Country analysis

Is it is possible today?

Ana Maria Henao- Restrepo Initiative for Vaccine Research

‘Scientific’ and decision-support modelling

Scientific Decision-driven Starting point What can we find out about X? What should be done about X? eg values of transmission parameters eg should we change the EPI schedule? Tasks Fit model/predict/learn/revise + explore policy options and scenarios Inputs Scientific evidence Scientific evidence Assumptions/hypotheses + estimates, preferences/values, consensus, attitudes to risk Output Understanding of causal chains + pros and cons of options for different outcomes Inconsistencies in the data Robustness of choices to scenarios/preferences Plausibility of hypotheses Important gaps in knowledge Important gaps in knowledge

• In DS modelling, uncertainty may arise not just from imprecision of observable data, but from the effects of events yet to come, including decisions by other ‘players’. • Exploring the implications of different scenarios or ‘futures’ is thus an important part of it. Prototype DS model for exploring alternative schedules

Excel: familiar interface users can examine formulae and trace cause-effect links relatively simple to develop and amend

Graphics: users can ‘see’ the data used, and the impact of scenarios on intermediate variables eg coverage

Simplified: model outcome is not lives or cases prevented; it is cases in a pre-vaccine cohort who would have had 1, 2, 3 and 4 doses of vaccine under a given schedule. Ie any assumptions about vaccine effectiveness or herd immunity are outside the model. 2 3 4 5 14/12/2016 15:59 Setup Country Bangladesh BGD Diseases Pertussis Hib SP IPD Rotavirus Impact on Severe cases Year 2020 Schedules decision support model_v6.xlsm 5 Pert Hib IPD Rota 2 3 Data Numbers of cases aged < 5y at risk from GDB studies Age distribution by disease, from the literature Age-specific vaccine coverage: most recent survey Protection: duration Results Age distributions: Severe cases Severe cases estimated in unvaccinated populations Bangladesh DHS6: age-specific population duration in years Bangladesh: coverage of cases, doses/child by age Pert coverage 5 250,000 Burden SEAR3.50% 120% 1st dose 2.0% Hib 5 Population 5 2nd dose No doses 205,196 3.00% 1.8% IPD coverage 5 197,733 197,733Pert 197,733193,134 100% 3rd dose 200,000 1st dose Hib 197,733 Rota Booster 5 1.6% 2.50% 2nd dose IPD 205,196 80% 1.4% 3rd dose 150,000 Rota 193,134 1.2% 2.00% Booster #N/A 60% DTP1 1.0% #N/A 1.50% 100,000 0.8% DTP2 ageof % week cases per of

frequency density 40% 0.6% 1.00% DTP3 50,000 0.4% 0.50% 20% MCV 0.2% #N/A #N/A 0.0% 0 0.00% 0% 0 52 104 156 Pert Hib IPD Rota 0 50 100 150 0 52 104 156 Age in weeks age in weeks age in weeks

Scenario Age distributions and adjustments Use this scenario as baseline in SA Clears current Current schedule Proposed schedule % of 'expected' cases not covered given target coverage include target final(36m) timeliness 0% 20% 40% 60% 80% 100% Default Adjusted Add this scenario to trial set for SA with age at 36m this dose? age (wks) coverage of coverage dose 1 1st dose DTP1 (wks)6 97.3% yes 6 as DTP1 as DTP1 1 1 dose 2 dose 3

10 94.9% Pert Age specific incidence by disease 2nd dose DTP2 yes 10 as DTP2 as DTP2 2 2 boost Pert location? 0.0% 500.0 1.578 1.578 2 3rd dose DTP3 14 92.0% yes 14 as DTP3 as DTP3 3 3 3.5% Pert dose 1 shape? 0.0% 500 79.09 79.09 Booster MCV1 38 88.8% yes 39 as MCV as MCV 4 4 dose 2 Hib dose 3 500 Hib 3.0% IPD boost Hib location? 0.0% 500.0 5.00 5.00 3 Age-specific coverage with chosen schedule Rota dose 1 shape? 0.0% 500.0 6.00 6.00 100% dose 2 2.5% dose 3 500 IPD boost IPD location? 0.0% 500.0 1.56 1.56 4 2.0% Pert 80% dose 1 shape? 0.0% 500.0 37.18 37.18 coverage dose 2 Hib dose 3

500 Rota IPD 60% boost Rota location? 0.0% 500.0 4.35 4.35 1.5% 5 Rota dose 1 shape? 0.0% 500.0 11.03 11.03 1st dose 2 40% 500 No data 1.0% dose dose 3 boost location? 0.0% 500.0 #N/A #N/A #N/A 2nd dose dose 1 shape? 0.0% 500.0 #N/A #N/A 0.5% 20% 3rd dose 2 500 No data dose 3 dose boost location? 0.0% 500.0 #N/A #N/A 0.0%#N/A 0% shape? 0.0% 500.0 #N/A #N/A - 50.0 100.0 150.0 0 52 104 156 age in weeks old new 2 3 4 5 14/12/2016 15:59 Setup Country Bangladesh BGD Diseases Pertussis Hib SP IPD Rotavirus Impact on Severe cases Year 2020 Schedules decision support model_v6.xlsm 5 Pert Hib IPD Rota 2 3 Data Numbers of cases aged < 5y at risk from GDB studies Age distribution by disease, from the literature Age-specific vaccine coverage: most recent survey Protection: duration Results Age distributions: Severe cases Severe cases estimated in unvaccinated populations Bangladesh DHS6: age-specific population duration in years Bangladesh: coverage of cases, doses/child by age Pert coverage 5 250,000 Burden SEAR3.50% 120% 1st dose 2.0% Hib 5 Population 5 2nd dose No doses 205,196 3.00% 1.8% IPD coverage 5 197,733 197,733Pert 197,733193,134 100% 3rd dose 200,000 1st dose Hib 197,733 Rota Booster 5 1.6% 2.50% 2nd dose IPD 205,196 80% 1.4% 3rd dose 150,000 Rota 193,134 1.2% 2.00% Booster #N/A 60% DTP1 1.0% #N/A 1.50% 100,000 0.8% DTP2 ageof % week cases per of

frequency density 40% 0.6% 1.00% DTP3 50,000 0.4% 0.50% 20% MCV 0.2% #N/A #N/A 0.0% 0 0.00% 0% 0 52 104 156 Pert Hib IPD Rota 0 50 100 150 0 52 104 156 Age in weeks age in weeks age in weeks

Scenario Age distributions and adjustments Use this scenario as baseline in SA Clears current Current schedule Proposed schedule % of 'expected' cases not covered given target coverage include target final(36m) timeliness 0% 20% 40% 60% 80% 100% Default Adjusted Add this scenario to trial set for SA with age at 36m this dose? age (wks) coverage of coverage dose 1 1st dose DTP1 (wks)6 97.3% yes 6 as DTP1 as DTP1 1 1 dose 2 dose 3

10 94.9% Pert Age specific incidence by disease 2nd dose DTP2 yes 10 as DTP2 as DTP2 2 2 boost Pert location? 0.0% 500.0 1.578 1.578 2 3rd dose DTP3 14 92.0% yes 14 as DTP3 as DTP3 3 3 3.5% Pert dose 1 shape? 0.0% 500 79.09 79.09 Booster MCV1 38 88.8% yes 39 as MCV as MCV 4 4 dose 2 Hib dose 3 500 Hib 3.0% IPD boost Hib location? 0.0% 500.0 5.00 5.00 3 Age-specific coverage with chosen schedule Rota dose 1 shape? 0.0% 500.0 6.00 6.00 100% dose 2 2.5% dose 3 500 IPD boost IPD location? 0.0% 500.0 1.56 1.56 4 2.0% Pert 80% dose 1 shape? 0.0% 500.0 37.18 37.18 coverage dose 2 Hib dose 3

500 Rota IPD 60% boost Rota location? 0.0% 500.0 4.35 4.35 1.5% 5 Rota dose 1 shape? 0.0% 500.0 11.03 11.03 1st dose 2 40% 500 No data 1.0% dose dose 3 boost location? 0.0% 500.0 #N/A #N/A #N/A 2nd dose dose 1 shape? 0.0% 500.0 #N/A #N/A 0.5% 20% 3rd dose 2 500 No data dose 3 dose boost location? 0.0% 500.0 #N/A #N/A 0.0%#N/A 0% shape? 0.0% 500.0 #N/A #N/A - 50.0 100.0 150.0 0 52 104 156 age in weeks old new 2 3 4 5 14/12/2016 15:59 Setup Country Bangladesh BGD Diseases Pertussis Hib SP IPD Rotavirus Impact on Severe cases Year 2020 Schedules decision support model_v6.xlsm 5 Pert Hib IPD Rota 2 3 Data Numbers of cases aged < 5y at risk from GDB studies Age distribution by disease, from the literature Age-specific vaccine coverage: most recent survey Protection: duration Results Age distributions: Severe cases Severe cases estimated in unvaccinated populations Bangladesh DHS6: age-specific population duration in years Bangladesh: coverage of cases, doses/child by age Pert coverage 5 250,000 Burden SEAR3.50% 120% 1st dose 2.0% Hib 5 Population 5 2nd dose No doses 205,196 3.00% 1.8% IPD coverage 5 197,733 197,733Pert 197,733193,134 100% 3rd dose 200,000 1st dose Hib 197,733 Rota Booster 5 1.6% 2.50% 2nd dose IPD 205,196 80% 1.4% 3rd dose 150,000 Rota 193,134 1.2% 2.00% Booster #N/A 60% DTP1 1.0% #N/A 1.50% 100,000 0.8% DTP2 ageof % week cases per of

frequency density 40% 0.6% 1.00% DTP3 50,000 0.4% 0.50% 20% MCV 0.2% #N/A #N/A 0.0% 0 0.00% 0% 0 52 104 156 Pert Hib IPD Rota 0 50 100 150 0 52 104 156 Age in weeks age in weeks age in weeks

Scenario Age distributions and adjustments Use this scenario as baseline in SA Clears current Current schedule Proposed schedule % of 'expected' cases not covered given target coverage include target final(36m) timeliness 0% 20% 40% 60% 80% 100% Default Adjusted Add this scenario to trial set for SA with age at 36m this dose? age (wks) coverage of coverage dose 1 1st dose DTP1 (wks)6 97.3% yes 6 as DTP1 as DTP1 1 1 dose 2 dose 3

10 94.9% Pert Age specific incidence by disease 2nd dose DTP2 yes 10 as DTP2 as DTP2 2 2 boost Pert location? 0.0% 500.0 1.578 1.578 2 3rd dose DTP3 14 92.0% yes 14 as DTP3 as DTP3 3 3 3.5% Pert dose 1 shape? 0.0% 500 79.09 79.09 Booster MCV1 38 88.8% yes 39 as MCV as MCV 4 4 dose 2 Hib dose 3 500 Hib 3.0% IPD boost Hib location? 0.0% 500.0 5.00 5.00 3 Age-specific coverage with chosen schedule Rota dose 1 shape? 0.0% 500.0 6.00 6.00 100% dose 2 2.5% dose 3 500 IPD boost IPD location? 0.0% 500.0 1.56 1.56 4 2.0% Pert 80% dose 1 shape? 0.0% 500.0 37.18 37.18 coverage dose 2 Hib dose 3

500 Rota IPD 60% boost Rota location? 0.0% 500.0 4.35 4.35 1.5% 5 Rota dose 1 shape? 0.0% 500.0 11.03 11.03 1st dose 2 40% 500 No data 1.0% dose dose 3 boost location? 0.0% 500.0 #N/A #N/A #N/A 2nd dose dose 1 shape? 0.0% 500.0 #N/A #N/A 0.5% 20% 3rd dose 2 500 No data dose 3 dose boost location? 0.0% 500.0 #N/A #N/A 0.0%#N/A 0% shape? 0.0% 500.0 #N/A #N/A - 50.0 100.0 150.0 0 52 104 156 age in weeks old new 2 3 4 5 14/12/2016 15:59 Setup Country Bangladesh BGD Diseases Pertussis Hib SP IPD Rotavirus Impact on Severe cases Year 2020 Schedules decision support model_v6.xlsm 5 Pert Hib IPD Rota 2 3 Data Numbers of cases aged < 5y at risk from GDB studies Age distribution by disease, from the literature Age-specific vaccine coverage: most recent survey Protection: duration Results Age distributions: Severe cases Severe cases estimated in unvaccinated populations Bangladesh DHS6: age-specific population duration in years Bangladesh: coverage of cases, doses/child by age Pert coverage 5 250,000 Burden SEAR3.50% 120% 1st dose 2.0% Hib 5 Population 5 2nd dose No doses 205,196 3.00% 1.8% IPD coverage 5 197,733 197,733Pert 197,733193,134 100% 3rd dose 200,000 1st dose Hib 197,733 Rota Booster 5 1.6% 2.50% 2nd dose IPD 205,196 80% 1.4% 3rd dose 150,000 Rota 193,134 1.2% 2.00% Booster #N/A 60% DTP1 1.0% #N/A 1.50% 100,000 0.8% DTP2 ageof % week cases per of

frequency density 40% 0.6% 1.00% DTP3 50,000 0.4% 0.50% 20% MCV 0.2% #N/A #N/A 0.0% 0 0.00% 0% 0 52 104 156 Pert Hib IPD Rota 0 50 100 150 0 52 104 156 Age in weeks age in weeks age in weeks

Scenario Age distributions and adjustments Use this scenario as baseline in SA Clears current Current schedule Proposed schedule % of 'expected' cases not covered given target coverage include target final(36m) timeliness 0% 20% 40% 60% 80% 100% Default Adjusted Add this scenario to trial set for SA with age at 36m this dose? age (wks) coverage of coverage dose 1 1st dose DTP1 (wks)6 97.3% yes 6 as DTP1 as DTP1 1 1 dose 2 dose 3

10 94.9% Pert Age specific incidence by disease 2nd dose DTP2 yes 10 as DTP2 as DTP2 2 2 boost Pert location? 0.0% 500.0 1.578 1.578 2 3rd dose DTP3 14 92.0% yes 14 as DTP3 as DTP3 3 3 3.5% Pert dose 1 shape? 0.0% 500 79.09 79.09 Booster MCV1 38 88.8% yes 39 as MCV as MCV 4 4 dose 2 Hib dose 3 500 Hib 3.0% IPD boost Hib location? 0.0% 500.0 5.00 5.00 3 Age-specific coverage with chosen schedule Rota dose 1 shape? 0.0% 500.0 6.00 6.00 100% dose 2 2.5% dose 3 500 IPD boost IPD location? 0.0% 500.0 1.56 1.56 4 2.0% Pert 80% dose 1 shape? 0.0% 500.0 37.18 37.18 coverage dose 2 Hib dose 3

500 Rota IPD 60% boost Rota location? 0.0% 500.0 4.35 4.35 1.5% 5 Rota dose 1 shape? 0.0% 500.0 11.03 11.03 1st dose 2 40% 500 No data 1.0% dose dose 3 boost location? 0.0% 500.0 #N/A #N/A #N/A 2nd dose dose 1 shape? 0.0% 500.0 #N/A #N/A 0.5% 20% 3rd dose 2 500 No data dose 3 dose boost location? 0.0% 500.0 #N/A #N/A 0.0%#N/A 0% shape? 0.0% 500.0 #N/A #N/A - 50.0 100.0 150.0 0 52 104 156 age in weeks old new 2 3 4 5 14/12/2016 15:59 Setup Country Bangladesh BGD Diseases Pertussis Hib SP IPD Rotavirus Impact on Severe cases Year 2020 Schedules decision support model_v6.xlsm 5 Pert Hib IPD Rota 2 3 Data Numbers of cases aged < 5y at risk from GDB studies Age distribution by disease, from the literature Age-specific vaccine coverage: most recent survey Protection: duration Results Age distributions: Severe cases Severe cases estimated in unvaccinated populations Bangladesh DHS6: age-specific population duration in years Bangladesh: coverage of cases, doses/child by age Pert coverage 5 250,000 Burden SEAR3.50% 120% 1st dose 2.0% Hib 5 Population 5 2nd dose No doses 205,196 3.00% 1.8% IPD coverage 5 197,733 197,733Pert 197,733193,134 100% 3rd dose 200,000 1st dose Hib 197,733 Rota Booster 5 1.6% 2.50% 2nd dose IPD 205,196 80% 1.4% 3rd dose 150,000 Rota 193,134 1.2% 2.00% Booster #N/A 60% DTP1 1.0% #N/A 1.50% 100,000 0.8% DTP2 ageof % week cases per of

frequency density 40% 0.6% 1.00% DTP3 50,000 0.4% 0.50% 20% MCV 0.2% #N/A #N/A 0.0% 0 0.00% 0% 0 52 104 156 Pert Hib IPD Rota 0 50 100 150 0 52 104 156 Age in weeks age in weeks age in weeks

Scenario Age distributions and adjustments Use this scenario as baseline in SA Clears current Current schedule Proposed schedule % of 'expected' cases not covered given target coverage include target final(36m) timeliness 0% 20% 40% 60% 80% 100% Default Adjusted Add this scenario to trial set for SA with age at 36m this dose? age (wks) coverage of coverage dose 1 1st dose DTP1 (wks)6 97.3% yes 6 as DTP1 as DTP1 1 1 dose 2 dose 3

10 94.9% Pert Age specific incidence by disease 2nd dose DTP2 yes 10 as DTP2 as DTP2 2 2 boost Pert location? 0.0% 500.0 1.578 1.578 2 3rd dose DTP3 14 92.0% yes 14 as DTP3 as DTP3 3 3 3.5% Pert dose 1 shape? 0.0% 500 79.09 79.09 Booster MCV1 38 88.8% yes 39 as MCV as MCV 4 4 dose 2 Hib dose 3 500 Hib 3.0% IPD boost Hib location? 0.0% 500.0 5.00 5.00 3 Age-specific coverage with chosen schedule Rota dose 1 shape? 0.0% 500.0 6.00 6.00 100% dose 2 2.5% dose 3 500 IPD boost IPD location? 0.0% 500.0 1.56 1.56 4 2.0% Pert 80% dose 1 shape? 0.0% 500.0 37.18 37.18 coverage dose 2 Hib dose 3

500 Rota IPD 60% boost Rota location? 0.0% 500.0 4.35 4.35 1.5% 5 Rota dose 1 shape? 0.0% 500.0 11.03 11.03 1st dose 2 40% 500 No data 1.0% dose dose 3 boost location? 0.0% 500.0 #N/A #N/A #N/A 2nd dose dose 1 shape? 0.0% 500.0 #N/A #N/A 0.5% 20% 3rd dose 2 500 No data dose 3 dose boost location? 0.0% 500.0 #N/A #N/A 0.0%#N/A 0% shape? 0.0% 500.0 #N/A #N/A - 50.0 100.0 150.0 0 52 104 156 age in weeks old new COBERTURAS DE VACUNACION CON DPT EN MENORES DE 1 AÑO SEGÚN MUNICIPIO. ANTIOQUIA 2017

San Juan de Urabá 81.39%

87.2% COBERTURA TOTAL ANTIOQUIA = 93.17% Necoclí90.53%

San Pedro de Urabá 94.54%

Turbo Nechí 84.48% Caucasia 90.8% 92.79% Apartadó

Carepa Cáceres 94.19% 87.35% Chigorodó 89.4%

Tarazá Zaragoza 94.93% 78.78%

Mutatá Valdivia Segovia 82.92%

Anorí 93.7% Briceño 94.59%

90.91% Campamento Toledo 63.55% Peque Remedios 88.29% 90.63% 88.94% San Andres de Cuerquia Amalfi Yondó Sabanalarga Guadalupe Vegachí 85.71% San José de la Montaña Angostura 82.81% Cañasgordas 89.89% Murindo 81.63% Buriticá Carolina del Principe 76.67% Giraldo Santa Rosa de OsosGómez Plata Yalí 85.11% Frontino 80.74% Abriaquí 88.89% 93% Olaya 59.26% 85.71% Entrerrios Yolombó 80.32% Cisneros Maceo Vigía del Fuerte Sopetrán Don Matías Santo Domingo San Pedro de los Milagros Puerto Berrio Barbosa 87.01% San Jeronimo Concepción San Roque CopacabanaGirardota 82.61% Alejandría Bello 89.36% 85% Ebéjico San Rafael 83.93% Anzá 88.5% 89.67% Caracolí Medellín San Vicente Heliconia 90.77% El PeñolGuatapé Betulia 80% 93.48% 87.6% 82.86% Itaguí87.88% San Carlos Armenia 91.44% Granada 78.98% Concordia Angelópolis El Retiro 90.19% Titiribí Caldas 93.6% San Luis 93.64% Cocorná 83.98% Amaga La Ceja 81.15% Carmen de Viboral Venecia La Unión 79.51% 85.45% San Francisco Fredonia Montebello Ciudad Bolívar 82.35% 94.07% 87.5% 81.57% Santa Bárbara Pueblorrico78.18% 79.41% La Pintada Sonsón Betania Jericó 83.62% Argelia 70.64% Támesis 71.2% 78.06% 75% Andes Valparaíso Jardín Nariño

CONVENCIONES Fuente de Cartografía base: I Dirección de Sistemas COBERTURAS DE VACUNACION CON DPT EN MENORES de Información y Catastro - 1 cm en el mapa impreso en Carta equivale a 19,684 metros en terreno DE 1 AÑO SEGÚN MUNICIPIO. ANTIOQUIA 2017 Gobernación de Antioquia 21,000 10,500 0 21,000 42,000 2012 metros Coberturas Útiles (95% o más) 1:1,968,383

Sistema de Coordenadas Proyectadas:MAGNA Bogotá Coberturas Bajo Riesgo (94.9% a 80%) Autor Secretaria de Salud Proyección:Tranversal de Mercator Falso Este: 1 000.000 Falso Norte: 1.000.000 Fecha de Elab: 05 de Junio de 2018 Meridiano Central: -74,07750792 Factor de Escala: 1,00000000 Coberturas Alto Riesgo (79.9% a 50%) Jaime Jiménez - Jaime Zuluaga Latitud de Origen: 4,59620042 Elaboró Unidad Lineal: Metros Sistema de Coordenadas Geográficas: Bogotá MAGNA Aprobó Dr. Ricardo Castrillón Quintero Datum: Magna Sirgas Coberturas Críticas (49.9% o menos) Numeración Monthly cumulative doses of MCV by year, Accra District, Ghana

450000

400000

350000

300000

250000

Axis Title 200000

150000

100000

50000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Monthly cumulative number of MCV doses in Ghana

1200000

1000000

800000

600000 Number of doses

400000

200000

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Ghana - MCV1

Description:

2017: Estimate based on coverage reported by national government. WHO and UNICEF are aware of the 2017 EPI coverage survey and await the report. Estimate challenged by: D- 2016: Estimate based on coverage reported by national government. Ocial estimate are based on 2017 EPI coverage survey results. Estimate challenged by: D- 2015: Estimate based on coverage reported by national government. Reported ocial govern- ment coverage level based on results of 2014 DHS. Estimate challenged by: D- 2014: Estimate based on coverage reported by national government. Estimate challenged by: D- 2013: Estimate based on coverage reported by national government supported by survey. Sur- vey evidence of 89 percent based on 1 survey(s). Measles rubella vaccine introduced in September 2013. Estimate challenged by: D- 2012: Estimate based on coverage reported by national government supported by survey. Survey evidence of 90 percent based on 1 survey(s). Estimate challenged by: D- 2011: Estimate based on coverage reported by national government supported by survey. Survey evidence of 94 percent based on 1 survey(s). Estimate challenged by: D- 2010: Estimate based on coverage reported by national government supported by survey. Survey evidence of 94 percent based on 1 survey(s). Estimate challenged by: D- 2009: Estimate based on coverage reported by national government. Estimate challenged by: D- 2008: Estimate based on coverage reported by national government. Estimate challenged by: D- 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2007: Estimate based on coverage reported by national government supported by survey. Survey Estimate 85 95 86 93 93 91 88 89 92 89 89 95 evidence of 90 percent based on 1 survey(s). Estimate challenged by: D- Estimate GoC • • • • • • • • • • • • 2006: Estimate based on coverage reported by national government. Estimate challenged by: D- Ocial 85 95 86 93 93 91 88 89 92 89 89 95 Administrative 85 95 92 94 92 92 93 89 93 94 95 95 Survey NA 90 NA NA 94 94 90 89 NA NA NA NA

The WHO and UNICEF estimates of national immunization coverage (wuenic) are based on data and information that are of varying, and, in some instances, unknown quality. Beginning with the 2011 revision we describe the grade of confidence (GoC) we have in these estimates. As there is no underlying probability model upon which the estimates are based, we are unable to present classical measures of uncertainty, e.g., confidence intervals. Moreover, we have chosen not to make subjective estimates of plausibility/certainty ranges around the coverage. The GoC reflects the degree of empirical support upon which the estimates are based. It is not a judgment of the quality of data reported by national authorities.

Estimate is supported by reported data [R+], coverage recalculated with an independent denominator ••• from the World Population Prospects: 2017 revision from the UN Population Division (D+), and at least one supporting survey within 2 years [S+]. While well supported, the estimate still carries a risk of being wrong.

Estimate is supported by at least one data source; [R+], [S+], or [D+]; and no data source, [R-], [D-], or •• [S-], challenges the estimate.

There are no directly supporting data; or data from at least one source; [R-], [D-], [S-]; challenge the estimate. • In all cases these estimates should be used with caution and should be assessed in light of the objective for which they are being used.

July 7, 2018; page 7 WHO and UNICEF estimates of national immunization coverage - next revision available July 15, 2019 data received as of July 4, 2018 Number of reported measles cases, Ghana 1980 -2018 90000

80000

70000

60000

50000

40000 Number of cases

30000

20000

10000

0 198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018