VACCINE PREVENTABLE DISEASES – WAY FORWARD IN NIGERIA - PowerPoint Presentation

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VACCINE PREVENTABLE DISEASES – WAY FORWARD IN NIGERIA

Prof G. C. Onyemelukwe

FWACP, (MON

)

19

TH

JULY 2013

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Mandatory for childhood

, social mobilization and health education are very necessary. Child Rights Act vaccination is a right. Niger state Assembly passed a bill in 2010/2011 for compulsory polio vaccination of children. Federal government from 2012 purchases all vaccines with donor support of GAVI, WHO, UNICEF, DFID, BILL GATES FOUNDATION, CLINTON HEALTH ACCESS INITIATIVE and other partners. Private sector participation in vaccination. GERIATRIC ACT BY NIGERIA NATIONAL ASSEMBLY PASSED 2009.Abuja Declaration of Africa Union on Tb, HIV and malaria in Africa.

VACCINATION POLICY IN NIGERIA

SINCE EDWARD JENNER – COW POX

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TYPE S

OF PREVENTIVE INTERVENTIONPRIMARY PREVENTION- AVOIDANCE OF DISEASE OCCURRENCESECONDARY PREVENTION PREVENTION (EARLY DETECTION AND REVERSAL) BEFORE COMPLICATIONSTERTIARY PREVENTION PREVENTION OR DELAY OF COMPLICATIONS IN ONGOING/ESTABLISHED CASESHotez P. 2009 rescuing the bottom billion through control of neglected tropical diseases. THE LANCET (373:P. 1570 – 1575)

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UNIVERSAL HEALTH

COVERAGEAccess for all to appropriate health services at an affordable cost, with highly cost effective prevention activities and therapies accessible to all citizens; Health care financing system mitigate risk of households falling into poverty or suffering large financial losses because of costly health system .Vaccine security involving all stakeholders is a sine qua non

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(a).

A wide range of health services, including highly cost- effective prevention activities and therapies, should be accessible to all citizens of a give a Country and (b). The system of financing healthcare

should mitigate, as

much as possible, the risk that households

would fall into poverty or suffer large financial losses as a result of a costly health problem.The Joint Learning Network for Universal Health Coverage chronicles the challenges and successes of specific reforms within countries, providing a learning platform for senior policy-makers and practitioners in more than a dozen countries.

ACCESSIBLITY AND AFFORDABILITY

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GOALS OF VACCINATION

Immunity and herd immunity: Herd Immunity is based on the idea that the pathogen will not spread when a significant part of the population has immunity against it. Primary prevention of cancer of cervix and liver possible. Mass immunization. Eradication of disease: World Health Organization coordinated the global effort to eradicate smallpox globally. Endemic measles, mumps and rubella in Finland eradicated. Polio has been eradicated in most countries except Pakistan, Afghanistan, and Nigeria as at 2013.

Individual, group

, selected vaccination of at risk groups: E.g rabies vaccination for veterinary workers.

Therapeutic vaccines or vaccination

– anti-IgE vaccines in asthma, anti-cancer therapeutic vaccines e.g. for prostate cancer. Passive delivery of monoclonal antibodies (MoAb) against cancers.

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FASTER PROGRESS WITH VACCINES TO MDGs

(2000-2015)MDG1: END POVERTY AND HUNGER – Vaccines protect from death, disability, free family finances MDG2: Achieve universal primary education – Healthy to immunized to attend

school

MDG3:

Promote gender equality- Healthy children free women

MDG4: Reduce Child mortality- Vaccines prevent 2.5 million child deaths per year, 79% in developing countries, Pneumonia Diarrhea Rota virus) kill 3 million.MDG5: Improve maternal health- Material neonatal tetanus vaccines

MDG 6:

Combat HIV/AIDS, malaria other disease- Vaccinate HIV positives,

Pneumonia, Diarrhea reduce transmission.

MDG7:

Ensure environmental sustainability – Rota virus vaccination reenergizes safe

drinking water.

MDG8:

Develop global partnership for development

- WHO, UNICEF, GAVI,

Bill

and Melinda Gates, IVAC, CLINTON HEALTH ACCESS

INITIATIVE

- Parliamentary Advocacy and financing for immunization in Nigeria (PAFFIN)

HERFON

-

Women Advocates for vaccine Access (WAVA)

-

Nigeria National Vaccine Summit,

PAN 2012

-

World Pneumonia Day 2011, 2012. GAVI initiative from 2000 – Save children

lives, access to Immunization.

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GUAGING

COUNTRY LEVEL MDGs ACHIEVEMENT(MIDTERM)

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VACCINE LANDSCAPE 2000 TO 2020

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PRE-NATAL

NEO-NATALCHILDHOODIMMUNE COMPROMISED

GERIATRIC IMMUNO-SENESENCE

TRANS-

PLACEN-TAL IMMU-NITY

1.ROU TINE UNIVE RSAL IMMU NIZA TION

2.BREAST

FEEDING

3.

TB,POLIO,

DTP,

Hib,YF, measlesROTAVIRUSpneumococciPREGNANCYHIV-AIDS 3.5millionSICKLE CELL DISEASECHRONIC DISEASESCANCERSAnti-cancer vaccineMonoclonal antibodies (MAb)ASTHMAAnti - IgE vaccinesSPECIAL INFECTIONSCHOLERAYELLOW FEVERLASSA FEVERMALARIASCHISTOSOMIASISFILARIASISAVIAN INFLUENZARABIES/RELATED VIRUSMENINGITISPNEUMONIA

IMMUNOLOGICAL SPECTRUM PRE NATAL TO OLD AGE

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MATERNAL ANTIBODIES IN BREAST MILK PROTECT THE CHILD FROM ENTEROVIRUS INFECTIONS.

Sadeharju K, Knip M, Virtanen SM, Savilahti E, Tauriainen S, Koskela P, Akerblom HK, Hyöty H; Finnish TRIGR Study Group. Pediatrics. 2007 May;119(5):941-6.Protective high maternal antibiotics in serum and breast milk better in breast fed > 2 weeks. Secretory IgA for mucosal defence of baby . Anti-tetanus

transplacental

antibodies after maternal

immuinization

.

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BREAST MILK ADVANTAGES

SIMPLE OLIGOSACCHRIDES – Binding sites to intercept bacteria entry into intestinal cell.2. MUCINS – Adhere to bacteria, viruses to eliminate them3. LACTOFERRIN – Bind iron, unavailable to organisms4. B12

BINDING PROTEIN

– deprive organisms of

Vit

B12 5. BIFIDUS FACTOR – promotes beneficial Lactobaccilus bifidus growth6. INTERFERON – In colostrum

, antiviral activity

7. FIBRONECTIN

– In

Colostrum

, repair of tissues, minimize

inflammation, make phagocytes more aggressive.

8. INDUCER FACTORS – Induce infants immune system9. ENHANCER EFFECT – higher levels of antibodies, cortisol, epidermal growth factor, nerve growth factor Insulin – like growth factor, somatomedin C, to close leaky mucosal lining of newborn.10. FREE FATTY ACIDS – damage membranes of enveloped viruses e.g. chicken pox virus11. SECRETORY IgA IN URINARY TRACT - Lactoferrin, lysozyme found in large amounts in urinary tract of breast fed.12. Induces increased local production of Lactoferrin

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CELLULAR DEFENCES IN BREAST MILK

Immune cells abundant in breast milk – white blood cells, leukocytes 40% are macrophages, manufacture lysozyme that destroy bacteria.Lymphocyte 10%.B Lymphocytes produce antibodies. Milk lymphocytes proliferate in presence of Escherichia coli. Produce gamma – interferon, monocyte chemotactic factor.

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Cell mediated INNATE SYSTEM WORKS WITH ADAPTIVE IMMUNE SYSTEM

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HELMINTH- AND BACILLUS CALMETTE-GUÉRIN-INDUCED IMMUNITY IN CHILDREN SENSITIZED IN UTERO TO FILARIASIS AND SCHISTOSOMIASIS

Indu Malhotra, Peter Mungai, Alex Wamachi, John Kioko, John H. Ouma, James W.

Kazura

and Christopher L. King

J.

Immunol. 1999 Jun 1; 162 (11): 6843 – 8.FOETAL IMMUNOLOGICAL PROGRAMMING Prenatal sensitization to filarial and schistosomiasis in mother induces immunology memory that persists in infancy in 50% of newborns, which leads to reduction

of induction of type I T cell immunity induced by BCG for

at least 2 – 10 years. Avoid parasite infection in pregnant

women.

2. Malnutrition in under 5 poor immunization antibody

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MEMORY B CELLS AND MEMORY T

H CELLS ARE GENERATED BY IMMUNIZATION AND HERD IMMUNITY INCREASEDEach case infects 10 A. Each case infects 10 other other individuals in individuals in a population a susceptible population. With 80% immunity.

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ANTI - IgE VACCINES FOR ASTHMA AND ALLERGY

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ASTHMA ALLERGENS IN NIGERIA

Dermatophagoides pteronnysinusDermatophagoides farinae Onyemelukwe et alEgg yolk, egg white Rast specific IgE in NigerianOkro, frying oil, pepper asthmatic patients. Ann.Allergy 1986;56(2) 167-70

Pollens

Onyemelukwe G.

Rast specific IgE to eggAirborne fungi etc. and milk in Nigerian asthmatic patients African J Med. Med Sci 2011;40(7) 51-7 A. Severe Acute: Chimeric IgE VaccinesDNA of Allergenic substances (Derf1) Dermatophagoides farinae

ANTISERA to spider bites, jellyfish stings and other

allergies.

D. CYTO – 003 wing Q beta derived virus like

particles VLP

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MALARIA VACCINE

Phase 3 trials of RTS, S/ASOI Malaria vaccine in Africa Infants (6573 infants). New Engl. J. Med 2012, 367, 2184-2296 RTS, S CLINICAL TRIALS PARTNERSHIPREDUCE EPISODES OF BOTH CLINICAL AND SEVERE MALARIA IN CHILDREN 5 – 17 months by about 50%. One month after 3doses all was positive for anticircumsporozoite antibodies.OTHER PARASITE VACCINE APPROACH1. PARASITE ANNEXINS (found in Nematodes, Trematodes,Protozoa) Annexins bind phospholipids. used T. Solium vaccination of pigs, Giardia duodenalis – trophozoite vaccine of cats, dogs.2. PARAMYOSIN in muscles of invertebrates, found in Schistosomiasis (SM97) filariasis, Taenia Solium, Echinococcus granulosa produce TH1 response

J.Vazquez

– Talavera et al; America Society Microbiology Infection and Immunology 2001.3. Wuchereria Bancrofti GST vaccination for lymphatic filariasis. Veerapathran A et al PLOS Neglected Tropical Diseases 2009.GST (Glutathione – S- Transferase). rWbGST as a potential vaccine candidate against Lymphatic filariasis.4. HOOKWORM VACCINES – (a) HHVI (Human Hookworm Vaccine Initiative) Na- ASP2tried in Brazil. Peptide-Based Subunit Vaccine against Hookworm Infection (PLOS ONE 2012 /article/info%3Adoi%2F10.1371%2Fjournal.pone.0046870. M. Skwarczynski et al.

PARASITES

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ADVANCES IN TOXOPLASMOSIS VACCINES

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CANCERS

CANCER PREVENTIVE VACCINES1. HPV ( 17 SEROTYPES) – 16 and 18 70%, other cervical cancer, vaginal, vulva, penile, oropharyngeal cancer

GARDASIL – 16, 18, 6, 11 (

Quadruvalent) GARDASIL MERCK and COMPANY Age 6 - 26 6, 11 cause 90% genital wart. Made of virus – like particles (VLPS) And correspond to HPV types 6, 11, 16, 182. CERVARIX (bivalent) GSK 16, 18. Age 9 – 25

3. HBV Vaccine

– children vaccinated at birth

CANCER THERAPEUTIC VACCINES

1. SIPULEUCIL – T (PROVENGE BY DENDREON) Use of

Dendritic

cells.

Metastatic prostate cancer – Immune response to prostatic acid phosphate (PAP)

Customized to each patient. Leukapharesis of antigen presenting cells (APCs) Dendritic cell cultured with protein PAP – GM – CSF. 3 treatments 2 weeks apart. Antologous vaccine2. RUSSIA: VITESPAN (2008) Heat shock protein HSPgp96 coupled to Dendritic cell – kidney cancer HEAT SHOCK PROTEINS NEW TECHNOLOGY FOR CELLULAR IMMUNIT. Response to Leprosy, tuberculosis and cancer.3. Vaccine against MUC-1 Cancer protein ImMUCIN VAXIL BIOTHERAPEUTICS ONGOING RESEARCH ON OTHER CANCER CAUSING ORGANISMS1. Hepatitis C – PLCC2. EBV – Burkitt’s lymphoma, NHL

3. KHSV – Kaposi sarcoma

4. HTLVI - Adult

Tcell

leukaemia

5. Helicobacter

pylori – Gastric cancer

6.

Schistoma

– bladder cancer

haematodium

.

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CERVICAL CANCER RISK PERCEPTION AND PREDICTORS OF HUMAN PAPILLOMA VIRUS VACCINE ACCEPTANCE AMONG FEMALE UNIVERSITY STUDENTS IN NORTHERN NIGERIA.

Iliyasu Z, Abubakar IS, Aliyu MH, Galadanci HS .J Obstet Gynaecol. 2010;30(8):857-62. doi: 10.3109/01443615.2010.511724. Of 375 females, 35.5% heard of HPV, 53.9% heard of cervical cancer, 74.0% willing to accept

VACCINE ACCEPTANCE(BUY IN)

IN NIGERIA

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HUMAN PAPILLOMA VIRUS VACCINE: KNOWLEDGE, ATTITUDE AND PERCEPTION OF PARENTS IN SOUTHWEST, NIGERIA

Kola M. Owonikoko, Adeola F. Afolabi, Lawrence A. Adebusoye, Oluseyi O.

Atanda

.

Ref. Medical Sciences and Public Health 1(1)2013; 13 – 19

Interviewed parent and guardians – 51.3% ignorant of vaccines, 89.4% agreed to vaccinate their children.

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MONOCLONAL ANTIBODIES IN CANCER THERAPY: 25 YEARS OF PROGRESS

MONOCLONAL ANTIBODY PRODUCTSAbbreviations: NHL, non-Hodgkin's lymphoma; VEGF, vascular endothelial growth factor; CLL, chronic lymphocytic leukemia; EGFR, epidermal growth factor receptor. NAME

TYPE

TARGET

CLINICALRituximabChimericCD20NHL TrastuzumabHumanized

Erb B2

Breast

Bevacizumab

Humanized

VEGF

Colorectal

Alemtuzumab

HumanizedCD52CLLCetuximabChimericEGFRColorectalPanitumumabHumanEGFRColorectal

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FDA APPROVED MONOCLONAL THERAPEUTIC ANTIBODIES

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FDA APPROVED MONOCLONAL THERAPEUTIC ANTIBODIES

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NIGERIA HEALTH WATCH

– YELLOW FEVER SOUTH AFRICA DIPLOMACYOn yellow fever, yellow cards, Nigeria and South Africa Paper protection?? Faking?? Saudi Pilgrims – POLIO IMMUNIZATION, MENINGITIS, CHOLERA, REQUIREMENTS

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"

MEDICINE IS A SOCIAL SCIENCE, AND POLITICS IS NOTHING ELSE BUT MEDICINE ON A LARGE SCALE“ RUDOLF VIRCHOW Nigeria: Vaccine suspicion aggravates measles outbreak in Kano and elsewhere and interrupts polio eradication

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FACTORS CONTRIBUTING TO INFECTIOUS DISEASE

REEMERGENCE AND ASSOCIATED DISEASES  CONTRIBUTING FACTOR(S) ASSOCIATED INFECTIOUS DISEASES1. Human demographics and behavior 

Dengue/dengue hemorrhagic fever, sexually transmitted diseases,

giardiasis

2.

Technology and industry Toxic shock syndrome, nosocomial (hospital-acquired) infections, hemorrhagiccolitis/hemolytic uremic syndrome3. Economic development and land use 

Lyme disease, malaria, plague, rabies, yellow fever, Rift Valley fever, schistosomiasis

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4.

International travel and commerce Malaria, cholera, pneumococcal pneumonia5. Microbial adaptation and change Influenza, HIV/AIDS, malaria, Staphylococcus

aureus

infections

6. Breakdown of public health measures Rabies, tuberculosis, trench fever, diphtheria, whooping cough (pertussis), cholera7. Climate change

 

Malaria, dengue, cholera, yellow fever

.

SOURCE: ADAPTED FROM US INSTITUTE OF MEDICINE, 1997

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LASSA ENDEMIC STATES

BAUCHIPLATEAUTARABANASARAWABENUEENUGUEBONYIONDO9. EDO

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RABIES ENDEMIC IN NIGERIA

Detection of rabies virus antibodies in fruit bats (Eidolon helvum) from Nigeria.Aghomo HO, Ako-Nai

AK,

Oduye

OO, Tomori O,

Rupprecht CE. J. Wild Dis. 1990.Five viruses related to rabies occurs in Africa related to rabies occurs in Africa Obodhang – Sudan Kotoukan – Nigeria

Mokola

– Nigeria (Shrews)

Lagos Bat – Nigeria (fruit bats)

Duvenlage

– South Africa (man bitten by bat)

Epizootic in Zimbabwe 1981 in dogs, cats. Africa is ancestral origin

Rabid dogs

in Nigeria lack of immunization for dogs. Human diploid vaccine available but in short supply in Nigeria as well as anti – serum.PS STAPH INFECTIONSEngineered genetically StaphVAX (NIH)USA

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OVER 100M NIGERIANS AT RISK OF YELLOW FEVER OUTBREAK

A. As many as 101 million Nigerians are at risk of a possible outbreak of yellow fever, if a mass vaccination campaign is not carried out, the National Primary Health Care Development Agency has warned. Some 377 local government areas in 25 states have been marked out as high risk areas, indicate an assessment survey of the country.Oyewale TomoriNOTEEBOLA OUTBREAK IN UGANDA

Ebola O

utbreak in Uganda 2012.

Fruit bats reservoir. Effects to other African countries including Nigeria. Surveillance and preparedness?? Occurs in

Remote villages in Central and West Africa from wild animals.

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WHO ESTIMATES

20M NIGERIANS HAVE HEPATITIS B VIRUS –SOGHIN(SOCIETY FOR GASTRO ENTEROLOGY AND HEPATOLOGY IN NIGERIA) Sept. 2007 Port Harcourt

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HIV, HEPATITIS B AND C VIRUSES’ COINFECTION AMONG PATIENTS IN A NIGERIAN TERTIARY HOSPITAL

Taiwo Modupe Balogun,, Samuel Emmanuel1, Emmanuel Folorunso OjerindePan African Medical Journal 2012:12:100HbsAg + Anti-HIV (4%)

HbsAg + HIV (28%)

HCV + HIV (14.7%)

Industrialized countries: HCV 20% acute hepatitis 70% chronic hepatitis, 40% cirrhosis, 60% hepatocellular carcinoma, 30% liver transplants.

15 – 60% normal African positive for one more markers of HBV

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EPIDEMIC HISTORY AND EVOLUTIONARY DYNAMICS OF HEPATITIS

B VIRUS INFECTION IN TWO REMOTE COMMUNITIES IN RURALNIGERIAJoseph C. Forbi*, Gilberto Vaughan, Michael A. Purdy, David S. Campo, Guo-liang Xia, Lilia M.Ganova-Raeva, Sumathi Ramachandran, Hong Thai, Yury E. Khudyakov.PLOS ONE July 2010 | Volume 5 | Issue 7 | e11615.HBV hyperdemic (seropravalence 10 – 40%) in Nigeria. As part of West Africa/ Central Africa crescent from Senegal to Namibia. 11% HBV DNA positive.37 distinct HBV variants belonging predominantly to genotype E(96.4%)Note HBV genotypes are 8- A,B,C,D,E,F,G,HHBV vaccine in program but became available in 20045.6% consists of genotype D and G in 5 individuals.6. HbVA3 probably from Cameroon.

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IMMUNOGENICITY AND SAFETY OF A DTaP – IPV//PRP~T COMBINATION VACCINE GIVEN WITH HEPATITIS B VACCINE:

A randomized open-label trial Maria Rosario Capeding a, Josefina Cadorna-Carlos b, May Book- Montellano c, Esteban Ortiz Bulletin of the World Health Organization. All antigens were adequately immunogenic without interfering with each other for the era of combined vaccines - pentavalent, hexavalent, heptavalent.RCDCs for anti-hepatitis B surface antigen titres in sera obtained at 6 and 18 weeks of age from infants in Groups A and BTECHNOLOGICAL CONJUGATION OF MULTIPLE ANTIGENS

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OTHER VIRUSES

2. ZIKA VIRUS INFECTIONS IN NIGERIA: VIROLOGICAL AND SEROEPIDEMIOLOGICAL INVESTIGATIONS IN OYO STATE. J Hyg (Lond). 1979 Oct; 83(2):213- 9.Fagbami AH.3. RIFT VALLEY FEVER VIRUS (BUNYAVIRIDAE: PHLEBOVIRUS): AN UPDATE ON PATHOGENESIS, MOLECULAR EPIDEMIOLOGY, VECTORS, DIAGNOSTICS AND PREVENTION

Michel Pepin,

Michèle

Bouloy, Brian H. Bird, Alan Kemp and Janusz Paweska. INRAEDP Sciences 2010 Epidemic in Kenya 1930, Egypt 1977, West Africa including Nigeria 1988, Arabian Peninsula 2000ROTAVIRUS ENDEMIC IN NIGERIA causing diarrhoea especially in childhood.

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946 cases

788 Influenza like (ILI)156 Severe acute respiratory infection (SARI)617 processed sample472 (76.5%) ILI 73 (11.8%) SARI72 (11.7 negative)617 IL1 cases, 42 positive for influenza 20 (47.6%) positive for influenza A22 (52.4%) positive for influenza B

20 positive samples for influenza A (100%) were positive for A/H5N1 subtype

73 processed SARI, 3(4.0%) were

positive for A/H1N12 (2.7%) positive for influenza bINFLUENZA SURVEILLANCE JAN – JUN 2013 BY NCDC

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RECOMBINANT VACCINE TO PREVENT H5N1 NOT YET AVAILABLE

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PRE-VACCINATION NASOPHARYNGEAL PNEUMOCOCCAL CARRIAGE IN A NIGERIAN POPULATION: EPIDEMIOLOGY AND POPULATION BIOLOGY

Ifedayo M. O. Adetifa mail, Martin Antonio, Christy A. N. Okoromah, Chinelo Ebruke, Victor Inem, David Nsekpong, Abdoulie Bojang, Richard A. Adegbola.Plus one 2012, 7 (1) e30548Pneumococcal carriage 52.5% higher in children (67.4%) than adults 26%, highest in infants < 9 months.

2. 42 serotypes seen:

19F, 6A, 6B, 23F, 11, 15B, 3, 18C, 9V, 14, 15B,

20, 21,7F, 4, 11, 13, 17, 7C, 19A, 21, 4, 12, Nontypables.3. PCV7 Serotypes – 4, 6B, 9V, 14, 18C, 19F, 23F. PCV10, Serotypes PCV7 + 1,5,7F.

PCV13, Serotypes PCV10 + 3,6A, 19A

4. H influenza H1b meningitis eliminated 90% by H1b vaccine.

5. Near elimination of meningococcal C in industrial countries

by

vaccination

BACTERIA - PNEUMOCOCCI

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PNEUMOCOCCAL SEROTYPES IN ZARIA, NORTHERN NIGERIA

Onyemelukwe G.C and Greenwood B.M. Journal of Infection 1982ST123

4

5

9

101112

15

17

18

19

21

23

25

41454648TMn233102

1

2

2

2

2

1

1

1

1

51

Pn

20

4

12

2

10

1

1

3

5

4

1

1

4

2

1

70

Bc

8

3

6

1

1

1

20

T

51

7

25

4

16

11

1

4

3

7

4

1

2

3

5

4

3

1

KEY:

ST= SEROTYPES

Mn= MENINGITIS

Pn=PNEUMONIA

Bc= BACTEREMIA/ANTIGENEMIA

T=TOTAL

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VACCINES STRATEGIES

1. Vaccination – pneumococcal conjugate vaccines. (PCV7,PCV10, PCV13 - serotypes 4,6B, 9V, 14, 18C, 19F, 23F, 1, 5, 7F, 3, 6A, 19A) - Pneumococcal polysaccharide protein D-conjugate vaccine (Synflorix; PHiDCV).2. Vaccination-Pentavalent vaccine. e.g.DTPw-HepB-Hib (Quinvaxem) - Hexavalent vaccine e.g. DTPa-HBV-IPV-Hib (Infanrix hexa) - These vaccines are compatible with measles vaccine and induce adequate immunological memory and persistent antibody production against Hib

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ADEQUATE ANTIBODY RESPONSES OF COMPONENT ANTIGENS

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PNEUMONIA BURDEN IN NIGERIA

Pneumonia reduction is part of MDG 4 targets1. Childhood deaths 200,000 under 5 years per year2. Vulnerable –elderly -Sickle Cell disease -diabetes patients -chronic liver disease patients - Nephrotic syndrome patients - Measles patients - HIV patients 3. Multiple resistance to antibiotics.4. Killer organisms. -Streptococcus pneumonia -Haemophilus influenza -Pneumocystis carinae

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TUBERCULOSIS: NATIONAL TUBERCULOSIS CONTROL TREND 2002 - 2011

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TREND OF TB/HIV KEY INDICATORS (2007 – 2011)

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TREND OF ANNUAL NEW CASES OF LEPROSY DETECTED

(1999 – 2011)

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NEW TB VACCINES

TB KILLS 1.4MILLION PER YEARBCG Protection short lived not adequately protective in children especially in developing countries.BCG not protective of latent Tb which occurs in ½ of

persons.

3. Recent trial in South Africa of new Tb vaccine MVA85A

against protective antigens of TB bacteria Ag85A (Prof Helen McShare, Oxford):Immune response provoked in adults; 4. 2797 healthy infants aged 4 – 6 months vaccinated

with BCG and then a cohort

with

MVA85A.

O

nly 17%

effects at preventing TB. LANCET Feb 2013 5. More candidate vaccines in progress.

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BACTERIA – SALMONELLA ,VIBRIO CHOLERA

1. NIGERIA–ENDEMIC FOR SALMONELLOSIS in man, chickens, domestic animals. Can Vivotif ( Typhoid live oral Ty21a) and others control Salmonellosis in Nigeria vis vis the various serotypes in Nigeria 2. SEROTYPE VARIATION IN VIBRIO CHOLERAE EL TOR

DIARRHOEA IN NORTHERN NIGERIA.

Onyemelukwe GC, Lawande RV

. Central African Journal of Medicine 1991: 37(6): 186 - 187 Serotyping of Vibrio cholerae organisms causing epidemics in Zaria and environs since 1975 to 1986 shows that Hikojima

serotype was prevalent from 1976-1978, but

Ogawa

became

prevalent from 1984 till 1986

. The internal and external pressures responsible for these selections are unclear. 3. CHOLERA – ORAL DUKORAL VACCINE (FORMALIN KILLED WHOLE CELL PLUS RECOMBINANT TOXIN B UNIT) OR SHANCOL VACCINE(NOT CONTAINING SUBUNIT TOXIN B) CONTROL CHOLERA?

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AEFI( ADVERSE EVENTS FOLLOWING IMMUNIZATION) – YET TO BE FULLY ESTABLISHED IN NIGERIA AS AT 2013 (AEFI COMMITTEE IN PLACE 2011)

FIVE GROUPS OF AEFI (IMPORTANT ROLES OF NAFDAC AND NPHCDA)1. VACCINE PRODUCT – RELATED REACTION – by inherent properties of product – limb swelling after DTP2. VACCINE QUALITY – RELATED REACTION eg failure of manufacturer to inactivate a lot of inactivated polio vaccine

3. IMMUNIZATION ERROR – RELATED REACTION

inappropriate vaccine handling, prescribing or administration which is preventable .

e.g

Transmission of infection by contaminated multidose vial.4. IMMUNIZATION ANXIETY – RELATED REACTION. Anxiety .e.g vasovagal syncope

5. COINCIDENTAL EVENT

e.g. fever occurs

at time of vaccination due to another infection (TEMPORAL ASSOCIATION) effect national health problem.

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2012

2013GEOGRAPHICAL

POLIO

1,3

1

3cVDPV5744138

26

26

0

9

15 northern states and FCT

LASSA FEVER

Cases

Death10589889226Edo state and 10 statesCHOLERACasesDeaths3064333Kwara, Kaduna , Zamfara

CSM

Cases

Deaths

916

58

750

30

26

Endemic

states

MEASLES

Cases

Deaths

7225

102

45,927

272

26

states

– 36 states and FCT

URTI

N/A

N/A

269

N/A

ACUTE WATERY

DIARRHOEA

Diarrhoea with blood

N/A

N/A

495

323

*ROTAVIRUS

Not

available

*YELLOW FEVER not available

NIGERIAN CENTER FOR DISEASES CONTROL (NCDC) CUMMULATIVE DATA

COMPARATIVE

JUNE 2012- JUNE 2013

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DISEASES

201220112010

CSM

1,206

1,167

4,983 MEASLES

11,061

10,715

2,563

YELLOW FEVER

250

387

570

LASSA FEVER 1,723 1,246 - PERTUSSIS 11,628 10,023 -

TETANUS

112

113

199

POLIO - WPV

122

62

21

cVDPV

8

35

27

NIGERIAN NATIONAL YEARLY DATA – 2010 - 2012 (SOURCE WHO)

INFECTIONS FACT SHEET

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Immunization schedule for children U 1year and WCBA

12/07/201357Women of child bearing age(WCBA Imm. schedule

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USA 2012 IMMUNIZATION SCHEDULE 0 – 6 YEARS

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Cumulative RI coverage for all antigens 2005-2012 IN NIGERIA

SOURCE ;NATIONAL PRIMARY HEALTH CARE DEVELOPMENT 2013

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Vaccine

TIMELINESS OF RECEIPT OF IMMUNIZATIONToo earlyOn timeAcceptably earlyDelayed

No.

%

No.

%No.%No.%OPV1

30

6.7

232

51.7

49

10.9

138

30.7DPT1378.128361.55311.68718.9HepB2122.89421.84510.428165.0OPV216

3.8

175

43.8

69

16.0

146

36.4

DPT2

24

5.8

215

51.8

69

16.6

107

25.8

OPV3

12

3.9

118

38.7

68

19.0

117

38.4

DPT3

16

4.5

166

46.7

71

19.9

103

28.9

HepB3

18

5.5

61

18.7

39

12.0

208

63.8

TIMELINESS AND COMPLETION RATE OF IMMUNIZATION AMONG NIGERIAN CHILDREN ATTENDING A CLINIC-BASED IMMUNIZATION SERVICE.

Ayebo E.

Sadoh

and Charles O.

Eregie

. J. Health

Popul

Nutr

. 2009;27(3):374-385

Timeliness of receipt of vaccines among 512 children attending a clinic-based immunization service. Commencement at age above 28days associated with non-completion

. VACCINATION CARDS OFTEN LOST

OR NOT AVAILABLE/RETRIEVABLE.

Slide61

NIGERIA IMMUNIZATION COVERAGE IS LOW NEEDS TO BE UP TO 90% AND ABOVE

Slide62

UNDER FIVE CHILD DEATH,

1 IN USA = 1744 IN NIGERIA

Slide63

USA HAS ADDITIONAL VACCINES

ROTAVIRUSPNEUMOCOCCIINFLUENZAHEPATITIS AMUMPSRUBELLA(MMR)MENINGOCOCCAL IN ROUTINE IMMUNIZATION SCHEDULE WHICH NIGERIA DOES NOT HAVE

BUT NO BCG IN USA

Slide64

ROUTINE

SUPPLEMENTAL MASS IMMUNIZATIONBCG and other routine vaccinesPolio supplemental Sub-national, MOPV, TOPV, BOPV

2. Cerebrospinal immunization

Oct 2011 – 5 states Jan 2012 – 5 states Nov 2013 – 8 states 22.29 million (1 – 29 years) With MENAFRIVAC – TYPE A3. Measles – All states in 2 phases Phase 1 – 19 northern states. 15.9 million – Oct 2013

Phase

2 – southern states

13.69

million – Oct – 1 week

after

NATIONAL STRATEGIC

RESPONSE BY NPHCDA WITH STATES AND LGAs

Slide65

4. Yellow fever

Nov – Dec 2013Akwa Ibom, Cross river, Nassarawa5. Neonatal Tetanus Elimination Initiative39 high risk LGAS Risk analysisi. 130 LGA’s (SE Zone) (SW zone)ii. 95 LGAs (S-S zone) (NC zone)iii. 166 LGAs North East zone

Slide66

IMPEDIMENTS TO USE OF VACCINES

IN NIGERIA1. SUPPLY DEMAND BARRIERS Supply inadequate for the large population vis – vis other GAVI supplied African countries.

Funding constraints

Logistical challenges

Lack of leadership to prioritize Inadequate finance to expand to other antigen, other ages(young women) and geriatric population.2. ACCEPTABILITY

Mother education, Cultural barrier by Fathers, Social

religious barrier, use of social networks by gatekeepers.

Religious resistance = Missed children

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3. IMMUNOGENICITY ISSUES

Vaccine potency and cold chain ineffectivenessImmunodeficiency of vaccine failed vaccinesNon – vaccine type shifts appearance – pneumococci, CVDPV, Non Typable Haemophilus influenza.4. WEAK HEALTH SYSTEM AND SERVICE DELIVERIESHuman resources, Accurate information.

5. SURVEILLANCE, MONITORING AND EVALUATION INADEQUATE

– ( LONG TERM FOCUS

ON SAFE WATER AND SANITATION)

Slide68

FINANCE AND VACCINE SECURITY

LOGISTICS, TRANSPORT, COLD CHAINGOVERNANCE Professionals keeping distance from immunisation

Slide69

WAY FORWARD

1. OSHOGBO DECLARATION: WEST AFRICAN COLLEGE OF PHYSICIANS INVOLVEMENT IN VACCINE SUCCESS, ADVOCACY WITH COPERATION WITH VETERINARY PRACTITIONERS TO CURB ZOONOSES.2. CREATE A NIGERIAN NUCLEUS TEAM OF VACCINE TECHNOLOGISTS

–

Vaccinologists

in training linked with established World centers.3. INNOVATIVE PRIVATE PUBLIC PARTERSHIP – FEDERAL GOVERNMENT, STATE, LOCAL GOVERNMENT,NPHCDA, WEST AFRICAN COLLEGE OF PHYSICIANS/ PAEDIATRIC ASSOCIATION OF NIGERIA.4.

GATE

KEEPERS NETWORKERS –

Gastroenterologists get, update and keep

Nigerian

surveillance data on infections through gut. Same with respiratory,

neurology etc specialists.5. PRESCHOOL ADMISSION WITH COMPLETE CERTIFICATE OF IMMUNIZATION - KINDERGATEN, PRIMARY, SECONDARY,TERTIARY.5. MAINTAIN VACCINE SECURITY – Industries, Manufacturers, UNICEF, Accurate and long term forecasts, affordable vaccines, logistics, cold chain maintenance6. Breast feeding exclusive policy7. In view of emergence of polio vaccine associated paralysis ( VAPP) as well as circulating derived poliovirus (cVDPV), nation to decide when and where to introduce IPV (Inactivated polio vaccine) alone or as part of hexavalent/ pentavalent or intercalation of OPV at birth with subsequent IPV.

8

. Vaccination of preterm babies with BCG.

9

. Surveillance epidemiology for disease patterns

Serotypes –

Meningococci

A,C, W135;

Vibrio

el

tor,

Pneumococci

, Salmonella

serotypes vaccination

Slide70

10

. VACCINE ACCEPTABILITY AND ACCOUNTABILITYSocial marketing expansionEducation of mothers and recipients11. ELIMINATION OF MALNUTRITION (under 5) affects vaccine performance.12.

MICRONUTRIENT DEFICIENCY

ELIMINATION

Vitamin D induces Tumor suppressor gene (

Goubart et al)Vitamin D induces Innate cells and immune cells to secrete Cathelicidin peptides and improves anti TB response

Vitamin D and Vitamin A induce expression of p21 (

cyclicin

dependent

Kinase

inhibitor p21.)

Organoselenium

in garlic and

brocolli Aqueate.13. MEASLES study mechanism of measles RNA editing by which it increases number of aggressive proteins, its RNA genome occurs for more virulence. Studies on strategies of evasion by HIV and other organisms.14. NEW VACCINE DEVELOPMENT – Vaccine TB Vaccine grand challenge.TB vaccine acceleration program .Study of Latent TB granulomaHSP vaccine development, more coverage, low cost.Malaria, HIV, Parasites etc.Serology surveys and data on vaccines for seroconversions national data.Serotype replacement after vaccination by non – vaccine serotypes: Pneumococci H.Influenzae Neglected diseases INTO view in urban and rural areas.

Slide71

15.

BEFORE TRAVEL – PILGRIMAGE.Yellow fever vaccinationMeningococcal vaccination A,C, W135 Cholera vaccination IPV vaccination for Muslim and Christian pilgrimages

16.

GERIATRIC POPULATION, SICKLE CELL AND OTHER VULNERABLE POPULATION

VACCINATION PROGRAM17. MATERNAL TETANUS VACCINATION AND EXPANSION OF MMR in women18. PREVENT PRENATAL MATERNAL INFECTION WITH PARASITES - TO AVOID FOETAL IMMUNE PROGRAMMING AND POOR BCG RESPONSE.

19.I

N COUNTRY MANUFACTURE OF VACCINES

MONO

CLONAL ANTIBODIES.

20.

ENVIRONMENT

Improved housing

NutritionWaterSanitationEnvironmental Tobacco smoke prevention21. AEFI – Adverse events following immunization monitoring and evaluation in Nigeria22. ADJUVANT Research : eg Adjuvant to promote TH1/ TH7 for BCG better response and other infections requiring cell mediated immunity response.23. EXPANSION OF CANCER TREATMENTS AND NONCOMMUNICABLE DISEASES

Slide72

MAGIC BULLET VACCINE – OMNIVALENT, OMNIPOTENT WITH ALL ANTIGENS –

1 OR 2 SHOTS!!!!I HAVE IT