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Pan American Health Organization
1
Maternal immunization in Latin America: current status and lessons
learned
Alba María Ropero-‐‑Alvarez Regional Advisor on Immunization
PAHO/WHO
Mexico City, October 18-‐‑21, 2015
Pan American Health Organization
2
• Background
• Maternal immunization in LAC
• Lessons learned from vaccine introduction for maternal immunization in Latin America
• Next steps
Outline
Newborn
Children under 5 years
Adolescents Adults
Senior Ci7zens
Pregnant Women
BCG Hep B
Pentavalent, Rotavirus,
PCV, IPV/OPV, MMR, YF
HPV, Meningococcal, Td, YF, Booster doses
Influenza, MR, Tdap , YF, Hep B
Influenza, Pneumococcal
Influenza, Td/Tdap
Vaccina7on Across the Life Cycle
0
50,000
100,000
150,000
200,000
250,000
300,000
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 130
20
40
60
80
100
Cases Coverage
Catch-up campaigns
*486 confirmed cases in 2013; data as of 11 April 2014.
Follow-up campaigns
Routine infant vaccination coverage (%
)
Con
firm
ed c
ases
(tho
usan
ds)
0
20000
40000
60000
80000
100000
120000
140000
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 120
20
40
60
80
100
Pertussis Diphtheria Coverage
Coverage (%
) Num
ber o
f Cas
es
Measles elimination*
0
1000
2000
3000
4000
5000
6000
7000
70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 120
10
20
30
40
50
60
70
80
90
100
Cases Coverage
Num
ber o
f cas
es
Coverage (%
)
Type 1 vaccine derived virus in 2000 and 2001: 21 cases
Polio Eradication
Diphtheria and Pertussis
Achievements in the Americas
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 130
20
40
60
80
100
Cases Routine coverage
Rubella Elimination* Acceleration Campaign
Num
ber o
f cas
es
Coverage (%
)
*11 confirmed cases in 2013; data as of 11 April 2014.
Bye-bye, rubella! ¡Adiós rubéola! Media coverage on rubella elimination | April 29-30, 2015 Cobertura de prensa sobre la eliminación de la rubéola | 29-30 de abril de 2015
0
200
400
600
800
1000
1200
1400
1600
1800
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
Year
0
50
100
150
200
250
1999 2001 2003 2005 2007 2009 2011* 2013
Year
Latin America minus Haiti
Haiti
Neonatal Tetanus Elimina7on Americas, 1985-‐2014
Source: PAHO-‐WHO/UNICEF Joint Repor7ng Form (JRF) and country reports *2011-‐2012 Hai7 not available.
Pan American Health Organization
Maternal Immuniza7on Pla^orm • MI is defined as vaccination:
-‐ Before pregnancy, during pregnancy and in the postpartum period in order to protect the mother and child
• Protection of: o The mother: prevention of diseases during pregnancy o The neonate: passive transfer of antibodies during a period
of high vulnerability which does not allow for active immunization (immune window)
• This platform facilitates the integration of maternal and newborn health services and immunization, including newborn Hep B and BCG vaccination.
Number of countries with: 2004 2008 2014
Policies for influenza vaccina7on 13 35 40
Vaccina&on of pregnant women 3 7 29
Vaccina7on of healthy children 6 22 25
Vaccina7on of children with chronic diseases
-‐ -‐ 5
Vaccina7on of the elderly 12 33 38
Vaccina7on of persons with chronic diseases
9 24 35
Vaccina7on of health care workers 3 32 38
Data was not collected from the French Departments (French Guiana, Guadeloupe, Mar7nique)
Countries and Territories in the Americas with Policies for seasonal influenza vaccina7on, 2004-‐2014
-‐ Informa7on on countries only targe7ng children with chronic diseases was not disaggregated Source: Country Reports to PAHO (JRF), MOH web pages, PAHO/WHO Surveys
0
20
40
60
80
100
ARG BOL BRA CHL CUB DOM ECU MEX NIC PAN PER PRY SLV URY VEN
2011 2012 2013 2014
Cob
ertu
ra (%
) Influenza Vaccina7on Coverage in Pregnant
Women, LAC, 2011-‐2014
*
Source: Country reports through PAHO-‐WHO/UNICEF Joint ReporOng Forms (JRFs) * PW at high risk unOl 2013
Hepa77s B Vaccina7on in Newborns in La7n America and the Caribbean,
2010-‐2014
0
20
40
60
80
100
ARG BRA COL CRI CUB DOM ECU GRD GTM HND MEX PAN PER SUR USA VCT VEN
2010 2011 2012 2013 2014
Source: Country reports through PAHO-‐WHO/UNICEF Joint ReporOng Forms (JRFs)
Pan American Health Organization
PAHO’s Maternal Immuniza7on Working Group
Members of the Working Group
o WHO (Justin Ortiz, Philipp Lambach)
o CDC (Joe Bresee, Sara Mirza, Jennifer Liang, Sarah Schillie)
o Emory University (Saad Omer) o CLAP (Bremen de Mucio) o FLASOG (Ricardo Fescina) o EPI Honduras (Ida Molina) o EPI Argentina (Carla VizzoWi) o Cincinnati Children’s Hospital
(Mark Steinhoff) o Santa Casa de Sao Pablo
University (Cassio de Moraes) o TAG Member (Anushua Sinha)
Pan American Health Organization
Title of the Presentation 13
Vaccine Pre-‐pregnancy Pregnancy Post-‐partum
Tetanus/ diphtheria Yes, ideal moment
Yes, 2 doses, if she was not previously vaccinated.
Yes, to complete schedule
Inac7vated influenza Yes, ideal moment
Yes if she was not vaccinated during pregnancy, to protect the newborn.
Regional Maternal Immuniza7on Vaccines recommended (TAG/SAGE)
14
Vaccine Pre-‐pregnancy Pregnancy Post-‐
partum
Tdap Yes, during outbreaks (ideal moment between 27-‐36 weeks of gesta7on) Yes
Hepa77s B Yes, ideal moment
Yes, IF she didn't complete schedule and IF high risk situa7on (eg. More than 5 sexual partners during last 6 months, STD, IDU, partner + for HBsAg)
Yes, to complete schedule: 3 doses.
Hepa77s A Yes, during outbreaks.
Yellow fever Yes, ideal moment (in endemic areas).
Yes, prior to travel to endemic areas with current outbreak, with prior risk/benefit analysis.
IPV Yes, prior to travel to endemic areas with current outbreak
OPV Yes, prior to travel to endemic areas with current outbreak
Rabies Aher high risk exposure.
Meningococcus conjugate
Yes, during outbreaks.
Meningococcus Polysaccharide (MPSV4)
Yes, during outbreaks.
Vaccines Recommended during Pregnancy in Special Situa7ons Only
Pan American Health Organization
Title of the Presentation 15
Vaccine Pre-‐pregnancy Pregnancy Post-‐partum
Rubella Yes, ideal moment (avoid concepOon for 4 weeks) No Yes, if not vaccinated during
pre-‐pregnancy Measles
Paperas
HPV Yes, ideal moment No
Vaccines Contraindicated during Pregnancy
Pan American Health Organization
Title of the Presentation 16
Newborn Vaccines Birth dose
BCG As soon as possible after birth.
Hepatitis B Ideally before the first 24 hours after birth.
Vaccines Recommended for the NEWBORN
Pan American Health Organization
17
Survey among 14 countries to document experience and lessons learned from vaccine introduc7on for
maternal immuniza7on in La7n America
Pan American Health Organization
Title of the Presentation 18
NiTAGs EVIDENCE REQUIRED Most countries have NiTAGs supporOng the MoH for vaccine introducOon (13/14)
Technical, operaOonal and Financial resources to evaluate feasibility and sustainability
– Experts in the field, – RepresentaOves of scienOfic socieOes including OB-‐GYN,
– EPI – Maternal health areas/programs
– Disease burden per potenOal target group (surveillance),
– Severity of illness (surveillance), – cost-‐effecOveness and cost-‐
benefit analyses – naOonal staOsOcs, surveys and
naOonal studies. – Vaccine safety and efficacy data
• WHO/ PAHO’s TAG recommendaOons
Decision-‐making for maternal vaccine introduc7on
Pan American Health Organization
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• Official communicaOons • Update of exisOng guidelines, protocols. • MoH primary health care services • interprogrammaOc work at all levels.
Modali7es of coordina7on between EPI and MCH areas
Pan American Health Organization
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Opera7onal aspects of maternal immuniza7on • Led by EPI and coordinated with
– ExisOng maternal health programs . – MCH, health services for trainings, monitoring and evaluaOon, supervision.
– Health promoOon and communicaOon departments for social communicaOon campaigns.
– Corresponding departments and various levels for InformaOon systems. (lack of clear denominators)
• Vaccine delivery is done through health services and outreach acOviOes and specific vaccinaOon campaigns (Td/Flu)
• EPI in charge of vaccine procurement through the Revolving Fund.
Pan American Health Organization
Fonte: hfp://pni.datasus.gov.br, acesso em 07/08/2013 às 16h
Target* Doses Vaccina7on coverage Children (6mo to <2yrs) 4.258.925 97,42% Healthcare workers 3.702.590 108,48% Pregnant women* 1.842.224 84,28% Post-‐partum women ≤45 days* 403.027 100,00% Indigeneous populaOons 530.624 88,09% Elderly 18.359.823 87,89%
Influenza Vaccina7on in Brazil 2013
Total: 36.672.606 91,44%
Pan American Health Organization
• Preventative material for SARI, material for pregnant women
Graphic Material
• Constantly updated MoH website
• Close work with the media Training
• In order to answer the public´s questions and concerns
MoH free
hotline
Social Communica7on
Campaigns
Pan American Health Organization
23
Enablers Obstacles Maternal health policy (prioritization of maternal health, MDG’s)
Resistance of OB-‐‑GYN to recommend vaccinating pregnant women.
Close collaboration and communication with scientific societies/associations and NiTAGs,
Emerging anti-‐‑vaccine groups.
High access to antenatal care in many countries
Insufficient research on safety and efficacy in pregnant women
Adequate planning and training of healthcare workers and service providers
Some healthcare providers and some users’ unfounded fear of vaccination during pregnancy not being safe.
Social communication plans Lack of active promotion of the maternal vaccination policy.
Pan American Health Organization
Next steps • Strengthen collaboration efforts among Agencies, Universities
and institutions related to maternal and child health
• Strengthen AEFI active surveillance, through Sentinel Hospitals
• Disseminate recommendations on maternal immunization -‐ in coordination with scientific societies and NITAGs
• Create alliances with the media and scientific societies to reach different audiences. Count on maternal immunization champions
• Promote the integration of immunization with other maternal health services
• Promote studies on safety, antibody interference, KAP among
others
Recommended