Global vaccination issues action Poverty inequity and

Global vaccination issues & action Poverty, inequity and inadequate social & health conditions are a reality for many people in developing countries. • Investing in health care is an important contributor to reduce poverty • Failure to immunise the world’s children results in ~ 3 million deaths per year • Over the last 30 years nearly all countries with per capita incomes over $US 600 have made the most of vaccination, poorer countries have not 1

2

3

The Global Alliance for Vaccines & Immunisation (GAVI) is an unincorporated public-private partnership launched in 2000. It comprises partners, including UNICEF, WHO, the Gates Foundation, the World Bank, developing country governments, donor country governments, the vaccine industry, civil society groups, and research and technical health institutes. A secretariat, based in Geneva, coordinates Alliance activities of policy development and country support. 4

5

Members of the partnership GAVI Board is currently made up of representatives from • Developing country govts: Armenia, Ethiopia, Rwanda, Vietnam & Yemen • Industrialised country govts: Italy, USA, UK, Netherlands, France • International Vaccine Institute: • Industrialised country vaccine industry: Glaxo. Smith. Kline • Developing country vaccine industry: Serum Institute of India, Ltd • Civil society organisations • Bill & Melinda Gates Foundation • WHO • UNICEF • The World Bank Group 6

• The Bill & Melinda Gates Foundation is a founding partner of the GAVI Alliance. • Its initial grant helped establish GAVI and it continues to support its work. • It has committed more than $1. 5 billion to GAVI, of which GAVI has received US $988 million, as at December 2007, to support global health efforts in two priority areas: • Accelerating access to existing vaccines, drugs, and other tools to fight diseases common in the developing world • Supporting research to develop new health solutions that are effective, affordable, and practical for use in developing countries 7

UNICEF is the world’s largest purchaser of vaccines for developing countries and a key partner in global immunisation efforts. Its supply division, based in Copenhagen, is responsible for global purchasing, including some $100 million per year spent on vaccines and safe injection equipment 8

The World Bank Group • The World Bank is a partner in the GAVI Alliance • It is owned by more than 180 member countries • Is the world’s largest source of development assistance, providing nearly $30 billion in loans annually to its client countries. • Works with ministries of finance and health in developing countries to value immunisation and new vaccine development • Makes loans and credits in support of immunisation • Consults with public and private sector partners to create new financing options to accelerate the development of critical vaccines for HIV/AIDS, malaria and TB 9

Global Immunization Vision and Strategy (GIVS) • UNICEF and WHO have developed the Global Immunization Vision and Strategy (GIVS) for the period 2002 -2015. • The GAVI Alliance is funding the vaccine program to achieve GIVS • Goal is to reduce vaccine-preventable illness and death by two thirds compared to 2000 levels, thus achieving the Millennium Development Goal for child health. • This equates to the saving of more than 40 million lives • Targets eight countries that account for 2/3 of the world's unimmunised children. (India, Nigeria, Indonesia, Pakistan, Ethiopia, DR Congo, Sudan, Philippines) 10

supported by a $37 million 4 -year grant from GAVI/The Vaccine Fund • Haemophilus influenzae type b (Hib) is a bacterium which can cause meningitis and severe pneumonia • 3 million cases of serious illness and 400, 000 deaths each year in children under 5 years of age from Hib • In 2006, only 26% of children worldwide received Hib vaccine • 1/3 of the countries eligible for funding from the GAVI Alliance (i. e. , Gross national income/capita <$1000 per year) are using Hib vaccines • The Hib Initiative focuses on coordination, communication and research. Hib Initiative Activities 11

Movie obtained from http: //www. hibaction. org/resource s. php Hib. Promo 2. mp 4 (3. 30 mins) 12

13

Percentage decline in incidence Hib following vaccine introduction 14

Hib-containing Vaccines The GAVI Fund enables eligible countries to purchase Hib containing vaccine for a small co-payment of 15 to 30 cents per dose, depending on country grouping A number of vaccine manufacturers have Hib-containing vaccines • 11 Hib-containing vaccines currently WHO pre-qualified for purchase At July 2008, vaccines are usually available for about of $US 2. 50 per dose. In July 2008, the WHO pre-qualified Easyfive™ and Shan 5™, two Hib-containing pentavalent vaccines: • Easyfive™, manufactured by Panacea Biotec, India, is a fully liquid combination pentavalent vaccine (DTw. P-Hep. B-Hib) Each dose contains : Diphtheria Toxoid, Tetanus Toxoid, Inactivated w-B. pertussis, Hepatitis B surface Ag, H. influenzae type b oligosaccharides) • Shan 5™ pentavalent (DTP-Hep. B-Hib), manufactured by Shantha Biotechnics Private Ltd. , India. (diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenza type B) 15

Developing Country Vaccine Manufacturers Network (DCVMN) represents a voluntary, public health-driven alliance of enterprises – state-owned and private, large and small – from developing and middle-income countries. Members: Bio Farma, Indonesia Bio Manguinhos/Fiocruz, Brazil Centre for Genetic Engineering and Biotechnology, Cuba Haffkine Bio-Pharmaceuticals Corp Ltd, India Institut Pasteur Dakar, Senegal LG Life Sciences Ltd, Korea Panacea Biotec, India Serum Institute of India Ltd, India 16

Developing countries are producing their own vaccines 17

18

19

Local strategies proven to deliver vaccines Immunisation programs need effective in country systems to ensure that children receive vaccines These must work at the local level to ensure the routine immunisation systems work with the people and health infrastructure for that country 1. 2. 3. 4. Types of strategies Bringing immunisation closer to the community Information dissemination to increase demand for vaccination Changing practices in fixed sites Innovative management practices 20

1. Bringing immunisation closer to the community Non-health workers can encourage people to seek immunisation Valuable to involve community members in immunisation delivery & education These are some examples: • INDIA - Women in the community provide health information & track immunisation • PNG- Vaccines given by trained Aid Post Orderlies at local health posts in rural communities • NIGERIA- Convenient locations and times with more parent education • SOUTH AFRICA -Local village health workers visit and maintain immunisation records, they keep cards for each child • BANGLADESH- Follow up of defaulters using low-literacy urban volunteers, uses a colour coded tracking system • MOZAMBIQUE- Outreach service to areas affected by conflict bushplanes to gain access, incentives to bring children in, house to 21 house visits

Example - mid-wives in Sri Lanka When new mothers leave hospital, midwives from the Family Health Bureau make regular house visits. For five years, the midwife will follow mother and child’s progress, providing health education and ensuring they don't miss vaccinations. Vaccines are even delivered behind the frontlines of northern parts held by the Liberation Tigers of Tamil Eelam. 22

2. Information dissemination to increase demand for vaccination Demand for vaccination is increased without changing service delivery. Communication campaigns relevant to the people & place Here are some examples: • WEST BANK- Development of staffed village resource rooms • PHILIPPINES- Communication of measles information via mass media campaign • BANGLADESH- Advocating by an NGO credit program for women to use immunisation services • KENYA -Outreach immunisation services & information delivery located in schools, school children provide the education to their own communities 23

Example: Nigeria - support of local leaders At an Immunisation Day Plus held at the fixed immunisation post in Isawa village, Muhammed Sabo Abdulkadir, the district head of Giade (right) and Yaya Abubakar, the village head of Isawa (left), are seen by members of the community to be endorsing vaccination. 24

3. Changing practices in fixed sites Improving the quality of health facility increases access & efficiency The aim is to get close to what the people normally do Examples: 1. SUDAN- Move vaccination location closer to physicians consulting rooms 2. NIGERIA- Re-organising health centres to have a quick immunisation line 3. MEXICO- Screening hospitalised children for vaccination status 25 4. ETHIOPIA- Reminder stickers and health education to reduce

4. Innovative management practices Can be to improve record keeping, education, vaccine delivery Think smart to achieve local effect Examples here: 1. NICARAGUA- Food incentives to improve attendance at child health clinics 2. INDONESIA- Train nurses in under-performing health centres using low cost on the job peer training 3. CAMBODIA - Using contractors to increase immunisation coverage & equity 4. MADAGASCAR- Use auto-disable syringes for increased safety, health workers more likely to vaccinate when it is easy 26

Value of local people Non-health workers can provide numerous services and have been proven to be very successful • They have community knowledge • Can be respected by the community • May gain access to community members not reached by mass media • Successful at motivating parents to use vaccination services Locally sensitive and relevant strategies complement existing health systems and international programs to provide vaccines 27

Example: health worker Ajebush • • Ajebush Wakalto (right) is one of Ethiopia’s 30, 000 10 th-grade graduates who has become a health extension worker, having received 12 months of training. Health extension workers are trained to provide basic services in almost 15, 000 communities. Improving health at community level, including providing services such as immunisation, frees the time of qualified personnel. 28

Global results for GAVI Further information on GAVI http: //www. gavialliance. org/ WHO projections for the period 2000 -2007 show GAVI support has: • prevented 2. 9 million future deaths • protected 36. 8 million additional children with basic vaccines (against diphtheria, tetanus, and pertussis) • protected 176 million additional children with new and underused vaccines • 158. 6 million additional children have been immunised against hepatitis B • 28. 3 million additional children have been immunised against Haemophilus influenzae type b (Hib) • In 2006 almost 30% of all the vaccine doses purchased by UNICEF for the GAVI Alliance came from developing country manufacturers. H. influenzae 29