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National Institute for Communicable Diseases &
University of Witwatersrand, South Africa
Respiratory and Meningeal Pathogens Research Unit,
& DST/NRF: Vaccine Preventable Diseases
Shabir A. Madhi
Role of vaccines in making the
world a better place for children
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently developed vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia
ii. Diarrhoea
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
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Global Trends in Under-5 Childhood Deaths, 2000 to 2010
• Reduction in all-cause under-5 mortality from 9.629 to 7.622 million between 2000 to 2010.
• 3.55 million deaths occurred in Africa in 2010
Liu L et al. Lancet 2012; 379: 2151-61
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Global Causes of Child Deaths in 2013
Liu L et al. Lancet 2015; 385: 430-440
• Under-5 mortality declined to 6.3 million in 2013.
• 51.8% (3.275 million) died due to infectious causes.
• 44% (2.76 million) died during neonatal period.
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Estimated Annual Rate of Reduction by Cause at
the Global Level between 2000 to 2013 Target of 4.4% year on year decline was required to achieve MDG4 Goal
of Reducing Under-5 Mortality by Two-thirds Between 1990 and 2015.
Liu L et al. Lancet 2015; 385: 430-440
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Distribution of Livebriths and under-5 deaths in
2013 and 2030
Liu L et al. Lancet 2015; 385: 430-440
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently developed vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia
ii. Diarrhoea
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
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Substantial Experience in last 15 years with
New Vaccine Introduction to EPI
Malaria (≈ 2015)
Maternal
Tetanus
(1983)
1920-1939: 1 vaccine
1940-1959: 3 vaccines
1960-1979: 4 vaccines
1980-1999: 3 vaccines
2000-2019: > 12 vaccines
Rabies
(1880’s)
1974: EPI
(BCG, OPV, DTP, Measles)
DTP+HepB+Hib
(Pentavalent)
(1998)
Courtesy Kate O’Brien. IVAC, JHU
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Percentage of deaths (2.5 million) from vaccine-preventable
diseases (VPDs) among children <5 years worldwide, 2002 Reduction in Vaccine Preventable Deaths have Lagged Behind
Development of New Vaccines.
Oth
er
VP
Ds
1%
(2
5 0
00
)
MMWR; 2006: 55:511-5 &WHO. 2004: Global Immunization Data
Over 50% of VPDs in under-5 children in 2002 due to diseases for which
vaccine available since the 1930s-early 90s.
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Progress and Challenges Toward Measles
Elimination
Source: http://www.immunize.org/photos/polio-measles.asp
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Global Measles Coverage At 84% In 2012 Measles Containing Vaccine Coverage By WHO Region,1980-2012
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13.8 Million Measles Deaths Averted Globally between
2000 to 2012.
Simons E et al. Lancet 2012; 379: 2173-78
During 2000-2012:
77% decrease in incidence
78% decline in deaths
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Within Region Inequity in Measles Coverage by Economic
Quintile Group Percentage of children under one year age who received measles vaccine, by
household wealth quintile and region.
Perc
en
t
Source: UNICEF. Pneumonia and Diarrhoea. June 2012. Available: www.childinfo.org/publications
Need to focus immunization efforts on reaching out to the poorest quintile, who
are also disadvantaged to access to curative health services
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Estimated Number of Deaths in Children aged
1-59 months by Cause, 2013 Approximately 1.2 million Vaccine Preventable Deaths in 2013
Liu L et al. Lancet 2015; 385: 430-440
Cause Number of Deaths (UR; 1000s)
Other Disorders 967 (781 - 1,134)
Pneumonia 800 (681 - 923)
Diarrhea 558 (429 - 731)
Malaria 456 (351 - 546)
Injury 324 (258 - 391)
Meningitis 151 (125 - 185)
AIDS 103 ( 76- 142)
Measles 102 ( 74- 166)
Pertussis 60 ( 43- 94)
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently discovered vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia: Pneumococcal Conjugate Vaccine
ii. Diarrhoea
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
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Death rate of Pneumococcal Disease in Children <5 years
(per 100,000) in 2000
0
50
100
150
200
250
300
350
400
450
500
Africa America EasternMediterranean
Europe Southeast Asia Western Pacific
Inci
den
ce r
ates
per
100
000
100,100 15,100 187,000 43,000 Number of deaths: 447,000
33,100
O’Brien K et al. Lancet 2009;374;893–902
90% of the 830 000 pneumococcal deaths
associated with pneumonia
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Direct Effect of Vaccination: Invasive Pneumococcal
Disease Among Children < 5 Years, 1998/99–2007 *100% Reduction in vaccine-serotype IPD in USA within 7 years of PCV7
introduction
Cases/1
00,0
00 p
op
ula
tio
n
0
10
20
30
40
50
60
70
80
90
1998 1999 2001 2000 2002 2003 2004 2005 2006 2007
Year
PC
V7 in
trod
uced
Serotype group
PCV7 type
Non-PCV7 type
19A
Pilishvili T, et al. J Infect Dis. 2010;201:32-41.
*
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Impact of 7-valent PCV on Incidence of Vaccine-
serotype Invasive Pneumococcal Disease. 80%-100% decline in vaccine-serotype IPD following PCV immunization of
children experienced consistently in all introducing countries.
Adapted from: Fitzwater SP et al. PIDJ; 2012: 31: 501-508
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Invasive Pneumococcal Disease Among Adults ≥ 65
Years, 1998/99–2007 *92% reduction in PCV7 serotype IPD in the Elderly Due to Indirect Effect Resulting from
Reduced Transmission from Children
Pilishvili T, et al. J Infect Dis. 2010;201:32-41.
Cases/1
00,0
00 p
op
ula
tio
n
0
5
10
15
20
25
30
35
40
1998 1999 2001 2000 2002 2003 2004 2005 2006 2007
Year
PC
V7 i
ntr
od
uced
Serotype group
PCV7 type
Non-PCV7 type
19A
*
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Number of IPD Cases and Deaths Prevented in USA
following PCV7/13 Childhood Immunization Greater 50% of cases and 90% of deaths averted occurred in unvaccinated
agegroups (i.e. indirect effect).
Death
s p
reven
ted
C
ases p
reven
ted
Moore M et al. Lancet Infect Dis; 2015; 15: 301-309
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Effectiveness of PCV7 Against All-cause Pneumonia
Hospitalization in USA Children; 1997 to 2009 40% reduction in all-cause pneumonia hospitalization in USA in children <2 years
age.
Griffin MR et al. N Eng J Med 2013; 369:155-63
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Indirect Effect of Childhood PCV7 Immunization on all-cause Pneumonia Hospitalization in USA Adults; 1997 to 2009
PCV vaccination of children results in protection against pneumonia in adults
Griffin MR et al. N Eng J Med 2013; 369:155-63
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Invasive Pneumococcal Disease in South African Children < 2
years age: 2005-2012 >80% reduction in PCV13 serotype IPD in HIV-infected and HIV-uninfected
children within 3 years of vaccine introduction.
Von Gottberg A et al New Eng J Med; 2014. 371 (20): 1889-99.
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PCV7/13 Introduction and Invasive Pneumococcal Disease by
age-group in South Africa: 2005-2012 Reduction in IPD Observed in Unvaccinated Agegroups, including HIV-infected
Adults 25-44 years of age.
PCV7 PCV13
Von Gottberg A et al New Eng J Med; 2014. 371 (20): 1889-99.
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Vaccine Introduction by Country Income Group for HibCV
and PCV Time lag for similar coverage of PCV into LMIC will be half that of HibCV.
Uptake of PCV to current DTP3 coverage levels in low income countries could
potentially prevent approximately 430 000 under-5 childhood deaths annually.
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently dieveloped vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia
ii. Diarrhoea: Rotavirus vaccine
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
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Rotavirus detection rates and deaths due to diarrhoea
and rotavirus by WHO child mortality group and region.
Country category Mean rotavirus
detection rate
(95%CI)
Number of
diarrhoea related
deaths
Number of deaths
attributed to
rotavirus
Very low child
mortality
49% (34-64) <1 000 <1 000
Low child mortality 40% (36-44) 67 000 27 000
Asia1 42% (35-48) 452 000 188 000
Americas1 42% (37-47) 13 000 5 000
Africa1 33% (28-38) 704 000 232 000
Total 1 236 000 453 000
1 High and medium mortality countries.
Tate JE, et al. Lancet Infect Dis; 2012; 12: 136-41 (adapted)
• Rotavirus accounts for 37% of all diarrhoea related death; and 5% of
all-cause deaths in children under-5.
• 95% of rotavirus deaths occur in 72 GAVI eligible countries
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Point estimates of Rotarix* and RotaTeq† vaccine Efficacy in
Relation to Country GDP Rotavirus Vaccine Efficacy Lower in Low-Income Settings
Nelson EAS & Glass RI, Lancet 2010; 367: 568-9
Possible reasons for lower
efficacy in developing countries
• High maternal antibody titres
• Breastfeeding at vaccination
• Micronutrient deficiencies
• Interfering microorganisms
• HIV and malaria
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Severe Rotavirus GE Episodes Prevented per 100 children
In South Africa (Middle Income) and Malawi (low income). Despite lower vaccine efficacy in low income settings, higher rate reduction of
severe cases
0
1
2
3
4
5
6
7
8
9
Africa South Africa MalawiSe
ve
re r
ota
vir
us
GE
ep
iso
de
s p
er
10
0
Placebo
Vaccine
3 episodes prevented
2.5 episodes prevented
3.9 episodes prevented
VE: 61.2% 76.9% 49.5%
(44.0 – 73.2) (56.0 – 88.5) (19.2 – 68.3)
Madhi SA, Cunliffe NA et al. NEJM. 2010; 362: 289-298
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Percentage Reduction in Number of Rotavirus
Hospitalizations in Children <5 years Following Rotavirus
Vaccine Introduction.
Tate JE & Parashar UD. Clin Infect Dis; 2014, 59: 1291-1301
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Number of Diarrhea-related Deaths among Children aged
<59 months in Mexico by age group. 41% reduction in all-cause diarrhoea deaths within one year of vaccine
introduction in infants
Richardson V et al. N Eng J Med 2010; 362; 299-305
41%; 95%CI 36 to 47
29%; 95%CI 17 to 39
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Percentage Reduction in Number of Diarrhoea Deaths
in Children <5 years Following Rotavirus Vaccine
Introduction in Middle-Income Countries.
Tate JE & Parashar UD. Clin Infect Dis; 59: 1291-1301
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently developed vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia
ii. Diarrhoea
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
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Vaccination of Pregnant Women: An Evolving Paradigm
Shift Aimed at Protection of The Fetus and Young
Infants.
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Success of Maternal Tetanus Vaccination in
Preventing Neonatal Tetanus Deaths
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1 270 000
787 000
580 000 490 000
248 000 200 000 180 000
128 000 59 000
58 000 49 000 9
37
56 59 57
62 61 61
74
68
75
65
0
10
20
30
40
50
60
70
80
90
100
-
200 000
400 000
600 000
800 000
1 000 000
1 200 000
1 400 000
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
Reported TT2+ coverage & estimated NT deaths 1980-2013
Est NT Deaths TT2+ (%)
WHO-UNICEF Data & CHERG Reports
TT 2+ C
ove
rage (p
ercentage
) N
um
be
r N
T D
eat
hs
Neonatal Tetanus Global Annual Reported
Cases and TT2plus coverage, 1980-2013
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Overview
● Trends in Global under-5 childhood morbidity and
mortality.
● Impact of recently developed vaccines aimed at
reducing under-5 mortality from:
i. Pneumonia
ii. Diarrhoea
● New horizons in reducing under-5/neonatal morbidity
and mortality by vaccination.
Influenza vaccination of pregnant women
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Incidence of laboratory-confirmed influenza associated
hospitalization in Soweto, South Africa. Highest incidence of severe influenza hospitalization is in infants <6 months
age for whom there is no licensed vaccine.
Cohen C/Madhi SA et al. Emerg Infect Dis; 2013; 19; 1766-1774
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Vaccine Efficacy of Influenza Vaccination of Pregnant
HIV- Women against PCR-confirmed Influenza Illness up
Until 24 weeks Post-partum.
● Vaccine efficacy (ITT): 50.4% (95%CI: 14.5; 71.2)
AR: 3.6%
AR: 1.8%
Madhi SA et al. New Engl J Med; 2014: 371: 918-31
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Vaccination of HIV- Pregnant Women in Preventing
Influenza-Confirmed illness in their Infants up until 24
Weeks of age.
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Cu
mu
lati
ve in
flu
en
za c
ases
Age (weeks)
Vaccine placebo
VE (ITT): 48.8% (95%CI: 11.5; 70.3)
VE (PP): 45.6% (95%CI: 2.4; 69.7)
AR: 3.6%
AR:1.9%
Madhi SA et al. New Engl J Med; 2014: 371: 918-31
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Vaccination of HIV- Pregnant Women in Preventing
Influenza-Confirmed illness in their Infants <6 months
age.
63.0%; 95%CI: 7.8-85.2
48.8%; 95%CI: 11.6- 70.4
Vaccine efficacy; 95%CI
Bangladesh
S. Africa
53.0%; 95%CI: 24.9- 70.6
Summary VE
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Images from: http://www.medicinenet.com/stages_of_pregnancy_pictures_slideshow/article.htm
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Estimated Preterm Birth Rates by Country for
Year 2010
Blencome H, et al. Lancet; 2012; 379: 2162-72
• In 2010 14.9 million (Range 12.3-18.1) born preterm.
• 11.1% of all births born preterm (range: 5% in Europe to 18% in Africa).
• 15% of all under-5 childhood deaths due to complications of prematurity.
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Effect of Influenza Immunization During Pregnancy
on Birth Outcomes (356 930 mother-newborn pairs)
Steinhoff MC et al. Lancet; 2014; 383: 1611-2
Overall effect:
Premature birth: OR 0.78 (95%CI: 0.74 to 0.82)
Small for Gestational Age: OR 0.83 (95%CI: 0.79-0.87)
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Other Vaccines Currently Recommended or In Clinical
Development For Immunization of Pregnant Women to
Protect Young Infants
● Pertussis vaccine:
80% pertussis deaths occur in infants <2 months age
Recommended in many High-Income countries and studies underway on
LMIC
Group B Streptococcus serotype-specific protein-polysaccharide
conjugate vaccine
Leading cause of neonatal sepsis in high-income and LMIC countries
Phase II studies on trivalent vaccine completed.
Respiratory Syncytial Virus
Leading cause of pneumonia hospitalization globally, with estimated
66,000-240,000 deaths annually.
Multiple vaccine candidates aimed at pregnant women under clinical
development.
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Conclusions
● Significant advances made since 1990 in reduction of mortality from
polio, measles and neonatal tetanus over relative short periods because
of vaccination.
● Newly licensed vaccine against major pathogens causing diarrhoea
(rotavirus), pneumonia (pneumococcus) and meningitis
(pneumococcus and meningococcus A/B/C/Y/W) have potential of
preventing approximately 650-750 thousand childhood deaths annually.
● Also, promise of other soon-to-be licensed vaccines against other
major infectious causes of under-5 mortality (malaria).
● Next frontier is targeting vaccination of pregnant women for reducing
death from neonatal and early-infancy vaccine-preventable diseases.
● Full benefit of advances in vaccine development will only be realised
when equity of access addressed between and within countries.