1. Global Overview Progress Towards Global Immunization Goals 21 st inter-country meeting of national managers of the Expanded Programme on Immunization Cairo, 26-29 June 2004

2. Global Goals UNGASS, WHA, MDGs UN General Assembly Special Session (UNGASS) goals by 2010: > 90% coverage of infants nationally & > 80% coverage in every district Vitamin A Deficiency Elimination World Health Assembly (WHA) resolutions & UNGASS goals by 2005: Polio Eradication Measles Mortality Reduction Maternal and neonatal tetanus (MNT) elimination Millennium Development Goal (MDGs): 2/3rd reduction in child mortality in 2015 (compared to 1990)

3. DTP3 coverage by WHO Region, 1995-2002

4. 33 million infants not immunized (DTP3), 2002 Source: WHO/UNICEF estimates, 2003 Slide Date: October 03

5. All countries (n=192) 2002 2003 reporting >80% DTP3 coverage in all districts 26% 26% countries >90% DTP3 national coverage 53% 53% 80% in all districts & 90% national: 26%26% VF-eligible countries (n=75) reporting >80% DTP3 coverage in all districts12% 13% plus countries >90% DTP3 national coverage 21% 21% 80% in all districts & 90% national:12% 12% Immunizationn coverage Progress towards UNGASS goal on coverage

7. Restoring outreach Linking services and community Monitoring and use of data for action Managing human and financial resources Strengthening supportive supervision Recommended strategies to reach > 80% coverage in every district

8. Careful planning at the local level! Map of City Neighbourhood factory market main road footpath small road tent city farming area boundary h.centre bus station slum area middle class houses housing dense housing

9. Vaccination Delivery Strategies to Reach All Ministry of Health, Turkey

10. Even where it is difficult!

11. Working with the community

12. Ensuring safety Injection safety assessments Update 25 April 2004 - includes assessments done by standardized and non standardized protocols List of countries planning injection safety assessment in 2004 is not exhaustive

15. Immunization safety: What is needed? Exclusive use of vaccines of assured quality No reuse of needles/syringes (AD syringes) Proper disposal & appropriate waste management Safe vaccine reconstitution and use of multi-dose vials Effective monitoring & management of safety issues & rumours

16. Pursuing global immunization goals through an "evidence-based" approach High performing surveillance/laboratory networks Coverage monitoring that is accurate and timely Cross-checking through surveys & assessments Development of investment cases Using the data to guide policy/strategy

17. Source: WHO/IVB The evidence……. 1.4 million child deaths globally are preventable by routine vaccination, 2002

18. Measles mortality reduction % reduction in estimated measles deaths by WHO region between 1999 & 2002

19. Global Measles/Rubella Laboratory Network - 2004 The designation employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the secretariat 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. Data as of April 2004 31 Provincial labs 326 Prefecture Labs 154 Sub-National Labs N=671 Global Specialised Labs National Laboratories Regional Reference Labs 160 Measles Strain Banks 149 countries Proposed National Labs

20. Compelling evidence on the burden of congenital rubella syndrome (CRS) Laboratory network reveals a “sea of rubella” Rubella infection in first 3 months of pregnancy has a 90% risk of CRS birth defects Documented CRS incidence 0.2 to 4.3/1000 live births in non-industrialized countries (studies from 50 countries) Estimated >100,000 infants with CRS each year CRS disability (deafness, blindness, heart disease, mental retardation) is costly for families and society

21. Countries with rubella vaccine in the national immunization system, 2003 Source: WHO Department of Immunization, Vaccines and Biologicals, April 2004 1996 67 countries 12% of birth cohort 2003 105 countries 23% of birth cohort

22. WHO position paper on rubella vaccines Weekly Epidemiological Record 2000;75:161-169 The primary purpose of rubella vaccination is to prevent CRS Can be achieved by immunizing child-bearing aged women (CBAW) Introduce rubella vaccine into childhood immunization only if: –Infant measles vaccine coverage > 80% and can be sustained –Ensure immunity among CBAW Warning! Inadequate childhood rubella vaccine coverage (<80%) can: –alter the transmission dynamics of rubella leading to increased susceptibility in CBAW –Increase the risk of CRS

23. Maternal and Neonatal Tetanus Elimination

24. Anticipated progress by 2005 among 57 targeted countries for MNT elimination 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. Source: WHO/UNICEF MNT collected data As of 30 April 2004 Countries with limited progress Countries on track for validation Validated countries by 2005

25. Polio Progress, 2004 cases as of 22 June Endemic countries Wild virus type 1 Wild virus type 3 Importations Paralyzed Children Asia & north Africa = 32 Sub-saharan Africa = 301

26. Enormous potential to contribute to MDG goals!! Causes of 4.1 million child deaths (out of 10.5 million child deaths globally)

27. Dare to dream! What may be possible in the next 10 years in vaccinology!

28. Status by end of 2003 All countries (n=192) HepB in schedule:75% Developing countries with adequate delivery systems* (n=149) HepB in schedule: 85% with comparable coverage to DTP3** 42% VF eligible countries with adequate delivery systems* (n=61) HepB in schedule: 82% with comparable coverage to DTP3** 30% What is possible! GAVI milestone By 2007, all countries will have introduced hepatitis B vaccine

29. Source: WHO/UNICEF joint reporting form, 2002 data from 192 WHO member states Hib vaccine not introduced (108 countries) Hib3 < 80% (10 countries) Hib vaccine introduced but no coverage data reported (29 countries) Hib3 > 80% (45 countries) 2002 (84 countries introduced (44%) Hib vaccine not introduced (167 countries) Hib vaccine introduced but no coverage data reported (25 countries) 1997 (25 countries introduced) Countries having introduced Hib vaccine and reported Hib3 coverage, 2002 Slide Date: October 03

30. Countries providing vitamin A supplementation with routine immunization services, 2002 Non deficient (56 countries) No Vitamin A distribution linked to routine immunization services (countries 71 or 52 % ) (Note: 15/71 provided vitA with immunization campaigns) Source: WHO/UNICEF joint reporting form, 2002; WHO SIA database data from 192 WHO member states Vitamin A distributed with routine immunization services (65 countries or 48%) Global Summary of EPI-linked VitA Distribution VitA with routine EPI:24 countries VitA with EPI campaigns:15 countries VitA with both (routine & EPI campaigns): 41 countries Total: 80 countries Slide Date: October 03

31. Changing landscape in the immunization world R&D accelerating New partnerships –Meningitis Vaccine Programme –African AIDS Vaccine Programme –Measles Aerosol Project –GAVI-ADIPS (Rotavirus-Pneumo) –Japanese Encephalitis Project –[HPV/cervical cancer Vaccine] Need for consolidation (less fragmentation of various immunization initiatives) New vaccines will cost more; financial sustainability becomes paramount Vaccine supply & quality issues are more complex –increased divergence of products for industrialized vs non-industrialized countries –increased number of manufacturers, particularly from non-industrialized countries –increased need for functional NRAs, –need for new regulatory pathways

32. Conclusion Urgency to pursue the current 2005 & 2010 goals –UNGASS coverage goal will not be met unless considerable acceleration to reach every district –Disease control goals (polio, measles, MNT, Vit A elim) Safety/quality is not an option, but a responsibility Enormous potential for impact with future vaccines Need strong evidence base for the old & the new Changing landscape

33. The way forward A WHO/UNICEF Global Vision for Immunization Reach more –Focus unprecedented attention on the "hard-to-reach" –Expand to other age-groups –Use school contacts Provide New –Ensure the widespread use of new or under-utilized vaccines Include others –Deliver additional health interventions at immunization contacts