Laure Dumolard

Global routine vaccination coverage, 2014.

The year 2014 marked the 40th anniversary of the World Health Organization’s (WHO) Expanded Program on Immunization, which was established to ensure equitable access to routine immunization services (1). Since 1974, global coverage with the four core vaccines (Bacille Calmette- Guérin vaccine [BCG; for protection against tuberculosis], diphtheria-tetanus-pertussis [DTP] vaccine, poliovirus vaccine, and measles vaccine) has increased from <5% to ≥85%, and additional vaccines have been added to the recommended schedule. Coverage with the 3rd dose of DTP vaccine (DTP3) by age 12 months is an indicator of immunization program performance because it reflects completion of the basic infant immunization schedule; coverage with other vaccines, including the 3rd dose of poliovirus vaccine (polio3); the 1st dose of measles-containing vaccine (MCV1) is also assessed. Estimated global DTP3 coverage has remained at 84%–86% since 2009, with estimated 2014 coverage at 86%. Estimated global coverage for the 2nd routine dose of measles-containing vaccine (MCV2) was 38% by age 24 months and 56% when older age groups were included, similar to levels reported in 2013 (36% and 55%, respectively). To reach and sustain high immunization coverage in all countries, adequate vaccine stock management and additional opportunities for immunization, such as through routine visits in the second year of life, are integral components to strengthening immunization programs and reducing morbidity and mortality from vaccine preventable diseases.

Government financing for health and specific national budget lines : The case of vaccines and immunization

A long standing question related to immunization financing and sustainability has been whether the existence of a specific line item for vaccines purchasing within the national health budget can contribute significantly to increasing national government financing of vaccines and routine immunizations. Based on immunization financing indicators from 185 countries collected through the joint WHO and UNICEF monitoring system, this paper attempts to answer this policy question. The study will present findings related to the status of countries that have such specific budget lines for purchasing vaccines and the levels of national budgetary allocation to the financing of vaccines and immunizations, particularly in low-income countries. The analysis shows evidence that the existence ofa specific line in the national budget is associated with increased governmental budget allocations for vaccines and routine immunization financing.

A global review of national influenza immunization policies: Analysis of the 2014 WHO/UNICEF Joint Reporting Form on immunization.

Introduction The WHO recommends annual influenza vaccination to prevent influenza illness in high-risk groups. Little is known about national influenza immunization policies globally. Material and Methods The 2014 WHO/UNICEF Joint Reporting Form (JRF) on Immunization was adapted to capture data on influenza immunization policies. We combined this dataset with additional JRF information on new vaccine introductions and strength of immunization programmes, as well as publicly available data on country economic status. Data from countries that did not complete the JRF were sought through additional sources. We described data on country influenza immunization policies and used bivariate analyses to identify factors associated with having such policies. Results Of 194 WHO Member States, 115 (59%) reported having a national influenza immunization policy in 2014. Among countries with a national policy, programmes target specific WHO-defined risk groups, including pregnant women (42%), young children (28%), adults with chronic illnesses (46%), the elderly (45%), and health care workers (47%). The Americas, Europe, and Western Pacific were the WHO regions that had the highest percentages of countries reporting that they had national influenza immunization policies. Compared to countries without policies, countries with policies were significantly more likely to have the following characteristics: to be high or upper middle income (p < 0.0001); to have introduced birth dose hepatitis B virus vaccine (p < 0.0001), pneumococcal conjugate vaccine (p = 0.032), or human papilloma virus vaccine (p = 0.002); to have achieved global goals for diphtheria-tetanus-pertussis vaccine coverage (p < 0.0001); and to have a functioning National Immunization Technical Advisory Group (p < 0.0001). Conclusions The 2014 revision of the JRF permitted a global assessment of national influenza immunization policies. The 59% of countries reporting that they had policies are wealthier, use more new or under-utilized vaccines, and have stronger immunization systems. Addressing disparities in public health resources and strengthening immunization systems may facilitate influenza vaccine introduction and use.

Status of New Vaccine Introduction - Worldwide, September 2016.

Since the global Expanded Program on Immunization (EPI) was launched in 1974, vaccination against six diseases (tuberculosis, polio, diphtheria, tetanus, pertussis, and measles) has prevented millions of deaths and disabilities (1). Significant advances have been made in the development and introduction of vaccines, and licensed vaccines are now available to prevent 25 diseases (2,3). Historically, new vaccines only became available in low-income and middle-income countries decades after being introduced in high-income countries. However, with the support of global partners, including the World Health Organization (WHO) and the United Nations Childrens Fund, which assist with vaccine prequalification and procurement, as well as Gavi, the Vaccine Alliance (Gavi) (4), which provides funding and shapes vaccine markets through forecasting and assurances of demand in low-income countries in exchange for lower vaccine prices, vaccines are now introduced more rapidly. Based on data compiled in the WHO Immunization Vaccines and Biologicals Database* (5), this report describes the current status of introduction of Haemophilus influenzae type b (Hib), hepatitis B, pneumococcal conjugate, rotavirus, human papillomavirus, and rubella vaccines, and the second dose of measles vaccine. As of September 2016, a total of 191 (99%) of 194 WHO member countries had introduced Hib vaccine, 190 (98%) had introduced hepatitis B vaccine, 132 (68%) had introduced pneumococcal conjugate vaccine (PCV), and 86 (44%) had introduced rotavirus vaccine into infant vaccination schedules. Human papillomavirus vaccine (HPV) had been introduced in 67 (35%) countries, primarily targeted for routine use in adolescent girls. A second dose of measles-containing vaccine (MCV2) had been introduced in 161 (83%) countries, and rubella vaccine had been introduced in 149 (77%). These efforts support the commitment outlined in the Global Vaccine Action Plan (GVAP), 2011-2020 (2), endorsed by the World Health Assembly in 2012, to extend the full benefits of immunization to all persons.

Monitoring of progress in the establishment and strengthening of national immunization technical advisory groups

The majority of industrialized and some developing countries have established technical advisory bodies to guide and formulate national immunization policies and strategies. These are referred to as National Immunization Technical Advisory Groups (NITAGs), WHO and its partners have placed a high priority on assisting in the establishment or strengthening of functional, sustainable, and independent NITAGs. To enable systematic global monitoring of the existence and functionality of NITAGs, in 2010, WHO and UNICEF included related questions in the WHO-UNICEF Joint Reporting Form (JRF) that provides an official means for WHO and UNICEF to collect indicators of immunization programme performance. This paper presents the status of NITAGs based on the analysis of the 2010 JRF. Although 115 countries (64% of responders) reported having a NITAG in 2010, only 50% of countries reported the existence of a NITAG with a formal administrative or legislative basis. Despite limitations in the ability to compare 2010 JRF data with that from a 2008 global survey, it appears that substantial progress has been achieved globally over with 43 committees reporting affirmatively about six NITAG process indicators, compared with 23 in the 2008 survey. Impressive progress has been observed in the proportion of countries reporting NITAGs with formal terms of reference (24% increase), a legislative or administrative basis (10% increase), and a requirement for members to disclose their interests (14% increase). Some of the poorest developing countries now enjoy support from a NITAG which meet all six process indicators. These may serve as examples for other countries.

Progress in the establishment and strengthening of national immunization technical advisory groups: analysis from the 2013 WHO/UNICEF joint reporting form, data for 2012.

The majority of industrialized and some developing countries have established National Immunization Technical Advisory Groups (NITAGs). To enable systematic global monitoring of the existence and functionality of NITAGs, in 2011, WHO and UNICEF included related questions in the WHO/UNICEF Joint Reporting Form (JRF) that provides an official means to globally collect indicators of immunization program performance. These questions relate to six basic process indicators. According to the analysis of the 2013 JRF, data for 2012, notable progress was achieved between 2010 and 2012 and by the end of 2012, 99 countries (52%) reported the existence of a NITAG with a formal legislative or administrative basis (with a high of 86% in the Eastern Mediterranean Region - EMR), among the countries that reported data in the NITAG section of the JRF. There were 63 (33%) countries with a NITAG that met six process indicators (47% increase over the 43 reported in 2010) including a total of 38 developing countries. 11% of low income countries reported a NITAG that meets all six process criteria, versus 29% of middle income countries and 57% of the high income ones. Countries with smaller populations reported the existence of a NITAG that meets all six process criteria less frequently than more populated countries (23% for less populated countries versus 43% for more populated ones). However, progress needs to be accelerated to reach the Global Vaccine Action Plan (GVAP) target of ensuring all countries have support from a NITAG. The GVAP represents a major opportunity to boost the institutionalization of NITAGs. A special approach needs to be explored to allow small countries to benefit from sub-regional or other countries advisory groups.

Assessments of global drivers of vaccine hesitancy in 2014—Looking beyond safety concerns

Vaccine hesitancy has become the focus of growing attention and concern globally despite overwhelming evidence of the value of vaccines in preventing disease and saving the lives of millions of individuals every year. Measuring vaccine hesitancy and its determinants worldwide is important in order to understand the scope of the problem and for the development of evidence-based targeted strategies to reduce hesitancy. Two indicators to assess vaccine hesitancy were developed to capture its nature and scope at the national and subnational level to collect data in 2014: 1) The top 3 reasons for not accepting vaccines according to the national schedule in the past year and whether the response was opinion- or assessment-based and 2) Whether an assessment (or measurement) of the level of confidence in vaccination had taken place at national or subnational level in the previous 5 years. The most frequently cited reasons for vaccine hesitancy globally related to (1) the risk-benefit of vaccines, (2) knowledge and awareness issues, (3) religious, cultural, gender or socio-economic factors. Major issues were fear of side effects, distrust in vaccination and lack of information on immunization or immunization services. The analysis revealed that 29% of all countries had done an assessment of the level of confidence in their country, suggesting that vaccine confidence was an issue of importance. Monitoring vaccine hesitancy is critical because of its influence on the success of immunization programs. To our knowledge, the proposed indicators provide the first global snapshot of reasons driving vaccine hesitancy and depicting its widespread nature, as well as the extent of assessments conducted by countries.

Forecasting demand for Hib-containing vaccine in the world's poorest countries: a 4-year prospective experience.

This article analyzes the performance of a Hib vaccine demand forecast developed in 2003 for 68 GAVI-supported countries between 2004 and 2007. During that period of time, corresponding to an acceleration of Hib vaccine uptake, several groups of countries were identified based on the stage of their decision-making process, perception of Hib disease burden and programme performance. Better forecast accuracy was obtained for countries having already introduced the vaccine or that were about to do so. The ability to anticipate global needs in terms of vaccine volumes was highly dependant on the actual year of introduction of a small number of very large countries.

Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015–2017

Highlights • WHO vaccine hesitancy definition understood; >90% countries report hesitancy.• Long list of reasons, varied by country income level; WHO region, changed overtime.• Most cited: risk-benefit (scientific evidence) equaled <25% of reasons cited.• Reasons cited based on assessments in only 1/3 of countries; need to increase this.

Global landscape of measles and rubella surveillance

BACKGROUND All six World Health Organization (WHO) regions have committed to eliminate measles, and three WHO regions have committed to eliminate rubella. One of the key tenets of measles and rubella elimination is to have a strong surveillance system in place. The presence of a case-based measles and rubella surveillance system that is national, population-based, provides laboratory confirmation, and directs action, is one of the requirements for elimination-standard surveillance. METHODS In order to understand the global landscape for measles and rubella surveillance, a questionnaire was sent to all 194 WHO member states (herein referred to as countries) requesting information on how surveillance was conducted for measles, rubella, and congenital rubella syndrome. Data were supplemented with information provided to WHO through other reporting mechanisms and by national policy documents available to the public. Frequencies and percentages were calculated. RESULTS Data were available to review from 164 (85%) countries, although not every country responded to every question. Case-based, population-based, national surveillance with laboratory confirmation was reported to be conducted in 136 (86%) of 158 countries for measles and 122 (77%) of 158 countries for rubella. Congenital rubella syndrome surveillance was reported to be conducted by 126 (77%) of 163 countries. Gaps were noted in the quality of measles-rubella surveillance conducted, and 26 (16%) of 158 countries reported not including all healthcare providers as mandatory reporters. CONCLUSIONS Many countries reported having some of the essential components in place to conduct elimination-standard surveillance for measles and rubella; however, in order to achieve elimination, the quality of surveillance needs to improve to detect all cases. In those countries without these essential components of elimination-standard surveillance, the first step is to implement these components.