What’s new in immunization and where

do PVOs fit in?

Presented to CORE Group Meeting

by Rebecca Fields and Robert Steinglass, MCHIP

October 12, 2012

Outline of presentation

What is new in the field of immunization Findings from ARISE with particular

relevance for PVOs New vaccine introduction

Pneumonia other12% Pneumoccocal

diseases*6%

Hib*2% Pertussis

2%Tetanus

1%Measles1%

Rotavirus*5%

Diarrhoea other10%HIV

2%Malaria9%

Perinatal32%

Other18%

Global U5 Mortality: Role of Vaccine Preventable Diseases (2008 data)

8.8 million under five deaths

17% (1.5 million) from vaccine preventable diseases

Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis, Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.* WHO/IVB estimates

The cause of 1.5 million deaths globally among children that are preventable by routine vaccination, 2008

Pneumoccocal diseases*

32%

Rotavirus*30%

Hib*13%

Pertussis13%

Measles8%

Tetanus4%

Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis, Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.* WHO/IVB estimates

What’s new in immunization?

Global Vaccine Action Plan (Decade of Vaccine) Many new entrants into immunization arena Need to move from RED to REC Role for CSOs recognized (RED modules, MLM

module on partnering with communities) Mechanisms to engage CSOs (e.g. GAVI

constituency) Inequity now recognized as key challenge BMGF strategy for routine imm being designed Polio erad. declared public health emergency New vaccines exposing cracks in RI system

Source: Optimize

1. Varies by nat'l schedule; represents maximum.1980: Diphtheria, pertussis, tetanus, measles, polio and tuberculosis; 2010 add'l vx: PCV, Rota, HepB, Hib, Yellow Fever, Rubella, JE, MenA. 2. Represents maximum; 1980: 1 BCG, 3 DTP, 3 OPV, 1 measles; 2010: based on 2012 WHO immun. position papers. 3. Based on projected vol. per immun. child for 20 countries according to introduction plans; compares 2001 vol. for tradt'l vx with 2020 expected vol.; growth driven by penta, PCV, Rotavirus, HPV. 4. Based on 2008 projections. Source: WHO Bulletin, 62 (5):729 -736 (1984); Optimize Vaccine Supply Chains, Optimize (2009); State of the world’s vaccines and immunization, WHO (2009); Vaccine volume calculator, S. Kone, WHO (2011); Immunization position papers, WHO (2012). Historical analysis of cMYPs in GAVI eligible countries, L. Brenzel and C. Politi (2012)

Diseases vaccinated against1

Vaccine volume per fully immunized child (cm3)3

Immunization cost per child ($) [including

delivery costs] 4 ~6x

4x

2.5x

2010+$30+

1980s realities 2010 and beyond realities

20050

1980$5

2008$17

Increased stress on

the RI system

Age groups targeted for immunization

Vaccine doses per child (#) [assuming

receives vx listed above] 2 ~3x

System requirements continue to grow

Across life

course

Routine Immunization System

Life Cycle

Vaccination

Polio Eradication

NUVI

Measles Elimination

Support other health

interventions

Tetanus

Eliminatio

nFamily

Planning

• RED is intended to be a flexible approach

• the idea is for countries/districts to tailor it to fit their situation

• so the intensity of implementing each component will vary from country to country

The five overlapping components of the Reaching Every District (RED) approach

Planning and managementof resources

Reaching the target populations

Linking services with communities

Supportive supervision

Monitoring for action

Source: ARISE/JSI, 2012

JSI’s ARISE ProjectAfrica Routine Immunization System Essentials (funded by BMGF)

Strengthen the evidence base to improve understanding of the drivers of RI system performance and exploring investment options.

What drives routine immunization performance in Africa?Why did coverage improve in some countries? Why did coverage improve in some districts and not others? (within the same country: Ethiopia, Ghana, Cameroon)

Visit us at arise.jsi.com

ARISE Project: A pathway to improving routine immunization coverage at district level in Africa

Take vaccination into heart of the

community

More workers,

build trust, local support,

vaccine supply.

Raised awareness, improved access,

increased use

Cadre of Community-centered Health Workers

Effect

Mechanism

Transformational step

Joint planning,

awareness- raising,

Performance review, Resource pooling

Shared Shared sense of sense of

purpose & purpose & accountabiliaccountabili

ty, ty, credibilitycredibility

Ensured service

availability,

decreased dropout rates

Partnership between the Health System and the Community

Effect

Mechanism

Transformational step

Gather information

on preferences;

choose appropriate

sites for outreach,

adapt servicesPersonal links, use

appropriate avenues, trust and credibility

of health workers and

service Increased physical and

social access;

increased acceptance,

improved completion

of vaccination

schedule

Tailor Immunization Services to Community Needs

Effect

Mechanism

Transformational step

CSHGP Historic Level of Effortsby Intervention

Role of PVOs/NGOs

Engage on global immunization issues Assure immunization is a core component of all

health programs Play a role at national and sub-national levels

(Inter-agency Coordinating Committee, plans) Staff need to stay technically up-to-date Make sure immunization doesn’t get lost amid so

many other objectives/initiatives

Why does civil society (e.g., PVOs) often NOT participate in routine immunization?

Feel unwelcome on ICC Uneasy relationship with

Government/MOH Increasing demand can

betray trust, if services don’t follow

Community work not valued

Immunization is too vertical, broader objectives

Looking for financial support

“New” vaccines – new opportunities

yellow fever rubella hepatitis B HPV (human papillomavirus virus) Hib (haemophilus influenzae type b) pneumococcal (conjugate) rotavirus meningococcal A (conjugate) typhoid JE (Japanese encephalitis) oral cholera

New vaccines bring new challenges

Increase in number of vaccines (6 12 -15) Difficult age restrictions (Rotavirus vaccine) New target age groups (HPV) New messages (disease syndromes, partial

protection) Integrated approaches to disease control Cold chain and logistics challenges (volume,

waste) Cost of new vaccines

Framework: Protection, prevention and treatment strategies for pneumonia & diarrhoea

Reduce Reduce pneumonia pneumonia

and and diarrhoea diarrhoea morbidity morbidity

and and mortalitymortality

PREVENTPREVENT

PROTECTPROTECT

TREATTREAT

24

Contribution of healthy actions for pneumonia and diarrhea interventions - examples

PROTECTPROTECT PREVENTPREVENT TREATTREAT

Exclusive breastfeeding for 6 months

Vaccines against measles, pertussis, Hib , rotavirus,

and pneumococcus

Home management of dehydration (ORS and

zinc)

Adequate nutrition Vitamin A supplementation

Community Case Management (CCM)

Hand-washing with soap Prevention of HIV in children

Case management in health facilities

Community-wide sanitation promotion

Cotrimoxazole prophylaxis for HIV exposed and

infected children

Case management at hospitals

Treatment and safe storage of household

water

Zinc supplementation for children with diarrhea

Example of BCC materials, Kenya

PCV 10 Poster – Global Action Plan Against Pneumonia

Poster during “Malezi Bora” child health week (linked with Africa Vaccination Week)

Challenges and opportunities with new vaccines – role for PVOs?

Resource mobilization for new vaccine introduction

High demand for the vaccine – real danger of stock outs

Community perceptions on multiple antigen vaccinations

Communication about disease syndromes when only some is vaccine-preventable

Real opportunity to achieve MDG 4

Renewed government/ partners interest in immunization

Renewed community interest in immunization

Training opportunity for health workers

Create momentum for GAPP implementation

Challenges Opportunities

Opportunities for PVOs to engage

1) Policies and plans exist – need to strengthen communication and community involvement for pneumo and DD prevention/ implementation; develop strategies for migrant and urban populations

2) National and local media – develop partnerships for positive messaging and supportive articles/programs

3) Technical Advisory Groups – integrate case management and prevention with behavior change interventions

4) Link with initiatives (World Pneumonia Day, World Handwashing Day, 2012 Year of RI Intensification)

5) Community mobilizers in place – improve/focus their support in high risk areas (mapping, due lists, referral)

Immunization has a role to play in your portfolio:

MCH IMCI/CCM Nutrition Safe Motherhood Infectious Diseases Child Health Child Survival PHC

Vaccinated, Immunized

& Protected!

Thank You

Every child should be a VIP…

Thank you!

www.mchip.net

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Extra slides

Global Vaccine Action Plan’s strategic objectives

• All countries commit to immunization as a priority• Individuals and communities understand value of vaccines

and demand immunization as both their right and responsibility

• Benefits of immunization are equitably extended to all people

• Strong immunization systems are an integral part of a well-functioning health system

• Immunization programs have sustainable access to predictable funding, quality supply and innovative technologies

• Country, regional and global research and development innovations maximize the benefits of immunization

MCHIP immunization strategies

Increase capacity for sustainable immunization coverage with all appropriate vaccines to reach unreached and reduce child mortalitySupport effective and sustainable introduction of safe, high-quality, life-saving new vaccinesEngage in disease control priority programs with focus to enhance positive effects on strengthening RI platformInfluence global and regional levels with program learning from the field

Sustainable Routine Immunization System

Policies

PracticesFinancing

CommunityAction

Advocacy &Communications

Monitoring &

Surveillance

Supportive Supervision

Supplies &

Logistics

Training

Management

Introduction of new vaccines are challenging the immunization system• Good planning, partnership and adequate resources • Effective commitment of Government, partners and community• Good coordination between MOH and ICC partners and close follow-up for the

introduction process• Additional storage capacity to accommodate new vaccine• Increased number of vaccines at the vaccination site level• Increased immunization waste to manage and dispose• More training for health workers and community volunteers• Revised technical guidelines, recording and reporting tools, IEC materials, etc.• Good communication with parents to address concerns• Good surveillance system prior to and after NV introduction• Extra financial resources required to buy vaccines

•

National Actions

Global Actions

Program Implementation

Preparation(3-6 months before

launch)Vaccine Launch

Post-Introduction

M&E

Initiate discussion and reach consensus to introduce a vaccine

and the type of product

Conduct nationwide cold Chain storage space assessment

Update/prepare cMYP and costing tables

Ensure it is incorporated into the national health sector

plan

Develop an introduction plan

Initiate surveillance to establish baseline

Prepare and/or amend application and submit

on time

Solicit ICC endorsement and commitment for implementation

Obtain ministerial signatures on the

application to GAVI

Country re-/submits application

IRC makes a recommendation to the GAVI Board

GAVI Secretariat prioritizes

applications for approval

Upgrade cold chain

Advocate for vaccine introduction

support

Conduct registration of the vaccine, review

vaccine supply distribution system, upgrade as needed

Revise, print and distribute EPI

management tools

Develop learning materials, conduct technical training

Make improvements to

waste management system, as needed

IEC/demand creation for new

vaccine

Initiate AEFI surveillance for the NV and strengthen AEFI

reporting system

Develop communications

strategies and key messages to address caregiver/ provider

concern(s)

PR events held to launch the

vaccine

Monitor and respond to any

reported adverse events

Conduct post-introduction evaluation

assessment a year following vaccine launch

Document lessons learned

Reduced morbidity

and mortality due to the targeted vaccine

preventable disease

Asses the magnitude of the problem: morbidity and

mortality due to the target disease with the

new vaccine

Scale Up Map for New Vaccine Introduction

Conduct impact

assessment

Source: MCHIP 2011

What do some country bilaterals say about ICC and

immunization?• ICC agenda is too

narrow, confining• Important ICC

decisions made beforehand

• Their technical assistance not valued

Potential country roles for NGOs in routine immunization

• Directly immunize• Support district MOH staff (capacity

building)• Mobilize communities and create

demand• Use birth and service registers to reduce

left-outs and drop-outs• Plan and monitor with communities• Advocacy

So why does Civil Society participate on campaigns?

• High-level request• Clear role• Credit/Recognition• Funding• Supply/services assured

“But they won’t participate for the long-run.”

So why do NGOs love to participate in “Child Health”/CCM/c-IMCI?

• Credit/recognition (appreciation from communities)

• Supply assured • Clear role• Funding

Promotion of “Healthy Actions”

•Motivate individuals, households, and communities to: Adopt “healthy actions” Engage in the fight

against leading child-killers

Increase demand for health services

Identify danger signs and seek treatment

• Improve knowledge, attitudes, norms and practices

• Motivate others to use immunization and other PHC services• Arrange a clean outreach site (school, community meeting room, etc.)• Transport vaccines and health workers, particularly for outreach sessions• Inform other community members when a health worker/team arrives at the outreach site• Provide a meal to the health worker when they are on outreach visits• Register patients, control crowds and make waiting areas more comfortable on the day of a fixed or outreach session • Deliver appropriate messages, including dispelling rumours about immunization• Assist with newborn and defaulter tracking• Arrange home visits when children are behind schedule, to explain immunization and to motivate caregivers• Provide equipment and even financial support

Understanding reasons for low coverage is easier when district and health facility staff establish rapport with the community and involve community members in planning, promoting, implementing and monitoring services

Illustrative community linkages with immunization