1. A program of the THE GLOBAL VACCINE ACTION PLAN SHAPING IMMUNIZATION PROGRAMMES IN THE CURRENT DECADE Thomas Cherian Department of Immunization, Vaccines & Biologicals World Health Organization, Geneva IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 1

2. 40 YEARS OF EPI: DID IT MEET EXPECTATIONS? IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 2 Small pox eradication and the birth of EPI

3. Third dose coverage form DTP containing vaccines, 1980-2013, by Income Source: WHO/UNICEF coverage estimates 2013 revision. July 2014 and Country Income Categories (World Bank) as of July 2014 (2013 GNI per capita). Income classification not available for: Cook Islands, Niue and Nauru Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 29 July 2014. High-income countries Global Low-income countries 96% 84% 79% IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

4. Global coverage estimates, 1980-2013 DTP 1 & 3, Measles 1 & 2, HepB 3, Hib3, PCV3 and Rota (last dose) Source: WHO/UNICEF coverage estimates 2013 revision. July 2014 Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

5. 5 Reduction in estimated measles deaths, 1985 - 2013 Source: WER 2014; 89 (46) 509-16 87% drop from 1985-2013 75% drop from 2000-2013

6. Impact of RV on diarrhoea mortality in Mexico and Brazil Richardson et al. NEJM 2010; 362:299; do Carmo GM et al. PLoS Med 2011; 8(4):e1001024 In Mexico and Brazil 35% and 22% reductions in diarrhoea-related mortality, respectively, were observed in children under 5 years, following the introduction of rotavirus vaccine IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

7. "The mission of the Decade of Vaccines is to extend, by 2020 and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live." “We envision a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases". Call for a Decade of Vaccines: Renewed optimism, untapped potential, unprecedented opportunity

8. Goals of the Global Vaccine Action Plan IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

9. Strategies towards attainment of the DoV Goals All countries commit to immunization as a priority 1 Strong immunization systems that are an integral part of a well functioning health system Benefits equitably extended to all people 3 4 Individuals and communities understand and demand immunization 2 Sustainable access to long-term funding and quality supply 5 Country, regional and global R&D efforts maximize the benefits of immunization 6 Certification of polio eradication Elimination of neonatal tetanus Elimination of measles in at least 5 regions Elimination of rubella in at least 2 regions Under 5 mortality rate declines significantly Hundreds of millions of cases and millions of future deaths averted Currently available and underutilized vaccines are scaled-up New or improved vaccines and technologies further enhance the benefits of immunization IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

10. Monitoring Framework Independent review

11. A program of the Assessment of progress IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 11

12. IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 12 http://www.who.int/immunization/global_vaccine_action_plan/en/

13. DTP3: All countries >90% national coverage, and >80% in every district by end 2015 Polio: transmission stopped by end 2014 Maternal and neonatal tetanus: eliminated by 2015 Measles: eliminated in 4 regions by end-2015 Rubella: eliminated in 2 regions by end-2015 Introduction of under-utilized vaccines: At least 90 low or middle income countries to have introduced one or more such vaccines by 2015 GVAP mid-point targets OFF TRACK ON TRACK IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

14. <1(86 countries or 44%) ≥1 - <5(28 countries or 14%) ≥5 - <10(11 countries or 6%) ≥10 - <50(33 countries or 20%) ≥50(15 countries or 8%) No data reported to WHO HQ Not applicable Measles Incidence Rate* 2013 *Rate per 1'000'000 population Outbreaks represent cases reported to WHO through end Dec 2013 except where noted †: DRC through 18 Feb 2014 Pakistan through end May 2013 Somalia through 31 Dec 2013 Data in WHO HQ as of 10 February 2014 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 2014. All rights reserved. Ukraine: 12,744 in 2012 3,308 in 2013 Somalia†: 9,983 in 2012 2,848 in 2013 Nigeria: 6,447 in 2012 55,335 in 2013 Romania: 7,452 in 2012 1,074 in 2013 Angola: 4,458 in 2012 6,505 in 2013 Dem Rep Congo†: 72,029 in 2012 89,108 in 2013 Ethiopia: 4,347 in 2012 3,982 in 2013 Pakistan†: 14,984 in 2012 >25,000 in 2013 Indonesia: 15,489 in 2012 8,147 in 2013 Thailand: 5,197 in 2012 1,825 in 2013 Georgia: 31 in 2012 7,830 in 2013 Sudan: 8,523 in 2012 2,679 in 2013 India: 18,668 in 2012 China: 6,183 in 2012 27,825 in 2013 Turkey: 57 in 2012 7,371 in 2013 14 (15 countries or 8%) Reported Measles Cases in 15 Large Outbreaks since Jan 2012

15. Maternal and neonatal tetanus elimination IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 15

16. Not for the first time… IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

17. ARE WE ON TRACK TO REACH OUR COVERAGE GOALS ? Source: WHO/UNICEF coverage estimates 2012 revision. July 2013 Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 17 July 2013. Global immunization coverage has stagnated in past 5 years IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

18. Missed opportunities for vaccination: failure of integration? Indonesia India IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

19. A program of the What are the challenges and possible solutions?? IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey 19

20. THE NEW “REALITY” OF EPI: THE CHANGING PARADIGM Source: BMGF/WHO 20

21. Number of Vaccines/Antigens Introduced Nationwide in Immunization Schedules - 2000 compared to 2013 Selected antigens are : Diphtheria, Tetanus, Pertussis, Measles, Polio - universal use Hepatitis B, Heamophilius Influenza type B, Pneumococcal conjugate Rotavirus Rubella Data Source: WHO/IVB Database, as at 08 July 2014 Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization Date of slide: 04 September 2014 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 2014. All rights reserved 5 antigens (DTP, Measles and Polio) 6 antigens 7 antigens 8 antigens 9 antigens Not applicable Not available 2000 2013 10 antigens

22. The current challenges Trained human resources Vaccine supply chains Information systems Inadequate systems Availability Financing Pricing & procurement Vaccine supply & price Unregistered & migrant populations Failure of integration: missed opportunities Conflicts and crisis Hesitancy and refusals Reaching the “5 th child” IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

23. The cMYP: basis of implementation of the GVAP Data driven and systems-oriented approach to planning IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 23

24. Country monitoring & accountability IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 24

25. What role could immunization managers play? Use data and evidence for planning Promote regular review and use of data at all levels Triangulate data from different sources (coverage, surveillance, vaccine stock) Align the cycles for assessment and planning Establish an accountability process at all levels Part of the regular data review processes Engage local community leaders in the review and accountability process Pay close attention to human resources Choosing the right people (when possible) Regular in-service training and supportive supervision Regular performance review & accountability Improve coordination with other programmes Create synergies to maximize impact and reduce missed opportunities IAIM Inguural Conference, March 3 - 4, 2015, Istanbul, Turkey 25

26. Summary The 40 years of EPI have seen great progress The full potential of immunization is still untapped The evolution of EPI has led to increasing complexity, exposing the fragility of the health systems The last miles are the most difficult; issues are complex and solutions are not simple The GVAP offers solutions, but requires greater country ownership of national programs and the concerted effort of all stakeholders if the ambitious targets for the decade are to be met. IAIM Inaugural Conference, March 3 - 4, 2015, Istanbul, Turkey

27. 27 Together we can make it happen!