National Immunization Conference Hilleman Lecture: Achieving Global Immunization for All: Can We Do the Right Thing? Stephen Cochi, MD, MPH Senior Advisor Global Immunization Division Centers for Disease Control and Prevention Global Immunization Division Centers for Disease Control and Prevention

Lofty Global Goals  > 90% coverage in every country and > 80% in every district  Introduce new vaccines  Achieve Polio Eradication  Reduce Measles Deaths by 90% by 2010  Strengthen immunization systems

What is Possible? How Are We Doing? There is good news…..and not so good news (i.e., challenges!!) (i.e., challenges!!)

Causes of 4.1 million deaths in <5 yr olds (out of 10.5 million total deaths) in 2002 Source: World Health Report 2004

2.5 million annual childhood deaths due to VPDs (2002) Source: WHO/IVB, Data as of 2002

Very modest reduction in annual childhood deaths from VPDs in * Source: WHO/IVB - *PROVISIONAL Data for 2005

Number of unvaccinated children (DTP3) by year and WHO regions, Source: WHO/UNICEF coverage estimates , August 2006 Date of slide: 4 September 2006 India Nigeria China Indonesia Pakistan

Number of Unvaccinated Children by Year and WHO Region, , Projected to 2010* `Source: WHO/UNICEF coverage estimates goal: At least 90% coverage in all countries! 62%↓

Global Immunization Vision Global Immunization Vision A world in 2015 in which…..  Immunization is highly valued  Every child, adolescent, and adult has access  More people are protected against more diseases  Vaccines are put to best use in improving health/security globally

Realizing the vision Four strategic areas - Reaching more people - Introducing new vaccines & technologies - Integrating with other interventions in health systems context - Global interdependence

Good News There is more funding for global immunization than ever before in history !!

Annual Costs of Immunization, % +40% +20%

$0 $200 $100 $300 $400 $500 $600 $700 US$ millions $800 High Low GAVI projected income through 2015 Two projected scenarios, including IFFIm, excluding AMCs Source: GAVI Secretariat, Feb 2006

The vaccines pipeline

New and Underutilized Vaccines  Hepatitis B vaccine  Hib vaccine  Rubella vaccine  Rotavirus vaccine  Pneumococcal conjugate  HPV vaccine

Hib Disease – The Global Burden ( WHO Estimates - Children < 5 years old)  3 million children with serious illness/ year serious illness/ year  > 400,000 deaths/year (>1,000 preventable deaths each day)  A leading cause of infectious death in children under 5 years of age

Despite availability of an effective and safe vaccine for over 15 years, and availability of GAVI support for 6 years, 75% of the world’s children still don’t have access to 75% of the world’s children still don’t have access to Hib vaccine Hib vaccine

Hib vaccine not introduced Hib vaccine introduced Source: WHO/IVB database, May Hib vaccine introduced or approved for GAVI support Hib vaccine in routine immunization schedule (outside GAVI support) Hib vaccine not introduced Countries using Hib vaccine in their national infant immunization system

1 dot = 1000 deaths Estimated global distribution of the 600,000 annual deaths caused by rotavirus

The Challenge: Avoid the time lag seen for hepatitis B and Hib vaccines HepB -- all developing countries Hib -- all developing countries Million doses Years from availability

Equity: Can we speed the time that vaccines get to children in greatest need?

The biggest challenge for live oral rotavirus vaccines today is whether they will work in the developing world !!

Leading infectious causes of mortality, 2000 estimates Deaths (millions) < 5 yrs old > 5 years old Pneumonia AIDSDiarrhoeaTBMalariaMeasles Source: WHO S. pneumoniae: ~1.6 million deaths, including ~800,000 child deaths* *New estimates being made

Multi- national Launched Clinical trial Phase III Clinical trial Phase II Clinical trial Phase I 9-valent 11-valent GSK 10-valent Prevnar (7-valent) 7-valent Pre-clinical stage >5 mulit-valent conjugate vaccine projects Emerging suppliers Expected launch 2008 ~20 vaccines in research/ Pre-clinical stage (includes conjugate & protein-based vaccines) Discontinued Development Stage Pneumococcal vaccine pipeline Source: BCG Global Supply Strategy 2005 PneumoADIP team analysis Wyeth 13-valent

HPV vaccine potential: Estimated numbers of new cancer cases and deaths in 2002 Source: Parkin et al., 2005, Global Cancer statistics 2002 Cervical cancer is 2nd most common cancer in women worldwide & 1 st cause of cancer-related deaths in women in developing countries

The Potential of Human Papillomavirus Vaccines (HPV) Over 90% effective in preventing new infections and precancerous cervical lesions caused by the HPV types that the vaccine covers * The vaccine to be given before HPV infection is acquired (e.g., year olds in US)* Most needed in resource poor countries but initial price is unaffordable ($300)* HPV will not eliminate need for screening, essential to detect cancers by other HPV types * BMJ, Editorial, 13 May 2006

Polio – the world in : World Health Assembly Voted to Eradicate Polio >350,000 cases >125 polio-endemic countries

Poliovirus spread, Case or outbreak following importation (last 6 months) Endemic countries Case or outbreak following importation ( months) Source: WHO, January countries, 71 events Number of importations from India Viral origin: 13 (18%) Number of importations from Nigeria viral origin: 58 (82%) Wild virus type 1 Wild virus type 3 Wild virus type 1 & 3

Polio – the world at end ,977 cases 4 endemic countries district with type 1 polio district with type 3 polio endemic areas

3-Pronged Approach to Finish Polio Eradication  New Tools  New Standards to Reduce International Spread  New Approaches to Address Challenges in Last 4 Endemic Areas

New Polio Vaccines monovalent OPV types 1 & 3 (mOPV1 & mOPV3) New Trial Data, Egypt 'monovalent' OPV protects 2 x greater

New international standards for polio outbreak response FAST: start within 4 weeks VERY LARGE: 2-5 million children. HIGH QUALITY:house-to-house. SUSTAINED:minimum 3 rounds. OPTIMAL VACCINE:mOPV Adopted by the World Health Assembly, May 2006

New Standards to Reduce Polio Exportations Executive Board (WHA) 22 January 2007 'S tanding Recommendation under IHR (2005), requiring full OPV immunization of all travellers from infected areas' Saudi Arabia requires proof of OPV for entry visas.

Fixed Sites: 5 days mOPV1, measles, DPT deworming meds, bednets, etc Mobile Teams (house-to-house): 5 days mOPV1, social mobilization. New 'Immunization Plus Days' (IPDs) Strategy, Nigeria

Measles Building on Polio Eradication

Data as of Sept 2004 Measles/rubella and yellow fever Measles/rubella and yellow fever Polio and measles/rubella Measles/rubella only Measles/rubella only Polio, Measles/rubella and yellow fever Polio, Measles/rubella and yellow fever Labs testing for: 331 Prefecture Labs 154 Sub-National Labs Global VPD Laboratory Network N=835 (Polio N=145 - Measles N=690)

Major Global Measles Virus Transmission Pathways B2 Suspected transmission pathways Transmission pathways with Epi links Acknowledgement: Data provided by WHO Measles/Rubella Laboratory NetworkB3 D4 D4 D8 H1H1 D6 Key B2 B3 D4 D6 D8 H1

Strategy for sustainable measles mortality reduction 1. Strong routine immunization of > 90% 2. Provide second opportunity for measles immunization 4. Improved case management 3. Surveillance

44% member states (65%), 44% of birth cohort Measles 2 nd opportunity, 1999 and % member states (89%); 64% of birth cohort measles 2 nd opportunity no measles 2 nd opportunity Activities : 46 Countries added 603 mil vaccinated in SIAs

Reducing Measles Mortality by >50% by 2005 (compared to 1999: 873,000 deaths) Estimated Measles Mortality by Year Source: Measles Initiative. Lancet Jan 18, 2007

GIVS Goal: 90% Reduction in Global Measles Deaths by 2010 (vs. 2000) 90% Source: WHO/IVB measles deaths estimates, November % measles mortality reduction goal achieved! % measles mortality reduction goal Enhanced measles case-based Surveillance building from Polio Eradication experience

Re-establishment of outreach services Supportive supervision Community links with service delivery Monitoring and use of data for action Planning & management of resources Launched in 2002, RED strategy was implemented in 53 countries by end of 2005 The Reach Every District (RED) Strategy for Routine Immunization Strengthening

Impact of RED activities on district- level distribution of DPT3 Coverage in 25 AFR countries implementing the RED strategy RED District Performance: "Low"= 80% DTP3 - "RED implementatiion" is as of 2006; starting date may vary Source of data: WHO-UNICEF Joint Reporting Form – Analysis includes only countries with full reporting on district level coverage in 2002 and districts2041 districts

Countries with DTP3 coverage <50%: 1990, 2000, DTP3 coverage < 50% (19 countries) 2000 DTP3 coverage < 50% (20 countries) 2005 DTP3 coverage < 50% (9 countries) Source: WHO/UNICEF estimates, WHO Member States. Data as of November 2006

Summary and Conclusions  Exciting progress on the global immunization front  Unprecedented financing for immunization is now available for low- income countries  Introduction of “new” vaccines is proceeding but financing will be the major challenge  Strengthening weak immunization systems in poor countries is difficult and will require long-term investments

Thank you