Global OverviewProgress Towards Global Immunization Goals

21st inter-country meeting of national managers of the

Expanded Programme on Immunization

Cairo, 26-29 June 2004

Global GoalsUNGASS, WHA, MDGs

• UN General Assembly Special Session (UNGASS) goals by 2010: • > 90% coverage of infants nationally & > 80% coverage in every district• Vitamin A Deficiency Elimination

• World Health Assembly (WHA) resolutions & UNGASS goals by 2005:

• Polio Eradication • Measles Mortality Reduction • Maternal and neonatal tetanus (MNT) elimination

• Millennium Development Goal (MDGs): •2/3rd reduction in child mortality in 2015 (compared to 1990)

Regional WHO-UNICEF Estimates 1995-2002

40%

50%

60%

70%

80%

90%

100%

1995 1997 1999 2001

AFRO

AMRO

EMRO

EURO

SEARO

WPRO

DTP3 coverage by WHO Region, 1995-2002

DTP3 coverage by WHO Region, 1995-2002

33 million infants not immunized (DTP3), 2002

Latin America and Caribbean

(1.37)

Sub-Sahran Africa (12.01)

Mid-East and N Africa (1.37)

South Asia (10.97 )

Central Europe, CIS (0.48)

East Asia and Pacific (7.21)

Industralized(0.55)

Source: WHO/UNICEF estimates, 2003

Slide Date: October 03

All countries (n=192) 2002 2003 • reporting >80% DTP3 coverage in all districts 26% 26%• countries >90% DTP3 national coverage 53% 53%

• 80% in all districts & 90% national: 26% 26%

VF-eligible countries (n=75) • reporting >80% DTP3 coverage in all districts 12% 13%• plus countries >90% DTP3 national coverage 21% 21%

• 80% in all districts & 90% national: 12% 12%

Immunizationn coverage Progress towards UNGASS goal on coverage

Where the unimmunized children are, 2002

95%

63%

40%47%

69%

40%

62%

Djibouti(0.25%)

Somalia(6.82%)

Yemen(6.56%)

Afghanistan(12.8%)

Sudan(16.33%)

Pakistan(48.4%)

Rest ofEMRO(8.84%)Number of

Children

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Unimmunized Children Immunized Children Coverage

• Restoring outreach

• Linking services and community

• Monitoring and use of data for action

• Managing human and financial resources

• Strengthening supportive supervision

Recommended strategies to reach

> 80% coverage in every district

Careful planning at the local level!

Map of City Neighbourhood

factory

market

main road

footpathsmall road

tent city

farming area

boundary

h.centre

bus station

slum area

slum area

middle class houses

housing

dense housing

Vaccination Delivery Strategies to Reach All

Ministry of Health, Turkey

Even where it is difficult!

Working with the community

Ensuring safetyInjection safety assessments

LegendDonePlanned 2004ReassessedReassessment 2004Selected sitesNo Data

Update 25 April 2004 - includes assessments done by standardized and non standardized protocolsList of countries planning injection safety assessment in 2004 is not exhaustive

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

400,000,000

450,000,000

500,000,000

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006UNICEF A-D Syringe shipments

1994 - 2006 ActualForecast

Immunization safety: Immunization safety: What is needed?What is needed?

Exclusive use of vaccines of assured quality

No reuse of needles/syringes (AD syringes)

Proper disposal & appropriate waste management

Safe vaccine reconstitution and use of multi-dose vials

Effective monitoring & management of safety issues &

rumours

Pursuing global immunization goalsthrough an "evidence-based" approach

• High performing surveillance/laboratory networks

• Coverage monitoring that is accurate and timely

• Cross-checking through surveys & assessments

• Development of investment cases

• Using the data to guide policy/strategy

Source: WHO/IVB

measles38%

Hib27%

pertussis20%

neonatal tetanus13%

YF, Diphtheria, Polio, Hepatitis B

< 1%

tetanus (nonneonatal)

1%

The evidence…….1.4 million child deaths globally are preventable by routine vaccination,

2002

Measles mortality reduction% reduction in estimated measles deaths by WHO region between 1999 &

2002

-40

-35

-30

-25

-20

-15

-10

-5

0

AFR EMR SEAR Others Global

Region

% r

edu

ctio

n

Global Measles/Rubella Laboratory Network - 2004

The designation employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the secretariat 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.

Data as of April 2004

31 Provincial labs

326 Prefecture Labs

154 Sub-National Labs

N=671

Global Specialised Labs

National Laboratories

Regional Reference Labs160

Measles Strain Banks

149 countries

Proposed National Labs

Compelling evidence on the burden of congenital rubella syndrome

(CRS) • Laboratory network reveals a “sea of rubella”

• Rubella infection in first 3 months of pregnancy has a 90% risk of CRS birth defects

• Documented CRS incidence 0.2 to 4.3/1000 live births in non-industrialized countries (studies from 50 countries)

• Estimated >100,000 infants with CRS each year

• CRS disability (deafness, blindness, heart disease, mental retardation) is costly for families and society

Countries with rubella vaccine in the national immunization system, 2003

Source: WHO Department of Immunization, Vaccines and Biologicals, April 2004

199667 countries12% of birth cohort

2003105 countries23% of birth cohort

WHO position paper on rubella vaccines

Weekly Epidemiological Record 2000;75:161-169

• The primary purpose of rubella vaccination is to prevent CRS

• Can be achieved by immunizing child-bearing aged women (CBAW)

• Introduce rubella vaccine into childhood immunization only if:– Infant measles vaccine coverage > 80% and can be sustained– Ensure immunity among CBAW

• Warning! Inadequate childhood rubella vaccine coverage (<80%) can:– alter the transmission dynamics of rubella leading to increased

susceptibility in CBAW– Increase the risk of CRS

Cumulative number of CBAW targeted and protected with 2 doses of TT during SIAs / year (in millions)

0

10

20

30

40

50

60

1999 2000 2001 2002 2003 2004*

CBAW not protectedCBAW protected

As of 30 April 2004

0.2

0.7

3

15.9

5.61.8

6.8

30.7

2

CBAW targeted

56.9

37.5

18.9

6.3

8

35.9

43.9

Maternal and Neonatal Tetanus Elimination

Anticipated progress by 2005 among 57 targeted countries for MNT elimination

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. Source: WHO/UNICEF MNT collected data

As of 30 April 2004

Countries with limited progress

Countries on track for validation

Validated countries by 2005

Polio Progress, 2004cases as of 22 June

Endemic countries

Wild virus type 1

Wild virus type 3

Importations

Paralyzed Children

Asia & north Africa = 32

Sub-saharan Africa = 301

Enormous potential to contribute to MDG goals!!

Causes of 4.1 million child deaths (out of 10.5 million child deaths globally)

Measles13%

Hib9%

Rotavirus10%

Pneumococcal17%

Malaria29%

HIV9%

TB1%

Meningococcal A/C, JE

<1%

Pertussis7%

Tetanus5%

YF, Diphtheria, Polio, Hepatitis B

0%

Dare to dream!What may be possible in the next 10 years in

vaccinology!Vaccine/Antigen

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020Route of adminstration

New or improved antigens for childhood immunizationMeasles aerosol aerosolRubella aerosol (pending final decision) aerosolMeningococcus A imPneumococcus (more than 7-valent) conjugate imRSV inGp A Strep im/inInfluenza A (cross-subtypic) im/inRotavirus (GSK or Merck) oralShigella oralETEC ETEC vaccine for travellers already available oralNew Tuberculosis ?Malaria if current GSK vaccine efficacious imLeishmaniasis if current IDRI candidate effective imHookwormJE inactivated JE vaccine already available imDengue imS-IPV imNB: This timing corresponds to the MOST advanced vaccine candidate. Other products are in preclinical phase.

New or improved antigens for adolescent/adult immunizationHPV imHIV ?HSV-2 im

New combination vaccinesDTPwHepHibMenAC imDTPaHepHibIPV im

New delivery technologiesdisposable cartridge jet-injector 1st application: measles, YF? im/scaerosol deliverynasal (already available for flu) 1st application: RSV?oral (already exists for OPV, cholera)cutaneous (patch) 1st application: ETEC travellers?ballistic 1st application: measles, HBV?stable liquid 1st application: measlesone-shot vaccine (to replace 3-shots) 1st application: HBV

pre-clinical developmentclinical developmentLicensure and marketing

Status by end of 2003All countries (n=192)

HepB in schedule: 75%

Developing countries with adequate delivery systems* (n=149)HepB in schedule: 85%with comparable coverage to DTP3** 42%

VF eligible countries with adequate delivery systems* (n=61)HepB in schedule: 82%with comparable coverage to DTP3** 30%

What is possible!

GAVI milestoneBy 2007, all countries will have introduced hepatitis B vaccine

Source: WHO/UNICEF joint reporting form, 2002data from 192 WHO member states

Hib vaccine not introduced (108 countries)

Hib3 < 80% (10 countries) Hib vaccine introduced but no coverage data reported (29 countries)

Hib3 > 80% (45 countries)

2002 (84 countries introduced (44%)

Hib vaccine not introduced (167 countries)

Hib vaccine introduced but no coverage data reported (25 countries)

1997 (25 countries introduced)

Countries having introduced Hib vaccineand reported Hib3 coverage, 2002

Slide Date: October 03

Countries providing vitamin A supplementationwith routine immunization services, 2002

Non deficient (56 countries)

No Vitamin A distribution linked to routine immunization services (countries 71 or 52 % ) (Note: 15/71 provided vitA with immunization campaigns)

Source: WHO/UNICEF joint reporting form, 2002; WHO SIA databasedata from 192 WHO member states

Vitamin A distributed with routine immunization services(65 countries or 48%)

Global Summary of EPI-linked VitA Distribution

VitA with routine EPI: 24 countries

VitA with EPI campaigns: 15 countries

VitA with both (routine & EPI campaigns): 41 countries

Total: 80 countries

Slide Date: October 03

Changing landscape in the immunization world

• R&D accelerating

• New partnerships– Meningitis Vaccine Programme– African AIDS Vaccine Programme– Measles Aerosol Project– GAVI-ADIPS (Rotavirus-Pneumo)– Japanese Encephalitis Project– [HPV/cervical cancer Vaccine]

• Need for consolidation (less fragmentation of various immunization initiatives)

• New vaccines will cost more; financial sustainability becomes paramount

• Vaccine supply & quality issues are more complex– increased divergence of products for industrialized vs non-industrialized countries– increased number of manufacturers, particularly from non-industrialized countries– increased need for functional NRAs, – need for new regulatory pathways

Conclusion• Urgency to pursue the current 2005 & 2010 goals

– UNGASS coverage goal will not be met unless considerable acceleration to reach every district

– Disease control goals (polio, measles, MNT, Vit A elim)

• Safety/quality is not an option, but a responsibility

• Enormous potential for impact with future vaccines

• Need strong evidence base for the old & the new

• Changing landscape

The way forward

A WHO/UNICEF Global Vision for Immunization

• Reach more– Focus unprecedented attention on the "hard-to-reach"– Expand to other age-groups– Use school contacts

• Provide New– Ensure the widespread use of new or under-utilized vaccines

• Include others– Deliver additional health interventions at immunization contacts