WHO Challenges and priorities for immunization policy making Philippe Duclos, WHO Science and Technology Options Assessment, STOA – AVIESAN Workshop, June 19 th 2012, European Parliament, Bruxelles

Health Statistics and Informatics: for information you can trust Major causes of death in neonates and children under five globally – millions deaths a year in children < 5 year About one third of all child deaths linked to malnutrition Children in low-income countries about 18 times more likely to die 63% (4.8 millions) infectious diseases Crédit to Colin Mathers – Unpublished -confidential

The world is getting heavier! Source: World Health Statistics: A snapshot of Global Health, 2012, World Health Organization WHO/IER/HIS/12.1

“Climate change is the greatest global health threat of the 21st century” University College London (UCL) Lancet Commission

Global coverage estimates, DTP3, Measles, HepB3, Hib3, PCV3 and Rota Source: WHO/UNICEF coverage estimates 2010 revision. July ,000 unvaccinated infants (DPT3) in EURO, % live in countries eligible for GAVI Alliance funding

Countries with % of districts achieving at least 80% DTP3 coverage, % districts (59 countries or 31%) % districts (35 countries or 18%) % districts (32 countries or 17%) No data (43 countries or 22%) Not applicable 0-49 % districts (24 countries or 15%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO All rights reserved Source: WHO/UNICEF estimates and WHO/IVB database, September WHO Member States. Date of slide : 12 June 2012.

European Region, reported measles incidence, 2011

The Global World and Vaccines Opportunities Rekindled political & public health interest Resources allocated and innovative financing mechanisms – GAVI $4.3 billion Progress made with coverage Global targets set "Pharma" engagement Rich pipeline of new vaccines Decade of Vaccines Challenges Conflicting priorities Vaccine field tends to be vertical Weak health services Lack of transparency about costing Changing epidemiology Lacks grassroots activism Threatened by vaccine "hesitancy"

“We envision a world where children, families, and communities enjoy life protected from the threat of disease. The purpose of the Decade of Vaccines is to extend the full benefits of immunization to all people, regardless of where they live”

WHO Vaccine Position Papers Position papers = Key reference documents Developmental and review process (follow recommendations of SAGE, extensive peer review, evidence-base, periodic updating) Format Weekly Epidemiological Record Current structure (Intro, background (Disease epidemiology, the pathogen, disease), info on vaccines (composition, safety, immune response, efficacy and effectiveness, cost effectiveness and any other relevant issue), WHO position on vaccine use) Additional posting of information on the web: Grading of Recommendations Assessment, Development and Evaluation (GRADE) tables, references, summaries (one pager and PowerPoint presentation)

Aspects for which there is a lack of data to support decision making Effectiveness in developing countries and herd immunity Adjust schedules: reduce number of doses, dose spacing and duration of protection (alleviate number of booster doses) Vaccines co-administration Risk groups: immunodeficient, pregnant women, very young and very old Impact of vaccination strategies Cost-effectiveness studies  Need good and coordinated surveillance

Communication methods for vaccine-hesitant populations Use of vaccine in humanitarian emergencies Accessibility to affordable vaccines and WHO's role Use of vaccines in immunocompromised populations Optimizing immunization schedules Non specific effects of vaccines Impact of introduction of new vaccines on strengthening of immunization and health systems Maternal immunization to enhance the protection of mothers and infants Involvement of the private sector Strengthening of NITAGs Thiomersal Vaccine stockpiles Recommendations on use of specific vaccines and monitoring of implementation and impact New Challenges: SAGE’s Agenda

Current political commitment does not translate into significant changes Reporting transparency – some member states fail to report VPD cases or forward samples to regional laboratories for confirmation – political context "Denominator" remains a problem in several member states Significant (negative) impact of health system changes/reforms on immunization programme implementation Need fair salaries for immunization and surveillance personnel including laboratory staff to maintain skilled workforce Expanding assistance to National Immunization Technical Advisory Groups Self-procuring member states face higher cost (e.g. >10USD per dose of pentavalent vaccine or MMR) in absence of competition Vaccination acceptance  a raising problem with varying underlying causes European Region: some specific challenges

WHO research priorities Biomarkers Assess performance, strategic information and support decision making – validate vaccine coverage and assess population susceptibility How to differentiate natural infection from vaccination Definition of correlates of protection Implementation research Identify problems in programmes implementation and their determinants, develop and identify and implement solutions Platform for researchers to share research results, and assess their potential contribution to global immunization vaccine policies and practices Establish networks and intercountry collaboration

Decade of Vaccines R&D at global level to maximize vaccination benefits: preliminary list of activities Short term New communication methods Representative epidemiological and impact studies to guide cost-effectivess studies Operational research on different approaches to immunize during the entire life course and in situation of emergencies Mid term Adjuvants: access and know how Administration without needles Thermostability New production methods Regulatory research Long term Improve understanding of innate and adaptative immunity microorganisms causes of variability in response to vaccines

Research and development of vaccine policies Need to identify research priorities to facilitate decision making and adjustment of policies Need for dialogue and exchange of information Continuous process

Thank you With acknowledging the input and assistance provided by WHO colleagues and particularly that from Dina Pfeifer (EURO) and Laure Dumolard (HQ)

Current vaccines and vaccines on the horizon Source – WHO, 2005