A program of the A Private Immunisation programme complimenting a National Programme Dr Simon Strachan MBChB(UCT) FCPaed(SA) Paediatrician Private Practice Johannesburg South Africa IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 1

Overview Access and distribution Size of the market Private 12% of the total Managing the schedules Vaccine gap is decreasing Robust private market carries the cost and utilises the public sector Pharmacovigilance Training and accreditation IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 2

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South Africa IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey square kilometres Roughly the same size as Niger, Angola, Mali, and Colombia. 1/8 the size of the US, 2 x France, >3 x Germany, 5 x Great Britain Population 54 million 30% of population younger than 15 years Gauteng 1.4% of land 24% of population

Development of EPI in South Africa EPI 1995DTP, OPV, BCG, Measles 1995Hepatitis B vaccine was introduced Hib vaccine introduced 2000Intradermal BCG vaccine Neonatal tetanus was eliminated South Africa was declared polio-free PCV 7 and Rotavirus Acellular pertussis vaccine Inactivated polio (IPV) Hib booster at 18 months 2010PCV HPV vaccine Hexaxim introduction IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 5

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Immunisation Clinics Public clinics Municipal clinics Staffed by registered sisters offering primary health care services Free to all Arrive and wait with all EPI vaccines only Private clinics Privately owned or housed within pharmacies or hospitals Staffed by registered sisters EPI and private vaccines available Consultation - fee for service Developmental screening, feeding advice, childcare advice IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 7

Vaccinator clinics Private sector IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 8

Market size IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 9 Private births are estimated at 10% -15% of the birth cohort of approximately 1.2 million – births

Market size Units of Vaccines sold IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey %

Unit sales in private Total Private market valueR IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 11

Market size IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey divide by

Vaccine Gap - smaller EPIPrivate only BCGRubella TetanusMumps DiphtheriaHepatitis A Acellular PertussisChickenpox Haemophilus InfluenzaeMeningococcal PneumococcusInfluenza Rotavirus Hepatitis B Inactivated Polio Measles Human Papilloma Virus IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 13

Private schedule IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 14

Differences in Schedules Schedules are identical up to 9 months of age Choice in the Private sector Additional visits : 12months + 15 months School entry: 6 years Td vs TdaP/IPV + MMR School based vaccination programme HPV – Public schools only at 9 years of age (Grade4) HPV – at 12 years in the private sector Pertussis Boosters at 12 years Meningococcal boosters at 12 years No national programme for adolescent or maternal vaccines IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 15

Vaccine distribution Procurement of vaccines for EPI at National level Provinces decide on: Funding Procurement Distribution Municipal clinics order from Regional depots and depots deliver to clinics Private vaccinators order EPI vaccines through the local clinic and collect from that clinic can order all vaccines directly from private suppliers have access to EPI vaccines if the vaccinator has completed EPI training IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 16

So who foots the bill? Low tender prices with free vaccines for all???? Service oriented delivery in the private market with choice at a cost. Provide free EPI vaccines to all private vaccinators IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 17

Private vs Tender price IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 18

Private price premium Source – IMS: Oct 2012 to June 2014 Private price premium above Public price

Real costs IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 20 VaccinesCost excluding vatTender price Heberbiovac (Hep B) Pentaxim (5 in 1) Prevenar (PCV 13) Rotarix (Rotavirus Rouvax (Measles)

Cost of vaccines first visit IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 21

Benefits of Private clinics Easy access and booked appointments Follow up and recall Out of stock More than just a vaccine clinic Well baby clinics Breastfeeding promotion Antenatal clinics Neurodevelopmental assessments Additional vaccines available State vaccines available at no cost Cocoon strategy/maternal vaccination Vaccine advocacy

Concerns No requirement for accreditation of clinic sisters Training provided by the EPI not readily accessible Rapid turnover of staff in public clinics Private sisters obtain private training No CME Vaccine coverage not accurate No requirement to keep or submit statistics in private Private clinics have difficulty in accessing state funded vaccines

Pharmacovigilance Adverse event reporting Directly through to the NDoH but this avenue is unreliable VAER typical occurs via the Pharmaceutical company reps and managers who then alert the EPI managers. The structures for VAER are not robust in either the private or the public sector IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 24

National accreditation All vaccinators: Must complete training programme Receive accreditation and maintain accreditation by: Attending on going education Providing statistics Private vaccinators will all receive government vaccines No vaccinator may operate without accreditation Public private partnerships to provide training and on going accreditation

Conclusion Robust private market is necessary when introducing new vaccines into the EPI Produce a private schedule that honours the EPI Private vaccinators are beneficial to the Public sector Cost of private vaccines directs people to the public sector Access to EPI vaccines for all must be ensured An effective system for VAER is required Standardised training and accreditation is necessary IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 26

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