china & nip countries_pcvaccine advocacy

Burden of Pneumococcal Diseases in China:

Socioeconomic disparities & comparisons of China provinces with 10 low/middle income countries which have implemented Prevenar in their NIPs

Presented to Pfizer/Shanghai, 17 June 2010

Prepared from peer-reviewed sources of data*

by A/Prof. Dr. Bob Bernstein, MD, PhD

Hubert Dept. of Global Health,

Rollins School of Public Health, Emory University

* See Notes pages for data sources

Outline*

Determinants of Health Inequities & Disparities

Global Burden of Preventable Pneumococcal Disease

Pneumoccocal Disease Situation in China

China Provinces and Countries with PCV in their NIP

Benefits of Implementing PCV in China

* NIP: National Immunization Program; PCV: Pneumoccoccal Conjugate Vaccine

Determinants of Health Inequities & Disparities

WHO/EURO Health for All Strategy*

* See http://whqlibdoc.who.int/euro/-1993/EUR_ICP_RPD414(2).pdf;

http://www.who.int/social_determinants/implementation/countries/expertmeeting062008/en/index.html; and

http://www.who.int/social_determinants/thecommission/finalreport/en/index.html (available in English & Chinese)...

Main Determinants of Health*

* Dahlgren G: “Policies and strategies to promote social equity in health” - Background document to WHO Strategy

paper for Europe (http://www.framtidsstudier.se/filebank/files/20080109$110739$fil$mZ8UVQv2wQFShMRF6cuT.pdf)

Which health differences are inequitable?

Four basic issues in reducing health disparities*

* Dahlgren G: “Policies and strategies to promote social equity in health” - Background document to WHO Strategy

paper for Europe (http://www.framtidsstudier.se/filebank/files/20080109$110739$fil$mZ8UVQv2wQFShMRF6cuT.pdf)

In God we trust; all others bring data; but, you can be data rich and information poor…

Burden of Preventable Pneumococcal Disease

The % of under-5 mortality due to all-cause pneumonia has decreased with development, but remains a major preventable killer of children*

* Source: courtesy of I Rudan et al, “Causes of deaths in children younger than 5 years in China in 2008”, The Lancet

2010; 375: 1083-1089.

* Black et al (2010) for WHO/UNICEF CHERG, The Lancet 375: 1969-1987. Prepared with the assistance of Prof. Yan GUO and Dr. Kit Yee CHAN, School of Public Health at Peking University, Beijing. “Other infections” include bacterial sepsis.

Pneumoccocal Disease Situation in China

China met its national MDG-4 Goal for reducing under-5 mortality by 71%, 1990-2008*


2010; 375: 1083-1089.

Under-5 mortality rates vary widely (>6-fold) in Chinaby the level of urban/rural socioeconomic development*


2010; 375: 1083-1089. Based on strata established by the China MoH Information & Statistic Center, the urban units

are more developed than are rural units; rural units type I are the most developed, and type IV are the least developed.

In China, all-cause pneumonia is at the top of the 8 main causes of under-5 mortality, especially in ages 1-11mo & 1-4yrs*


2010; 375: 1083-1089.

Pneumonia

46.8% among

post-neonates

(age 1-11 mo)

Pneumonia

15.4% among

toddlers

(age 1-4 yrs)

Pneumonia

16.5% among

under-5

(age 0-59 mo)

Spn

contributes to

sepsis

as well as

pneumonia

among

neonatal

causes of

death

(age <1 mo)

Source: http://graphs.gapminder.org/world/china.php

U5MR: 8-fold range among

provinces of mainland China

(NB: log scale)

GDP/pc: 10-fold range among


(NB: log scale)

Under-5 Mortality Rate by GDP per capita, China 2008

(5.0)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

(5000) 0 5000 10000 15000 20000 25000

GDP per capita (Int'l $ PPP)

Under-5 mortality rate per

1,000 live births

Prepared by Dr. Bob Bernstein from data provided by Igor Rudan (WHO/CHERG) and Zhang Zhongxing

(GapMinder Foundation) – bubble size is proportional to the number of live births per year (per China NBS)

Shanghai

(109,800 LB)

Beijing

(100,800 LB)

Tianjin

(80,300 LB)

Sichuan

(746,200 LB)

Guizhou

(554,800 LB)

Xingjian Uyghur

(336,000 LB)Tibet

(48,720 LB)Shaanxi

(370,000 LB)Yunnan

(661,500 LB) Hebei

(883,200 LB)

Heilongjian

300,200 LB)

Shandong

(1,162,500 LB)

Zhejiang

(535,000 LB)Hunan

(749,700 LB)

Henan

(1,090,400 LB)

-20,000

0

20,000

40,000

60,000

80,000

100,000

120,000

-5000 0 5000 10000 15000 20000 25000

Unde

r-5

IPD

case

s


Incidence of vaccine-preventable invasive pneumococcal

disease (IPD) cases by GDP per capita, China 2008

Prepared by Dr. Bob Bernstein from data provided by Kate O’Brien (JHU/PneumoADIP & WHO/GDB team),

Igor Rudan (WHO/CHERG), and Zhang Zhongxing (GapMinder Foundation) – bubble size is proportional to the

number of live births per year (per China NBS)

Shanghai

(109,800 LB)

Beijing

(100,800 LB)

Tianjin

(80,300 LB)Tibet

(48,720 LB)

Henan

(1,090,400 LB)Shandong

(1,162,500 LB)

Hebei

(883,200 LB)

Jiangsu

(699,200 LB)

Sichuan

(746,200 LB)

Zhejiang

(535,000 LB)

Guizhou

(554,800 LB)

Anhui

(756,400 LB)

Yunnan

(661,500 LB)

Hunan

(749,700 LB)

-1000

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

(5000) 0 5000 10000 15000 20000 25000

Under-5 pneumonia deaths


Number of Under-5 Pneumonia Deaths by GDP per capita,

China 2008

Prepared by Dr. Bob Bernstein from data provided by Igor Rudan (WHO/CHERG) and Zhang Zhongxing

(GapMinder Foundation) – bubble size is proportional to the number of live births per year (per China NBS)

Shanghai

(109,800 LB)

Tianjin

(80,300 LB)

Beijing

(100,800 LB)

Zhejiang

(535,000 LB)

Shandong

(1,162,500 LB)

Xingjian Uyghur

(336,000 LB)

Sichuan

(746,200 LB)

Guizhou

(554,800 LB)

Hebei

(883,200 LB)Yunnan

(661,500 LB)

Tibet

(48,720 LB)

The % of under-5 mortality due to all-cause & vaccine-preventable pneumonia varies 6-7 fold across the 31 provinces of mainland China*

* Source: courtesy of I Rudan et al, “Causes of deaths in children younger than 5 years in China in 2008”, The Lancet 2010; 375:

1083-1089. According to WHO/CHERG, about 17-37% of all-cause pneumonia is attributable to S pneumoniae (GB Grant et al,

“Recommendations for treatment of childhood non-severe pneumonia”, Lancet Infect Dis 2009; 9:185-196)

Under-5 mortality & % all-cause pneumonia varies 6-7 fold

across provinces in mainland China*

* Source: Rudan et al (2010), “Causes of deaths in children younger than 5 years in China in 2008”,

The Lancet 2010; 375: 1083-1089. According to WHO/GDB-JHU/PneumoADIP, about 16-51% of all-

cause pneumonia is attributable to S pneumoniae (O’Brien et al 2009, web annex)

Shanghai:

U5MR 4.9/1,000 LB

5.9% Pneumonia

Sichuan:

U5MR 38.8

24.5% Pneumo

Beijing:

U5MR 6.3

6.5% Pneumo

Guangdong:

U5MR 8.6

8.2% Pneumo

Zhejiang:

U5MR 11.8

10.4% Pneumo

Shanxi:

U5MR 22.7

16.8% Pneumo

1.21.40.81.10.90.60.72.6

1

4.4

1.1

8.5

1.12.7

1.4

7.79.4

1.3 0.72.2 1.3

5.4

0

41.7

3.9

1.3

13.6

0.9 0.8

14

5.9 6.6

0.4

3.6

0.7

7.2

02468

101214161820

0 20 40 60 80

Perc

en

t o

f U

nd

er-

Fiv

e D

eath

s D

ue

to P

neu

mo

nia

GNI per capita (PPP $000)

Pneumonia Mortality in 43 Countries

Not yet announced (50 million births/year in 7 Asian countries): “C” = China (16.16 M births/yr), “Ia” = India (24.44 M

births/yr), “Io” = Indonesia (4.25 M births/yr), “M” = Malaysia (0.59 M births/yr), “P” = Philippines (2.29 M births/yr), “T” =

Thailand (0.85 M births/yr), & “V” = Viet Nam (1.39 M births/yr). For GNI Purchasing Power Parity (PPP) values, see

http://www.nationsonline.org/oneworld/countries-classification, and for U-5MR values, see “Pneumonia: the Forgotten Killer of

Children” (www.childinfo.org/files/Pneumonia_The_Forgotten_Killer_of_Children.pdf); Wong Swee Lan, Hussain Imam Muhammad

Ismail (2008). “A Study on Under-Five Deaths in Malaysia in the Year 2006. MoH/Malaysia Clinical Research Centre, Kuala Lumpur

(http://www/crc.gov.my); and the following WHO web sites: http://www.who.int/whosis/whostat/2008/en/index.html and

http://www.who.int/countries/mys/en/.

S

Singapore – what could explain the

high % of U5 deaths attributable to

pneumonia – does this indicate a

socioeconomic disparity in

healthcare access or performance?

Who are these SG children?

Ia

Io

M

PTV

C

China

China Provinces Compared with Countries that have

Implemented Pneumococcal Conjugate Vaccine

in their National Immunization Programs

Relatively wealthy and highly competitive “Top

Ten” Chinese cities like Beijing (#4), Shanghai (#3),

and Tianjin (#7) need to ensure future prosperity by

protecting the health of their children (“better city +

better health = better life”)

Rwanda is a GAVI aid recipient country with a

pop’n of 11M, and a GDP/pc & pneumonia

mortality statistics similar to the provinces of

Guizhou (pop’n 38M) & Sichuan (pop’n 82M)

provinces…

Market Access

strategic

planning 2b

Use these results for

advocacy with CDC

leaders in cities of

Sichuan & Guizhou

provinces together

with potential private

sector/foundation

partners – consider a

GAVI-like public-

private partnership

with concessional

vaccine sales prices

for poor residents of

these cities

- basis of argument

could include need to

reduce socioeconomic

disparities & improve

equity in access to NIP

vaccines and other

essential drugs

Prepared by Dr. Bob Bernstein from data provided by Kate O’Brien (JHU/PneumoADIP & WHO/GDB team), Igor Rudan

(WHO/CHERG), & Zhang Zhongxing (GapMinder Foundation) – bubble size is proportional to the number of live births per year

(per China NBS and US Census Bureau Int’l Data Base)

Incidence Invasive Pneumococcal Diseases, under-5 children,Region 1, China, 2008

0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in

under-5 children Chongqing

Gansu

Hubei

Hunan

Qinghai

Shaanxi

Sichuan

Incidence Invasive Pneumococcal Diseases, under-5 children,selected low & middle income NIP countries, 2008

0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in

under-5 children Costa Rica

Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia

Burden of IPDs – China provinces compared to low/middle-income NIP countries

Incidence Invasive Pneumococcal Diseases under-5 children,Region 2, China, 2008

0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in

under-5 children

Anhui

Jiangsu

Shanghai






0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in


Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia


0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in

children under-5

Fujian

Jiangxi

Zhejiang






0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in


Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia


0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. cases IPD in

under-5 children

Beijing

Hebei

Shandong

Tianjin






0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in


Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia


0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000

GDP per capita (Int' $ PPP)

No.

case

s IP

D in

unde

r-5

chil

dren

Guangdong

Guangxi Zhuang

Guizhou

Hainan

Yunnan






0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in


Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia


0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No.

case

s IP

D in

unde

r-5

chil

dren

Heilongjiang

Henan

Neimenggu

Jilin

Liaoning

Xingjian Uyghur






0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in


Hungary

Peru

Slovak Rep

Turkey

Uruguay

Venezuela

Mexico

Rwanda

The Gambia





0

20,000

40,000

60,000

80,000

100,000

120,000

0 1,000 2,000 3,000 4,000 5,000 6,000


No. IPD cases in

under-5 children Chongqing

Gansu

Hubei

Hunan

Qinghai

Shaanxi

Sichuan




Incidence Invasive Pneumococcal Diseases under-5 children,Region 2, China, 2008

0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000 25,000


No. IPD cases in

under-5 children

Anhui

Jiangsu

Shanghai





0

20,000

40,000

60,000

80,000

100,000

120,000

0 2,000 4,000 6,000 8,000 10,000 12,000


No. IPD cases in

children under-5

Fujian

Jiangxi

Zhejiang





0

20,000

40,000

60,000

80,000

100,000

120,000

0 5,000 10,000 15,000 20,000


No. cases IPD in

under-5 children

Beijing

Hebei

Shandong

Tianjin





0

20,000

40,000

60,000

80,000

100,000

120,000

0 2,000 4,000 6,000 8,000 10,000

GDP per capita (Int' $ PPP)

No. cases IPD in

under-5 children

Guangdong

Guangxi Zhuang

Guizhou

Hainan

Yunnan





0

20,000

40,000

60,000

80,000

100,000

120,000

0 2,000 4,000 6,000 8,000


No. cases IPD in

under-5 children

Heilongjiang

Henan

Neimenggu

Jilin

Liaoning

Xingjian Uyghur

Benefits of Implementing PCV in China NIP*

* NIP: National Immunization Program; PCV: Pneumoccoccal Conjugate Vaccine

Incidence of childhood clinical pneumonia*at the country level, 2000**

*courtesy of I Rudan et al (WHO/CHERG), “Epidemiology

and etiology of childhood pneumonia”, Bulletin of the

World Health Organization 2008; 86: 408–416.

*Importance of size of population & birth cohort:

-- of the 15 countries with the highest estimated

absolute number of new cases of clinical

pneumonia per year, China is #2.

**The annual pneumococcal (Spn) disease incidence

varied greatly by country, from 188 (131–284) to 6387

(4937–7909) per 100 000 children younger than 5

years. The greatest number of Spn cases was in

southeast Asia because of larger populations

(O’Brien KL & WHO/GDB team, The Lancet 2009; 374:

893-902).

China is #14 in the incidence

rate of new cases per child-

year.

Under-5 Mortality Rates & Numbers of Deathsfrom Pneumococcal Diseases, at country level, 2000*

China Spn mortality & Strep pneumo deaths:

- relatively low Spn mortality rate of 31

(uncertainty: 20-42)/100K live births;

- relatively low Spn CFR of 1.7% (global range

4-9% for pneumonia; 27-80% for meningitis; &

21-62% for severe NPNM Spn disease);

- but a relatively large population (WHO/GDB:

96.4 million under-5) &

- therefore a relatively large # Spn deaths

* from: O’Brien KL & WHO/GDB team, “Burden of

disease caused by Streptococcus pneumoniae in

children younger than 5 years: global estimates”,

The Lancet 2009; 374: 893-902.

NB: the China NBS estimate for the mid-yr

2010 under-5 population is about 67

million children (71% less than WHO/GDB

estimate of 96.4 million which was for the

year 2000, 10 yrs ago)…

Source: http://graphs.gapminder.org/world/china.php

U5MR: 8-fold range among


(NB: log scale)

GDP/pc: 10-fold range among


(NB: log scale)

china & nip countries_pcvaccine advocacy

Documents