Think Locally, Act Globally The 42nd National Immunization Conference, Atlanta, GA David Fleming, MD March 18, 2008

Impact of Vaccines in the 20th Century Disease 20th Century Annual Morbidity 2005 Total Percent Decrease Smallpox 48,164 100 Diphtheria 175,885 Pertussis 147,271 25,616 83 Tetanus 1,314 27 98 Polio (paralytic) 16,316 1* >99.9 Measles 503,282 66 Mumps 152,209 314 >99 Rubella 47,745 11 Congenital rubella 823 1 99.8 Haemophius influenzae (<5 yrs) 20,000 (est) 226 (serotype B or unknown) 99 *Imported vaccine-associated paralytic polio Sources: CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th Edition, January 2007. CDC. Impact of vaccines universally recommended for children – United States, 1900-1998. MMWR 1999;48(12):243-8. CDC. Notice to Readers: Final 2005 Reports of Notifiable Diseases. MMWR 2006;55(32):880-93.

A Ten Year Transformation in Global Immunization: 23/11/2018 12:4423/11/2018 12:44 23/11/2018 12:4423/11/2018 12:44 23/11/2018 12:44 Increased coverage for routine vaccines Substantial increase in coverage in developing countries, particularly sub-saharan Africa. Increased coverage for new and underused vaccines 15.6 million children immunised against hepatitis B 28.3 million children immunised against Hib 26.3 million children immunised against yellow fever Increased spending Spending on immunization in developing countries has risen from all sources. 4 4 HARWYN\Presentations\GROUP Presentation Oct 05 FINAL.ppt HARWYN\Presentations\GROUP Presentation Oct 05 FINAL.ppt HARWYN\Presentations\GROUP Presentation Oct 05 FINAL.ppt 4 4 4

Varicella vaccine uptake

+4 doses of diphtheria, tetanus toxiods, and pertussis vaccines; 3 doses of polio vaccine; 1 dose of measles-mumps-rubella vaccine; 3 doses of Haemophius influenzae type b vaccine; 3 doses of hepatitis vaccine

GAVI Alliance: a public-private partnership 10

Vaccine introduction strategy Alliance Introduction Design Agreement on policy objectives to guide introduction decisions Design of processes and methods for development of vaccine introduction strategy Alliance Vaccine Introduction Strategy Development Definition of Alliance’s vaccine introduction strategy Vaccines for introduction Activities for support (ADIP’S) Timeframe for introduction Thorough engagement with countries and other stakeholders WHO Vaccine Recommendations Thank WHO and SAGE for the work being done on this. Warmly welcome the expert guidance enabling well targeted activities- a core feature of the Alliance. Scale of new vaccines in pipeline requires consideration of how to prioritise investment. GAVI’s investment strategy will be presented to the Board by mid ’08. Definition of priority vaccines Recommendations for vaccine use Alliance process of analysis, evaluation and prioritization will start with this list 12

Funding innovations IFFIm: International Finance Facility for Immunisation: US$ 4 billion frontloaded from the capital markets AMC: Advance market commitment for pneumo vaccine: accelerating access 13

Health System Strengthening (HSS) US$800 million approved for the 2006-10 period Countries can use this flexible funding for individual priorities including: Recruiting and training health care workers Building/updating facilities Reporting & monitoring systems DECISION The GAVI Alliance Board: Feb 2008 Approved an increase in the GAVI Health Systems Strengthening window by US$ 300 million, allowing all countries to apply for one round, and three countries (Pakistan, Rwanda and Sierra Leone) with planning cycles ending in December 2009, to reapply for one additional round of funding. This decision is taken with the understanding that the above considerations will be addressed.   Reaching MDG 4 or 5 by 2015 will need significant investment in the Health Systems to actually deliver the health packages required to reduce childhood and maternal mortality and morbidity. The GAVI Alliance has launched an initial health strengthening investment of $500 million 2006 - 2010 that will assist countries to identify and overcome health system bottlenecks to delivering childhood health services, with a specific focus on immunization. This investment aims to integrate and harmonize as much as possible and will be driven by country feedback and needs. 14

Immunization Services Strengthening (ISS) Performance-based, data driven program. US$20 provided up front for each additional child pledged to be vaccinated. “No strings attached” to use of money. Local data with independent audits. Effective in increasing coverage rates across a range of baselines. DECISION The GAVI Alliance Board: Feb 2008 Approved an increase in the GAVI Health Systems Strengthening window by US$ 300 million, allowing all countries to apply for one round, and three countries (Pakistan, Rwanda and Sierra Leone) with planning cycles ending in December 2009, to reapply for one additional round of funding. This decision is taken with the understanding that the above considerations will be addressed.   Reaching MDG 4 or 5 by 2015 will need significant investment in the Health Systems to actually deliver the health packages required to reduce childhood and maternal mortality and morbidity. The GAVI Alliance has launched an initial health strengthening investment of $500 million 2006 - 2010 that will assist countries to identify and overcome health system bottlenecks to delivering childhood health services, with a specific focus on immunization. This investment aims to integrate and harmonize as much as possible and will be driven by country feedback and needs. 15

? Total doses administered in 2007 = 9750 Total doses for 100% coverage: 60,678 (based on 3-dose series, cohort of 11-12 yr females=20, 216) Proportion administered 16% 18

Panel Advises Flu Shots for Children Up to Age 18                                                                                                                                                                                      David Maxwell for The New York Times In 2006, Tommy Mericle received a flu shot at the Mahoning County District Board of Health in Ohio By LAWRENCE K. ALTMAN Published: February 28, 2008 All children ages 6 months to 18 years in this country should receive an influenza shot every year, a federal advisory panel said on Wednesday.

2006 National Coverage = 77% # States* Percent range 13 80-89% 32 70-79% 6 60-69% *includes DC http://www.cdc.gov/DataStatistics/2007/childimmunization/