Globale vaksinasjonsprogrammer Utvikling og utfordringer Marianne A. Riise Bergsaker Avdeling for vaksine Divisjon for smittevern Nasjonalt folkehelseinstitutt 1 Pediaterdagene 2013
Where are you going to, my pretty maid? I`m going milking,sir, she said. What is your fortune, my pretty maid? My face is my fortune, sir, she said 2
Hva er forskjellen på program og annen vaksinasjon? All vaksinasjon tar sikte på å beskytte enkeltindividet Vaksinasjonsprogram har som mål å endre sykdommens epidemiologi utryddelse (eradication) redusere forekomsten eller fjerne (eliminere) den fra en del av verden oftest mål om å redusere risikoen også for ikkevaksinerte Forutsetter minimum vaksinasjonsdekning, som kan (og bør) beregnes før programmet iverksettes 3
Flokkimmunitet To elementer: Hvis så mange blir immune at bakteriene / virusene ikke finner noen mottakelige, dør smitten ut av seg selv Hvis vaksinen hindrer smittebæring (ikke bare sykdom), blir det færre som kan smitte sykdommen videre Til sammen flokkimmunitet Beskytter også den som ikke er vaksinert. 4
Nødvendig vaksinasjonsdekning for å hindre smitte (Lancet 1990, 335, s. 641-5) 5
Kriterier for vurdering om en vaksine skal innføres i et program Sykdommen Sykdommens alvorlighet Insidensen av sykdommen i den aktuelle befolkningen Vaksinen Effekt Sikkerhet/bivirkninger Økonomiske vurderinger Hvilke kostnader og hvilke gevinster? Vil dette vaksinasjonsprogrammet fungere i praksis? 6
Forutsetninger for å utrydde sykdom ved hjelp av vaksinasjon: effektiv vaksine finnes vaksineimmunitet hindrer kolonisering/ bæring vaksinen gir langvarig immunitet agens finnes kun hos mennesker 7
Vaksinasjon - en verdensomspennende aktivitet Expanded Programme on Immunisation - EPI Vision: A world free from suffering, disability and death due to vaccine preventable diseases 8
Meldte tilfeller av difteri i Norge 800 Tilfeller per 100 000 innbyggere 600 400 200 Vaksinen inn i program i 1952 0 1882 1898 1914 1930 1946 1962 1978 1994 2010 9
Meldte dødsfall i Norge grunnet stivkrampe 1900-2010 Vaksinen inn i program i 1952
Meldte tilfeller Poliomyelitt i Norge 80 Tilfeller per 100 000 innbyggere 60 40 20 11 0 1904 1919 1934 1949 1964 1979 1994 2009
Meldte tilfeller av meslinger 1900-2010 Vaksinen inn i program 2-doseprogram med MMR
Invasiv Haemophilus influenzae 1977-2003 (MSIS-tall) Vaksinen inn i program 13
Meldte tilfeller av systemisk pneumokokksykdom 1977-2011 14
EPI BASISPROGRAM: BCG DTP OPV MCV TT ved fødsel alder 6, 10 og 14 uker alder 6, 10 og 14 uker alder 9 måneder kvinner i fertil alder tillegg av andre vaksiner avhengig av behov, økonomi, infrastruktur 15
Estimerte dødsfall forårsaket av vaksineforbyggbare sykdommer Sykdom 2002 2008 Dødsfall <5 år Vaksineforebyggbare sykdommer hvor vaksine inngår i de fleste lands vaksinasjonsprogram Dødsfall <5 år Meslinger 540 000 118 000 Hib 386 000 199 000 Kikhoste 294 000 195 000 Stivkrampe 198 000 Neonatal 59 000 Andre 2 000 Difteri Polio Hepatitt B 4 000 <1 000 < 1 000 Sykdommer hvor vaksine er tilgjengelig men ikke inngår i de fleste lands program Japans encefalitt 5 000 Meningokokk 10 000 Rotavirus 402 000 453 000 Pneumokokksykdom 716 000 476 000 Dødsfall totalt (alle årsaker) 10 468 000 8 825 000 16 Kilde: WHO
17 Estimerte dødsfall forårsaket av vaksineforbyggbare sykdommer 2008
Global Immunization 1980-2011, DTP3 coverage global coverage at 83% in 2011 75 68 717070737372727373747473757779808182838483 63 172022 475155 42 35 Global A frican American Eastern Mediterranean European South East Asian Western Pacific urce: WHO/UNICEF coverage estimates 2011 revision. July 2012 munization Vaccines and Biologicals, (IVB), World Health Organization. 4 WHO Member States. Date of slide: 18 July 2012.
GLOBAL Annual surviving infants cohort = 129 million 83% DTP3 coverage 107 million children vaccinated Additional children to reach Children unvaccinated at different coverage level 83% 0 22.4 million Slide Date: August 20 90% 9.4 million 13.0 million 100% 22.4 million 0 ource: WHO/UNICEF coverage estimates, 1980-2011, as of August 2012 and World Population Prospects: he 20110 Revision", New York, United Nations, 2011 94 WHO Member States.
22.4 million infants not immunized (DTP3), 2011 Western Pacific, 0.89 African, 8.45 South East Asian, 9 urce: WHO/UNICEF coverage estimates 2011 revision. July 2 munization Vaccines and Biologicals, (IVB), rld Health Organization. WHO Member States. Date of slide: 25 July 2012. European, 0.61 Eastern Mediterranean, 2.31 American, 1.16
Developing * countries with % of districts achieving at least 80% DTP3 coverage, 2011 1,375,750 5,500 Kilometers 56 developing countries d economies in nsition per UN World onomic & Social rvey, 2011 assification boundaries and names shown and the gnations used on this map do not imply the ession of any opinion whatsoever on the of the World Health Organization erning the legal status of any country, itory, city or area or of its authorities, or erning the delimitation of its frontiers or ndaries. Dotted lines on maps represent roximate border lines for which there may yet be full agreement. HO 2012. All rights reserved 100 % districts (35 countries or 22%) 80-99 % districts (37 countries or 23%) 50-79 % districts (37 countries or 22%) 0-49 % districts (25 countries or 17%) Not available Not applicable No data (22 countries or 16%); DTP3 estimated coverage for 2011 17 countries > 90%; 5 countries< 90% Developed Countries (38 countries) Source: WHO/UNICEF coverage estimates 2011 revision. July 2012 Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 22 August 2012.
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Problemer for utrydding av polio 24 Vaksinasjonsdekning (barn): ca. 95% Effektiv vaksine Problemområder: Afrika sør for Sahara, Pakistan, Afghanistan Uvaksinerte lommer i befolkningen innebærer risiko for utbrudd så lenge smitten finnes Risiko for utbrudd så lenge det finnes områder sykdommen kan importeres fra Vaksinestammer har revertert til virulens gjennom sirkulering i delvis immune befolkninger Økonomisk og politisk vilje
Polio eradication: the last push Wild poliovirus spread*, 2003-08 Wild virus type 1 Wild virus type 3 Wild virus type 1 & 3 Endemic countries** Ongoing outbreak (due to imported wild poliovirus) 93 events, 26 countries Number of importations from Nigeria Viral origin: 68 events (73%) Number of importations from India Viral origin: 25 events (27%) 25 Controlled outbreak (due to imported wild poliovirus) Spread of the virus *Excludes viruses detected from environmental surveillance and vaccine derived polio viruses www.polioeradication.org/casecount. Data in WHO HQ as of Feb 2008
Slide Date: : 04 Sep Polio Eradication Progress, 1988 2011 Certified Polio-free regions (114 countries) Not Certified but non-endemic (73 countries) Endemic with wild polio virus* ( 3 countries) boundaries and names shown and the designations used on this map do not imply the expression of opinion whatsoever on the part of the World Health Organization concerning the legal status of any ntry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or ndaries. Dotted lines on maps represent approximate border lines for which there may not yet be full eement. WHO 2012. All rights reserved s of 28 February 2012, India is no longer considered to be a polio-endemic country. Source: WHO/POLIO database, as of August 2012
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Measles and Rubella Elimination Goals by WHO Region, August 2011 Americas, Europe, E. Mediterranean, W. Pacific, Africa have measles elimination goals Americas and Europe have rubella elimination goals SEAR: 95% Measles Mortality Reduction by 2015
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Immunization coverage with measles containing vaccines in infants, 2011 0 9001,800 3,600 Kilometers <50% (4 countries or 2%) 50-79% (38 countries or 20%) rce: WHO/UNICEF coverage estimates 2011 revision. July 2012 p production: Immunization Vaccines and Biologicals, (IVB), rld Health Organization. WHO Member States. Date of slide: 18 July 2012. 80-89% (29 countries or 15%) >=90% (123 countries or 63%) Not available Not applicable The boundaries and names shown and the designations used on this map do not im the expression of any opinion whatsoever on the part of the World Health Organiza concerning the legal status of any country, territory, city or area or of its authoritie 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 2012 All rights reserved
Measles case distribution by month and WHO Regions, 2007- July 2012 USA included in this graph from 2008 onward; India is not included in this graph. WHO HQ, 08 August 2012
Reported measles cases with onset date from January to July 2012 WHO HQ, 08 August 2012
Mortality rate* per 100,000 children under five years of age due to Streptococcus pneumoniae, 2000 * HIV+ve deaths excluded <10 10- <100 100-<300 300-<500 >500 Date of slide: 03 August 2009
Number of Countries Having Introduced Pneumococcal Conjugate Vaccine to Date Introduced* (78 countries or 40%) Planned introduction in 2012 (15 countries or 8%) Data Source: Joint Reporting Form, 2011 and NUVI database Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization Date of slide: 11 September 2012 * Includes partial introductions Planned introduction in 2013 (24 countries or 12%) Not Introduced (77 countries or 40%) Not available Not applicable 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 2012. All rights reserved
Mortality Rate per 100,000 Child Deaths due to Rotavirus Disease < 10 deaths per 100,000 10 to 50 deaths per 100,000 50 to 100 deaths per 100,000 100 to 500 deaths per 100,000 Source: WHO/IVB database, 193 WHO Member States. Data as of July 2009 Date of slide: September 2009 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 2009. All rights reserved
Invaginasjon etter rotavirusvaksinasjon, USA 1999 36 Murphy TV & Al. N Engl J Med 2001; 344:565-72
Number of Countries Having Introduced Rotavirus Vaccines to Date Introduced* (40 countries or 21%) Planned introduction in 2012 (10 countries or 5%) Data Source: Joint Reporting Form, 2011 and NUVI database Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization Date of slide: 11 September 2012 * Includes partial introductions Planned introduction in 2013 (6 countries or 3%) Not Introduced (138 countries or 71%) Not available Not applicable 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 2012. All rights reserved
Countries having introduced Hib vaccine in 1997 and 2011 1997 29 countries introduced 2 countries partially introduced 2011 174 countries introduced 3 country partially introduced 0 1,650 3,300 6,600 Kilometers oundaries and names shown and the designations used on this map do not imply xpression of any opinion whatsoever on the part of the World Health Organization rning the legal status of any country, territory, city or area or of its authorities, or rning the delimitation of its frontiers or boundaries. Dotted lines on maps sent approximate border lines for which there may not yet be full agreement. HO 2012. All rights reserved Source: WHO/UNICEF coverage estimates 2011 revision. July 2012 Map production: Immunization Vaccines and Biologicals, (IVB), World Health Organization. 194 WHO Member States. Date of slide: 3 September 2012
Kilde: UNICEF SD 2005 Vaksinemarkedet er sårbart
Drift av et program er sårbart Vedvarende (kostnader) Distribusjon av vaksiner (kuldekjede, tilgjengelige vaksiner) Tilgjengelighet (lokalisasjon, helsepersonell) Kompetent helsepersonell Informasjon Systemer for å overvåke effekten av et program 40
Vaksinasjonsdekning under utryddelsesnivå : Meslinger: Økt risiko for komplikasjoner (encefalitt, alvorlige pneumonier) ved sykdom i høyere alder Poliomyelitt: Økt risiko for paralytisk polio ved sykdom i høyere alder 41 Rubella: Færre tilfelle av rubella, men flere tilfelle av medfødt rubella syndrom
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43 Utvikling av vaksinasjonsprogram (R.T.Chen
Vaksinasjon er en av de mest kostnadseffektive forebyggende tiltak vi har i dag Gro Harlem Brundtland, 1998 44
45 Perspektivet