Decreasing transmission and initiation of countrywide vaccination: Key challenges for future management of COVID-19 pandemic in Bangladesh.

With a fragile healthcare system, Bangladesh, much like other countries in South East Asia, struggled during the early days of COVID-19 pandemic. In following months several encouraging initiatives were undertaken including nationwide lockdown, maintaining social distancing and setting up COVID-19 dedicated laboratories and hospitals. Despite fear of an escalation in COVID-19 transmission during the winter months like their European counterparts, fortunately infection rates subsided and Bangladesh came out largely unharmed. But the next phase of COVID-19 pandemic management that includes viral transmission suppression and conduction of nationwide immunization program require several urgent steps from government of Bangladesh (GoB) and relevant stakeholders. This qualitative research piece discussed about issues including an urgent need to enhance critical care facilities around the country, especially in peripheral districts; ramping up COVID-19 testing at existing laboratories in view of diagnosing each case, and ensuring vaccines for the vulnerable populations in the country. Furthermore, the researchers shed light on other issues including a need to reinforce a struggling healthcare workforce, encouraging people to take vaccine, proper maintenance of social distancing regulations, routine epidemiological surveillance, management of environment and biomedical waste and undertaking a holistic approach to combat the pandemic and its environmental and financial consequences.

Trends in vaccine investment in middle income countries.

Although a proven and effective preventive health measure, childhood immunization programs remain vulnerable to budgetary pressures. Sustainable financing of immunization programs is an important issue that presents a challenge for middle-income countries (MIC) in particular, in part due to technological advances meaning more vaccines are available. This study aimed to analyse trends in immunization program investment across 15 MIC selected based on availability of data, income level classification, and regional representativeness. We assessed investment trends in relation to vaccine coverage, vaccine access, and broader health indicators. Immunization and expenditure data were obtained from the World Health Organisation (WHO) database and the WHO UNICEF Joint Reporting Form and WHO Vaccine Product, Price and Procurement from 2006-2016. We calculated a weighted average index of vaccine commitment (WAIVC) based on vaccine coverage, vaccine scope, and weighted by vaccine innovation measured by approximating vaccine expenditure. Correlation analyses were conducted between immunization expenditure per-capita and each WAIVC, infant mortality and life expectancy. Correlation analyses at a global and individual country level indicate an improvement in immunization access, vaccination commitment measured by WAIVC, and scope of available vaccines in countries with sustained increases in vaccination funding. Increases in national immunization expenditure were correlated with reduced infant mortality and increased life expectancy. Vaccine expenditure comprises a small proportion (less than 2%) of total healthcare spending and has not uniformly increased in accordance with the scope of available vaccines. The present analysis supports the premise that countries with consistent increases in vaccine expenditure have increased vaccine coverage and commitment measured by WAIVC and improved broader health outcomes, indicating the value of sustained investment in vaccination for improved population health. The benefits of vaccine expenditure in this holistic fashion are critical to inform policy decisions on national budget allocation for vaccine funding.

Age impact on human papillomavirus vaccination in France in 2014: A study from the National Health Insurance Database.

INTRODUCTION: Human papillomavirus (HPV) is the main cause of cervical cancer. In France, since March 2007, HPV vaccination has been recommended for girls aged 14, in addition to a catch-up program for girls aged 15 to 23. In October 2012, the target population was changed to 11- to 14-year-old girls. The main objective of the present study was to evaluate the impact of the recommendation change on HPV vaccination coverage and compliance. METHODS: We conducted a descriptive study of the Échantillon Généraliste des Bénéficiaires (EGB), which is a random 1/97 permanent sample from the French National Health Insurance Database. We focused our analyses on girls aged 11 to 17 years who were covered by the main insurance scheme (which covers 77% of the French population). RESULTS: We included 16,195 girls in this analysis. At the last update of the database (06/15/2014), 42% of 17-year-old girls had been vaccinated, with more than 50% of them having been vaccinated at age 14. Between January 2012 and June 2014, patients were reimbursed for a total of 7698 doses of the HPV vaccine. During the first trimester of 2013, the number of vaccinated 11- to 13-year-old girls increased, growing by more than 20-fold between the last trimester of 2012 (n=8) and the last trimester of 2013 (n=178). Less than 60% of the vaccinated patients received 3 injections. DISCUSSION: Implementation of the new recommendations was rapid but had only a slight impact on vaccination coverage.

Civil society organizations, the implementing partners of the Global Vaccine Action Plan.

The authors illustrate by way of civil society (CS) experiences in Pakistan, India, and Ghana how the guiding principles of CS and civil society organizations (CSOs) align with those of the Global Vaccine Action Plan (GVAP); (i.e., country ownership, shared responsibility and partnership, equity, integration, sustainability, and innovation). These experiences show how CS is contributing to GVAP goals such as global polio eradication and improving vaccination coverage by removing barriers and ultimately working toward achieving Millennium Development Goal (MDG) 4-reducing child mortality. A number of CSOs working in the field of child health share some of the objectives enlisted in GVAP: that immunization becomes a national health priority; individuals, families, communities understand the importance of immunization; benefits of immunization are equitably extended to all people; and vaccination systems are part of an integrated health system.

Vaccine preventable diseases and vaccination policy for indigenous populations.

There are many similarities regarding the health status of Indigenous people in the 4 English-speaking developed countries of North America and the Pacific (United States, Canada, Australia, New Zealand), where they are all now minority populations. Although vaccines have contributed to the reduction or elimination of disease disparities for many infections, Indigenous people continue to have higher morbidity and mortality from many chronic and infectious diseases compared with the general populations in their countries. This review summarizes the available data on the epidemiology of vaccine-preventable diseases in Indigenous populations in these 4 countries in the context of the vaccination strategies used and their impact, with the aim of identifying successful strategies with the potential for wider implementation.

Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise.

In this paper, we revisit the revolutionary principles-equity, social justice, and health for all; community participation; health promotion; appropriate use of resources; and intersectoral action-raised by the 1978 Alma-Ata Declaration, a historic event for health and primary health care. Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the "health for all" goals. Health has moved from under-investment, to single disease focus, and now to increased funding and multiple new initiatives. For primary health care, the debate of the past two decades focused on selective (or vertical) versus comprehensive (horizontal) delivery, but is now shifting towards combining the strengths of both approaches in health systems. Debates of community versus facility-based health care are starting to shift towards building integrated health systems. Achievement of high and equitable coverage of integrated primary health-care services requires consistent political and financial commitment, incremental implementation based on local epidemiology, use of data to direct priorities and assess progress, especially at district level, and effective linkages with communities and non-health sectors. Community participation and intersectoral engagement seem to be the weakest strands in primary health care. Burgeoning task lists for primary health-care workers require long-term human resource planning and better training and supportive supervision. Essential drugs policies have made an important contribution to primary health care, but other appropriate technology lags behind. Revitalisng Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor.

Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia 2003 to 2006.

This, the second report on vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, brings together the relevant sources of routinely collected data on vaccine preventable diseases--notifications, hospitalisations, deaths, and childhood and adult vaccination coverage. As a result of continued improvements in the collection of data on Indigenous status, this second report is considerably more comprehensive, with data available from more jurisdictions, and more detailed presentation, including time trends and vaccination coverage by jurisdiction. Vaccination coverage data provide evidence of successful program delivery and highlight some areas for improvement. For universally funded vaccines in children, coverage is similar in Indigenous and non-Indigenous children by 24 months of age. However, delayed vaccination is more common in Indigenous children, with 6%-8% fewer children fully vaccinated at 12 months of age. More timely vaccination, particularly within the first six months of life, is particularly important in reducing the disproportionate burdens of disease due to pertussis and Haemophilus influenzae type b (Hib). For vaccination programs targeted specifically at Aboriginal and Torres Strait Islander children and adults, coverage is substantially lower than for those programs targeted at all Australians. This is true for hepatitis A and polysaccharide pneumococcal vaccine for children, and influenza and polysaccharide pneumococcal vaccine for adults. Targeted vaccination programs present a particular challenge for health services in urban areas. Nevertheless, the impact of vaccination programs in preventing disease and reducing the disparity of disease burden between Aboriginal and Torres Strait Islander and non-Indigenous people has been substantial. This is evident in data on notifications, hospitalisations and deaths. Diseases which, in the past, have had devastating and often disproportionately high impact on Indigenous people, such as diphtheria, measles, poliomyelitis, smallpox and tetanus, are now completely or almost completely absent from Australia. Hepatitis B infection, another disease responsible for high levels of infection and substantial serious illness and death in the pre-vaccine era, is also now well controlled in age groups eligible for vaccination. Although invasive Hib disease is now rare in Australia since the introduction of vaccination in 1993, higher rates of disease persist in Aboriginal and Torres Strait Islander children. More research is needed into the contribution of environmental factors, delayed vaccination and vaccine failure to this continued disparity. Hepatitis A has disproportionately affected Aboriginal and Torres Strait Islander children in the past. Vaccination programs in north Queensland and in various other countries have been very successful in reducing the burden of hepatitis A. It is too early to assess the impact of the vaccination program for Aboriginal and Torres Strait Islander children that commenced in regions outside north Queensland in November 2005. For some other diseases the situation is more complicated. The substantial impact of the national meningococcal C vaccination program since 2003 is evident in this report, although the higher proportion of non-vaccine preventable serotype B disease in Aboriginal and Torres Strait Islander people underlines the need for a new vaccine to cover this serotype. Pneumonia remains the most important communicable disease contributor to premature mortality in Aboriginal and Torres Strait Islander people of all ages. In young Indigenous adults, the eightfold higher rate of hospitalisation compared with their non-Indigenous peers, and the 11-fold higher rate of invasive pneumococcal disease, suggest the need for more widespread use of influenza and pneumococcal vaccines in this age group. Current coverage for Indigenous 15-49 year olds, where influenza and pneumococcal vaccines are funded only for those with risk factors, is low even though some 70% of this age group have one or more risk factors. Overall, the data presented in this report provide powerful evidence for the impact of vaccines in reducing disease in Aboriginal and Torres Strait Islander people, and also point to areas for further improvement. Immunisation programs are an example of how preventive health programs in general can be enhanced to close the gap in morbidity and mortality between Indigenous and non-Indigenous Australians.

Developments in influenza vaccination coverage in England, Scotland and Wales covering five consecutive seasons from 2001 to 2006.

This study aims at assessing trends in influenza vaccination coverage from 2001 to 2006 in Great Britain, at understanding drivers and barriers to vaccination and at identifying vaccination intentions for influenza season 2006/2007. In seasons 2001/2002 to 2005/2006, telephone-based household surveys representative of the population from age 16 were conducted, with about 2000 interviews per season (10,095 in total). Overall influenza vaccination coverage rate in Great Britain reached 25.9% in season 2005/2006. A sub-analysis showed that the highest coverage was reported in Wales reaching 33.3%. In the elderly recommended vaccination (from age 65), the coverage reached 79% in 2005/2006. Advice from the family doctor and the perception that influenza is a serious illness were the most frequent reasons for getting vaccinated. The most frequent reasons for not getting vaccinated, in persons never vaccinated before, were that they had not considered immunisation or had not received a recommendation from their family doctor. Those vaccinated in the past but not in the current season said they had not thought about vaccination/forgot. A gap continues to exist between those with intention to get vaccinated and those actually vaccinated, indicating a potential to increase vaccination coverage rate in the future. Our study shows that stable vaccination coverage rates were observed from 2002 to 2006 in Great Britain. The coverage had increased in Wales and in Scotland. The coverage among the elderly above 65 years was the highest in Europe. Although Great Britain complies with national and international goals of vaccination coverage rates effort is needed to ensure high vaccination coverage rates at the same level in the future.

New hepatitis B vaccine formulated with an improved adjuvant system.

A new hepatitis B vaccine (FENDrix, GlaxoSmithKline Biologicals) containing as active substance 20 microg of recombinant hepatitis B virus surface antigen produced in Saccharomyces cerevisiae has recently been licensed in Europe. It is prepared with a novel adjuvant system: aluminum phosphate and 3-O-desacyl-4 -monophosphoryl lipid A. It is intended for use in adults from the age of 15 years onwards for active immunization against hepatitis B virus infection for patients with renal insufficiency (including prehemodialysis and hemodialysis patients). It is applied in a four-dose scheme: day 0, month 1, 2 and 6 after day 0. Due to the improved adjuvant system it induces higher antibody concentrations that reach protective levels in a faster fashion. Furthermore, due to higher titers reached after the primary immunization course, protective levels are retained for a longer period of time. Vaccination with FENDrix induces more transient local symptoms, with pain at the injection site being the most frequently reported solicited local symptom. Other symptoms such as fatigue, gastrointestinal disorders and headaches were also frequently observed but resolved without sequelae. The higher risk of hepatitis B transmission in patients with end-stage renal disease and the often immunocompromised status of these patients afford a tailored vaccination strategy that, up to now, has consisted of injecting double doses of ordinary hepatitis B vaccines. With the introduction of FENDrix there now exists an efficient alternative with superior immunogenicity that is, despite comparatively higher reactogenicity, well tolerated.

Financial requirements of immunisation programmes in developing countries: a 2004-2014 perspective.

Vaccines are a key contributor to public health, especially in developing countries. Despite numerous demonstrations of the cost-effectiveness of immunisation, vaccines spending accounted for only 1.7% of the total pharmaceutical market in 2002, when UNICEF estimated that 34 million children were not reached by routine immunisation, most of them in developing countries. Several international organizations or initiatives, like the Global Alliance for Vaccines and Immunisation (GAVI), have defined a long-term goal of universal immunisation in developing countries. There is an urgent need to estimate the financial resources required to meet this goal. The objective of this study was to anticipate the funding needs for childhood immunisation in developing countries over the 2004-2014 period. The study scope includes all the 75 countries eligible for support from GAVI, and covers existing vaccines that are considered as a priority for GAVI (DTP (diphtheria, tetanus, pertussis), hepatitis B, Haemophilus influenzae type b (as a stand alone presentation or in combination with DTP) and yellow fever) as well as future vaccines (meningitis A and C, rotavirus, human papilloma virus (HPV), malaria, Streptococcus pneumoniae and tuberculosis) likely to be available within the 10-year period. We developed a methodology to estimate the number of doses required, based on disease prevalence and incidence, target populations, introduction dates of new vaccines, coverage dynamics and dosing regimen. The introduction price and price evolution of vaccines over time were modelled, taking into account the type of vaccine, the expected return on investment from vaccine manufacturers and the competitive landscape. Non-vaccine costs (capital costs and non-vaccine recurrent costs) were estimated based on the number of people immunised and number of doses dispensed, using available case studies as a reference. According to the optimal scenario that would consider the provision of all vaccines to all relevant developing countries as soon as they are available, funding requirements to cover the associated total costs over the 10-year period were estimated to be about US$ 30 billion. Vaccines-related costs represent the largest share, with estimated costs of US$ 21 billion (among which 18 billion for new vaccines), the remaining needs being split between capital costs and other recurrent costs. Accounting for the main imponderables (such as delay in vaccines launch compared to industry plans) as well as probable phasing of vaccine introduction in countries, the total costs of immunisation would be reduced to US$ 14-17 billion over the same period. Vaccines-related costs represent the largest share (US$ 7.1-9.3 billion, among which 4.3-6.5 billion for new vaccines). This study advocates for the anticipation of the substantial financial resources needed to (a) purchase and introduce these vaccines in the developing countries in order to reduce the time lag between availability in industrialised and developing countries; and (b) stimulate vaccine researchers and manufacturers to continue research and development of much needed vaccines for the developing world.

Vaccine preventable diseases and vaccination coverage in Aboriginal and Torres Strait Islander people, Australia, 1999 to 2002.

This report complements the Vaccine Preventable Diseases and Vaccination Coverage reports produced biannually since 2000 by the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in association with the Australian Institute of Health and Welfare. It integrates the available sources of routinely collected data relevant to the current status of vaccine preventable diseases and vaccine coverage in Aboriginal and Torres Strait Islander people in Australia. It aims to better inform Indigenous communities, Indigenous health care providers and planners of immunisation services of the current status and future needs for vaccine prevention in Indigenous people. The data presented here demonstrate that vaccination programs have had a significant impact on the health of Aboriginal and Torres Strait Islander people. Several areas are highlighted for further development of vaccination policy recommendations, in particular high rates of preventable hepatitis A and B, influenza and pneumococcal disease. Areas where more research is needed include means to more accurately monitor vaccination status, the applicability of meningococcal serogroup B vaccines when available, and effective ways of increasing vaccination coverage and timeliness of vaccination. Such issues need to be considered and implemented in full cooperation with Aboriginal and Torres Strait Islander people.

From Cannes 1993 to the present.

In 1993 the Viral Hepatitis Prevention Board focused its attention on the serious threat hepatitis B poses to the community at large. The Cannes 1993 meeting "Action Towards Control of Hepatitis B as a Community Health Risk" was the first initiative and the springboard for other activities. The rationale behind universal hepatitis B vaccination strategies and the prerequisites for implementing these strategies were analyzed. Background information on country-specific hepatitis B epidemiology and on the feasibility of vaccination strategies were presented and discussed. The congress participants concluded that it is insufficient and ineffective to focus a vaccination campaign on a limited subset of the population (the so-called 'risk groups'), and the need for universal hepatitis B immunization was clearly recognized. Since Cannes 1993 many countries have responded to the call for universal hepatitis B immunization. Many have performed economic evaluation studies, while others have initiated sero-epidemiological studies to generate input data for burden of disease calculation. These studies indicate that epidemiological and economic arguments cannot be used to delay the implementation of universal hepatitis B vaccination. Some countries have improved their surveillance systems and included viral hepatitis in the surveillance programmes. Others have put hepatitis B on the political agenda. Where are we now? In the six years since the Global Advisory Group of the Expanded Programme on Immunization set 1997 as the target for integrating HB vaccination into national immunization programmes world-wide, more than 90 countries have included hepatitis B vaccine as part of their routine infant or adolescent immunisation programmes. In the WHO European Region, Albania, Bulgaria, France, Germany, Italy, Luxembourg, Moldova, Poland, Portugal, Romania, Andora, Austria, Greece, Malta, Switzerland, Israel, Slovenia and Spain have implemented universal vaccination programmes. Belgium, the Netherlands and several other European countries are seriously studying the issues or are making budgetary provisions for the introduction of HB into their vaccination programmes. Most of the European countries which now use the vaccine routinely have started with adolescent immunization. Italy and France have begun with both adolescent and infant HB immunization. The rewards of effective implementation of immunization programmes in these countries are becoming apparent and their success offers an exemplary model for other countries. The deadline was 1997! In Europe, work remains to be done before interventions, that will bring us closer to the WHO goal of universal immunization and to the goal of controlling hepatitis B in the community, are implemented. To this end, the VHPB has continuously supported the efforts of countries in Europe to meet the WHO target by convening meetings of international experts and issuing publications on the prevention and control of viral hepatitis.

Evolution of the Viral Hepatitis Prevention Board--VHPB.

The Viral Hepatitis Prevention Board (VHPB) was formed in 1992 to provide authoritative information and advice on hepatitis B as an occupational hazard and to act as a scientific lobby group to promote hepatitis B vaccination as part of an overall risk reduction strategy. The VHPB published Viral Hepatitis, a newsletter whose format and content was designed to appeal to both professional and lay readers seeking information on hepatitis. The VHPB was successful in lobbying the European Parliament to add the Code of Practice on Vaccination to legislation protecting workers from occupationally acquired infections. The first initiative on occupational hepatitis B culminated in an international congress in March 1993 and the publication of 'Hepatitis B as an Occupational Hazard' in the WHO occupational health series. Since 1993 the Board has discussed HBV as a community acquired infection; control of hepatitis A (HAV) and eligibility for hepatitis A vaccine and combined hepatitis A and B vaccines; hepatitis C; and reviewed progress towards the control of HBV and the adoption of universal vaccination programmes in countries of low endemicity. A major international congress in Cannes in November 1993 took stock of actions taken to control hepatitis B as a community health risk in industrialised countries. The constitution and membership of the Board underwent significant change at the end of 1994. A Secretarial was located within the Centre for the Evaluation of Vaccination at the University of Antwerp to deal with all administrative matters and publications in peer reviewed journals. The format of Viral Hepatitis was re-focused to increase the scientific content. The Board extended its actions geographically in 1996 to include the countries of Central and Eastern Europe (CEE) and the Newly Independent States (NIS) of the former Soviet Union. The success of the VHPB has exceeded all the expectations of the founding members. The major focus of the annual programme of meetings and of publications remains on hepatitis B and its prevention through vaccination. But more and more the broad range of prevention and control strategies for all forms of hepatitis is dealt with.

Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.

Compulsory universal vaccination against hepatitis B was introduced in 1991 in Italy for all newborns and 12-year-olds. Despite the decreasing circulation of the virus noted in the late-1980s, it was clear that only universal immunization would control hepatitis B infection and limit the transmission of the virus. Data collected during the first six years after vaccination was implemented show the success of the strategy. Over 90% of infants in the country and adolescents living in north-central Italy were immunized. Since 1995, the decrease in acute cases of hepatitis B has accelerated in the age groups 0-14 and 15-24, particularly in two regions of the north; during the same period, no comparable decrease in incidence was seen in older age groups. Monitoring coverage of vaccination and incidence of acute disease and seroepidemiological studies will continue and should show a rapid progression towards the elimination of HBV circulation in the country.

Poliomyelitis eradication and its impact on primary health care in the Philippines.

Since 1992, the Philippines has conducted four national immunization days (NIDs) for polio eradication. Surveillance for acute flaccid paralysis (AFP) began in 1992. Through good routine immunization, the incidence of paralytic polio had decreased to low levels in the Philippines even before the NIDs were initiated. With continuously improving AFP and virologic surveillance, wild poliovirus has not been isolated since May 1993. NIDs had a direct positive effect on child health through supplementary immunization with oral poliovirus vaccine, measles vaccine, and tetanus toxoid, as well as through the distribution of vitamin A. Following the successful NIDs, the government budget for vaccine purchases increased significantly. Also, the NID strategy was used as a model for several other priority prevention programs of the Department of Health. Through the development of AFP surveillance, polio eradication also helped to improve surveillance for other Expanded Programme on Immunization diseases.