Transcript Future trends and perspectives in immunization Kim Mulholland London School of Hygiene and

Future trends and perspectives in
immunization
Kim Mulholland
London School of Hygiene and
Tropical Medicine
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.
The Millennium Development Goals
1.
2.
3.
4.
5.
6.
Halve poverty and hunger
Achieve universal primary education
Eliminate gender disparity
Reduce by 2/3 the child (< 5) mortality rate
Reduce by 3/4 the maternal mortality rate
Halt and reverse the spread of HIV AIDS and
incidence of malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
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
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.
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
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
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)
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
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
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)
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
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?
Who are the highest risk
communities?
• Economically deprived
• Geographically isolated
• Ethnographically excluded
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
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