New Vaccines in Developing Countries: Evidence, Practice, Policy, and Challenges Global Vaccines 202X: Access, Equity, Ethics Philadelphia, USA 2 May 2011 Jon Kim Andrus, MD Deputy Director

Number of childhood vaccines routinely used industrialized countries and in Latin America and the Caribbean, Current GAP HPV Varicela Hepatitis A Meningococcal Seasonal flu Rotavirus Pneumococcal Measles, DPT Poliomyelitis, BCG Haemophilus Influenzae b Rubella Mumps Hepatitis B**

Accelerating Policy

Priorities HPV vaccine and cervical cancer Source: IARC 2004 estimates Cervical Cancer Disease Burden Taking advantage of new technologies while enhancing approaches to screening to reduce mortality of this disease of poverty Reducing the developing country uptake time lag >2 decades Taking advantage of new technologies while enhancing approaches to screening to reduce mortality of this disease of poverty Reducing the developing country uptake time lag >2 decades 77,000 new cases per year 33,000 deaths per year 77,000 new cases per year 33,000 deaths per year

Urged Member States to: Expand legal and fiscal space and identify new revenue sources to sustainably finance the introduction of new vaccines against rotavirus, pneumococcus, influenza, and human papillomavirus; Support the mortality reduction targets, consistent with GIVS and the MDGs, for HPV, RV, influenza, and pneumo associated disease; Utilize the PAHO Revolving Fund for Vaccine procurement to purchase new and underutilized vaccines 47th Directing Council, September 2006

ProVac Policy Framework Technical criteria Programmatic criteria Financial criteria www. paho.org/immunization Andrus et al. Public Health Reports 2007;122(6):811-19

Tools for Economic Analysis Costs Health Gains Vaccine Intro Costs Tool Burden of Disease Tools Economic Analysis Cost Effectiveness Studies Rotavirus Cost Effectiveness Studies Pneumococcus Cost Effectiveness Studies HPV Cost Effectiveness Studies Influenza

Number of Countries with Seasonal Influenza Vaccination Programs in the Americas, Countries

Accelerating Deployment

Pro-Vac Workshop, September 2006 Congenital Rubella Syndrome

Strategies Strategies always rely on: Immunizing susceptible population Conducting effective surveillance Sustaining the gains

* Vaccination of men and womenVaccination of women only Source: Country reports Andrus JK, et al. Vaccine 2008 Coverage (%) Rubella Vaccination Coverage in Selected Countries of the Americas,

Rubella elimination and primary health care PAHO. Changing lives: The EHDI experience in Costa Rica. EPI Newsletter August 2007;29(4):1. Castillo-Solorzano C, Andrus JK. Rubella elimination and improving health care for women. Emerging Infectious Diseases 2004;10(11):17-21.

14 Rubella Elimination Source: Country reports Accelerated rubella control Measles Elimination Rubella and Measles Elimination, The Americas, 1980–2009

Future Challenges

Pro-Vac Workshop, September Pan American Health Organization Uptake of Pentavalent Vaccine in the Americas Year Number of Countries $0 $1 $2 $3 $4 $5 $6 $7 $8 Price ($) Countries PurchasingPrice per dose 4 Countries, 3.9 million Doses 31 Countries, 10.5 million Doses $7.20 $3.94

Urban cluster of yellow fever cases in Paraguay, 2008 A urban cluster of human YF cases, Asunción Metropolitan area*. A urban cluster of human YF cases, Asunción Metropolitan area*. 10 deaths 10 deaths Median of age: 24 years (11-39) Median of age: 24 years (11-39) Female: 55% Female: 55% Infestation Index by Ae. Aegypti: 23% Infestation Index by Ae. Aegypti: 23% *Laurelty, Central Department

In summary, there is no magic bullet to ensuring equitable and sustainable introduction of new vaccines into developing countries. Ultimately, the solution requires a strategic vision grounded in long-term goals, not short- term fixes. Pan American Health Organization www. paho.org/immunization