40 years of childhood vaccination programmes in Africa
Mind the gap
Charles Shey Umaru WiysongeMD, MPhil, PhD, MASSAf
Centre for Evidence-based Health Care, Stellenbosch University, South Africa
Email : [email protected]
5th Infection Control African Network Conference
Meikles Hotel, Harare, Zimbabwe, 05 November 2014
Potential conflicts of interest
• Deputy Director (past), Expanded Programme on Immunisation, Cameroon
• Member, WHO African Task Force on Immunisation
• Member, Global Alliance for Vaccines and Immunisation (GAVI) Independent Review Committee
• Member(appointed), Strategic Advisory Group of Experts on Immunisation (SAGE)
3
It all started with smallpox …
Estimated crude birth and death rates per 1,000 for England, 1541-1871(source: Mercer A.J. Population Studies 1985; 39: 287-307)
Prevention of Smallpox
5
The basis of modern vaccination was laid in 1796 ...
Dr Edward Jenner (England)
Collection of the University of Michigan Health System, gift of Pfizer Inc. UMHS.23
6
PathogenImmune response
Cureand protection
Disease
Toxins
Infection
Natural infection vs vaccination
Specific memory
VaccineImmune response
Protection
- live attenuated - toxoid- inactivated- subunit
Timeline for licensure of human vaccines
1789 Smallpox1885 Rabies1896 Typhoid1896 Cholera1987 Plague
Public health achievements of the 20th century
Annual global VPD deaths in children under-5, 2004
WHO 2008
Causes of under-five deaths (Global) in 2008
Black RE et al., Global, regional and national causes of child deaths in 2008. Lancet 2010.
Expanded Programme on Immunisation
• WHO developed a standard EPI schedule in 1974
• 6 basic antigens for infants
• Tuberculosis (Bacille Calmette-Guerin: BCG)
• Polio
• Diphtheria, tetanus, pertussis (DTP)
• Measles
• Proportion of children who receive 3 doses of DTP (DTP3) before 1yr is a standard measure of EPI performance
National DTP3 coverage in Africa from 1980 to 2010
Machingaidze S, Wiysonge CS, Hussey GD. PLoS Med 2013
District coverage data in Africa
In 2005
• 16 (30%) countries reported 80% DTP3 coverage in at least 80% of their districts
In 2010
• 16 (30%) countries reported 80% DTP3 coverage in at least 80% of their districts
Machingaidze S, Wiysonge CS, Hussey GD. PLoS Med 2013
14
Comprehensive and relevant evidence-based information is needed to equip African countries with the arsenal to take well-informed actions on improving childhood immunisation coverage.
Study design & data sources
• Study design– Cross-sectional study
• Data sources– Demographic Health Surveys
• Comparable variables
• Between 2003 – 2011
– World Bank data
– WHO/UNICEF immunisation data
15
Determinants
Individual
Child’s age, sex, birth order
Mother’s age, education, employment, media access, health seeking behaviours
No U5C, polygamous family, wealth index
Community
Neighbourhood poverty
Illiteracy rate
Unemployment rate
Media access
Average household size
Female-headed households
Residential mobility
Place of residence
Ethnic diversity
Societal
Fertility rate
Gross domestic product
Expenditure on health
Adult illiteracy rate
16
Statistical analysis • Multilevel modeling
– Takes into account the hierarchical structure of data
– Potentially avoids atomistic and ecological fallacy
– Enables the partitioning of variation between levels.
17
Level1: Individuals
Level 2: Community
Level 3: Country
Source population
Clustering effects
• Children in the same neighbourhood are subject to common contextual influences.
• There is some evidence for a possible neighbourhood and country contextual phenomenon shaping a common risk of un-immunisation
18
Risk of having an un-immunised childFactors OR (95% CI)
Mother’s age: 15-24 versus 35 or older 1.18 (1.06 - 1.32)
Wealth index (with richest quintile as reference)
Poorest 1.36 (1.17 - 1.59)
Poorer 1.30 (1.13 - 1.51)
Middle 1.21 (1.06 - 1.39)
Richer 1.15 (1.02 - 1.30)
Mother’s education (with secondary or higher as reference)
No formal education 1.35 (1.18 - 1.53)
Primary 1.26 (1.12 - 1.40)
Media access* 0.94 (0.90 - 0.99)
Health seeking behaviour* 0.56 (0.54 - 0.58)
Community level
Urban (vs. rural) 1.12 (1.01 - 1.23)
Illiteracy rate 1.13 (1.05 - 1.23)
Country-level
Fertility rate 4.43 (1.04 - 18.92)
Intra-cluster correlation (%)
Country 21.1
Community 32.5
Fin
anci
ng
Capacity building
Man
agem
ent
1. Vaccine supply & quality
2. Logistics
3. Services delivery
4. Surveillance
5. Communication
Operations
Fin
anci
ng
Capacity building
Man
agem
ent
1. Vaccine supply & quality
2. Logistics
3. Services delivery
4. Surveillance
5. Communication
Operations
Fin
anci
ng
Capacity building
Man
agem
ent
1. Vaccine supply & quality
2. Logistics
3. Services delivery
4. Surveillance
5. Communication
Operations
1. Vaccine supply & quality
2. Logistics
3. Services delivery
4. Surveillance
5. Communication
Operations
Health system building blocksImmunisation system componentsHealth system environment
• Individual and contextual factors were associated with childhood immunisation;
• Suggesting that public health programmes designed to improve uptake of childhood vaccines should address people, and the communities and societies in which they live.
Factors associated with childhood immunisation research
Univariable Multivariable
Variable IRR (95% CI) p-value IRR (95% CI) p-value
DPT3 coverage 0.40 (0.07, 2.36) 0.310 * not included
Gross domestic product 1.44 (1.24, 1.66) 0.000 1.27 (0.74, 2.18) 0.380
Adult literacy rate 1.16 (0.42, 3.18) 0.771 not included
Physicians/100,000 population 1.24 (0.96, 1.60) 0.096 not included
Total expenditure on health 3.21 (1.09, 9.41) 0.034 0.66 (0.14, 3.11) 0.596
Private expenditure on health 2.77 (1.61, 4.79) 0.000 2.82 (1.29, 6.19) 0.010
R & D expenditure 1.44 (1.22, 1.72) 0.000 1.09 (0.61, 1.94) 0.782
Human development index 2.37 (0.59, 9.51) 0.224 not included
* Is this an indication of lack of interactive communication between health decision-makers, programme managers, and researchers?
Wiysonge CS et al, BMC Med 2013
"The mission of the Decade of
Vaccines is to extend, by 2020
and beyond, the full benefits of
immunization to all people,
regardless of where they are born,
who they are, or where they live."
“We envision a world in which all
individuals and communities
enjoy lives free from vaccine-
preventable diseases".
The Global Vaccine Action PlanGuiding Principles Strategic objectives of the Decade of Vaccines Goals
Shared responsibility & partnership
Country ownership
Equity
Integration
Sustainability
Innovation
All countries commit to immunisation as a priority
Strong immunisation systems are
an integral part of a well-functioning
health system
The benefits of immunisation are
equitable extended to all people
1. Achieve a world free of
poliomyelitis
2. Meet global and regional
elimination targets
3. Meet vaccination
coverage targets in
every region, country
and community
4. Develop and introduce
new and improved
vaccines and
technologies
5. Exceed the Millennium
Development Goal 4
target for reducing child
mortality
1
3
4Immunisation
programmes
have sustainable
access to
predictable
funding, quality
supply and
innovative
technologies
5
Country, regional and global research and development
innovations maximize the benefits of immunisation
6
Individuals and communities
understand the value of vaccines
and demand immunisation as both
their right and responsibility
2
Meet vaccination coverage targets in every region, country and community
Target 1: reach 90% national coverage and 80% in every district with DTP3 by 2015
Where DTP3 un-immunized children are located
1 dot = 200 unvaccinated children
80% located in 10 countries
Source: Country reported data JRF
Inequitable access
• 13/24 countries have ≥ 10% difference in DTP3 between highest and lowest wealth quintiles
• 10 of the 13 are in Africa
DTP 3 coverage in highest (blue) and lowest (red) wealth quintiles
Weak delivery systems
• 36 countries have dropout rates ≥ 10%; with 11 ≥ 20%.
• 50% of these countries are in Africa
• CAR; Cameroon; DRC; Ethiopia; Guinea; Guinea-Bissau; Equatorial Guinea, Liberia; Lesotho, Madagascar, Mali, Mozambique, Mauritania, Nigeria, Sierra Leone, Chad, Togo, Uganda
0 1,700 3,400850 Kilometers
DTP1-DTP3 dropout rate (2012)
< 10% (158 countries)
10-19% (25 countries)
≥ 20% (11 countries)
Poor data quality
37% countries with admin coverage> WHO/Unicef
estimates
DQS conducted in many countries but corrective
actions are not always implemented
There is a lack of validation mechanisms of
coverage data, particularly at subnational level
Inconsistency in denominator figures over years
National census data outdated
Lack of collaboration between EPI and national
statistics offices
DTP3 WUENIC and Country reported data in AFR
# district with DTP3 > 100%
Country with WPV case in previous 6 months
Endemic country
Poliovirus type 1
2Onset of paralyses 29 October 2013 – 28 October 2014
1Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance.
Country with WPV case 6-12 months ago
Data in WHO HQ as of 28 October 2014
Wild Poliovirus Cases1, Previous 12 Months2
Cameroon 09-Jul-14 5 6
Equatorial Guinea 03-May-14 5 5
Ethiopia 05-Jan-14 1 2
Nigeria 24-Jul-14 7 8
AFR 24-Jul-14 18 21
Afghanistan 18-Sep-14 15 17
Iraq 07-Apr-14 2 2
Pakistan 01-Oct-14 31 247
Somalia 11-Aug-14 4 8
Syria 21-Jan-14 11 13
EMR 01-Oct-14 63 287
Global 01-Oct-14 81 308
Onset of most
recent case
Number of
districtsCountry
Total WPV
(All type1)
Wild Poliovirus Cases1, Previous 6 Months2
Country with WPV case in previous 6 months
1Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance.
Endemic country
Poliovirus type 1
2Onset of paralyses 29 April – 28 October 2014
Data in WHO HQ as of 21 October 2014
Cameroon 09-Jul-14 1 2
Nigeria 24-Jul-14 2 3
Equatorial Guinea 03-May-14 1 1
AFR 24-Jul-14 4 6
Afghanistan 18-Sep-14 7 8
Pakistan 01-Oct-14 28 156
Somalia 11-Aug-14 2 5
EMR 01-Oct-14 37 169
Global 01-Oct-14 41 175
CountryOnset of most
recent case
Number of
districts
Total WPV
(All type 1)
Comparison of 2013 and 2014 DataYear to Date (01 January to 28 October)
Data for 2013 as of 29 October 2013 and for 2014 as of 28 October 2014
Data in WHO HQ as of 28 October 2014
>90 days
2013 2014 2013 2014 2013 2014 2013 2014 2014
African 15542 17444 71 18 72 58 1799 2070 806 as of 27 October
Central 2793 2800 1 11 39 14 205 301 68
South/East 3877 4257 21 1 12 10 777 737 355
West 8872 10387 49 6 21 34 817 1032 383
American 1287 1274 0 0 0 1 513 291 193 as of 25 October
Eastern Mediterranean 8950 9171 241 239 2 7 981 853 164 as of 27 October
European 1278 1234 0 0 0 0 337 421 135 as of 27 October
South East Asian 46630 46593 0 0 6 2 4476 4815 1217 as of 27 October
Western Pacific 4797 4865 0 0 2 0 1261 1262 417 as of 28 October
Global 78484 80581 312 257 82 68 9367 9712 2932
Data received
in HQTotalWHO region
AFP Cases Wild VirusPolio
Compatible
Pending Final
Classification
Status of MNT elimination in AFR. Oct 2013
TT SIAs ongoing, and efforts
to systematically use school
health programs for TT
provision
Advocating with countries to
change TT vaccine to DT/dT
The validation of MNT
elimination is expected to take
place in 5 countries in 2014
Reduction in estimated measles deaths
by WHO Region. 2000 - 2012
MCV2 introduction in AFR (as of April 2014 )
- MCV2 already in EPI in 15 countries
- RWA, TAN to introduce in 2014
- BFA, MOZ, MAL, SIL, SEN applied for
2014
- ZIM to apply to GAVI in 2014
- NAM: to consider in 2014
http://www.gavialliance.org/support/nvs/hib/
Hib introduction
Penta, PCV and Rota roll out
29/47 Countries : Angola, Benin, Botswana,
Burkina Faso, Burundi, Cameroon, Congo,
Central Afr Rep, DRC, Ethiopia, Gambia,
Mauritania, Ghana, Kenya, Liberia,
Madagascar, Malawi, Mali, Mozambique,
Rwanda, STP, Senegal, Sierra Leone, South
Africa, Swaziland, Tanzania, Uganda, Zambia,
Zimbabwe
PentaPCV
Rota
In country EPINot yet in country EPINot AFR
46/47 Countries : South Sudan yet to introduce
16/47 Countries : Angola, Botswana, Burkina Faso,
Burundi, Cameroon, Congo, Ethiopia, The Gambia,
Ghana, Malawi, Mali, Rwanda, Sierra Leone, South Africa,
Tanzania, Zambia
Cape Verde
Comoros
Mauritius
Seychelles
Seychelles
Mauritius
Comoros
Cape Verde
STP
STP
South Africa: Rotavirus Surveillance Pre and Post
Vaccine Introduction (Dr. George Mukhari Hospital)
Vaccine Introduction
Aug 2009
Aug 2009
Source: LM Seheri et al Vaccine 2012
Declining trends in severe diarrhea
MenA conjugate vaccine roll out
19,154,810
54,613,721
103,181,879
150,277,576
0
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
120,000,000
140,000,000
160,000,000
2010 2011 2012 2013
So far, no reported case of NmA among the vaccinated populations
2013 = Lowest ever reported number of suspect cases during an epidemic season
Cumulative number of vaccinated individuals
Countries’ plan to introduce IPV GAVI applications
March round (5) May round (10) Sept round (21) Missing information (1) Non-eligible countries (9)
Comoros Benin Angola Lesotho Algeria
Ethiopia DR Congo Burkina Faso Botswana
Liberia Kenya Burundi, Cape Verde
Nigeria Madagascar Cameroon Equatorial Guinea
Tanzania Malawi CAR Gabon
Rwanda Chad Mauritius
Senegal Congo Namibia
Sierra Leone Cote d'Ivoire Seychelles
The Gambia Eritrea Swaziland
Uganda Ghana
Guinea
Guinea Bissau
Mali
Mauritania
Mozambique
Niger
Togo
South Sudan
Sao Tome & Principe
Zambia
Zimbabwe
IPV Introduction in AFRO
Preparation for IPV introduction:
Orientation provided to all EPI Managers and partners (one-day workshop organized during
the 3 EPI Managers’ meetings in February/March 2014)
Training of pool of consultants (73) to support countries: Anglophone (03-04 Apr) &
Francophone (14-15 Apr)
Plan to expand the AFR and ISTs capacities to support the accelerated introduction
Coordination mechanisms with all partners in place
Some challenges related to IPV introduction Accelerated introduction timeline (by end 2015)
Issue of high cost of vaccines in GAVI non eligible countries
Communication in the context of multiple injections (3 injections to the child at the same visit)
0 1,700 3,400850 Kilometers
NITAGs in 2012
116 Countries Reporting the Existence of a NITAG
104 Countries Reporting the Existence of a NITAG with
ToRs
99 Countries having a NITAG with administrative or
legislative basis
63 Countries meeting the 6 NITAG criteria
Country ownership
• Data on immunization expenditures is inadequate to draw conclusions on trends
• The number of NITAGs meeting functionality criteria have increased significantly
• Only 3 Countries in Africa have a NITAG meeting all 6 WHO criteria of functionality
• Capacity strengthening required for NITAGs to collect, synthesize and use data and evidence for decisions
•
• NITAGs have important role in improving quality of national data and monitoring progress at national level
Surveillance systems
• High quality surveillance is essential for assessing whether immunization programmes are having the desired impact
• Surveillance quality and timely reporting is inadequate to meet national programme needs
• Inconsistencies noted in surveillance data from different sources, i.e. JRF versus surveillance reports
• Greater investments and technical assistance is required to strengthen systems
Trend of government funding vaccines (2006-2012)
54% 55%
58%53%
40%35% 36%
$1.1$1.2
$1.4 $1.4 $1.5 $1.5
$2.0
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008 2009 2010 2011 2012
Average, million $Percentage
Percentage of government funding vaccines (average % in selected countries)
Percentage of government funding vaccines (average % in the region)
Government funding vaccines in absolute values (average million $ in selected countries )
Trend of government funding routine immunization (2006-2012)
52% 51% 52% 48%53%
48% 48%
$2.3
$3.7$3.9
$3.2$2.9 $2.8
$3.3
$0.0
$0.5
$1.0
$1.5
$2.0
$2.5
$3.0
$3.5
$4.0
$4.5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008 2009 2010 2011 2012
Average, million $Percentage
Percentage of government funding RI (average % in selected countries)
Conclusion
40 years of EPI in Africa
I ACKNOWLEDGE WHO FOR MOST OF THE DATA
PRESENTED IN THIS TALK
THANK YOU
MERCI
GOD BLESS YOU
Website : www.sun.ac.za/cebhc
Email : [email protected]
Twitter : @CharlesShey