1. What’s new in
immunization and where do
PVOs fit in?
Presented to CORE Group Meeting
by Rebecca Fields and Robert Steinglass, MCHIP
October 12, 2012

2. Outline of presentation
 What is new in the field of immunization
 Findings from ARISE with particular
relevance for PVOs
 New vaccine introduction

3. Global U5 Mor tality: Role of
Vaccine Preventable Diseases
(2008 data)
8.8 million under five deaths
Pneumonia other 17% (1.5 million)
Pneumoccocal
12%
diseases* from vaccine
6% preventable diseases
Other Hib*
18% Pertussis
2%
2%
Tetanus
Measles 1%
1%
Perinatal
Rotavirus*
32%
5%
Diarrhoea other
HIV 10%
Malaria 2%
9%
Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis,
Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.
* WHO/IVB estimates

4. The cause of 1 .5 million deaths globally
among children that are preventable by
routine vaccination, 2008
Tetanus Pneumoccocal
Measles 4% diseases*
8% 32%
Pertussis
13%
Hib*
13%
Rotavirus*
30%
Source: Black RE at all, Global, regional, and national causes of child mortality in 2008: a systematic analysis,
Lancet. 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.
* WHO/IVB estimates

5. What’s new in immunization?
 Global Vaccine Action Plan (Decade of Vaccine)
 Many new entrants into immunization arena
 Need to move from RED to REC
 Role for CSOs recognized (RED modules, MLM
module on partnering with communities)
 Mechanisms to engage CSOs (e.g. GAVI constituency)
 Inequity now recognized as key challenge
 BMGF strategy for routine imm being designed
 Polio erad. declared public health emergency
 New vaccines exposing cracks in RI system

6. Source: Optimize

7. System requirements continue
to grow
Diseases
vaccinated 2.5x
against1
Vaccine doses per
child (#) [assuming receives ~3x
vx listed above] 2
Vaccine volume per Increased
fully immunized child 50 200
4x stress on the
(cm3)3
2010+
RI system
Immunization cost per $30+
2008
child ($) [including delivery $17 ~6x
costs] 4
1980
$5
Across
Age groups targeted for life
immunization course
1980s realities 2010 and beyond realities
1. Varies by nat'l schedule; represents maximum.1980: Diphtheria, pertussis, tetanus, measles, polio and tuberculosis; 2010 add'l vx: PCV, Rota, HepB, Hib, Yellow Fever, Rubella, JE, MenA. 2. Represents maximum;
1980: 1 BCG, 3 DTP, 3 OPV, 1 measles; 2010: based on 2012 WHO immun. position papers. 3. Based on projected vol. per immun. child for 20 countries according to introduction plans; compares 2001 vol. for tradt'l vx
with 2020 expected vol.; growth driven by penta, PCV, Rotavirus, HPV.
4. Based on 2008 projections. Source: WHO Bulletin, 62 (5):729 -736 (1984); Optimize Vaccine Supply Chains, Optimize (2009); State of the world’s vaccines and immunization, WHO (2009); Vaccine volume calculator, S.
Kone, WHO (2011); Immunization position papers, WHO (2012). Historical analysis of cMYPs in GAVI eligible countries, L. Brenzel and C. Politi (2012)

8. Me
Eli asles
min
ati
on
nus tion amily g
ta ina F
in
Te im P lann Polio
Eradi
El cation
Life Cycle
Support other NUVI Vaccination
health
interventions
Routine Immunization System

9. The five overlapping components of the
Reaching Ever y District (RED) approach
Planning and • RED is intended to be a
flexible approach
management
Monitoring of resources
 • the idea is for
for action Reaching countries/districts to tailor it
the target to fit their situation
populations
Supportive • so the intensity of
supervision Linking implementing each
services with component will vary from
communities country to country

10. Source: ARISE/JSI, 2012

11. Africa Routine Immunization System
Essentials
(funded by BMGF)
Strengthen the evidence base to improve understanding of the
drivers of RI system performance and exploring investment
options.
What drives routine immunization performance in Africa?
Why did coverage improve in some countries?
Why did coverage improve in some districts and not others?
(within the same country: Ethiopia, Ghana, Cameroon)
Visit us at arise.jsi.com

12. ARISE Project : A pathway to improving
routine immunization coverage at district level in
Africa

13. Cadre of Community-centered
Health Workers
Take vaccination
into heart of the Mechanism
community
More workers,
build trust, Transformational
local support,
vaccine supply. step
Raised
awareness,
improved Effect
access,
increased
use


14. Partnership between the Health
System and the Community
Joint
planning, Mechanism
awareness-
raising,
Performanc
e review,
Resource
pooling
Transformational
Shared step
sense of
purpose &
accountabilit
y, credibility
Effect
Ensured
service
availability,
decreased
dropout
rates

15. Tailor Immunization Services to
Community Needs
Gather
information on
preferences; Mechanism
choose
appropriate
sites for
outreach, adapt
services
Personal links,
use appropriate Transformational
avenues, trust step
and credibility
of health
workers and
service
Increased
physical and
social access;
Effect
increased
acceptance,
improved
completion
of
vaccination
schedule

18. CSHGP Historic Level of Ef for ts
by Inter vention

19. Role of
PVOs/NGOs
 Engage on global immunization issues
 Assure immunization is a core component of all
health programs
 Play a role at national and sub-national levels (Inter-
agency Coordinating Committee, plans)
 Staff need to stay technically up-to-date
 Make sure immunization doesn’t get lost amid so
many other objectives/initiatives

20. Why does civil society (e.g., PVOs)
of ten NOT par ticipate in routine
immunization?
 Feel unwelcome on ICC
 Uneasy relationship with
Government/MOH
 Increasing demand can
betray trust, if services
don’t follow
 Community work not
valued
 Immunization is too
vertical, broader objectives
 Looking for financial
support

21. “New” vaccines – new opportunities
 yellow fever
 rubella
 hepatitis B
 HPV (human papillomavirus virus)
 Hib (haemophilus influenzae type b)
 pneumococcal (conjugate)
 rotavirus
 meningococcal A (conjugate)
 typhoid
 JE (Japanese encephalitis)
 oral cholera

22. New vaccines bring new
challenges
 Increase in number of vaccines (6  12 -15)
 Difficult age restrictions (Rotavirus vaccine)
 New target age groups (HPV)
 New messages (disease syndromes, partial
protection)
 Integrated approaches to disease control
 Cold chain and logistics challenges (volume,
waste)
 Cost of new vaccines

23. Framework: Protection, prevention and treatment
strategies for pneumonia & diarrhoea PREVENT
PROTECT Reduce
pneumonia
and
diarrhoea
morbidity
and
mortality
TREAT

24. Contribution of healthy actions for
pneumonia and diarrhea interventions -
examples
PROTECT PREVENT TREAT
Exclusive breastfeeding for Vaccines against measles, Home management of
6 months pertussis, Hib , rotavirus, dehydration (ORS and zinc)
and pneumococcus
Adequate nutrition Vitamin A supplementation Community Case
Management (CCM)
Hand-washing with soap Prevention of HIV in Case management in health
children facilities
Community-wide sanitation Cotrimoxazole prophylaxis Case management at
promotion for HIV exposed and hospitals
infected children
Treatment and safe storage Zinc supplementation for
of household water children with diarrhea
24

25. Example of BCC materials,
Kenya
PCV 10 Poster – Global Action Plan Against Pneumonia
Poster during “Malezi
Bora” child health
week (linked with
Africa Vaccination
Week)

26. oppor tunities with new
vaccines – role for PVOs?
Challenges Opportunities
 Resource mobilization for  Real opportunity to
new vaccine introduction achieve MDG 4
 High demand for the  Renewed government/
vaccine – real danger of partners interest in
stock outs immunization
 Community perceptions  Renewed community
on multiple antigen interest in immunization
vaccinations  Training opportunity for
 Communication about health workers
disease syndromes when  Create momentum for
only some is vaccine- GAPP implementation
preventable

27. Oppor tunities for PVOs to engage
1) Policies and plans exist – need to strengthen communication
and community involvement for pneumo and DD prevention/
implementation; develop strategies for migrant and urban
populations
2) National and local media – develop partnerships for positive
messaging and supportive articles/programs
3) Technical Advisory Groups – integrate case management and
prevention with behavior change interventions
4) Link with initiatives (World Pneumonia Day, World
Handwashing Day, 2012 Year of RI Intensification)
5) Community mobilizers in place – improve/focus their support in
high risk areas (mapping, due lists, referral)

28. Immunization has a role to play
in your por tfolio:
 MCH
 IMCI/CCM
 Nutrition
 Safe Motherhood
 Infectious Diseases
 Child Health
 Child Survival
 PHC

29. Every child should be a
VIP…
Vaccinated,
Immunized &
Protected!
Thank You

30. Thank you!
www.mchip.net
Follow us on:

31. Extra slides

32. Global Vaccine Action Plan’s strategic
objectives
• All countries commit to immunization as a priority
• Individuals and communities understand value of vaccines
and demand immunization as both their right and
responsibility
• Benefits of immunization are equitably extended to all
people
• Strong immunization systems are an integral part of a well-
functioning health system
• Immunization programs have sustainable access to
predictable funding, quality supply and innovative
technologies
• Country, regional and global research and development
innovations maximize the benefits of immunization

33. MCHIP immunization strategies
Increase capacity for sustainable immunization coverage
with all appropriate vaccines to reach unreached and
reduce child mortality
Support effective and sustainable introduction of safe,
high-quality, life-saving new vaccines
Engage in disease control priority programs with focus to
enhance positive effects on strengthening RI platform
Influence global and regional levels with program
learning from the field

34. Sustainable Routine Immunization System
Financing
Practices
Community
Action
Policies Supportive

Supervision Training
Supplies Monitoring
& &
Logistics 
Advocacy Surveillance
 &
Manageme
nt Communication
s

35. Introduction of new vaccines are
challenging the immunization system
• Good planning, partnership and adequate resources
• Effective commitment of Government, partners and
community
• Good coordination between MOH and ICC partners and
close follow-up for the introduction process
• Additional storage capacity to accommodate new vaccine
• Increased number of vaccines at the vaccination site level
• Increased immunization waste to manage and dispose
• More training for health workers and community volunteers
• Revised technical guidelines, recording and reporting tools,
IEC materials, etc.
• Good communication with parents to address concerns
• Good surveillance system prior to and after NV introduction
• Extra financial resources required to buy vaccines

36. Scale Up Map for New Vaccine Introduction
Program Implementation
National Global
Preparation
Actions Actions (3-6 months before Vaccine Launch Post-Introduction
Asses the magnitude of
the problem: morbidity launch)
and mortality due to the Advocate for vaccine
target disease with the introduction support
new vaccine
Upgrade cold chain
Initiate discussion and
reach consensus to
introduce a vaccine and Conduct registration of
the type of product the vaccine, review
vaccine supply
distribution system,
Initiate surveillance to upgrade as needed
establish baseline
Prepare and/or amend Country
application and submit re-/submits Make improvements Conduct post-
on time application to waste management introduction
system, as needed evaluation
Update/prepare cMYP PR events held assessment a Reduced
and costing tables to launch the year following morbidity
Ensure it is IRC makes a Develop learning vaccine
incorporated into the recommendation materials, conduct vaccine launch and
national health sector to the GAVI technical training mortality
plan Board Monitor and due to the
respond to any Conduct
Conduct nationwide Revise, print and
reported adverse impact targeted
cold Chain storage space distribute EPI
assessment GAVI management tools events assessment vaccine
Secretariat preventable
Develop an prioritizes Initiate AEFI disease
applications for surveillance for the NV Document
introduction plan
approval and strengthen AEFI lessons
reporting system learned
Solicit ICC endorsement
and commitment for Develop communications
implementation strategies and key
messages to address
caregiver/ provider
concern(s)
Obtain ministerial
signatures on the
application to GAVI IEC/demand creation
for new vaccine
M&E
Source: MCHIP 2011

37. What do some country
bilaterals say about ICC and
immunization?
• ICC agenda is too
narrow, confining
• Important ICC
decisions made
beforehand
• Their technical
assistance not valued

38. Potential country roles for NGOs in
routine immunization
• Directly immunize
• Support district MOH staff (capacity
building)
• Mobilize communities and create demand
• Use birth and service registers to reduce
left-outs and drop-outs
• Plan and monitor with communities
• Advocacy

39. So why does Civil Society
participate on campaigns?
• High-level request
• Clear role
• Credit/Recognition
• Funding
• Supply/services assured
“But they won’t participate for the long-run.”

40. So why do NGOs love to participate
in “Child Health”/CCM/c-IMCI?
• Credit/recognition
(appreciation from
communities)
• Supply assured
• Clear role
• Funding

41. Promotion of “Healthy
Actions”
•Motivate individuals,
households, and
communities to:
 Adopt “healthy actions”
 Engage in the fight against
leading child-killers
 Increase demand for
health services
 Identify danger signs and
seek treatment
• Improve knowledge,
attitudes, norms and
practices

42. Illustrative community linkages with immunization
• Motivate others to use immunization and other PHC services
• Arrange a clean outreach site (school, community meeting room, etc.)
• Transport vaccines and health workers, particularly for outreach sessions
• Inform other community members when a health worker/team arrives at the
 outreach site
• Provide a meal to the health worker when they are on outreach visits
• Register patients, control crowds and make waiting areas more comfortable on
 the day of a fixed or outreach session
• Deliver appropriate messages, including dispelling rumours about immunization
• Assist with newborn and defaulter tracking
• Arrange home visits when children are behind schedule, to explain
 immunization and to motivate caregivers
• Provide equipment and even financial support
Understanding reasons for low coverage is easier when district and health facility
staff establish rapport with the community and involve community members in
planning, promoting, implementing and monitoring services