National workshop on immunization and influenza Belgrade, Serbia 22 December 2011

1. The importance of childhood immunization and their role in reaching the Millennium Development Goals National workshop on immunization and influenza Belgrade, Serbia 22 December 2011 Dr Nedret Emiroglu Executive Manager Division of Communicable Diseases, Health Security and Environment WHO European Regional Office

2. WHO European Region 53 Member States (~890 million)

3. Millennium Development Goals Goal 4: Reduce child mortality Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate • Under-five mortality rate • Infant mortality rate • Proportion of 1 year-old children immunised against measles

4. Good progress in achieving MDG 4 in the WHO European Region In 2009 11 countries achieved MDG 4 target Source: WHO European Region estimates; WHO, 2011

5. Probability of dying before the age of 5 per 1 000 live births 70 Large discrepancies between countries 60 50 40 30 20 10 0 Central Asian Republics 1980 1990 2000 2010 Source: WHO/Europe Health for all Database Commonwealth of Independent States European Region European Union

6. A big challenge … Globally every year… 7,6 million children die before their 5th birthday 3,2 million newborn babies in the first month of life 2,4 million infants between 1 – 12 months Silent tragedies that have to be prevented!

7. About a quarter of under-5 deaths globally are vaccine preventable* rotavirus (21%) pneumococcus (30%) 24% 76% measles (16%) Hib (15%) pertussis (10%) tetanus (6%) Meningococcus A (< 1%) other (<1%) • 10.4 million deaths under 5 years of age • 2.45 million or 24% deaths under 5 from vaccine preventable diseases • 1.16 million deaths under 5 years of age from diseases targeted by conventional EPI vaccines • 1.29 million form diseases where licensed vaccine is available *(Estimated annual childhood deaths, 2004)

8. The way forward… By 2015: Saving 16 million lives of women and children Preventing 33 million unwanted pregnancies Protecting 88 million children from stunting Protecting 120 million children from pneumonia

9. A Global Outlook • 1st time in documented history no. • of children dying every year has fallen • below ten million • Result of improved access to immunization, integrated delivery of essential health interventions, as well as clean water and sanitation. • Vaccine development is surging. • Over 80 new products are in late stage clinical testing • Over 30 target diseases for which there is no vaccine currently. • Since 2000, the global vaccine market has tripled

10. Developing countries vaccine manufacturers playing a large role: now meet 86% of the global demand for traditional vaccinesMore than ever before, stringent measures are taken to ensure all people of the world have access to vaccines and immunization equipment that are safe, effective and of good quality.There are significant direct savings associated with vaccination against major vaccine-preventable diseases. A Global Outlook (cont.)

11. Immunization is more than just about preventing death • The most cost-effective intervention in public health • Keeping people healthy has benefits beyond the immediate health benefits and contributes to economic growth I would be hard-hearted enough to let the sick die if you could tell me how to prevent others from falling sick - Mohandas Gandhi

12. WHO European Region: Immunization programmatic goals Health 2020 • Immunization Systems Strengthening • Stewardship/ sustainable financing • Quality-assured vaccines, supply and safety • Access to and utilization of immunization services • Use of new and under-utilized vaccines • Communication & Advocacy • Accelerated Disease Control • Diseases with eradication & elimination goals • Priority bacterial and viral diseases • Communication & Advocacy • Enhanced Surveillance & Monitoring • Surveillance for disease control and prevention • Strengthening laboratory networks • Communication & Advocacy

13. Immunization Programme priorities WHO European Region Measles and rubella elimination by 2015 Sustaining polio-free status Ensuring equity to safe, affordable vaccines Strengthening national immunisation programmes in the context of overall health systems development Support for introduction of new and under-utilized vaccines using safe injection practices Strengthening national VPD surveillance systems, including laboratory networks

14. Regional immunization coverage estimates 1990-2010, WHO European Region Source: WHO/UNICEF Coverage Estimates.

15. The challenge Approximately 700,000 million children born each year in the European Region are not fully immunized, and Since the year 2000, some countries with traditionally high vaccination coverage have reported decreased coverage rates, below the 95% threshold recommended by WHO.

16. Regional Measles and Rubella Elimination Goals Resolution EUR/RC55/R7 Original target: 2010 Resolution EUR/RC60/R12 European Region Strategic Plan New target: 2015

17. Renewed commitment to MR elimination by 2015 and sustained support for polio-free status Member States: Commit and give goals high priority Ensure required resources Strengthen routine immunization Focus on pockets with low coverage and mobilize European Immunization Week Strengthen health system components Strengthen surveillance systems in line with IHR polio, measles and rubella 17

18. Renewed commitment to MR elimination by 2015 and sustained support for polio-free status WHO European Regional Office: Provide leadership and strategic direction-Strategic Plan 2011-2015 Provide technical guidance to Member States Work with Member States on addressing : vulnerable groups increasing demand for immunization 18

19. Progress in implementing Strategic Plan to eliminate measles and rubella in theWHO European Region, 1990-2011 Catch-up SIAs Data as of 1st Dec 2011; Source: monthly measles and rubella reporting to WHO EURO

20. Reported measles casesWHO European Region, 2004-2010 Ukraine Romania Continual transmission in western part of the Region Bulgaria France Measles cases 2011 2004 2005 2006 2007 2009 2008 2010` Data Source: Monthly Measles Rubella Surveillance data, CDS/WHO/EURO Month and year Data as of 1 Dec 2011

21. Major challenges to achieving measles and rubella elimination in the European Region • Continued political commitment and transparency by governments • Required human and financial resources in face of competing public health priorities and economic situation • Increasing momentum of vaccine refusals • General complacency in absence of disease (low risk perception) • Variable public trust in vaccines • Multiple reasons but results are the same -> declining coverage • Marginalized and vulnerable groups require tailored approaches to increase uptake of vaccine 21

22. European Immunization Week23-30 April 2011 52 participating Member StatesActivities included multi-media information campaigns (in 30+ countries), competitions, outreach, launch events, congresses and seminars, and a host of other initiatives 550+ media “hits” across the European Region and globally(CNN and Al Jazeera)2200+ views/listens/downloads of EIW multimedia materials145+ members contributed blogs, comments & pictures to EIW campaign siteMore than 10 million children were vaccinated in AprilStatements of support from HRH Princess Mathilde of Belgium, HRH Crown Princess Mary of Denmark, Bill Gates, GAVI Alliance and many more……eiw.euro.who.int EIW2012: 21-27 April

23. Confirmed wild poliovirus cases,WHO European Region*, 2010 Wild poliovirus type 1 Tajikistan: 458 cases Turkmenistan: 3 cases Russian 14 cases Federation Kazakhstan: 1 case AFP cases Uzbekistan: 147 cases • More than 55 million doses of mOPV1 and tOPV (in 5 Member States) • More then 9 millions of US $ Data as of 31 August 2010 * AFP cases in Uzbekistan Source: Weekly AFP reporting to WHO European Region

24. 25th Regional Certification Commission (RCC) conclusions 2011 The RCC commended countries’ actions, including the allocation of large amounts of staff and money to stop further poliovirus transmission. There is no evidence of continued wild poliovirus transmission, there is no need to repeat the process of certifying polio eradication in the Region. However, we must remain vigilant and acknowledge that some countries remain at risk due to sub-optimal coverage or a decline in quality of AFP surveillance 24

25. Risk of transmission following importation of wild poliovirus: WHO European Region, 2010-2011 High risk Intermediate risk Low risk 7 1 3 8 2 6 5 4 Malta 1-Bosnia & Herzegovina 2-Georgia 3-Montenegro 4-Malta 5-Turkey (Eastern) 6-Tajikistan 7-Ukraine 8-Uzbekistan 25

26. Several new vaccines fighting serious diseases such as pneumonia, meningitis and some causes of childhood diarrhoea are currently being introduced in the European Region and are already showing their effect in reducing childhood mortality and morbidity. As many as 50 countries in this Region have already introduced the vaccine against Haemophilus influenza type B that causes severe cases of meningitis in children under five. In addition, 12 countries provide routine immunization against invasive pneumococcal diseasesFive countries have introduced rotavirus vaccines into their immunization programs. New and under-utilized Vaccines (NUVI) in the European Region

27. Introduction of new and underutilised vaccines in WHO European Region Hib Vaccine implementation, WHO European Region, November 2011 Introduced Plan introduction Not introduced Source: WHO/UNICEF JRF

28. Pneumococcal vaccine implementation, WHO European Region, 2011 Source WHO/UNICEF JRF

29. Meningococcal C conjugate vaccine implementation, WHO European Region, 2010 The boundaries and name shown and the designation used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimination of its frontiers of boundaries. Source: WHO/UNICEF JRF PMM, Istanbul, Turkey 16-18 November 2010 29

30. Cancer is responsible for 1 out of 8 deaths worldwide - more than AIDS, tuberculosis and malaria combined. 40% of the 12 million people diagnosed with cancer worldwide each year could avert the killer disease by protecting themselves against infections and changing lifestyles. Vaccines can play a key role: about 21 percent of all cancers are due to infections like the human papillomavirus, or HPV (cervical cancer), and hepatitis infections (stomach and liver cancer). Nearly 80 % of the world's cervical cancer deaths are in poor countries.

31. Introduction of HPV vaccine in WHO European Region Sources: JRF, WHO survey, EUVAC.NET

32. Cervical cancer screening programmes Large differences in the region From very effective organized public screening programmes with high coverage (Finland, Iceland, Netherlands, Slovenia...) To opportunistic screening only in private clinics (e.g. Georgia)

33. Influenza vaccines • Influenza vaccines introduced 1940s • Vaccination is primary means of preventing influenza today • Excellent safety record • High efficacy:70-90% in healthy adults • …but lower in the elderly... • 60% in persons >60 years • 30-40% in persons >85 years • More on this in Dr Dina Pfeifer’s presentation later…….

34. New vaccines introduction- WHO’s role Support for establishing and reinforcing national immunization technical advisory groups (NITAGs) Regional guidelines on new vaccines introduction Capacity building of National Immunization Programme Managers Support Member States to reinforce surveillance for diseases targeted by new vaccines Build up laboratory networks for rotavirus and invasive bacterial diseases (Belarus and Russian Federation)

35. Summary Strong regional immunization programmes overall due to efforts by Member States and partnerships Increasing momentum of vaccine refusals Marginalized and vulnerable groups require attention, general complacency in absence of disease (low risk perception), variable public trust. Need to reframe activities within the adopted resolution to optimize coverage, meet elimination and eradication goals, effectively introduce new vaccines, and respond to outbreaks Cannot afford to jeopardize progress made towards goals 35

36. Thank you