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 : charlesw@sun.ac.za

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 : charlesw@sun.ac.za

Twitter : @CharlesShey