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: 991–1023.

3. The Millennium Development Goals 1. Halve poverty and hunger2. Achieve universal primary education3. Eliminate gender disparity4. Reduce by 2/3 the child (< 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

4. MDG’s • 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

5. 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: 991–1023.

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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)

12. 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

13. 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?

14. Who are the highest risk communities? • Economically deprived • Geographically isolated • Ethnographically excluded

15. 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

16. 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