maternalimmunizationinlatin)) america ... · alba maría’roperoalvarez...

Pan American Health Organization

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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


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• 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.


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.

Progress of Maternal Immuniza7on in the Americas

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)


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)


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)

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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



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



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


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Survey among 14 countries to document experience and lessons learned from vaccine introduc7on for

maternal immuniza7on in La7n America



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


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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


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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.


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%


• 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


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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.


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

maternalimmunizationinlatin)) america ... · alba maría’roperoalvarez...

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