Future trends and perspectives in immunization

Kim MulhollandLondon School of Hygiene and

Tropical Medicine

Improving future goal setting: analysis and critique of the

Millennium Development Goals

Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, Dorward A, Godfrey-Faussett P, Hanvoravongchai P, Kingdon G, Little A, Mills A, Mulholland K,

Mwinga A, North A, Patcharanarumol W, Poulton C, Tangcharoensathien V, Unterhalter E. The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting

after 2015: Lancet and London International Development Centre Commission.

Lancet 2010; 376: 991–1023.

1. Halve poverty and hunger2. Achieve universal primary education3. Eliminate gender disparity4. Reduce by 2/3 the child (< 5) mortality rate5. Reduce by 3/4 the maternal mortality rate6. Halt and reverse the spread of HIV AIDS and incidence of malaria and other diseases7. Ensure environmental sustainability8. Develop a global partnership for development

The Millennium Development Goals

MDG’s

• The positive side…– provided a focus for advocacy to improve

targeting and flow of aid

• The problems….– confusion between targets, indicators and goals– ownership issues– tendency to increase inequity

Future development goal setting: five principles

• Holism – consider all elements of well-being• Ownership – from national to global consensus• Equity – a pro-poor, rights-based approach• Sustainability – beyond economic growth• Global obligation – goals for all, not just the poor

Lancet 2010; 376: 991–1023.

Immunization – part of the problem?

• The model “vertical program”• Successful EPI programmes have established

parallel infrastructure in many countries, bypassing inadequate health services

• Campaigns approach– Disrupts and undermines health services– Even damages struggling EPI programmes

Immunization and equity

• Traditionally immunization is seen as pro-poor (= pro-equity)– Coverage beyond the reach of the routine health

services– Campaigns may reach 100% of the population– Herd immunity provides protection for unvaccinated

children• Reaching Every District (RED) approach– a sub-national approach to immunization data

collection

New vaccines promote inequity

• Between countries– New vaccine use has been restricted to lowest risk

children in low risk countries

• Within countries– Promotion of lifesaving vaccines in private sector

of high mortality countries– Routine immunization excludes children not

reached by the health services (highest risk)

Immunization and equity – impact of the MDGs

• Vaccination interventions = “low hanging fruit”

• New vaccines presented with substantial (largely unproven) promise:– Pneumococcus (800,000 – 1 million deaths/yr)– Rotavirus (500,000 deaths/yr)

• But:– Death from diarrhoea or pneumonia = death from

lack of basic health care

The fundamental problem with modern immunization data…

• Most data are national averages• Lives saved = coverage X effectiveness– Inaccurate– Fundamentally misleading

• Children who die from diarrhoea or pneumonia are usually marginalized, outside the health system

• More honest would be:– Coverage amongst the highest risk group X

effectiveness

Post 2015…• The world can/will strive for greater fairness in

health – equity must be front and centre

• Pure survival is not enough, preventative strategies must be paramount– Nutrition – maternal and infant– Healthy environment– Immunization– Prevention of specific diseases – AIDS, malaria

• Health care must be comprehensive and integrated (= non-vertical)

Immunization and equity – “Trickle down” or “Affirmative action”?• 100% coverage with all suitable vaccines =

perfectly equitable• In the real world – 1% or 50% unimmunized,

these will be the highest risk children• As coverage approaches 100%– Excluded are an increasingly small group of

increasingly high risk children

Use of immunization to promote equity

• Identify highest risk children and ensure that coverage is highest among these groups– Selective use of vaccines against treatable

diseases (eg. Shigella)– Alternative strategies• eg. maternal immunization to prevent early infant

illnesses and/or maternal infections

– Who are the highest risk communities?

Who are the highest risk communities?

• Economically deprived• Geographically isolated• Ethnographically excluded

Who are the highest risk communities?

• Economically deprived• Geographically isolated• Ethnographically excluded• Transient communities• Internally displaced communities• Refugees• Victims of wars and natural disastersEven when we can do nothing else, we can provide

these communities with life-saving vaccines

Priorities for 2025

• Immunization must be at the vanguard of global efforts to achieve fairer, more equitable health outcomes

• Strategies and new vaccines must focus on– The needs of the highest risk communities (not

always in the poorest countries)– Ensuring that vaccination continues to be a major

force to promote equity in health outcomes