Immunization Past Successes Future Challenges

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ImmunizationPast Successes - Future Challenges

• USAID Mini University
• 10 May 2004
• Murray Trostle Dr P.H.

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Immunization

• The health of the people is really the
  foundation upon which all their happiness and all
  their powers as a state depend.
• Benjamin Disraeli

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Why immunization?
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Immunization

• In 1796 Edward Jenner developed the first vaccine
  smallpox
• While a number of vaccines were developed through
  the 1970s, immunization coverage was very low in
  developing countries.

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Vaccine Chronology

• 1796-smallpox
• 1885-rabies
• 1897-plague
• 1923-diphtheria
• 1926-pertussis
• 1927-tuberculosis
• 1927-tetanus
• 1935-yellow fever

• 1955-IPV
• 1962-OPV
• 1964-measles
• 1967-mumps
• 1970-rubella
• 1981-hepatitis B
• 1988-Hib
• 1998-pneumococcus

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Immunization

• In 1974 WHO launched the Expanded Programme on
  Immunization (EPI)
• At the start of EPI coverage was around 5
  globally. By 1990 it had risen to 75.
• This period was characterized by considerable
  attention from donors as immunization was one of
  the twin engines that propelled the growth of
  primary health care.

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Timeline of major immunization events against
DTP3 coverage
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Immunization

• EPI involved six antigens and conducted around
  500 million immunizations every year
• By 1990 EPI was preventing approximately 3
  million child deaths each year or 10,000 lives
  saved each day!

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Global Estimated Deaths Occurring and Prevented
2000Measles, Neonatal Tetanus and Pertussis
Deaths prevented
Deaths prevented
Deaths occurring
Deaths prevented
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Immunization

• In 1993 the WDR rated immunization as one of the
  most cost effective interventions for saving
  lives
• During the 90s immunization progress stagnated
  and donors turned to other investments
• Progress platued and by 2002 the global coverage
  was the same as in 1990 and new vaccines were not
  being taken up

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Timeline of major immunization events against
DTP3 coverage
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Immunization

• In 2000 the donors formed the Global Alliance for
  Vaccines and Immunization (GAVI) to reinvigorate
  immunization
• Along with GAVI came the Vaccine Fund which was
  started with a 750 million grant from the Bill
  Melinda Gates foundation
• Since 2000 donors have contributed a total of
  1.3 billion to the Vaccine Fund

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GAVI Board composition

• Countries
• Bilaterals
• Bill and Melinda Gates Children Vaccine Program
• Industry
• Rockefeller Foundation
• Technical Agencies
• UNICEF
• WHO
• World Bank

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GAVI impact

• 40 countries introduced Hep B
• 9 countries introduced Hib
• 10 countries added yellow fever vaccine
• 48 countries received financial support for
  expanding coverage
• 37 countries received support for safety syringes
  for all immunizations

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Immunization

• Even with this remarkable progress serious issues
  remain for immunization
• Improve coverage
• Financing
• New vaccines
• Sustainability

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What is affecting coverage?
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Global Immunization 1980-2002, DTP3
coverage global coverage at 75 in 2002
Source WHO/UNICEF estimates, 2003
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Factors impacting on coverage

• Regional distribution
• Poverty
• Access to services
• Demand for services
• Resources
• Financial
• Human

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Vaccinated and unvaccinated children by coverage
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Countries reporting national DTP3 coverage in
infants ³ 80 for each of last three years
(2000-2002)
Source WHO Vaccine Preventable Diseases
Monitoring System, 2003
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Slide Date February 03
36 million children not immunized (DTP3), 2001
Source WHO/UNICEF estimates, 2002
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Distributional benefits DTP3 Coverage by
Wealth Quintile(most recent DHS)
Source Gwatkin and Deveshwar-Bahl
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Immunization coverage (DTP3) and infant mortality
in India by socio-economic category
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Immunization coverage (DTP3) and infant mortality
in Bolivia by socio-economic category
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Immunization status for the DTP series(1999 DHS
data)
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Avoid top-down approaches
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What are the financing issues?
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Financing

• Cost of new vaccines
• Cost of increasing coverage
• Covering all elements of immunization to include
  routine, campaign, shared costs, new and old
  vaccines

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Cost of new vaccines in developing countries

• Older, traditional vaccines range from 0.24 to
  0.45 per child immunized
• New vaccines are a different story
• Hep B vaccine is 0.66 per child
• Hib vaccine is 7.50 per child
• Combination vaccines are 10.80 per child

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Will new vaccines become less expensive?

• Older, traditional vaccines are inexpensive
  because they are
• older
• off patent technologies
• made by many manufacturers almost exclusively in
  developing countries.
• Most new vaccines
• not yet off patent
• are not made in large quantities by many
  manufacturers.

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Immunization program costs in 12 GAVI-assisted
countries
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Why the huge gap?

• Primary contributor to the gap the substantial
  cost of the new vaccines
• Some countries have increased coverage to the
  extent that this is having an impact on program
  cost too. (This is good news !?)

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How is the gap being addressed?

• Global partners are working with manufacturers to
  try to reduce or further off set prices
• Some countries are
• allocating more financial resources to
  immunization
• Considering dropping new vaccines if they cant
  find a way to pay
• looking to loans
• soliciting donor partners for support
• looking into social health insurance to cover
  immunization

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What is the future for introducing new vaccines?
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New and under-utilized vaccines

• Under-utilized vaccines
• Hib, Hep B, Yellow fever
• New vaccines
• Pneumococcal
• Meningococcal
• Rotavirus
• Future vaccines
• HIV.AIDS, malaria, TB

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Vaccine cost to immunize a child
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Barriers Beyond Price

• Global commitment for this kind of
• Government commitment to preventive care and
  competing priorities
• Financial management
• Human capacity system constraints
• Hard to reach populations
• Cold chain logistics
• Capacity
• Management and maintenance

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Where do we go from here?
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Immunization priorities

• Build capacity
• The twin engine effect may still be alive
• Promote responsibility
• Countries must commit the resources and effort
• Address disease
• The bottom line is still to save lives
• Fulfill our responsibility
• Saving the lives of children is a global
  responsibility

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Future of immunization

• Critical areas of attention for countries and
  donors
• Resources
• Financial
• Technical
• Technology
• Disease impact
• Polio
• Measles
• NNT

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Future of immunization

• Critical areas of attention for countries and
  donors
• Service delivery
• Maintaining current status
• Reaching the unreached
• Sustainability
• Financial
• Political
• Development

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The best way to escape from a problem is to
solve it. Alan Saporta
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ImmunizationPast Successes - Future Challenges

• Thank You