems

Vaccine supply & • Availability • Financing price • Pricing & procurement

• Unregistered & migrant populations Reaching the “5th • Failure of integration: missed opportunities child” • Conflicts and crisis • Hesitancy and refusals

25 | The immunization information system

INPUTS PROCESS OUTCOMES IMPACT

• Finances • Session • Immunization • Mortality & • Commodities monitoring coverage morbidity • Human • Programme reduction resources reviews • Economic • EVM impact • Data quality & surveillance assessments Country immunisation supply chains do not meet WHO standards

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

Best practise Maintaining Sufficient Efficiently Reliable Respecting for vaccines in storage managing distribution vaccine international the correct capacity for stocks of and transport management vaccine temperature existing vaccines in system up to policies and arrival in ranges vaccines the country the last mile practise country

1. EVM (Effective Vaccine Management) Assessments in low and lower-middle income countries Source: WHO, 2014 Weak immunisation supply chains systems are another bottleneck to achieving immunization goals 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

28 | 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

29 | Tight supply situation for measles and MR vaccines

• High demand between MV 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. MR

Data from UNICEF SD as of 19/05/2014

12th MR LabNet Are Low and Middle Income Countries Lagging Behind with Introduction of New Vaccines?

Percent of countries with vaccine in schedule by income group (2000-2013) Hib PCV3 Percentage 100 100 80 80 60

60 Countries without Hib: 40 Small UMIC lag LIC: None for PCV 40 LMIC: Egypt, South Sudan 20 UMIC: China, Iran, and 20 Thailand 0 0 2000 2002 2004 2006 2008 2010 2012 2014 2000 2002 2004 2006 2008 2010 2012 2014 HIC Rota LIC HPV LMIC 100 100 UMIC 80 80 60 60 40 40 20 20 0 0 2000 2002 2004 2006 2008 2010 2012 2014 2000 2002 2004 2006 2008 2010 2012 2014

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.

Sustainable access to vaccines in middle income countries 1/20/2015 31 The MIC Task Force has prioritized the following areas for action:

Description of need

• Greater access to information on pricing/contracts and 1 Access to affordable vaccine capacity to use this information supply • Greater/easier participation in pooled procurement • More/faster entry PQ vaccines into global markets

Prioritization of national • Mobilization of domestic resources to cover NUVI costs, 2 immunization financing without jeopardizing other critical spending

• Effective and efficient evidence-based decision-making Informed decision-making process 3 regarding new vaccine introductions • NITAG functionality • Availability of and ability to analyze evidence • Harmonization of regulations concerning registration of PQ vaccines Strengthening regulatory & 4 • Access to revolving funds procurement systems • Capacity to issue tenders • Capacity to forecast demand 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

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

Migrant sites High risk areas in settled population

= 10 Migrant sites = 10 HR sites ~ 256,000 Migrant ~ 166,000 HR areas in settled Source: SIA sitescoverage data population 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

40 35 30 25 20 15 10 5 0 Tailoring Immunization Programmes: Addressing Vaccine Hesitancy 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

39 | Together we can make it happen!

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