Dr. Mohamed El Bakry
Chairman of the Pediatrics Department
Banha University
Intercontinental City Stars
May 19th, 2011
Vaccinations
…
Where we R??
Where 2 go??
Bakry , 2011
Vaccine
Vaccination Schedule
Schedule
BCG
DTwP
DTwP Hep
Hep B
Influenza
6-59 months; >50 years
MenAC
MenACWY
MMR
12-15 months; 4-6 years
OPV
Td
TT
Vitamin A
Hep A
12-23 months
DTaP
2, 4, 6, 15-18 months; 4-6 years
Hib
2, 4, 6, 12-15 months
HPV
11-12 years
IPV
2, 4, 6-18 months; 4-6 years
MenC conj
11-12 years
Pneumo conj
2, 4, 6, 12-15 months
Pneumo ps
>= 2 years
Rotavirus
2, 4, 6 months
Tdap
11-12 years
Varicella
12-18 months; 4-6 years
Bakry , 2011
Licensed vaccines in routine use in
the USA, 1980 and 2008
FDA licensed vaccines in routine use in 1980
FDA licensed vaccines in routine use in 2008
•Diphtheria
•Diphtheria
•Tetanus
•Tetanus
•Pertussis
•Pertussis
•Polio
•Polio
•Measles
•Measles
•Mumps
•Mumps
•Rubella
•Rubella
•Influenza
•Influenza
•Pneumococcal
•Pneumococcal
•Hemophilus influenza type B
•Hepatitis A
•Hepatitis B
•Herpes
•Human papillomavirus
•Meningococcal
•Rotavirus
•Varicella
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
Birth
DTwP
DTwP Hep
Hep B
2, 3, 16-18 months
Influenza
MenAC
MenACWY
MMR
12, 13-24 months
OPV
Td
16-18, 26-28, 38 48, 58, 68 years
TT
Vitamin A
DT
6, 11-15 years
DTaPHibIPV
2, 3, 4, 16-18 months
DTaPIPV
11-13 years
HPV
1st contact; +2, +6 months (girls at 14 years)
IPV
6, 11-13 years
Pa
26-28 years
Pneuma conj
2, 3, 12 months
YF
12 months, 11, 21, 31, 41, 51 years
Bakry , 2011
Vaccine
Vaccination Schedule
Schedule
BCG
birth
DTwP
4-6 years
DTwP HibHep
2, 4, 6 months
Hep B
Birth
Influenza
MenAC
MenACWY
MMR
1, 4-6 years
OPV
4, 6, 12 18 months; 4-6 years
Td
>= 7 years
TT
(CBA, pregnant)
Vitamin A
DT
< 7 years
DTwP Hib
18 months
Hep A
2, 4, 6 months
HIB
2, 4, 6 months
IPV
2 months
Measles
9 months
Pneuno conj
2, 4, 6, 12 months
Pneumo ps
Risk groups
Varicella
1, 4-6 years
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
birth
DTwP
18 months
DTwP HibHep
2, 4, 6 months
Hep B
birth
Influenza
(high risk groups)
MenAC
MenACWY
(pilgrims)
MMR
12, 18 months
OPV
4, 6, 18 months; 6, 17 years
Td
12, 17 years
TT
(pregnant/wound)
Vitamin A
9, 18 months
DT
6 years
IPV
9 weeks
Measles
(part of country)
Pneumo conj
2, 4, 6, months
Rabies
(high risk – animal bites)
Rubella
15-49 years (post partum)
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
birth
DTwP
6, 10, 14 weeks
DTwP HibHep
6, 10, 14 weeks
Hep B
Influenza
MenAC
MenACWY
MMR
OPV
Birth; 6, 10, 14 weeks
Td
TT
1st contact, +1, +6 months; +1, +1 year
Vitamin A
9-24 months
Measles
9, 18 months
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
Birth
DTwP
DTwP HibHep
6, 10, 14 weeks
Hep B
Influenza
MenAC
MenACWY
MMR
OPV
6, 10, 14 weeks
Td
TT
1st contact; +1, +6 month; +1, +1 years
Vitamin A
Measles
9 months
Pneumo Conj
From January 2011
Rotavirus
From July 2010
Bakry , 2011
Vaccination Coverage 2009
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
Birth
DT
6 years
DTwP
3, 4, 5, 18-24 months
Hep B
Birth, 1, 6 months
Influenza
MenA
6-18 months (x2)
MenAC
3, 6 years
MMR
18-24 months
OPV
2, 3, 4 months, 4 years
Td
TT
Vitamin A
Hep A
18, 24-30 months
JapEnc
8 months, 2 years (or 8 months (x2); 2 , 6 years)
Measles
8 months
MM
18-24 months
MR
8 months
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
3 days, 7, 14 years
DTwP
3, 4, 5, 6, 18 months
DTwP Hep
3, 6 months
Hep B
1st day; 3,6 months
Influenza
MenAC
Part of country
MenACWY
Part of country
MMR
12 months; 6 years; part of country
OPV
18, 20 months; 14 years
Td
6-7, 14 years; +19 years
TT
Vitamin A
Dip
+10 years
DT
3, 4, 5, 6 months
Measles
12 months; 6 years
MM
12 months; 6 years
Mumps
12 months; 6 years
Bakry , 2011
Vaccination Schedule
Vaccine
Schedule
BCG
Birth
DTwP
6, 10, 14 weeks
DTwP Hep
Hep B
Influenza
MenAC
MenACWY
MMR
OPV
Birth, 6, 10, 14 weeks
Td
TT
1st contact, +1, +6 months, +1, +1 year
Vitamin A
9 months
Measles
9 months
Bakry , 2011
‫أم الدنيا‬
Vaccination Schedule
Vaccine
Schedule
BCG
Birth
DTwP
2, 4, 6, 18 months
DTwP Hep
2,4,6 months
Hep B
2, 4, 6 months
Influenza
MenAC
3, 6, 12, 15 years
MenACWY
MMR
12, 18 months
OPV
Birth, 2, 4, 6, 9, 18 months
Td
TT
Vitamin A
9, 18 months
Bakry , 2011
Egypt Vaccine Market
optional
obligatory
Hib
BCG
Rotavirus
OPV
Varicella
HBV
Influenza
MMR
PCV
DTP
HAV
Mening
Bakry , 2011
Vaccination Coverage 2009
100
90
80
70
60
Egypt
50
Russia
40
China
Somalia
30
20
10
0
BCG
DTP1
DTP3
HepB3
MCV
Pol3
Bakry , 2011
Bakry , 2011
Where do we want to go??
Global
Alliance for
Vaccines &
I mmunization
GAVI
Is a global alliance between
PRIVATE and PUBLIC
sectors committed to saving
CHILDREN’S lives &
protecting peoples health by
increasing access to
immunization in peer countries.
Bakry , 2011
GAVI
“Supporting
children’s
immunization is
undoubtedly the
best investment
we’ve ever made” –
Bill Gates, CoChair Bill &
Melinda Gates
Foundation
Bakry , 2011
Alliance board 2008
Vaccine industry of
developing &
industrialized
countries
Independent
individuals
WHO
World Bank
GAVI
Civil Society
Organizations
Bill & Melinda Gates
Foundation
Governments of
donor countries
Research of Health Governments of
institutions developing countries
Bakry , 2011
GAVIs’ Goal!
Reducing childhood
mortality by 2/3 by 2015
Bakry , 2011
FACTS
• 9 million children die before their 5th
birthday every year
• 2.4 million children die from diseases
that are vaccine preventable (That is
one child every 20 seconds!)
• 24 million children in the world remain
unvaccinated!!
Bakry , 2011
Causes of under five child deaths in
low income countries
Bakry , 2011
GAVI supports 72 countries
Afghanistan
Angola
Armenia
Azerbaijan
Bangladesh
Benin
Bhutan
Bolivia
Burkina Faso
Burundi
Cambodia
Cameroon
Central African Republic
Chad
Comoros
Congo
Dem Republic of Côte d'Ivoire
Cuba
Djibouti
Eritrea
Ethiopia
Gambia
Georgia
Ghana
Guinea
Guinea Bissau
Guyana
Haiti
Honduras
India
Indonesia
Kenya
Kiribati
Korea DPR
Kyrgyz Republic
Lao PDR
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritania
Moldova
Mongolia
Mozambique
Myanmar
Nepal
Nicaragua
Niger
Nigeria
Pakistan
Papua New Guinea
Rwanda
São Tomé
Senegal
Sierra Leone
Solomon Islands
Somalia
Sri Lanka
Sudan
Tajikistan
Tanzania
Timor Leste
Togo
Uganda
Ukraine
Uzbekistan
Viet Nam
Yemen
Zambia
Bakry , 2011
Zimbabwe
½ the worlds
population
GAVI
• Averted 5 million deaths 2000-2010
• Committed 4 billion US $ for 75
countries between 2000-2015
• Start up grant US $ 750 million in
1999 by Bill & Melinda Gates
Foundation
• Additional Hepatitis B vaccination 3
doses for 267 million children
Bakry , 2011
GAVI supporting new
vaccines
Pentavalent
(DPT,
HBV, Hib)
Rotavirus
vaccine
Pneumococc
al
??
Bakry , 2011
Vaccine preventable deaths and the global
immunization vision and strategy, 2006 - 2015
Priorities in Public Health interventions
VPD deaths can be averted if existing vaccines used at full potential
In 2002 deaths from diseases for which vaccines are WHO recommended
<1,000 children < 5 died from polio
4,000 children died from diphtheria
15,000 children died from yellow fever
198,000 children died from tetanus
294,000 children died from pertussis
386,000 children died from (Hib) Hemophilus influenza type B
540,000 children died from measles
Bakry , 2011
Immunization coverage with DTP3, Hepatitis and Hib
vaccines in GAVI supported countries 2000-2011
Bakry , 2011
Vaccination and decline of
Hib disease in Finland
Bakry , 2011
GAVI’s Strategy
GAVI’s ability to secure predictable long-term funding and prompt
demand for vaccines
Manufacturers (including in developing countries) have increased
commitment to providing suitable vaccines for developing countries
Increased competition for vaccine production
Decreased prices of GAVI supported vaccines
Bakry , 2011
The GAVI alliance strategy
2011-2015
Bakry , 2011
HSS: Health System
Strengthening
six key components
Health service delivery: a
network of health facilities
to provide access to
primary & secondary care.
Bakry , 2011
Health workers: in the right
place at the right time with
training, experience &
incentives
Bakry , 2011
Health information
systems: to generate
quality data and to
measure what is being
done & achieved
Bakry , 2011
Logistics & supply systems:
so that drugs, equipment
and fuel are available
Bakry , 2011
Health financing: to raise
sufficient funds for health
& improve financial risk
protection
Bakry , 2011
Leadership & governance:
to ensure that strategic
policy frameworks exist
and there is proper
accountability and
oversight
Bakry , 2011
Egypt is strong in this
area because of good
infrastructure of existing
high vaccination coverage
Bakry , 2011
Vaccine
Research
& the
future
Vaccines by Period of Development
18th
Century
Smallp
ox
(1798)
19th
Century
Early
20th
Century
Rabies
BCG
tuberculosis
Hog cholera
Pertussis
(1926)
Diphtheria
Diphtheria
(1923)
Antitoxin
Cholera
Plague
Typhoid
(1896)
Influenza
(1936)
Tetanus
toxoid (1927)
Yellow fever
(1935)
Rickettsia
(1936)
Influenza A
(1936)
Post
WW II
19801999
Yellow Fever
(1935)
Adenovirus
Influenza (1945)
Diphtheria
Typhoid (1952)
Polio salk (1955)
Meningococcus
(1962)
Polio
Sabin (1963)
Measles (1963)
Rabies (1980,
human)
Hemophilus
influenza
Hepatitis B (1987)
Typhoid (1992)
20002010
Future
Pneumococca
l
H. Pylori
Meningococc
al disease
Streptococ
uss
Influenza
HIV
Parainfluenza
Hepatitis C
Human
papillpmavirus
(HPV)
adenoviruse
s
Salmonella
Japanese
encephalitis
Hepatitis B (1981)
Varicella (1995)
Mumps (1967)
Tick-borne
encephalitis rubella
(1970)
Anthrax (1970)
Hepatitis A (1995)
MMR (1971)
Rotavirus (1998)
Pertussis acellular
(1993)
Lyme disease
(1998)
Bakry , 2011
Introduction of first generation of
vaccines used on humans
Originals
• 1798 Smallpox
• 1885 Rabies
• 1897 Plague
• 1923 Diphtheria
After WW II
• 1955 Injectable Polio
Vaccine (IPV)
• 1962 Oral Polio Vaccine
(OPV)
• 1926 Pertussis
• 1964 Measles
• 1927 Tuberculosis (BCG)
• 1967 Mumps
• 1927 Tetanus
• 1970 Rubella
• 1935 Yellow Fever
• 1981 Hepatitis B
Bakry , 2011
Vaccines used by the expanded
Programme on Immunization (EPI)
From 1974 onwards
•BCG
•Polio
•DTP
•Measles*
Added Later
•Yellow fever (in endemic
countries
•Hepatitis B
•MMR used in
industrialized countries
and now in many
developing countries
Bakry , 2011
Stages of vaccine development
Vaccine
development
proceeds through
discovery process
engineering
toxicology and
animal studies to
human phase I, II
and III trials. The
process can take
more than 10 years,
depending on the
disease
Bakry , 2011
An ideal Vaccine should be
Good immune response
• Both cell mediated immunity and antibody responses
• Immunity is long lived
• Single dose
Safety
• Danger of reversion to virulence, or severe disease in immunocomprised
Stability
• Organisms in the vaccine must remain viable in order to infect and
replicate in the host
• Vaccine preparations are therefore very sensitive to adverse storage
conditions
• Maintenance of the cold chain is very important
Expense
• Cheap to prepare
Bakry , 2011
Calculated Cost effectiveness for any
Vaccine
No of doses of vaccine given
Cost of Vaccination
(doses + admin.)
No of Episodes of disease prevented
e.g
Otitis Media
-Saving
Pneumonia
-Saving
Invasive Diseases
-Saving
No life Years Saved
Net Cost of Vaccine Program
No life Years Saved
= Net Cost of Vaccine Program
= Cost per Life –Year Saved
Pneumococcal Vaccine (1000 children)
30
25
20
20
18
Children
15
10
5
2009
2010
Pneumococcal Vaccine (1000 children)
140
138
126
118
98
Private
GAVI
78
58
38
18
18
2009
20
2010
Conclusions
Lobbying for improving states of
vaccinations in Egypt.
Start by introduction of Hib as
part of the national program
Then gradually introduce other
vaccines according to priorities
Bakry , 2011
Possible candidates
•
•
•
•
Varicella
Hepatitis A
Rota
Pneumococcal
Bakry , 2011
Funding
• Approach MoH for co-ordination of
plans
• Approach GAVI to renew status of
Egypt
• Negotiate prices of vaccines with
producers
• Approach civil society associations for
funding start ups and maintenance
• Cost sharing with the public
Bakry , 2011
‫المطلوب‪:‬‬
‫توفير اكبر قدر من التطعيمات لالطفال‬
‫شارع شارع‬
‫حارة حارة‬
‫زنجا زنجا (زنقة زنقة)‬
‫الطفـــل‬
‫يريد‬
‫حقــه‬
‫فــى‬
‫التطعــــيم‬
Thank You
Timeline of vaccines (20th century)
1932
Yellow
fever
1945 1952
polio
Influenza
1954
1957
1962
Adenovirus
–4&7
Japanese
encephalitis
1964
1962
measles
Oral polio
vaccine
Mumps
Bakry , 2011
Timeline of vaccines
1970
1974
rubella
1977
1978
pneumonia
Chicken
pox
meningitis
1981
1992
Hepatitis
B
1998
rotavirus
Hepatitis
A
Bakry , 2011
New vaccines and combinations
•
•
•
•
•
•
•
•
•
•
•
Hepatitis B (and A) catch up
Haemophilus influenza b (Hib)- universal
MMR, Measles, mumps, rubella x 2 – universal
DPT x 4 – update policies, catch up, also for elderly (H
zoster)
Influenza – all ages
Pneumococcal pneumonia – all ages
Rotavirus
Human papilloma virus (HPV) and cancer cervix
Future vaccines – streptococcus, cytomegalovirus (CMV),
helicobacter, HIV, malaria, avian flu
Cocktails- maximum combination of routine vaccines
New methods of production of vaccines
Bakry , 2011
WHO/UNICEF’s current
vaccines
Bakry , 2011
• Cold chain monitor card: upon arrival to a health clinic, vaccines are
stored in refrigerators and temperatures recorded on a chart. The
temperatures are monitored and recorded twice a day to ensure
that a safe temperature is maintained
• Vaccine vial monitor (VVM): the vaccine vial monitor consists of a
temperature sensitive label placed on each vial that registers
cumulative heat exposure for that vial. GAVI resolved that all
vaccines be purchased by the Vaccine Fund after 2003 will include
VVM (immunization focus, July 2003, GAVI newsletter)
• Freeze watch: in the freeze watch, a vial with a red liquid that bursts
and stains a white placard if exposed to temp. below zero for > 1
hour is packed with DTP, TT (freezing pt. -6.5 C) (WHO,
vaccines-cold chain, 2005)
GIVS Global Immunization vision
and strategy 2006-2015
Bakry , 2011
Canadian Institutes of Health
Research CIHR in the 1st 10
st
years of 21 century research in
development of new vaccines has
accelerated to meet antibiotic
resistance infections as well as
combat cancers and diseases that
were once thought invincible.
Bakry , 2011
Canadian successes in
vaccines research include
• an acellular pertussis vaccine;
• a candidate vaccine for Severe Acute Respiratory Syndrome (SARS);
• a cattle vaccine against E. coli 0157:H7;the development of vaccine
•
•
•
•
•
•
technology to prevent meningitis;
candidate vaccines against hemorrhagic fevers;
the preparation for and assessment of the impact of human papilloma virus
(HPV) immunization in Canada;
the development of therapeutic cancer vaccines;
the safe administration of vaccines produced in eggs to egg-allergic
individuals;
the evaluation of influenza vaccination strategies and transmission
dynamics within a community; and,
the development of new vaccination strategies for Human
Immunodeficiency Virus (HIV-1)
Bakry , 2011
WHO state of the art of
new vaccines:
Research and development 2006
Sexually transmitted diseases
•
•
•
•
Chlamydia trachomatis
Gonorrhea
Herpes simplex type 2
HIV/AIDS
Bakry , 2011
Vector borne viral infant
•
•
•
•
Dengue fever
Japanese encephalitis
Tick-borne encephalitis
West Nile virus
Bakry , 2011
Zoonotic infections
•
•
•
•
•
Anthrax
Hepatitis E
Leptospirosis
Plague
Rabies
Bakry , 2011
Viral cancer
• Epstein-Barr virus
• Hepatitis C
• Human papillomavirus
Bakry , 2011
Diarrhea disease
•
•
•
•
•
•
•
Caliciviruses
Campylobacter
Cholera
Enterotoxigenic Escheria coli (ECTC)
Rotavirus
Shigellosis
Typhoid fever
Bakry , 2011
Respiratory infections
Influenza
Parainfluenza viruses
Respiratory syncytial virus (RSV)
Severe acute respiratory syndrome
(SARS)
• Streptococcus pneumoniae
• tuberculosis
•
•
•
•
Bakry , 2011
Bacterial infections
•
•
•
•
•
•
Helicobacter pylori
Neisseria meningitidis
Mycobacterium ulcerans (Buruli ulcer)
Staphylococcus aueus
Group A Streptococcus
Group B Streptococcus
Bakry , 2011
Parasitic diseases
•
•
•
•
•
Amoebiasis
Hookworm disease
Leishmaniasis
Malaria
schistosomiasis
Bakry , 2011