Future trends and perspectives in immunization

1
Future trends and perspectives in immunization

• Kim Mulholland
• London School of Hygiene and Tropical Medicine

2
Improving future goal setting analysis and
critique of the Millennium Development Goals
Waage J, Banerji R, Campbell O, Chirwa E,
Collender G, Dieltiens V, Dorward A,
Godfrey-Faussett P, Hanvoravongchai P, Kingdon
G, Little A, Mills A, Mulholland K, Mwinga A,
North A, Patcharanarumol W, Poulton C,
Tangcharoensathien V, Unterhalter E. The
Millennium Development Goals a cross-sectoral
analysis and principles for goal setting after
2015 Lancet and London International Development
Centre Commission. Lancet 2010 376 9911023.
3
1. Halve poverty and hunger2. Achieve
universal primary education3. Eliminate gender
disparity4. Reduce by 2/3 the child (lt 5)
mortality rate5. Reduce by 3/4 the maternal
mortality rate6. Halt and reverse the spread of
HIV AIDS and incidence of malaria and other
diseases7. Ensure environmental
sustainability8. Develop a global partnership
for development
The Millennium Development Goals
4
MDGs

• The positive side
• provided a focus for advocacy to improve
  targeting and flow of aid
• The problems.
• confusion between targets, indicators and goals
• ownership issues
• tendency to increase inequity

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Future development goal setting five principles

• Holism consider all elements of well-being
• Ownership from national to global consensus
• Equity a pro-poor, rights-based approach
• Sustainability beyond economic growth
• Global obligation goals for all, not just the
  poor

Lancet 2010 376 9911023.
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Immunization part of the problem?

• The model vertical program
• Successful EPI programmes have established
  parallel infrastructure in many countries,
  bypassing inadequate health services
• Campaigns approach
• Disrupts and undermines health services
• Even damages struggling EPI programmes

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Immunization and equity

• Traditionally immunization is seen as pro-poor (
  pro-equity)
• Coverage beyond the reach of the routine health
  services
• Campaigns may reach 100 of the population
• Herd immunity provides protection for
  unvaccinated children
• Reaching Every District (RED) approach
• a sub-national approach to immunization data
  collection

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New vaccines promote inequity

• Between countries
• New vaccine use has been restricted to lowest
  risk children in low risk countries
• Within countries
• Promotion of lifesaving vaccines in private
  sector of high mortality countries
• Routine immunization excludes children not
  reached by the health services (highest risk)

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Immunization and equity impact of the MDGs

• Vaccination interventions low hanging fruit
• New vaccines presented with substantial (largely
  unproven) promise
• Pneumococcus (800,000 1 million deaths/yr)
• Rotavirus (500,000 deaths/yr)
• But
• Death from diarrhoea or pneumonia death from
  lack of basic health care

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The fundamental problem with modern immunization
data

• Most data are national averages
• Lives saved coverage X effectiveness
• Inaccurate
• Fundamentally misleading
• Children who die from diarrhoea or pneumonia are
  usually marginalized, outside the health system
• More honest would be
• Coverage amongst the highest risk group X
  effectiveness

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Post 2015

• The world can/will strive for greater fairness in
  health
• equity must be front and centre
• Pure survival is not enough, preventative
  strategies must be paramount
• Nutrition maternal and infant
• Healthy environment
• Immunization
• Prevention of specific diseases AIDS, malaria
• Health care must be comprehensive and integrated
• ( non-vertical)

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Immunization and equity Trickle down or
Affirmative action?

• 100 coverage with all suitable vaccines
  perfectly equitable
• In the real world 1 or 50 unimmunized, these
  will be the highest risk children
• As coverage approaches 100
• Excluded are an increasingly small group of
  increasingly high risk children

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Use of immunization to promote equity

• Identify highest risk children and ensure that
  coverage is highest among these groups
• Selective use of vaccines against treatable
  diseases (eg. Shigella)
• Alternative strategies
• eg. maternal immunization to prevent early infant
  illnesses and/or maternal infections
• Who are the highest risk communities?

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Who are the highest risk communities?

• Economically deprived
• Geographically isolated
• Ethnographically excluded

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Who are the highest risk communities?

• Economically deprived
• Geographically isolated
• Ethnographically excluded
• Transient communities
• Internally displaced communities
• Refugees
• Victims of wars and natural disasters
• Even when we can do nothing else, we can provide
  these communities with life-saving vaccines

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Priorities for 2025

• Immunization must be at the vanguard of global
  efforts to achieve fairer, more equitable health
  outcomes
• Strategies and new vaccines must focus on
• The needs of the highest risk communities (not
  always in the poorest countries)
• Ensuring that vaccination continues to be a major
  force to promote equity in health outcomes