Vaccine-Preventable Disease Control in the Western Pacific Region Mark Jacobs Director, Communicable Diseases
Outline Regional goals Disease-specific updates Hepatitis B Measles Polio Rubella Tetanus Remaining challenges 2
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Regional goals related to specific vaccine-preventable diseases Hepatitis B: Reduce chronic infection rate among 5-yearolds to less than 1% Japanese encephalitis: To accelerate control Measles: To achieve and sustain measles elimination Polio: Sustain regional polio-free status until global certification; eliminate vaccine-derived poliovirus risk Rubella: Eliminate rubella and prevent congenital rubella syndrome Tetanus: By 2015 to achieve maternal and neonatal tetanus (MNT) elimination 4
Hepatitis B goal 64 th WHO WPRO Regional Committee Meeting, October 2013 Resolution WPR/RC64.R5: The Western Pacific Region should aim to reduce HBsAg seroprevalence to less than 1% in 5-year-old children by 2017; Ensure at least 95% coverage of the eligible population at the national level of the hepatitis B vaccination regimen (including the birth dose), and at least 85% coverage in all districts 5
Hepatitis B birth dose coverage improvement strategies Increase health facility deliveries Increase hepatitis B education during ANC Increase links with communities and outreach vaccination Use hepatitis B outside the cold chain where needed (with guidelines and NRA approval) 6
Hepatitis B vaccination coverage, Western Pacific Region, 1990-2014 100 V a c c i n a t i o n C o v e r a g e ( % ) 90 80 70 60 50 40 30 20 10 0 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 HepB3 Coverage HepB Birth Dose Coverage 7
Status of verification towards reaching the <1% prevalence goal, WPR, 2015 8
Impact of hepatitis B vaccination and birth dose >7 million deaths estimated to have been prevented by hepatitis B vaccination in the Western Pacific Region in the past 25 years 548 094 deaths prevented by hepatitis B vaccination among children born in 2014 Regional hepatitis B prevalence now estimated to be 0.96% among children in 2012 birth cohort (those who will be 5 years old in 2017) 9
Key challenges for hepatitis B Birth dose vaccination coverage is still low in several countries (Lao PDR, Papua New Guinea, the Philippines, Solomon Islands, Viet Nam) Recent hepatitis B related AEFIs led to increased vaccination hesitancy in some countries Even with high coverage, substantial numbers of new infections (50 000) are occurring among new birth cohorts in China 10
Goal of measles elimination In 2005, WPRO Regional Committee resolved to achieve measles elimination by 2012 In 2012, WPRO Regional Committee reaffirmed its commitment to eliminate measles as quickly as possible The World Health Assembly endorsement of the Global Vaccine Action Plan includes goals that: By 2015, four of six WHO regions achieve measles elimination By 2020, five of six WHO regions achieve measles elimination 11
Key facts on measles elimination Measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available In 2013, there were 145 700 measles deaths globally about 400 deaths every day or 16 deaths every hour Measles vaccination resulted in a 75% drop in measles deaths between 2000 and 2013 worldwide In 2013, about 84% of the world's children received one dose of measles vaccine by their first birthday through routine health services up from 73% in 2000 During 2000-2013, measles vaccination prevented an estimated 15.6 million deaths making measles vaccine one of the best buys in public health 12
Key strategies for measles elimination Achieve and maintain high (>95%) coverage with two doses of measles containing vaccine Monitor disease using effective case based surveillance Develop and maintain outbreak preparedness Communicate and engage the community to create demand for vaccination 13
Reported Measles Incidence Rate*, Jul 2014 to Jun 2015 *Rate per 1'000'000 population 14 Data source: surveillance DEF file Data in HQ as of 10 August 2015 <1 (73 countries or 38%) 1 - <5 (36 countries or 19%) 5 - <10 (18 countries or 9%) 10 - <50 (30 countries or 15%) 50 (20 countries or 10%) No data reported to WHO HQ Not applicable (17 countries or 9%) The boundaries and names shown and the designations 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 delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2015. All rights reserved.
Reported confirmed measles cases by month of onset, Jan 2010-Jun 2015, Western Pacific Region 15
Summary of Progress Towards Measles Elimination, as assessed by the Regional Verification Commission, March 2015 1 2 3 Categories Verified as having achieved elimination <36 months since achieving interruption of endemic measles transmission May be ready for verification but additional information needed Countries, Areas, Epidemiological Blocks Australia, Brunei Darussalam, Cambodia, Japan, Macao (China), Mongolia, Republic of Korea (n=7) New Zealand (n=1) Hong Kong SAR (China), Singapore (n=2) 4 Periods with low/no documented transmission followed by outbreaks Lao People s Democratic Republic, Pacific islands (n=2) 5 Ongoing measles virus transmission China, Malaysia, Papua New Guinea, the Philippines, Viet Nam (n=5) 16
Key challenges in measles elimination Measles virus is one of the most (or perhaps the most) infectious of all viruses Very high (>95%) population immunity required Complacency or vaccine hesitancy because measles is considered a benign childhood illness rather than recognized as the fifth leading cause of death among children under 5 years of age Immunity gaps among very young children (eg too young to be vaccinated) and adult populations that missed vaccination and not previously infected 17
Goal of polio eradication 1954: Jonas Salk develops a killed polio virus. 1961: Albert Sabin develops an oral polio vaccine. 18 1988 World Health Assembly resolved to eradicate polio by 2000
Progress on polio eradication 1988: 125 countries; 350,000 cases per year 2015: 2 countries with reported cases; 36 cases year to date 19
Progress on polio eradication Poliovirus types Type 1: Ongoing transmission Type 2: Last reported from India in 1999 Type 3: Last reported from Nigeria in 2012 Regional certification of polio-free status 1994: Region of the Americas 2000: Western Pacific Region 2002: European Region 2014: South East Asia Region 2014: Last wild poliovirus case reported from African Region 20
Key strategies for polio eradication Poliovirus detection and interruption: Maintaining sensitive surveillance systems worldwide Strengthening immunization systems and withdrawal of OPV: Introduce at least one dose of IPV and switch from topv to bopv Containment and certification: Contain polioviruses and potentially infected waste to prevent accidental reintroduction Legacy planning: Turn over polio programme assets for use in other disease control programmes 21
IPV introduction in the Western Pacific Approximate number of live births 2012 (JRF) IPV using country/area Country/area with sequential (IPV/OPV) schedule OPV country/area not GAVI eligible OPV country/area eligible for GAVI support for IPV 22
Key challenges for polio eradication Reaching children in insecure border area of Afghanistan and Pakistan where polio workers have been killed Polio eradication is not just the job of polio-infected countries; all countries should Maintain high population immunity Maintain sensitive surveillance for acute flaccid paralysis Very rapid timelines for IPV introduction Identification and containment of all polioviruses and potentially infectious material in all laboratories (private and public) world wide 23
Goal of rubella elimination In 2012, World Health Assembly endorsed the Global Vaccine Action Plan goals that: By 2015, two of six WHO regions achieve rubella elimination By 2020, five of six WHO regions achieve rubella elimination In 2013, the Regional Committee for the Western Pacific resolved to eliminate rubella and prevent congenital rubella syndrome (CRS) 24
Rubella incidence per million, 2014 0 1,050 2,100 4,200 Kilometers <1 case per million (82 countries or 42%) >1--<5 (21 countries or 11%) >5--<10 (12 countries or 6%) >10--<50 (12 countries or 6%) >= 50 (7 countries or 4%) Not available / No data reported to WHO HQ (60 countries or 31%) Not applicable 25 Source: Joint Reporting Form as at 15 May 2015. 194 WHO Member States. Map production: Immunization Vaccines and Biologicals, (IVB). World Health Organization Date of slide: 15 May 2015 The boundaries and names shown and the designations 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 delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2015. All rights reserved
Vaccination for rubella in the Western Pacific Region 26 26
Regional progress toward rubella elimination Australia, New Zealand, the Republic of Korea and Singapore have been approaching rubella elimination Japan developed and officially issued a national plan and strategy for rubella elimination in 2014 and determined 2020 as target year Mongolia aims to eliminate rubella by 2020 and has started development of a National Strategy for Measles and Rubella Elimination 2016-2020 Cambodia will start development of a national plan and strategy for rubella elimination 27
Key strategies for rubella elimination Use only combination measles-rubella vaccines for all routine and supplementary doses Monitor rubella disease and occurrence of CRS using sensitive case based surveillance Communicate with and engage community to create demand for vaccination 28
Key challenges for rubella elimination Disease control programme is not as well established as measles; many countries do not include rubella as reportable disease Three countries in region have not yet introduced rubella vaccine into routine programme, but are expected to do so by 2016 (Papua New Guinea, Vanuatu, and Viet Nam) In the past, many countries vaccinated only girls, which leaves a large susceptible pool for disease transmission among adult men 29
Maternal and Neonatal Tetanus Elimination The World Health Assembly first called for elimination of neonatal tetanus in 1989 In 1999, goal was expanded to include elimination of the maternal tetanus Neonatal tetanus (NT) occurring 28 days of life Maternal tetanus occurring during or 6 weeks following delivery At that time, 57 countries had not eliminated MNT In October 2014, WHO Regional Committee for the Western Pacific endorsed goal of MNT elimination in all countries by 2015 30
Key strategies for MNT Elimination Tetanus toxoid containing vaccine supplementary immunization campaigns for all women of reproductive age in high risk districts Tetanus toxoid containing vaccination of pregnant women Clean delivery and clean umbilical cord care (ideally through skilled birth attendants in health care facility setting) Neonatal tetanus surveillance 31
From 2000 to April 2015, 37 countries eliminated MNT *(Plus Ethiopia except Somali Region; 30 of 34 provinces in Indonesia; and 16 of 17 regions in Philippines) Source: WHO/UNICEF Database Date of slide : 26 May 2015 Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization 0 750 1,500 3,000 4,500 6,000 Kilometers MNT not eliminated (N=22) MNT eliminated from 2000- April 2015 (N=37) MNT eliminated before 2000 Not Applicable 32
MNT elimination in the Western Pacific: Only 6 countries included in list of 59 high risk countries Viet Nam: Validated in 2005 China: Validated in 2012 Lao PDR: Validated in 2013 Philippines: 16/17 regions validated in Feb 2015 Cambodia: Validated in June 2015 Papua New Guinea: Pending LEGEND: Validated 16 of 17 regions validated (Philippines) Not yet validated (Papua New Guinea) 33
Key challenges for MNT elimination Philippines: Insecurity in the Autonomous Region of Muslim Mindanao Papua New Guinea: Competing priorities for scarce resources in a setting of developing health care delivery system 34
In conclusion Enormous strides made by countries of WPR in tackling VPD Elimination of measles and rubella, and eradication of polio, is within our grasp Some key challenges remain- Expanding coverage in hard to reach groups Maintaining national focus as case numbers drop Retaining community support Balancing opportunities re new vaccines with achieving and sustaining necessary coverage with existing vaccines Reduced donor support for immunisation in some countries, adding to difficulty of maintaining national focus and building on past success 35