Global Immunization Overview: Progress and Potential

Global Immunization Overview:
progress and potential

(including an update on the H1N1
response)
Thomas Cherian
Expanded Programme on Immunization
WHO, Geneva
About a quarter of under-5 deaths globally
(Estimated annual childhood deaths, 2004)
Meningococcus A (< 1%)

rotavirus (21%)
pneumococcus (30%)
76% 24% measles (16%)

Hib (15%)
pertussis (10%)
tetanus (6%)
other (<1%)
10.4 million deaths under 5 years of age

2.45 million or 24% deaths under 5 from vaccine preventable diseases
•1.16 million deaths under 5 years of age from diseases targeted by conventional EPI
vaccines
•1.29 million from diseases where licensed vaccine is available
2| GOTC-CME | Charlotte June 2010

Uneven Coverage Patterns Across Interventions
Hib3 immunization 85
Neonatal tetanus protection 81
DPT3 immunization 81
 Only vaccinations
Measles immunization 80
Vitamin A supplementation (2 78 reaching 80%
Improved drinking water 69 coverage
Complementary feeding (6‐9 62
Skilled attendant at delivery 53
4+ antenatal care visits 49 Interventions able
Careseeking for pneumonia 48 to be scheduled
Improved sanitation facilities 43
routinely have higher
Early initiation of breastfeeding 43
Malaria treatment 40 coverage than those
Diarrhoea treatment 38 needing functional
Antibiotics for pneumonia 32
health systems and
Exclusive breastfeeding 28
Children sleeping under ITNs 7 24-hour availability
IPTp for malaria 7
0 20 40 60 80 100
Median national coverage levels for 18 Countdown interventions and approaches, 68 priority countries,
most recent estimate.
Source: WHO CAH

| GOTC-CME department
| Charlotte June 2010
3
Projected Changes in Under-5 yr mortality due
to VPDs
Preventable with current pace of
progress with coverage improvements
3.0
M illio n s
2.5 Preventable if coverage

is scaled up to 90%, 60%-70%
2.0
impact of campaigns and reduction in
rate
1.5 widespread use of new
vaccines
1.0
0.5
Not preventable by 2015
0.0
15
12
13
14
02
03
04
08
09
10
11
05
06
07
00
01
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20

The Global Immunization Vision & Strategy
Reaching the world's children with life-saving vaccines
Four strategic areas
- Reaching more people

- Introducing new vaccines &
technologies
- Synergies with other
interventions in health
systems context
- Global interdependence …

Progress & setbacks… with
the "traditional" EPI vaccines
Are we on track to reach our coverage goals?
Global DTP3 Coverage 1980-2008 and projections 2009-2010
100
80
% coverage
60
40
20
0
1980
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
Global African American
Eastern Mediterranean European South East Asian
Western Pacific
Source: WHO/UNICEF coverage estimates 1980-2008, July 2009

193 WHO Member States.

Globally, in 2008,
23.5 million infants not receiving DTP3
0 2 4 6 8 10
India
Nigeria
Pakistan
Indonesia
Democratic Republic of the Congo
Ethiopia
China
2008
Uganda
2007
Chad
2006
Iraq
Source: WHO/UNICEF coverage estimates 1980-2008, July 2009 193 WHO Member States. Date of slide: 27 July 2009

Over 75% of unvaccinated children in India live in 7
states
Unvaccinated children (in millions)
India 6.4 1.82 3.27
Rest India Bihar Uttar Pradesh

Nigeria 2.4
Indonesia 1.3 Bihar, 16%
Rajasthan,
China 1.2 10%
Ethiopia 0.8 MP, 9%

UP, 29%
Pakistan 0.7
WB, 5%
DR Congo 0.6 Jharkhand,
Philippines 0.5 5%
Rest India,
23%
Bangladesh 0.5 Orissa, 3%
Angola 0.4
Niger 0.4 India: State wise proportion of
un-immunized children
Sudan 0.3
0
Source: WHO-UNICEF Estimates 2 4 6 8 10 12

"Global Measles Deaths Drop by 78% but
Resurgence likely"
1000000
Estimated number of measles deaths worldwide,
2000–2008 and projections of possible resurgence
800000 in measles deaths worldwide, 2009–2013
No. of deaths
600000
400000
200000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
Estimates* Projected worst case† Projected status quo†
Worst case: MCV1 level, no follow-up SIAs in 47 priority countries

Status quo: MCV1 increases and follow-up SIAs continue, no SIAs in India
Wkly Epid Rec, 4 december 2009

12 | GOTC-CME | Charlotte June 2010
No. 49, 2009, 84, 505–516
Measles outbreaks in Africa 2009-10
 Outbreak reports as of June 16, 2010:

– Outbreaks reported in 30 African countries
– Over 79,000 cases and 1127 deaths reported
– Major resurgence in southern Africa after > 10 years of very
low incidence as a result of intensified immunization activities
 Reasons:
– Weak "routine" deliver and dependence on campaigns
– Inflated coverage estimates for campaigns
– Delays in conducting campaigns due to lack of political support
and financial commitment
– Cross-border spread, and religious (and other) objectors

Introducing New vaccines
…further expanding EPI
ADIPs focus on faster uptake for the world’s
poorest children
ESTIMATE
Million doses
200 HepB – 75
lowest
50% coverage** income
150
50% coverage**
countries
33% coverage**
100
50 Hib - 75
10% coverage** lowest
income
0 countries
1 3 5 7 9 11 13 15 17 19 21 23
15 | GOTC-CME | Charlotte June 2010 Years from availability

Turning a Vicious Cycle into a “Virtuous
Cycle”
Limited supply
Increased
production
Higher
Uncertain prices capacity
demand
Lower
Predictabl
prices
e demand

Accelerating the Development and Introduction of
New Vaccines: establishing, communicating, &
delivering the value of vaccination
Establish value Communicate value Deliver value
Surveillance Audience research Demand forecast/roll-outs

Research Key messages Financing
Cost-effectiveness Media relations Target product profiles
Disease burden & Generate political Reliable supply of

vaccine impact are will to prioritize affordable
well defined at disease prevention vaccine and
country level and vaccine assured financing
introduction

Countries Using Hib Vaccines in 2009
and Status of GAVI Approval
 Hib Vaccine now

introduced in 157
countries (81%)
 Introductions in 2009:
3 non-GAVI and 18
GAVI-eligible
countries
 GAVI applications:
4 countries approved
Yes (154 countries or 80%)
2 countries submitted Yes part of the country (3 countries or 2%)
in Sept 2009 GAVI approved (4 countries or 2%)
No (32 countries or 16%)
Source: WHO/IVB database, 193 WHO Member States. Data as of January 2010
The boundaries and names shown and the designations used on this map do not imply the expression of
193 WHO Member States. Date of slide: 28 January 2010 – Provisional Data 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 2010. All rights reserved
Countries Using Pneumococcal Vaccines in 2009
 PCV now introduced in

35 countries – plus 3
partial introductions
 Introductions in 2009: 2
non-GAVI and 2 GAVI-
eligible countries
11 countries approved
in 2008
14 countries submitted Yes (32 countries or 16%)
in Sep 2009 Yes part of the country (3 countries or
2%)
GAVI approved (11 countries or 6%)
The boundaries and names shown and the designations used on this map do not imply the expression of
193 WHO Member States. Date of slide: 28 January 2010 – Provisional Data any opinion whatsoever on the part of the World Health Organization concerning the legal status of any

boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
Countries Using Rotavirus Vaccines in 2009
 RV now introduced in 22
countries
 Introductions in 2009: 4
non-GAVI and 1 GAVI-
eligible country
1 country approved
8 countries submitted in
Sep 2009
Yes (22 countries or 11.5%)
GAVI Approved (1 country or 0.5%)
193 WHO Member States. Date of slide: 28 January 2010 – Provisional Data 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
20 | GOTC-CME | Charlotte June 2010 boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
Accelerating the introduction of
pneumococcal vaccines

Prevention of epidemic meningococcal meningitis in
Africa through vaccination
 African meningitis belt 2008-09 largest epidemic since 1996:
80,000 cases; 5,000 deaths
 Men A conjugate vaccine developed through private public
partnership with an Indian Manufacturer and available at cost
of $ 0.40
 Vaccine licensed in India in 2010 and WHO prequalification
expected soon
 First vaccine introductions expected in 2010 in Burkina Faso,
Mali and Niger
 Definition of immunization strategy to induce rapid protection
and herd immunity
– Single dose mass campaigns targeted at 1-29 year olds
– EPI schedule, follow-up campaigns in 1-4 year olds
– Evaluation of the effect on transmission (African
Meningococcal Carriage Consortium)

Vaccine Product Characteristics
Prequalification
Norms and Standards NRA Strengthening
Clinical Research
Policy guidelines
Country Data
NITAGs
Decision-Making Advocacy
Monitoring and
Cancer Control
Surveillance
Planning,
Children & Financing &
Surveillance & Lab Networks
Common Platforms Adolescents Procurement
Programme performance PIEs
Post-Marketing, AEFI cMYPs
Demand and Supply Forecasting
Pooled Procurement
Healthy Vaccine Market
Vaccine Delivery
Diarrhoea Pneumonia
Control Delivery Systems, Equitable Access
control
Vaccine Management
HR Development
Communication
Operational Research
Sentinel site surveillance for Invasive
Bacterial Diseases and Rotavirus Diarrhoea
Yes (46 Member States or 24%)

Data collected from WHO Regions
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.
Slide date: 13 November 2009 ©WHO 2009. All rights reserved
Formalize Rota & IBD Laboratory Networks, 2010
IBD
Global: Rota
IBD & Rota

Regional: IBD Rota
IBD & Rota
IBD
Rota IBD
IBD
IBD
Rota
IBD & Rota
WHO Global Reference Laboratories

WHO Regional Reference Laboratories

The Advance Market Commitment for
Pneumococcal Vaccines
$7
AMC subsidy
AMC Price per Dose
Tail price cap

$3.50
GAVI Country Co-pay ( $0.10 - $0.30 per dose

funding initially) *
$0
2 4 6 8 10 Years
supplier’s share Supply Commitment
1stEligible
of AMC funds Fulfilled
Vaccine available
depleted
AMC
Period Tail Period
* Co-financing levels will be in line with the applicable GAVI co-financing policy. 27
Response to the H1N1
pandemic…..the ongoing
controversy
Pandemic Influenza H1N1 Overview
 April 2009
– First infections reported to WHO
 25 April
– WHO declares public health emergency of international concern
 End of May
– Confirmed infections in >48 countries & territories
 11 June
– WHO declares pandemic (phase 6)
 1 July
– 120 countries & territories with confirmed infections

Pandemic Update
(31 May 2010)
 As of 30 May, worldwide more than 214 countries have

reported laboratory confirmed cases of pandemic
influenza H1N1 2009, including a cumulative reported
18,138 deaths.
 Overall, influenza activity at low level globally

– The most active areas of pandemic influenza virus transmission
currently are in parts of the Caribbean and Southeast Asia
– In temperate zones, in between seasons; sporadic detection of
H1N1 pandemic strain
– Among influenza strains detected in May 2010, influenza B
predominates; pandemic H1N1 still predominant influenza A strain,
though H3N2 is now predominant in parts of Africa.

Summary of clinical features
 Majority of cases have uncomplicated influenza illness that resolves
without antiviral treatment
 Majority of deaths caused by severe viral pneumonia
– Renal failure / multiple organ failure, hypotension and shock
– Bacterial co-infection at presentation and nosocomial
 50-80% of severe cases have underlying conditions
– Varies by country and by definition of 'underlying condition'
– Average about 55% with underlying conditions
– Pregnancy, asthma or other lung disorders, cardiovascular, diabetes,
immunosuppression, neurologic disorders
– Obesity may be newly recognized risk factor but needs more study
 Severe cases and deaths have occurred in young and previously
healthy adults and less often children

Use of vaccine during the pandemic
 Made in a period of uncertainty about full impact of

pandemic and of data on vaccine effectiveness and
doses required
 With the knowledge of insufficient supply for global use,

but recognizing the need for global equity in vaccine
distribution
 Mortality and morbidity reduction considered main goal
 Recommended prioritization of health workers and

groups at high risk for mortality

Pandemic Vaccine Experience
Industrialized countries
 More than 265 M doses distributed from September
2009 through Feb 2010
 Estimated 175 M doses administered
 Vaccination coverage varies between less than 10% to

45 % of the population
 No unusual safety issues reported

Vaccine Deployment in Developing Countries
(as of 10/6/10)
Number of Countries
 99 Countries have requested 50

45
vaccine donation and 86 have 45
40
Co untries requested do nated vaccine
NDP s appro ved
signed letters of agreements 35
30
25
Vaccine delivered by WHO
20 18 17
16 16
 68 National vaccine deployment

15 11
10 10 8 9 9
10
6 7
5
4 3 4 4
5
and vaccination plans approved; 0
AFRO AM RO EM R O EU R O SEA R O W PR O
10 more expected to be approved

by mid-June Number of doses
14,000,000 12,595,000
 34.2 million doses of vaccine 12,000,000
delivered to 53 countries 10,000,000

8,385,800 8,139,500
8,000,000
 Planned delivery in June 10-30: 6,000,000
32.4 million doses in 21 countries 4,000,000
1,933,600
2,000,000
272,000
0
January February March April May

Lessons learnt: the communications
challenge
 Explaining virus instability and uncertainty regarding future
evolution of the pandemic
 The "pandemic" label: science, public perception and social
consequences
 Changing public perception: panic to complacence and suspicion
 Fear of adverse events exceeded fear of disease over the course
of the pandemic
 Targeted vaccination of risk groups led to allegations of being used
as "guinea pigs"
 Anti vaccine groups and new communication channels through
internet , blogs etc., made control of information difficult

Lessons learnt : use of vaccine
 Decisions need to be made with limited data in hand for

mounting an appropriate response.
– Safety, effectiveness and number of doses required
– Difficulty at national level to adapt pandemic preparedness plans
(One dose /2 doses, new risk groups)
 Contracts with manufacturers even before

recommendations on vaccine use were available
– Need for more flexible contracts with manufacturers
 Importance of strengthening existing surveillance systems

– Global Influenza Surveillance Network; expand beyond strain
monitoring and include developing countries

Vaccine was not available to all
countries at the same time
Introduction in high income countries preceded by more
than 4 months any introduction in developing countries
Started in Started in October Started in November Countries starting

September Austria, Belgium, Canada, Bahrain, Cyprus, campaigns
Australia, Finland, France, Germany, Denmark, Ireland, Israel, in Jan/Feb 2010:
China, Japan, Mexico, Norway, Jordan, Kuwait, Azerbaijan,
Hungary, Portugal, Republic of Netherlands, Qatar, Afghanistan, Iran,
Oman Korea Romania, Russia, Saudi Mongolia
Sweden Arabia, Singapore,
United Kingdom Spain, Switzerland,
USA Turkey, UAE

To summarize
 Vaccines can and have been delivered successfully with high

coverage even in the most challenging situations
 With the availability and use of newer vaccines, there is a huge

potential to make a big impact on child mortality
 Opportunity to eliminate additional diseases, e.g. measles,

congenital rubella & epidemic meningococcal meningitis
 Significant challenges in achieving the potential of vaccines

– Weak systems and financial sustainability in developing countries
– Fears, suspicion, misinformation, and media hype in industrialized
(and also some developing) countries (Wakefield, H1N1, PIL litigation
in India)

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Global Immunization Overview:

progress and potential

Meningococcus A (< 1%)

76% 24% measles (16%)

10.4 million deaths under 5 years of age

2| GOTC-CME | Charlotte June 2010

Source: WHO CAH

2.5 Preventable if coverage

4| GOTC-CME | Charlotte June 2010

Four strategic areas

- Reaching more people

5| GOTC-CME | Charlotte June 2010

Source: WHO/UNICEF coverage estimates 1980-2008, July 2009

7| GOTC-CME | Charlotte June 2010

Democratic Republic of the Congo

8| GOTC-CME | Charlotte June 2010

Rest India Bihar Uttar Pradesh

Ethiopia 0.8 MP, 9%

9| GOTC-CME | Charlotte June 2010

Estimates* Projected worst case† Projected status quo†

Worst case: MCV1 level, no follow-up SIAs in 47 priority countries

Wkly Epid Rec, 4 december 2009

 Outbreak reports as of June 16, 2010:

13 | GOTC-CME | Charlotte June 2010

15 | GOTC-CME | Charlotte June 2010 Years from availability

16 | GOTC-CME | Charlotte June 2010

Establish value Communicate value Deliver value

Surveillance Audience research Demand forecast/roll-outs

Disease burden & Generate political Reliable supply of

17 | GOTC-CME | Charlotte June 2010

 Hib Vaccine now

18 | GOTC-CME | Charlotte June 2010

 PCV now introduced in

19 | GOTC-CME | Charlotte June 2010

GAVI Approved (1 country or 0.5%)

No (170 countries or 88%)

21 | GOTC-CME | Charlotte June 2010

22 | GOTC-CME | Charlotte June 2010

Yes (46 Member States or 24%)

25 | GOTC-CME | Charlotte June 2010

IBD & Rota

WHO Global Reference Laboratories

26 | GOTC-CME | Charlotte June 2010

Tail price cap

GAVI Country Co-pay ( $0.10 - $0.30 per dose

29 | GOTC-CME | Charlotte June 2010

 As of 30 May, worldwide more than 214 countries have

 Overall, influenza activity at low level globally

30 | GOTC-CME | Charlotte June 2010

31 | GOTC-CME | Charlotte June 2010

 Made in a period of uncertainty about full impact of

 With the knowledge of insufficient supply for global use,

 Mortality and morbidity reduction considered main goal

 Recommended prioritization of health workers and

33 | GOTC-CME | Charlotte June 2010

 Estimated 175 M doses administered

 Vaccination coverage varies between less than 10% to

 No unusual safety issues reported

34 | GOTC-CME | Charlotte June 2010

 99 Countries have requested 50

vaccine donation and 86 have 45

NDP s appro ved

signed letters of agreements 35