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What's New in Immunization_


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What's New in Immunization_

  1. 1. What’s new inimmunization and where do PVOs fit in? Presented to CORE Group Meeting by Rebecca Fields and Robert Steinglass, MCHIP October 12, 2012
  2. 2. Outline of presentation What is new in the field of immunization Findings from ARISE with particular relevance for PVOs New vaccine introduction
  3. 3. Global U5 Mor tality: Role of Vaccine Preventable Diseases (2008 data) 8.8 million under five deaths Pneumonia other 17% (1.5 million) Pneumoccocal 12% diseases* from vaccine 6% preventable diseases Other Hib* 18% Pertussis 2% 2% Tetanus Measles 1% 1% Perinatal Rotavirus* 32% 5% Diarrhoea other HIV 10% Malaria 2% 9%Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis,Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.* WHO/IVB estimates
  4. 4. The cause of 1 .5 million deaths globally among children that are preventable by routine vaccination, 2008 Tetanus Pneumoccocal Measles 4% diseases* 8% 32% Pertussis 13% Hib* 13% Rotavirus* 30%Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis,Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.* WHO/IVB estimates
  5. 5. What’s new in immunization? Global Vaccine Action Plan (Decade of Vaccine) Many new entrants into immunization arena Need to move from RED to REC Role for CSOs recognized (RED modules, MLM module on partnering with communities) Mechanisms to engage CSOs (e.g. GAVI constituency) Inequity now recognized as key challenge BMGF strategy for routine imm being designed Polio erad. declared public health emergency New vaccines exposing cracks in RI system
  6. 6. Source: Optimize
  7. 7. System requirements continueto grow Diseases vaccinated 2.5x against1 Vaccine doses per child (#) [assuming receives ~3x vx listed above] 2 Vaccine volume per Increased fully immunized child 50 200 4x stress on the (cm3)3 2010+ RI system Immunization cost per $30+ 2008 child ($) [including delivery $17 ~6x costs] 4 1980 $5 Across Age groups targeted for life immunization course 1980s realities 2010 and beyond realities 1. Varies by natl schedule; represents maximum.1980: Diphtheria, pertussis, tetanus, measles, polio and tuberculosis; 2010 addl vx: PCV, Rota, HepB, Hib, Yellow Fever, Rubella, JE, MenA. 2. Represents maximum; 1980: 1 BCG, 3 DTP, 3 OPV, 1 measles; 2010: based on 2012 WHO immun. position papers. 3. Based on projected vol. per immun. child for 20 countries according to introduction plans; compares 2001 vol. for tradtl vx with 2020 expected vol.; growth driven by penta, PCV, Rotavirus, HPV. 4. Based on 2008 projections. Source: WHO Bulletin, 62 (5):729 -736 (1984); Optimize Vaccine Supply Chains, Optimize (2009); State of the world’s vaccines and immunization, WHO (2009); Vaccine volume calculator, S. Kone, WHO (2011); Immunization position papers, WHO (2012). Historical analysis of cMYPs in GAVI eligible countries, L. Brenzel and C. Politi (2012)
  8. 8. Me Eli asles min ati on nus tion amily g ta ina F in Te im P lann Polio Eradi El cation Life CycleSupport other NUVI Vaccination healthinterventions Routine Immunization System
  9. 9. The five overlapping components of the Reaching Ever y District (RED) approach Planning and • RED is intended to be a flexible approach managementMonitoring of resources  • the idea is for for action Reaching countries/districts to tailor it the target to fit their situation populations Supportive • so the intensity of supervision Linking implementing each services with component will vary from communities country to country
  10. 10. Source: ARISE/JSI, 2012
  11. 11. Africa Routine Immunization SystemEssentials(funded by BMGF)Strengthen the evidence base to improve understanding of thedrivers of RI system performance and exploring investmentoptions. What drives routine immunization performance in Africa? Why did coverage improve in some countries? Why did coverage improve in some districts and not others? (within the same country: Ethiopia, Ghana, Cameroon)Visit us at
  12. 12. ARISE Project : A pathway to improvingroutine immunization coverage at district level inAfrica
  13. 13. Cadre of Community-centered Health Workers Take vaccination into heart of the Mechanism community More workers, build trust, Transformational local support, vaccine supply. step Raised awareness, improved Effect access, increased use 
  14. 14. Partnership between the Health System and the Community Joint planning, Mechanism awareness- raising, Performanc e review, Resource pooling Transformational Shared step sense of purpose & accountabilit y, credibility Effect Ensured service availability, decreased dropout rates
  15. 15. Tailor Immunization Services to Community Needs Gather information on preferences; Mechanism choose appropriate sites for outreach, adapt services Personal links, use appropriate Transformational avenues, trust step and credibility of health workers and service Increased physical and social access; Effect increased acceptance, improved completion of vaccination schedule
  16. 16. CSHGP Historic Level of Ef for tsby Inter vention
  17. 17. Role ofPVOs/NGOs Engage on global immunization issues Assure immunization is a core component of all health programs Play a role at national and sub-national levels (Inter- agency Coordinating Committee, plans) Staff need to stay technically up-to-date Make sure immunization doesn’t get lost amid so many other objectives/initiatives
  18. 18. Why does civil society (e.g., PVOs) of ten NOT par ticipate in routine immunization? Feel unwelcome on ICC Uneasy relationship with Government/MOH Increasing demand can betray trust, if services don’t follow Community work not valued Immunization is too vertical, broader objectives Looking for financial support
  19. 19. “New” vaccines – new opportunities yellow fever rubella hepatitis B HPV (human papillomavirus virus) Hib (haemophilus influenzae type b) pneumococcal (conjugate) rotavirus meningococcal A (conjugate) typhoid JE (Japanese encephalitis) oral cholera
  20. 20. New vaccines bring newchallenges  Increase in number of vaccines (6  12 -15)  Difficult age restrictions (Rotavirus vaccine)  New target age groups (HPV)  New messages (disease syndromes, partial protection)  Integrated approaches to disease control  Cold chain and logistics challenges (volume, waste)  Cost of new vaccines
  21. 21. Framework: Protection, prevention and treatmentstrategies for pneumonia & diarrhoea PREVENT PROTECT Reduce pneumonia and diarrhoea morbidity and mortality TREAT
  22. 22. Contribution of healthy actions forpneumonia and diarrhea interventions -examples PROTECT PREVENT TREAT Exclusive breastfeeding for Vaccines against measles, Home management of 6 months pertussis, Hib , rotavirus, dehydration (ORS and zinc) and pneumococcus Adequate nutrition Vitamin A supplementation Community Case Management (CCM) Hand-washing with soap Prevention of HIV in Case management in health children facilities Community-wide sanitation Cotrimoxazole prophylaxis Case management at promotion for HIV exposed and hospitals infected children Treatment and safe storage Zinc supplementation for of household water children with diarrhea 24
  23. 23. Example of BCC materials, KenyaPCV 10 Poster – Global Action Plan Against Pneumonia Poster during “Malezi Bora” child health week (linked with Africa Vaccination Week)
  24. 24. oppor tunities with newvaccines – role for PVOs? Challenges Opportunities Resource mobilization for  Real opportunity to new vaccine introduction achieve MDG 4 High demand for the  Renewed government/ vaccine – real danger of partners interest in stock outs immunization Community perceptions  Renewed community on multiple antigen interest in immunization vaccinations  Training opportunity for Communication about health workers disease syndromes when  Create momentum for only some is vaccine- GAPP implementation preventable
  25. 25. Oppor tunities for PVOs to engage1) Policies and plans exist – need to strengthen communication and community involvement for pneumo and DD prevention/ implementation; develop strategies for migrant and urban populations2) National and local media – develop partnerships for positive messaging and supportive articles/programs3) Technical Advisory Groups – integrate case management and prevention with behavior change interventions4) Link with initiatives (World Pneumonia Day, World Handwashing Day, 2012 Year of RI Intensification)5) Community mobilizers in place – improve/focus their support in high risk areas (mapping, due lists, referral)
  26. 26. Immunization has a role to playin your por tfolio: MCH IMCI/CCM Nutrition Safe Motherhood Infectious Diseases Child Health Child Survival PHC
  27. 27. Every child should be aVIP… Vaccinated, Immunized & Protected! Thank You
  28. 28. Thank you! Follow us on:
  29. 29. Extra slides
  30. 30. Global Vaccine Action Plan’s strategic objectives• All countries commit to immunization as a priority• Individuals and communities understand value of vaccines and demand immunization as both their right and responsibility• Benefits of immunization are equitably extended to all people• Strong immunization systems are an integral part of a well- functioning health system• Immunization programs have sustainable access to predictable funding, quality supply and innovative technologies• Country, regional and global research and development innovations maximize the benefits of immunization
  31. 31. MCHIP immunization strategiesIncrease capacity for sustainable immunization coveragewith all appropriate vaccines to reach unreached andreduce child mortalitySupport effective and sustainable introduction of safe,high-quality, life-saving new vaccinesEngage in disease control priority programs with focus toenhance positive effects on strengthening RI platformInfluence global and regional levels with programlearning from the field
  32. 32. Sustainable Routine Immunization System Financing Practices Community Action Policies Supportive  Supervision Training Supplies Monitoring & & Logistics  Advocacy Surveillance  & Manageme nt Communication s
  33. 33. Introduction of new vaccines arechallenging the immunization system• Good planning, partnership and adequate resources• Effective commitment of Government, partners and community• Good coordination between MOH and ICC partners and close follow-up for the introduction process• Additional storage capacity to accommodate new vaccine• Increased number of vaccines at the vaccination site level• Increased immunization waste to manage and dispose• More training for health workers and community volunteers• Revised technical guidelines, recording and reporting tools, IEC materials, etc.• Good communication with parents to address concerns• Good surveillance system prior to and after NV introduction• Extra financial resources required to buy vaccines
  34. 34. Scale Up Map for New Vaccine Introduction Program Implementation National Global Preparation Actions Actions (3-6 months before Vaccine Launch Post-IntroductionAsses the magnitude ofthe problem: morbidity launch)and mortality due to the Advocate for vaccine target disease with the introduction support new vaccine Upgrade cold chainInitiate discussion and reach consensus tointroduce a vaccine and Conduct registration of the type of product the vaccine, review vaccine supply distribution system,Initiate surveillance to upgrade as needed establish baselinePrepare and/or amend Countryapplication and submit re-/submits Make improvements Conduct post- on time application to waste management introduction system, as needed evaluation Update/prepare cMYP PR events held assessment a Reduced and costing tables to launch the year following morbidity Ensure it is IRC makes a Develop learning vaccine incorporated into the recommendation materials, conduct vaccine launch and national health sector to the GAVI technical training mortality plan Board Monitor and due to the respond to any Conduct Conduct nationwide Revise, print and reported adverse impact targetedcold Chain storage space distribute EPI assessment GAVI management tools events assessment vaccine Secretariat preventable Develop an prioritizes Initiate AEFI disease applications for surveillance for the NV Document introduction plan approval and strengthen AEFI lessons reporting system learnedSolicit ICC endorsement and commitment for Develop communications implementation strategies and key messages to address caregiver/ provider concern(s) Obtain ministerial signatures on the application to GAVI IEC/demand creation for new vaccine M&E Source: MCHIP 2011
  35. 35. What do some country bilaterals say about ICC and immunization?• ICC agenda is too narrow, confining• Important ICC decisions made beforehand• Their technical assistance not valued
  36. 36. Potential country roles for NGOs in routine immunization• Directly immunize• Support district MOH staff (capacity building)• Mobilize communities and create demand• Use birth and service registers to reduce left-outs and drop-outs• Plan and monitor with communities• Advocacy
  37. 37. So why does Civil Society participate on campaigns?• High-level request• Clear role• Credit/Recognition• Funding• Supply/services assured“But they won’t participate for the long-run.”
  38. 38. So why do NGOs love to participate in “Child Health”/CCM/c-IMCI? • Credit/recognition (appreciation from communities) • Supply assured • Clear role • Funding
  39. 39. Promotion of “Healthy Actions”•Motivate individuals, households, and communities to:  Adopt “healthy actions”  Engage in the fight against leading child-killers  Increase demand for health services  Identify danger signs and seek treatment• Improve knowledge, attitudes, norms and practices
  40. 40. Illustrative community linkages with immunization • Motivate others to use immunization and other PHC services • Arrange a clean outreach site (school, community meeting room, etc.) • Transport vaccines and health workers, particularly for outreach sessions • Inform other community members when a health worker/team arrives at the  outreach site • Provide a meal to the health worker when they are on outreach visits • Register patients, control crowds and make waiting areas more comfortable on  the day of a fixed or outreach session • Deliver appropriate messages, including dispelling rumours about immunization • Assist with newborn and defaulter tracking • Arrange home visits when children are behind schedule, to explain  immunization and to motivate caregivers • Provide equipment and even financial supportUnderstanding reasons for low coverage is easier when district and health facilitystaff establish rapport with the community and involve community members inplanning, promoting, implementing and monitoring services