India – Strengthening Urban Immunization is Need of Time & action plan to reduce inequities and improve coverage India is making efforts to increase full immunization coverage by designing various strategies as Special immunization campaigns as Missions Indradhanush due to observed slow growth from past trends. Though efforts are being done at various level for improvement still there is not equity among various fronts as Urban vs Rural, Poor vs Rich, educated vs Illiterate, states vs Union Territories, and issue of inequities is observed among different platforms. Still mostly one major front always remains neglected i.e. difference rate at which immunization coverage in Urban and Rural areas is improving, this can be seen with the help of figure below. As per UN world urbanization report 2018 India’s 34% population is living in Urban areas, and it will be around 60% by year 2030. Currently we can see growth in immunization coverage in urban areas compared to Rural is slow as Rural coverage increased from 39% to 61 %(i.e. growth of 22%) whereas Urban coverage growth from 58% to 64%(i.e. 6% only) So now it becomes most important to review current efforts taken to focus more on Urban population as these are not so much helping in current scenario and ways to improve Urban immunization coverage. In India main Immunization related activities are as same as Rural areas in term of planning and reporting. Though it seems that India is focusing to improve Urban immunization coverage but on reality there are many shortcomings/weakness/barriers in system as below: - • NUHM is formed and constituted with budget allocation. In year 2018-2019 the allocation for National Urban Health Mission (NUHM) has increased by 34% at Rs 875 crore BUT The allocation for the funding pool for immunization has decreased by 30%. * (Source: Demand Nos. 42 & 43, Ministry of Health and Family Welfare, Union Budget 2018-19, PRS.) • Though allocation of FHW (Female health worker-ANM) post are filled in most of urban areas, there areas demarcation for responsibility allocation in term of immunization activities is uncertain and not as per need, so most of the beneficiaries needs to visit Urban headquarter hospitals for Vaccination services. • Though ANM /FHW are there but a crucial link between FHW/ANM and community i.e Accredited Social Health Worker (ASHA), who were appointed for community mobilization and tracking of children at community level is missing in urban areas because of Policy decision (Only some slums were given Urban ASHA/USHA) • So as in rural area there is 1 ASHA /1000 Population, for tracking of beneficiaries and their mobilization to vaccination site, Urban areas are lacking. Currently Urban areas have been given 1-4 ASHA for only selected areas, though Population ranges from 25 thousand to 10 Lakh (In some metros around 50 lakhs to 1 Crore). • Also, as most of the beneficiaries have to visit Urban /District headquarter hospitals for vaccination so area wise due list is not available with FHW/ANM, and so not able to track dropouts or left outs. No mobilization /sensitization is done in urban areas, beneficiaries are expected to come for vaccination on their own knowledge and judgments. • No record of vaccination from private practioners in Most of the urban areas. • Focus only given to some major areas where vaccination sites are already planned as per previous years planning, no revisions being done to modify Micro plans for Urban areas form past many years • ANM /FHW which are posted in Urban areas are mostly dealing with Communicable disease reporting and other programs there is shortage of workdays for Immunization as in most of the states FHW is dedicated to do only 3-4 Immunization sessions in One month, so most of the areas are labelled as TAGGED with Vaccination sites on Paper for microplanning reporting purpose only to show all areas are covered • Also timing and far distant vaccination sites due to poor microplanning continuing from past many years in most of the Urban areas not feasible for beneficiaries to travel for too far vaccination sites is Urban areas, as most of the parents are of working communities i.e 8 am to 5 pm but /and timing of vaccination is 9 am to 2 pm \ • Though data is available for analysis of coverage and which is clearly showing no much growth in immunization coverage, no concrete plans have been decided as Urban task forces are not being conducted at various levels regularly (National/State/District), and mostly on paper without any string decisions. • Regarding campaigns under Mission Indradhanush, as there were NO ASHA’s in Most of the urban areas (Except few Urban Slums Named as USHA) for due listing and tracking of children’s, Mission Indradhanush was not helpful as sessions were not planed as per requirement, so ANM planed sessions at regular session site and timing with having “0” or 1 to 2 regular beneficiaries, so overall DROPOUT and LEFT OUT remains as it was. Opportunities in current context I would like to suggest as follows • Policy changes: - In term of HR/ Manpower/Budget allocation dedicated for Urban Immunization, along with use of DIGITAL tools and apps to track vaccination services in urban areas. • Supportive Supervision: - Supervisory network for Immunization to be trained for supportive supervisions with help of standard training modules • Monitoring: - Monitoring of activities related to Urban immunization to be done by Partners as WHO /UNICEF etc. and inputs to be shared • Evaluation: -Regular Urban task force with active participation from agencies working in Urban areas to be done and should be evaluated for progress at all levels with proper documentations of issues identified and action planed and follow ups. Mode of conducting these activities and reason for selection can be discussed as follows: - Identification of beneficiaries ‘and due listing- In Urban context through LQAS in identified States and Urban areas based on available recent coverage evaluation surveys as NHFS, RCM etc. and with use of due listing and mapping through digital tools (Mobile Apps/maps etc.) Policy change – Advocacy through Urban Task forces regularly at all levels with its tracking specially for advocating need for special community mobilisers in Urban areas same as of Rural (Accredited Social Health Activist ASHA/ Urban ASHA)-Same can be done with help of identified man powers of other Urban NGO’s and ICDS (Integrated Child Development services) Departments workers i.e. AWW- Anganwadi workers0 also to support communication and mobilization for RI sessions. Also, policy changes for HR recruitment and sufficient budgeting to make accordingly. Planning and implementation of Special Vaccination Campaign /activity yearly for selected Urban areas (In 14 states and 7 Metro Urban areas having population over 1 crore) for Due listing, communication and Mobilization of beneficiaries’ (I would like to name it -CMCI Communication and mobilization campaign for Immunization -More details can be obtained from https://www.msjonline.org/index.php/ijrms/article/view/2269 ) Supportive supervision by in charge Government officers at various level with quality monitoring by Partners as WHO, UNICEF etc. and using surveillance data available and monitoring findings to improve quality of activities undergoing

L’événement: Enquêtes de couverture vaccinale post-campagne (après une ASV) Lundi 15 juillet 2019 à 16 heures de Genève (vérifier l'heure)
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Une ASV est toute activité vaccinale conduite en plus des services de vaccination systématique.

Les enquêtes de couverture vaccinale post-campagne: Quelles sont leurs spécificités? Comment utiliser le Manuel de référence de l’OMS pour les enquêtes de couverture vaccinale par sondage en grappes afin de mieux les préparer? Quelles sont les nouvelles ressources disponibles pour améliorer leur qualité? Avec la participation de:  Dr. Carolina Danovaro (OMS) Dr. Mamadou Diallo (UNICEF) Dr. David Koffi (ADS) et Dr. Carol Tevi-Benissan (OMS) Cet événement est ouvert à tous, sans condition. Il sera également diffusé via Facebook Live sur cette page.   Cliquez ici pour participer à l'événement…

Hello everyone, Mozambique, at present, uses only a simple measles vaccine in the Measles Routine for measles prevention.
However, with support from GAVI, Mozambique is preparing a campaign against Measles and Rubella for April 2018, then introducing the Measles and Rubella Vaccine into Routine Immunization. At this time, the country has already been prepared for the Anti-Measles and Rubella sufficient for Campaign and for introduction and routine use. But we have a problem: how the campaign data is already fixed; And still simple measles vaccine doses in districts and health units, including the National Vaccine Depot, which is difficult to create in three months. The question is:
How to manage the two types of vaccines, especially after a campaign without wasting one?
How to manage the simple measles vaccine that after the campaign we will not use and we will have in large quantities?

The theme “Close the immunization gap” continues in this year’s World Immunization Week campaign with the slogan "Immunization for all throughout life". The campaign – takes place from 24 to 30 April – aims to remind us that vaccination needs to continue throughout a person’s life.


WHO developed a campaign toolkit for partners and members of the global immunization community to help raise awareness on why immunization is necessary to protect individuals and communities from preventable diseases and to promote engagement and action locally. The toolkit contains banners, posters, key messages, a visual identity and campaign guidelines. They can be downloaded in different formats and in multilingual versions.

Three feature stories have been posted on the campaign website showcasing Nepal’s efforts to keep children safe through immunization a year after a major earthquake; Austria’s creative and innovative campaign to encourage measles vaccination among unimmunized adults; and looking towards an Ebola-free future as plans step up on how to use an Ebola vaccine in response to an outbreak. Read the news releaseand watch athe campaign video.Take the immunization quizDo check out the online quizto test your knowledge on immunization. Each of us is responsible not only for our own health and wellbeing, but also of our family members. The Week serves as a reminder to check whether you and your family have all the vaccines you need. If in doubt, ask your local healthcare provider.

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Evolution, growth and development, extension-expansion, operational research are all natural processes. Launch of a new programme with a properly fitting outfit, infuses rejuvenation, jubilance, reminds the commitment and sustains interest among the service providers in implementing the old programme. Mission Indradhanush completed one year and we thought of sharing the “Power of Peer Education” for sustenance of the success during the inter MI periods through regular outreach sessions as recommended in the MI guidelines also. The attached is partially shared with RI/MI stakeholders and now sharing with techNet community for valuable inputs.

Global commitment eradicated polio in 4 regions. Before eradication, globally an estimated 959 cases used to occur per day which is now reduced to

The need to keep vaccines in a 2°C to 8°C cold chain is a constraining factor for many immunization campaigns due to limited storage capacity and/or limited ice pack freezing capacity; supplementary immunization activities planned across sub-Saharan Africa to introduce MenAfriVac™ are a good example. In 2012, the licence for the Serum Institute of India’s meningitis A vaccine, MenAfriVac®, was changed based on a thorough review of scientific data by regulatory authorities and the World Health Organization (WHO) to allow for the use of the vaccine for a period of up to 4 days at temperatures of up to 40°C in a controlled temperature chain (CTC). WHO has published three documents to provide support on use and adoption of CTC: 1. This document gives guidance on how to use the CTC: Use of MenAfriVac (meningitis A vaccine) in a controlled temperature chain (CTC) during campaigns Use of MenAfriVac (meningitis A vaccine) in a controlled temperature chain (CTC) during campaigns 2. A training module that teaches how to integrate the CTC into your routine immunization programme: Training module for organizing immunization sessions 3. This document tells countries how to adapt the generic training module to the local situation: Adaptation guide and facilitator's guide

It is customary to develop and share user-friendly ‘OPERATIONAL GUIDELINES’ for clarity and uniformity among service providers as and when a new vaccine (e.g. H1N1, Pentavalent) is introduced or there is a change in strategy (e.g. from 1 dose measles vaccine to 2 doses). From this month (April 2013), in Karnataka (India), 2 doses of the JE vaccine are to be administered in the endemic districts, instead of a single dose, with the DPT/OPV booster + measles 2nd dose; the first dose is to be given when the child is brought for the first dose of the measles vaccine. This gives an opportunity to revamp/refresh/reorient health care providers in running the programme like a well-oiled engine, and becomes a new weapon in the armamentarium. 2-doses-strategy-of-JE-Vaccine.pdf

I have attached a PPT on operational guidelines to introduce the newer pentavalent vaccine for further editing/inputs from the viewers. This will give an opportunity to refresh and re-orient the service providers on DPT and hepatitis B also. Operational-guidelines-New-Pentavalent-Vaccine.pdf

Introduction Raymond Hutubessy is a senior health economist affiliated to the Immunization, Vaccines and Biologicals (IVB) Department of the World Health Organization (WHO), and is the executive secretary of the WHO Immunization and Vaccines related Implementation Research Advisory Committee (IVIR-AC). His main research interests focus on economic and financial analyses of vaccine introduction decisions in low- and middle-income countries (LMICs). In this Q&A, he will discuss the importance of this work in relation to the global context of vaccine introduction decisions. Q&A 1. What is the importance of conducting economic analyses for vaccine introduction decisions? Vaccines for prevention of communicable diseases have been shown to be extremely effective in terms of health outcomes. Therefore, conducting economic analyses to get the most value for money from vaccine introduction decisions is of high importance; evidence and information resulting from these analyses are not the only input to the decision-making process for vaccine introduction decisions, but they are important ones. The relationship between health and economic growth is one of the cornerstones of development economics: health status is determinant of productivity that can be shown to influence economic growth. Specifically, vaccines have a broader value in terms of their indirect effects (for example, herd immunity) and other externalities (for example, improvements in the cognitive development of children, higher school attendance and attainment, macroeconomic impact). Therefore, in addition to the traditional economic appraisals for vaccine introduction decisions it is useful to policy makers and other stakeholders involved with vaccine introduction decisions to demonstrate the broader added value of vaccines and investments in health in general. Economic appraisals address different key issues with regard to decisions on vaccine introduction. These appraisals range from priority-setting issues across vaccines and other competing health interventions, to affordability and budget impact analysis, and costing and financing issues with regard to the introduction decisions of immunization programmes. For these different policy questions, different analytical tools are available, such as cost-effectiveness analyses, costing studies, budget impact and optimization analysis. 2) What are the main issues that should be considered? First, because many economic evaluations are based on analytical decision tools such as mathematical infectious disease models, costing tools, decision trees models and so on, transparency is needed on the choice of the modeling methodologies, parameters and country data used and assumptions made by the analyst. Standardization of methods of cost-effectiveness is therefore needed and analysts in the field should adhere to these guides. This allows users to make comparisons of different study results by different groups. The WHO, in addition to other organizations, has developed several guidelines on economic evaluations in health, and vaccines and immunization programs in particular. The full interview is attached. 1741-7015-11-71.pdf

by Dan Brigden, PATH In November 2012, the first immunization campaign to use a controlled temperature chain (CTC) took place in Banikoara in northern Benin. This photo set contains photographs taken during the campaign, where over 155,000 people were vaccinated using the CTC approach. Access the photo slideshow directly. You can click “Show info” in the top right corner to view/hide photograph descriptions, and click the following button in the bottom right corner to view the slideshow in full-screen mode. The photo set accompanies an article on the MenAfriVac CTC campaign in the February 2013 edition of Op.ti.mize, an electronic newsletter on the vaccine supply chain. You can view an archive of all Op.ti.mize newsletters here: http://www.path.org/projects/project-optimize-newsletter .

by Simona Zipursky, PATH; Mamoudou Harouna Djingarey, WHO/AFRO; Olivier Ronveaux, WHO/AFRO; Sylvestre Tiendrebeogo, Consultant In November 2012, the first immunization campaign to use a controlled temperature chain (CTC) took place in Banikoara in northern Benin. MenAfriVac is a meningitis A vaccine developed by the Serum Institute of India with support from PATH and the World Health Organization (WHO) through the Meningitis Vaccine Project. It is the first vaccine to be licensed by regulatory authorities and authorized by WHO for use at ambient temperatures of up to 40°C for up to four days. The campaign in Banikoara provided us with a unique opportunity to get a better understanding of how the CTC approach works in the field. The Beninese Ministry of Health was able to more clearly assess opportunities and challenges with the approach and WHO was able to identify ways to improve guidance and training materials developed through the Immunization Practices Advisory Committee. Everyone involved was able to see how the CTC works in field conditions and what adjustments to campaign procedures need to be made before the approach can be applied in other settings. Overall, the effort was a resounding success. Although the results from the monitoring study are still being analyzed, no serious adverse events following immunization were recorded during the campaign. We were also reassured that there was no increase in vaccine wastage. With MenAfriVac only prequalified for use at ambient temperatures up to 40°C, we had feared that using the CTC approach in Benin’s often searing midday heat might lead to unacceptably high levels of vaccine wastage. But over the course of the campaign, closed vial wastage (the number of vaccine vials thrown away without being opened) accounted for just 10 out of 15,500 vials, and some of those were due to vial breakage. We found that simple solutions proved extremely effective. Our system to keep track of how long vials had been out of the cold chain for is a good example. At the end of each day, any unused vials that had been kept in a CTC for a day were marked with a single line. At the beginning of the following day, these marked vials were used first. If by chance these marked vials were not used again, at the end of each subsequent day, they were marked with an additional line (up to three). This system was easy for health care workers and supervisors to implement and ensured that prequalification conditions were met. Another challenge was how to know if the 40°C temperature threshold had been exceeded. The ambient temperature reached 39°C on many days, and we were worried that vaccines would be exposed to even higher temperatures during transportation or by direct exposure to the sun. To ensure this did not happen, we used a peak threshold indicator—a simple laminated card with a temperature-sensitive sticker that changes color when the threshold (in this case 40°C) is reached. One indicator was placed in each vaccine carrier. Vaccinators were instructed to check the indicator each time they took a vial out of the vaccine carrier and contact their supervisor if they noticed the sticker had changed color. In this way, vials found to have been exposed to temperatures above 40°C would be discarded. After extensive use, the indicators were deemed easy to read and use by health care workers, and supervisors’ reports validated their correct use in the field. Together with the vaccine vial monitors (VVMs) on the vaccine’s label, which monitor a vaccine’s cumulative exposure to heat, the peak threshold indicator gave health care workers confidence that the vaccines kept in a CTC were still safe and effective to use. [size=10]A peak threshold indicator placed in a vaccine carrier. Photo: WHO/Olivier Ronveaux[/size] Aside from these few simple modifications, the pilot in Banikoara used existing equipment, including the standard grey vaccine carriers employed in other campaigns. This allowed us to protect vaccines from high temperatures and direct sunlight. Just as importantly, we found that these “grey boxes” were so well known within the community as symbols of immunization that replacing them with something else would have been a social mobilization challenge. While many anticipated challenges were ultimately easy to address, new challenges emerged. The peak threshold indicator, designed to irreversibly change color when the threshold was reached, turned out to be very sensitive when exposed to direct sunlight. Even with an ambient temperature of just 28°C, if the indicator was placed in in the path of the sun, it quickly changed color. As a result, we adjusted our guidance to health care workers, suggesting they read the indicator in the vaccine carrier rather than removing it from the vaccine carrier and placing it on a table to read. With this additional guidance, the problem was solved. Concern that health care workers would be confused by having more than one set of rules to follow on immunization campaigns proved unfounded. It had been feared that using the CTC approach for one campaign and then returning to the regular cold chain for another might lead to inappropriate cold chain procedures being followed. But in the polio vaccination campaign conducted in Banikoara just a week after the MenAfriVac campaign, the cold chain was again used properly. At the end of the MenAfriVac CTC campaign, vaccinators and supervisors were asked what they thought of the approach. After weighing the benefits, the challenges, the learning curve, and the limitations, every person asked said they preferred conducting campaigns “the CTC way.” Such high acceptance in Benin was not necessarily expected, as the cold chain functions relatively well and the roads are generally manageable. There is much work to do before the CTC can be applied elsewhere. Not just in putting what we learned from Benin into action, but also in taking what we heard from Benin—the need for more vaccines to be licensed for CTC, the call for more flexibility—and work with manufacturers and regulators to make that happen. The work is moving forward, and the results from Benin suggest a positive future for CTC. This article is accompanied by a slideshow of photographs taken during the MenAfriVac CTC campaign in Banikoara. You can view the photo set on Flickr.

Diarrheal disease is among the five leading causes of morbidity and mortality among under-five children in Malawi. In the multiple indicator survey conducted in 2006, nearly a quarter (23.3%) of under-five children reported having a diarrhea episode in the previous two weeks. Rotavirus infection contributes significantly to diarrheal diseases among children under the age of five years. To reduce this burden, Malawi launched rotavirus vaccine on October 29, 2012. While the launch happens in a day, numerous plans are prepared, many decisions are made, and a number of steps are taken along the way to arrive at this celebratory day. Preparations for the introduction of rotavirus vaccine were started over two years ago by first expanding the cold storage space at all levels. To increase cold storage capacity, additional walk-in cold rooms were procured and installed with the support of UNICEF, and refrigerators were procured through WHO and UNICEF support and distributed to districts and health facilities. The GAVI New Vaccines Introduction grant was used to fund most of the preparatory activities. In early 2012, the Government of Malawi and other immunization partners - - mainly CHAI, MCHIP, UNICEF and WHO - - have revitalized the national task force (NTF) to coordinate and prepare a detailed plan of action for the introduction of rotavirus vaccine. The content of the plan of action included adapting the rotavirus introduction field guide to be used as training and reference materials at all levels; conducting advocacy, communication, and social mobilization activities; revising the management tools; conducting supportive supervision visits to monitor the introduction of pneumococcal vaccine (PCV) which was launched in November 2011; and assessing readiness for the introduction of rotavirus vaccine. Furthermore, Malawi conducted the PCV post-introduction evaluation (PIE) and Data Quality Self-Assessment (DQS) during this time in order to apply the lessons learned in the PCV introduction to the introduction of rotavirus vaccine. Additionally, cascaded trainings were conducted at national, zonal, and district levels. These trainings involved all managers and service providers, including all health surveillance assistants who conduct most of the vaccinations at the peripheral level. Social mobilization activities were conducted using all media outlets. The rotavirus vaccine was distributed to all zones before launching. Most importantly, Malawi conducted all of the preparatory activities on time and the launch was conducted as planned. Maternal and Child Health Integrated Program (MCHIP), USAID’s flagship maternal and child health program, provides technical and financial support to the Government of Malawi in these preparatory activities. Certainly, the launching is one of the milestones in the introduction process, but as we move forward, there is a need to strengthen the technical capacity for full integration of the rotavirus vaccine into the routine immunization program by conducting supportive supervision visits and facilitating basic Expanded Program on Immunization (EPI) trainings. In addition, Malawi rotavirus introduction applies the age restriction for vaccination (1st dose before 15 weeks of age and last dose before 32 weeks of age). Such age restrictions require strong communication for timely vaccination. Therefore, all partners need to support the communication activities at all levels in order to follow this successful launch with a successful integration into Malawi’s routine immunization system. ____________ I have attached what we at MCHIP call a scale-up map for new vaccine introduction. It focuses on the many steps required to apply and prepare for the smooth introduction of a new vaccine. At MCHIP, we found it necessary to create this graphic to remind senior staff that the launch itself, which generates so much attention and excitement, is but one step in a long process. ~Robert Steinglass, MCHIP ___________ MCHIP is the USAID Bureau for Global Health’s flagship maternal, neonatal and child health (MNCH) program, which focuses on reducing maternal, neonatal and child mortality through a package of MNCH interventions. The immunization component focuses on providing countries with technical support to strengthen routine immunization and introduce new vaccines. For more information, please visit http://www.mchip.net or email info@mchip.net with questions. MCHIP-New-Vaccine-Introducation-Scale-Up-Map.ppt

by Kamel Senouci and Lara Gautier, AMP Many national immunization programs rely on the professional advice of national immunization technical advisory groups (NITAGs) to help them make critical decisions on introducing new vaccines. Implemented in April 2008 by Agence de Médecine Préventive (AMP) in partnership with the International Vaccine Institute, the SIVAC Initiative supports the development of these NITAGs in low- and middle-income countries. In this article, we take a look at how SIVAC has supported the establishment and achievements of NITAGs around the world. NITAGs work to enhance the use of evidence-based decision-making processes in the development of immunization programs and policies at the national level. SIVAC supports this valuable work by providing technical assistance in the creation of NITAGs and offering support once they have been created. This can include training, tools development, and knowledge-sharing through the NITAG Resource Center, a multilingual website that offers information, tools, and short learning modules. The first country to receive SIVAC’s support was Côte d’Ivoire, whose NITAG—the Comité National d’Experts Indépendants pour la Vaccination et les Vaccins de la Côte d’Ivoire (CNEIV-CI)—was officially created in January 2010. As part of the development of a draft recommendation by CNEIV-CI on the management of adverse events following immunization (AEFI), SIVAC provided technical support in developing terms of reference documents for the evaluation and management of AEFI in Côte d’Ivoire. These were validated in June 2012 at the second regular meeting of CNEIV-CI. In January 2011, the inaugural meeting of Mozambique’s NITAG—the Comité de Peritos para a Imunização (CoPI)—was held in Maputo. Supported by SIVAC, the CoPI rapidly began to issue recommendations on vaccine policies. During its first year, two meetings were held and nine recommendations were issued on topics such as the reliability of data from the Expanded Programme on Immunization (EPI), cold chain logistics requirements, and the introduction of new and underused vaccines. These recommendations were then adopted and implemented by the country’s Ministry of Health. At the CoPI’s last meeting in April 2012, three further recommendations were issued on vaccine safety issues, EPI staff training, and new mechanisms for vaccine registration. His Excellency Dr. Alexandre Lourenço Jaime Manguele, the Minister of Health, confirmed the key role of the CoPI in strengthening the country’s immunization program through an evidence-based approach. In June 2012, the minister signed an agreement extending SIVAC support through mid-2013. During 2011 and 2012, SIVAC helped Kazakhstan, Kyrgyzstan, and Mongolia to establish their own NITAGs. Benin, Senegal, and Vietnam plan to establish NITAGs in the coming months, with SIVAC support. While the main thrust of SIVAC activities to date has focused on establishing new NITAGs in low- and middle-income countries, SIVAC also works to strengthen existing NITAGs. This involves providing assistance to NITAGs on how to ensure greater compliance with international NITAG standards and how to help NITAGs to make evidence-based recommendations that are relevant to the national context. In this way, since 2010, SIVAC has been supporting NITAGs in Indonesia, Lebanon, Nepal, and Tunisia. For example, the Indonesian Technical Advisory Group for Immunization (ITAGI) recently issued a recommendation regarding a pilot study on inactivated polio vaccine in the country. The ITAGI is also working on recommendations related to the pneumococcal and rotavirus vaccines. The Comité Technique des Vaccinations (CTV) of Tunisia is also very active: since the 2011 rubella epidemic, the CTV has been coordinating the adoption of the strategy for the elimination of rubella and increasing monitoring of congenital rubella syndrome. The CTV is also modifying its vaccination strategy for rubella vaccine in the EPI to reach new age targets. SIVAC is also helping NITAGs and national immunization programs to conduct cost-effectiveness analyses of new vaccine introductions. This is being performed as part of the ProVac International Working Group established by the ProVac Initiative of the Pan American Health Organization Immunization Project, which was created to share ProVac tools and methodologies with other regions. In collaboration with World Health Organization Regional Offices, SIVAC will provide direct technical assistance for cost-effectiveness evaluations of potential new vaccine introductions in four middle-income countries: Albania, Azerbaijan, Egypt, and Iran. This work began in May 2012 in Albania with a cost-effectiveness analysis on the potential introduction of rotavirus vaccine. NITAGs in low- and middle-income countries have demonstrated their value by issuing important recommendations on new immunization policies and vaccine introductions. However, NITAGs can further improve the decision-making processes, and SIVAC is working hard to provide tailor-made support to countries by promoting evidence-based processes that can improve their immunization policies and programs. For more information, please visit the SIVAC Initiative website. We encourage your questions or comments. Please click reply at the bottom of the page.

The Indian government suspended research in April 2010 on the feasibility and safety of human papillomavirus (HPV) vaccine in two Indian states (Andhra Pradesh and Gujarat) amid public concerns about its safety. This paper describes cervical cancer and cancer surveillance in India and reviews the epidemiological claims made by the Programme for Appropriate Technology in Health (PATH) in support of the vaccine in these two states. National cancer data published by the Indian National Cancer Registry Programme of state registry returns and the International Agency for Research on Cancer cover around seven percent of the population with underrepresentation of rural, northern, eastern and north-eastern areas. There is no cancer registry in the state of Andhra Pradesh and PATH does not cite data from the Gujarat cancer registries. Age-adjusted cervical cancer mortality and incidence rates vary widely across and within states. National trends in age standardized cervical cancer incidence fell from 42.3 to 22.3 per 100,000 between 1982/1983 and 2004/2005 respectively. Incidence studies report low incidence and mortality rates in Gujarat and Andhra Pradesh. Although HPV prevalence is higher in cancer patients (93.3%) than healthy patients (7.0%) and HPV types 16 and 18 are most prevalent in cancer patients, population prevelance data are poor and studies highly variable in their findings. Current data on HPV type and cervical cancer incidence do not support PATH's claim that India has a large burden of cervical cancer or its decision to roll out the vaccine programme. In the absence of comprehensive cancer surveillance, World Health Organization criteria with respect to monitoring effectiveness of the vaccine and knowledge of disease trends cannot be fulfilled.

http://jrsm.rsmjournals.com/content/105/6/250.full

Cross-posted from the February 2012 Global Immunization News issue. Many thanks. 29/02/2012 from Jhilmil Bahl, WHO HQ As the introductions of Pneumo and Rota vaccines in 2012 are fast approaching, training materials are being developed at WHO/HQ. Rotarix materials will be available by mid-March on the NUVI website, in English and French and will consist of: - A slide set, consisting of seven modules for training Healthcare Workers (HCWs) and facilitator notes - A pocket guide – shorter version of the above for trainees to take away with them - A picture Guide (A3 spiral bound)– that trainers can use in situations where there is no electricity or computer, etc. Rotateq materials will be available by end April on the NUVI website, in English and French composed of: - A slide set, consisting of seven modules for training HCWs and facilitator notes - A pocket guide – shorter version of the above for trainees to take away with them - An A3 spiral bound Picture Guide – that trainers can use in situations where there is no electricity or computer, etc. An updated rotavirus introduction manual is also being developed and can be shared upon [email=mayersg@who.int]request[/email]. It will be posted on the NUVI website once finalized. PCV materials (PCV 10 and PCV 13), will be made available by mid-March on the NUVI website, in English and French composed of: - A slide set, consisting of seven modules for training HCWs and facilitator notes Introduction manuals for both PCV13 and PCV10 developed at WHO/HQ can be shared upon [email=mayersg@who.int]request[/email] and will be posted on the NUVI website once finalized. Other materials planned: Adaptation notes - slides/pages where country adaptations may be required will be highlighted; PCV 10 DVD from Kenya is available (parts of this could be used in other countries), script in English is also available for translation and adaptation to the local context if countries would like to shoot their own footage; Video for Rotavirus vaccine training in Ethiopia in Amharic is planned for 15 May 2012 but other countries can use the part of the footage and/or use the script prepared in English if they would like to shoot their own complementary footage.

The American Academy of Pediatrics (AAP) recommends that the HPV vaccine be administered at 11 to 12 years of age in both boys and girls.I do not know the studies that show cost-benefit analysis of the vaccine in females, especially in a scenario when many countries are against this vaccine. The rationale of AAP is 2-fold: First, the vaccine is most effective if it is administered before the individual begins engaging in sexual activity, mainly because the vaccine is inactive against HPV strains acquired before vaccination. Second, children mount the most robust antibody responses to the vaccine when they are between the ages of 9 and 15 years, the AAP says. The link: http://www.medscape.com/viewarticle/759223 Let's debate the rationale engaging intellectuals who are opposing its introduction internationally and then proceed, just a suggestion. Thanks and regards,

Cross-posted from the January 2012 Global Immunization News issue. Many thanks. 31/01/2012 from Osman Mansoor, UNICEF Pneumonia and diarrhoea remain the top two causes of child deaths. The availability of new vaccines against the top causes of pneumonia (Hib, PCV) and diarrhoea (RV) in children offers the opportunity to rapidly reduce child deaths towards the achievement of MDG4. However, these vaccines cannot prevent all cases of pneumonia and diarrhoea and it is important that these new vaccines do not give rise to unrealistic expectations that could eventually damage the Expanded Programme on Immunization (EPI). In addition, the introduction of new vaccines offers the opportunity to promote the other interventions that will reduce deaths – especially breast-feeding, hand washing and care-seeking if a child develops danger signs. UNICEF has developed a Framework for developing evidence-based communication strategies to mobilize and engage communities to adopt these healthy actions, including demanding for immunization. It is available at this link , where a Translate button offers translation into hundreds of languages. However, these machine translations are not perfect. The site also includes the Framework in a Word version in English and French. Now a Russian translation is available in word. Please contact Osman Mansoor for a proper translation into another language to help a country use the Framework to develop a communication plan. Any tools, materials, and resources that have been used for new vaccine introduction, are also sought so that country-developed resources can be shared globally.

Dear Friends, Sharing with you the PPT by Katie Hampson for comments, that was telecasted world over in a webinar by World Rabies Day.

This article appears in the 23 June 2011 issue of Vaccine: "Assessing the potency of oral polio vaccine kept outside of the cold chain during a national immunization campaign in Chad". This study provides proof-of-concept evidence that certain typs of OPV remain potent and thus can be kept, for limited periods of time, and administered at ambient temperatures. Full article available for purchase at http://www.ncbi.nlm.nih.gov/pubmed/21699946. Any comments, thoughts or similar experiences to share?

In collaboration with Merck & Co., Inc. and GSK, PATH Seattle has prepared a list of countries where each of these company's vaccines is licensed and a world map showing the countries where one of the vaccines is licensed for use and the countries where both vaccines are licensed for use.
These two documents can be seen on TechNet21 website:
Global HPV vaccine licensure status: June 2011
Map: Global HPV vaccine licensure status June 2011
Licensure, of course, does not mean that the vaccine in in use in these countries but it does open up the way for introduction.

Any updates about how soon we may see HiB and Pneumococcal vaccines included in the national immunization schedule of India? What stage are the efforts of the government in this regard?

In recent years, supply chain management has received growing attention as both a priority and a challenge for many countries scaling up immunization services with new vaccines. Indeed, the vaccine supply chain and logistics systems face the challenge to manage an increasing number of vaccines of higher value, greater volume and greater complexity in terms of packaging and presentations. Yet, little additional resources to adequately expand the supply chain systems are available, and alternative solutions to manage the increasing throughput of vaccines need to be explored. More and more countries are recognizing the benefits of engaging the private sector in supply chain and logistics functions by outsourcing the physical storage and handling of commodities to specialized logistics operators when such expertise is available in country. Although outsourcing is a growing trend and the theoretical benefits are clear, the true costs and benefits of doing so are not well documented. To bridge this information gap, an outsourcing review has recently been completed by WHO and the Collaborating Centre for Cold Chain Management (CCCCM) under the auspices of project Optimize. The review focused on the Western Cape Province experience in South Africa and provides evidence based information around the cost and benefits of outsourcing the vaccine supply chain to a 3rd party private sector company for vaccine procurement, warehousing, inventory management and the distribution of vaccines directly to health centres. Of interest is that the review was conducted in a context where three new vaccines were being introduced into the national immunization schedule in 2010 - Pentaxim (DTP-IPV-Hib), Rotarix (rotavirus) and Prevnar (Pneumo) vaccines. The full report has been uploaded to the Documents area of the Resources Section of the TechNet21 website.

Pentavalent stories: Lucknow deaths subjudice http://hindu.com/2010/08/24/stories/2010082457281300.htm Initially, it was said that three deaths had occurred due to the anti-measles vaccine and one death due to the BCG shot. Then it was said the children were given BCG vaccine instead of anti-measles, and it was also said that the shots were pentavalent vaccines given during a pilot project under the universal immunisation programme. All these questions would be answered once the enquiry was completed, the Minister said, adding there was an internationally prescribed procedure to be followed during vaccination. http://ipsnews.net/news.asp?idnews=52638 Infant Deaths Cast Doubt on Vaccination Policy By Ranjit Devraj NEW DELHI, Aug 27, 2010 (IPS) - The deaths of four infants during a recent vaccination drive in Lucknow, capital of northern Uttar Pradesh state, has raised questions about the Indian government's plan to introduce five-in-one vaccines in a countrywide immunisation programme. Union health minister Ghulam Nabi Azad told journalists this week that "action would be taken against those found guilty of negligence." He refused to speculate on the cause of the deaths, but said an investigation has been launched and would submit its report shortly. Unconfirmed reports said the Lucknow vaccinations on Aug. 21 were carried out as a pilot project to test the efficacy of pentavalent vaccines. The health ministry is planning to introduce these vaccines into its Expanded Programme of Immunisation (EPI), to replace the standard triple vaccine now in use. Pentavalent vaccines provide protection against hepatitis B and haemophilus influenza type B (Hib), that causes pneumonia and meningitis, in addition to the triple vaccine's protection against diphtheria, pertussis and tetanus (DPT). "We need to definitely know whether pentavalent vaccines were used in Lucknow," Dr. Mira Shiva, an expert on pharmaceuticals and member of the Central Social Welfare Board, told IPS. Shiva is part of a group of eminent doctors and public health experts who have filed a suit against the government's use of pentavalent vaccines on the grounds of safety and higher costs saying it would still leave some 10 million rural children uncovered each year. Members of the litigant group include: Prof. Debabar Banerji of the Centre for Social Medicine and Community Health, Jawaharlal Nehru University, Ritu Priya, advisor to the National Rural Health Mission, K.B. Saxena, former union health secretary, Gopal Dabade of the non-profit Drugs Action Forum and Jacob M. Puliyel, paediatrician at St. Stephens hospital in Delhi. The experts have argued that pentavalent vaccine costs about eight dollars per dose, while the trivalent DPT inoculation costs just three cents, and is manufactured in the country. What has really strengthened the case of the petitioners is that the pentavalent vaccine has been linked to infant deaths in neighbouring countries like Pakistan, Sri Lanka and Bhutan which accepted them on advice from the World Health Organisation (WHO). The petitioners submitted in the Delhi High Court on Feb. 3 that the government had not conducted proper evaluations of the vaccine, and were acting in a "disjointed and uncoordinated manner" under pressure from the WHO. They warned that introducing the vaccine would invite "disaster for immunisation in the public health system." Pentavalent vaccines were launched in Bhutan in September 2009 but their use was suspended Oct. 23, three days after five infants died at the referral hospital in the capital Thimphu. Four more infants died soon after being vaccinated, in the towns of Samtse and Paro. A joint investigation by the Bhutanese government, WHO and UNICEF from Oct. 29 to Nov. 24 concluded that the pentavalent vaccine did not cause the deaths. However, the independent Bhutan Observer newspaper reported on Aug. 6 that Thimphu would not reintroduce the vaccine until June 2011 "due to the inability of national experts to establish the true cause of death in each case." Sri Lanka withdrew pentavalent vaccines in April 2008 after 25 adverse reactions and five deaths, but reintroduced them this year after the WHO declared the vaccine as "unlikely" to be fatal. Pakistan, which reported three deaths, has also reintroduced the vaccine on WHO assurances. Dabade and Puliyel, who closely studied the WHO report on Sri Lanka, told IPS that the global body had tweaked protocol while writing it. "WHO usually has six classifications for adverse effects following immunisation – certain, probable, possible, unlikely, unrelated and unclassifiable. But the report removed the 'probable' and 'possible' categories and classified the Sri Lankan deaths under the 'unlikely' category," they told IPS. By changing its own criteria, the WHO had become open to the charge of orchestrating an "elaborate cover up." This should be an eye-opener for the Indian Council of Medical Research (ICMR) which has recommended that pilot studies of the vaccine should be carried out, they added. Puliyel has also questioned the value of introducing Hib vaccines "in all routine immunisation programmes", a recommendation by the WHO which has been accepted by India’s National Technical Advisory Group on Immunisation (NTAGI). "WHO recommends that the Hib vaccine should be universally included in immunisation programmes, irrespective of a particular country’s disease burden or the natural immunity within the country against (the infection)," Puliyel said. As far as India is concerned, Puliyel said, it was unfortunate that NTAGI chose to overlook studies carried out by the ICMR at Vellore in South India. These studies showed the incidence of pneumonia requiring hospital care from all causes, including Hib, was a low three in 100 while that of meningitis was just two in 100. Puliyel added that in the West, the vaccine may have reduced the incidence of Hib disease but led to "a proportionate increase in non-Hib strains of H. influenzae." "The fact that this push and pull over vaccines is happening when alarm bells are sounding over how vaccine manufacturers influenced WHO decisions during the recent swine flu scare, does not inspire confidence,’’ Dabade commented. (END)

Friends - please see here the Call to Action recently approved by the GAVI Alliance Civil Society Constituency Steering Committee regarding the forthcoming Pledging Conference on June 13 in London. We invite your endorsement of the Call. If you/your organization wish to endorse the Call, please so indicate by sending me an email (ahinman@taskforce.org) indicating your name, your organization's name, and the fact that you endorse the Call. If you cannot obtain the endorsement of your organization but wish to endorse the statement as an individual, please do so. I would very much appreciate it if you could send me your endorsements by close of business Wed Jun 8 to enable compilation of the signatories. Many thanks. Alan R. Hinman, MD, MPH

Dear Moderator, I am perturbed to know that people of Bangladesh have to pay Tk 40.25 to get obsolete Nerve Tissue Vaccine (NTV), recommended not to be used by WHO, but they are getting Pentavalent Free ! Banglaseh spends approximately Tk 1 crore ( 10 Million )every year on nerve tissue vaccine. I appeal to donor agencies to help Bangladesh procure and produce tissue culture antirabies vaccine so that many people (about 1500) could be saved from the jaws of death and a lot of money of poor patients could be saved. This will also enable them to have life long immunity that can be reactivated on re-exposure through a 4 site intradermal single vial of tissue culture vaccine. If we refer to the paper published in Vaccine, 86.2% receive NTV post exposure in Bangladesh which is a very serious issue and needs attention of policy makers. http://iacib.org/publications/JVAC11169.pdf Regards,

Many thanks! A dozen updates this week as the new vaccine pledging meeting approaches. Will the funds pledged next month cover the needs for introduction of rotavirus, pneumococcal and HPV vaccines? ‘The doubt is permitted,’ as they say in French. Here are the titles of the new technical updates. Scroll down for details, also available at http://www.childsurvival.net : · VACCINE PROGRESS REVEALS RESOURCE GAPS IN DEVELOPING COUNTRIES · HPV VACCINATION FOR GHANA? · VACCINATION STRATEGIES FOR EPIDEMIC CHOLERA IN HAITI WITH IMPLICATIONS FOR THE DEVELOPING WORLD · BENEFITS AND COSTS OF PNEUMO AND ROTA VACCINE IN UGANDA · ROTAVIRUS: REALIZING THE POTENTIAL OF A PROMISING VACCINE · RESPIRATORY ADMINISTRATION OF MEASLES VACCINE · A RESEARCH AGENDA FOR MALARIA ERADICATION: VACCINES · RABIES VACCINATION IN DEVELOPING COUNTRIES · TOWARD NOVEL VACCINES AGAINST TUBERCULOSIS · PREVENTION OF ROTAVIRUS GASTROENTERITIS IN INFANTS AND CHILDREN · READER COMMENT ON CHOICE OF VACCINE REFRIGERATORS · A NEW WRINKLE IN COLD CHAIN SOLUTIONS Robert Davis

In this podcast, Steve McCarney, cold chain technologies specialist with Project Optimize, PATH, shares his insights with Pharma IQ, on how advances in vaccines and emerging markets have impacted the cool chain and will continue to do so. He also assesses the impact of technology innovations on the efficiency and sustainability of supply chain and logistics systems and the availability and quality of products that move through the system. Listen to the webcast at coolchaineurope or use the player below. [mp3]http://dna.gravlab.com/webteam/webiq/SteveMcCarney.mp3[/mp3]

Webinar now available on Cervical Cancer Action website; Please visit the Cervical Cancer Action Multimedia web page to watch and listen. For more information, please contact info@cervicalcanceraction.org [size=14]HPV vaccination in developing countries: Recent lessons from six pilot programs[/size] by Scott Wittet, Lead, Advocacy and Communication, Cervical Cancer Prevention Programs, PATH Watch the English Webcast (requires Flash)

Many thanks to Diana Chang Blanc for sharing this information with us. Introducing a vaccine: Policy and Programme Considerations Dear Colleagues, You may recall a brochure from the June 2010 NUVI Meeting "market place" describing an updated Vaccine Product Menu which would be available in 2010. This email is to announce the availability of this updated product menu as part of a more comprehensive new vaccines resource entitled "Introducing a vaccine: policy and programmatic considerations", which has been published on the New Vaccines website. This site brings together in one page, resources useful to address policy and programmatic aspects of introducing a new vaccine. This new site expands on and replaces the previous "Vaccine Production Selection Menu" which was produced in 2005 and which was previously available in CD format. The new site may be used as a reference for decision-making and implementation by country level policy-makers, national immunization programme managers, and others working on immunization. The page brings together links to the following resources: - Guidance on vaccine introduction (general and vaccine-specific) - WHO recommendations for routine immunization (immunization schedules and position papers) - WHO prequalified vaccines - UNICEF-procured vaccine products and presentations with weighted average prices - Tools to calculate vaccine wastage We hope that you find this new resource useful and we welcome your suggestions to make it better. Kind regards, Hemanthi