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Global Issues in Comparing Vaccination Strategies Dr Lara Wolfson Vaccine Assessment & Monitoring Department Global Issues in Comparing Vaccination Strategies Dr Lara Wolfson Vaccine Assessment & Monitoring Department of Immunization, Vaccines & Biologicals

Vaccination Strategies: WHO • Overview of work at WHO • Examples of current work Vaccination Strategies: WHO • Overview of work at WHO • Examples of current work • Unmet needs

Measuring Mortality and Morbidity 1. 2. 3. 4. Estimates of current disease burden for Measuring Mortality and Morbidity 1. 2. 3. 4. Estimates of current disease burden for vaccinepreventable diseases Forecasts of future disease burden & cost-effectiveness under different vaccination scenarios Methods and Materials to assist RO’s and countries in estimation and forecasting of disease burden, introduction of new vaccines, costeffectiveness assessments Support to users of burden of disease data, technical assistance for costeffectiveness Innovation Accelerated Disease Control Immunization Systems

Estimating (Total) Mortality at WHO Complete vital registration Age-specific mortality rates DHS and other Estimating (Total) Mortality at WHO Complete vital registration Age-specific mortality rates DHS and other surveys No recent data UN estimates Incomplete vital registration Sample registration system Censuses Independent studies / reports / models 5 q 0 45 q 15 Life tables UN population estimates All-cause mortality envelope by age and sex Epidemiological data from studies, verbal autopsies, WHO programme estimates (child, maternal, injuries, noncommunicable, TB, HIV/AIDS) Cause-specific mortality patterns Country level age, sex and cause specific mortality estimates

Vaccine-Preventable Diseases: 24% Vaccine-Preventable Diseases: 24%

Causes of 4. 1 M Child Deaths, 2002 Causes of 4. 1 M Child Deaths, 2002

Proportional Mortality Approaches Proportional Mortality Approaches

Natural History Approaches Natural History Approaches

Method 1 Pr ion im a at ry da lid Va ta Looking at Method 1 Pr ion im a at ry da lid Va ta Looking at all the sources of data Best estimate Method 2 Method 3 Sensitivity analysis

General Approach • Get best data/information (literature/grey literature review) • Primary data • Secondary General Approach • Get best data/information (literature/grey literature review) • Primary data • Secondary data • Seek expert advise/opinion • natural history of the disease • methods/models • context • Develop consultative process with ROs/countries • Develop best methods/models • Use best assumptions/probabilities • Conduct sensitivity analysis • Validate/check consistency & coherence • Document (explicit & transparent) • Subject to in-house review, then expert review

Expected Outputs • Burden of Disease Estimates – By country, age group, sex, year Expected Outputs • Burden of Disease Estimates – By country, age group, sex, year – With estimates of uncertainty, document methods – Country consultation, continuous update of inputs (? !? ) • "Scenarios" (aka Comparing Strategies) – Recommendations for best practice – Tools for use at country level – Provide support to advocacy efforts • Cost-Effectiveness – Tools and guidelines, training, support

HQ produces burden of disease estimates Publish methods, database Of results, inputs Country clearance HQ produces burden of disease estimates Publish methods, database Of results, inputs Country clearance Simultaneous Develop scenario models And database of inputs Publish tools Country Requests CEA assistance Develop costing tools and guidelines IF! Targeted Country for Field-testing or Evaluation Collaborate with country On CEA Update annually Publish tools

GAVI and the Vaccine Fund • 75 out of 192 member states with GNI GAVI and the Vaccine Fund • 75 out of 192 member states with GNI <$1000 eligible for support • Immunization Systems Strengthening (ISS) support –performance/reward based system • New Vaccine Support (NVS) – vaccine provided for 1 st five years • "Next Window" – 2005 -2009 • ICF (Investment Case Framework)

The ADIP Paradigm The ADIP Paradigm

The Example: Measles • Need to develop a method for estimating measles mortality and The Example: Measles • Need to develop a method for estimating measles mortality and morbidity • Measure progress towards Measles Mortality Reduction Goal (50% reduction in measles deaths from 1999 -2005) • Evaluate the impact of supplemental immunization activities (SIA’s) and routine coverage • Develop a tool for countries to use to estimate their own disease burden and monitor progress

"Current" Burden of Measles

CFR Literature Review CFR Literature Review

869, 000 in 1999 to 610, 000 in 2002 869, 000 in 1999 to 610, 000 in 2002

Measles: Comparing Vaccination Strategies in 35 African Countries, 2005 -2015 Measles: Comparing Vaccination Strategies in 35 African Countries, 2005 -2015

SIR Model for 192 Member States SIR Model for 192 Member States

How to calculate R 0? How to calculate R 0?

Looking at Scenarios Looking at Scenarios

Data extracte d Model develop ed Current Estimat es Deaths/ Cases Averted WHO Clearan Data extracte d Model develop ed Current Estimat es Deaths/ Cases Averted WHO Clearan ce Expert review Methods written Country review process complet ed Manuscript submitted Publish ed partial complet ed complet ed completed complet ed complet ed complet ed NA NA complet ed Measles - static model Lit review Disease/syndrome Measles - SIR model yes complet ed NA Q 1 2004 Q 2 2004 Q 4 2004 Q 1 2004 Q 2 2004 Q 3 2004 Q 1 2004 Q 3 2004 Q 1 2004 Measles - prop model Pertussis Polio Neonatal tetanus completed Maternal tetanus Total tetanus Hepatitis B Hib meningitis Hib pneumonia Q 3 2004

Work that is needed (urgently!!) High Priority/Some Work Started • Pneumococcal Disease (Meningitis, Pneumonia) Work that is needed (urgently!!) High Priority/Some Work Started • Pneumococcal Disease (Meningitis, Pneumonia) • Rotavirus • Yellow Fever • Rubella/CRS • Diphtheria Lower Priority/Not Started • • • Meningoccocus A/C Japanese Encephalitis Mumps Dengue Typhoid Cholera ETEC Papillomavirus RSV Shigella Streptococcus group A Infant TB

CEA Disease Costing Tools Costing studies completed Costing studies in progress Measles Yes Burkina CEA Disease Costing Tools Costing studies completed Costing studies in progress Measles Yes Burkina Faso, Kenya, Tanzania, Laos, Zambia, Rwanda Sudan, Nepal, Philippines, Afghanistan, Kazakhstan, Turkey, Kosovo Pakistan Indonesia Neonatal Tetanus Hepatitis B Yes Hib Yes Moscow, Albania, Thailand Rubella In progress Oman, Fiji, Tonga Pneumococcal Yes South Africa, Kenya Polio Rotavirus Mozambique, Mongolia South Africa In progress Ghana

Data Collected by the Global Monitoring System (VAM) Data Collected by the Global Monitoring System (VAM)

Mixed Bag of Needs • Simple tools for use in country to make policy Mixed Bag of Needs • Simple tools for use in country to make policy decisions – but validated compared to complex methods. • Valid assessments of current burden of disease (MDG!!) • Guidance on plugging "data holes" • Introduction of new vaccines