Introduction
Immunization is considered as one of the greatest public health achievements of human history and most cost effective public health intervention. Everyyear, vaccines prevent more than 2.5 million child deaths globally1.Vaccines used in national immunization programs (NIPs) are safe and effective and help to prevent common vaccine preventable diseases (VPDs)2. Public awareness in benefit of vaccination and trust in vaccine safety is vital to implement vaccination programs successfully. It is extremely important for medical professionals to know the update of global, regional and national immunization programs so that they can promote for childrento get timely necessary immunizations, which is their right and vital for their survival and fitness.
Success history of vaccine development
Dr. Edward Jenner, a British physician,successfully introduced the modern concept of vaccination in 1796and much development has occurred in vaccines and immunization. In 1979, the World Health Assembly officially declared the eradication of smallpox andit was regarded as one of the greatest public health achievements in history.
In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created to help the poorest countriesin introducing new and under-used life-saving vaccines into their national programs.
Global Vaccine Action Plan 2011-2020
The Global Vaccine Action Plan (GVAP) is a framework approved by the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. GVAP contains five goals and five targets to achieve by the year 2020.3
These targets were assessed annually by Strategic Advisory Group of Experts (SAGE). Although there were progresses in some areas, the group had a serious concerns regarding the rate of progress, during their mid-term review. 4.5.
South East Asia Regional Vaccine Action Plan 2016-2020( SEAR-VAP)
Myanmar is one of the eleven member countries of WHO South East Asia region (WHO-SEAR). WHO-SEAR office also endorsed regional vaccine action plan 2016-2020 (SEAR-VAP) in line with the GVAP. The goals were modified according to the needs of the region. The SEAR-VAP proposes eight goals :
- Routine immunization systems and services are strengthened
- Measles is eliminated and rubella/CRS ( Congenital Rubella Syndrome ) controlled
- Polio-free status is maintained
- Elimination of maternal and neonatal tetanus is sustained
- Control of Japanese encephalitis is accelerated
- Control of hepatitis B is accelerated
- Introduction of new vaccines and related technologies is accelerated
- Access to high quality vaccines is ensured6
Every year, the Immunization Technical Advisory Group (ITAG ) reviews the challenges and achievements of member countries and make recommendations for the coming year.
Routine immunization systems and services are strengthened
Based on the provisional WHO/UNICEF2017 country estimates, the coverage of DPT3 in the Region waslikely to remain at 88% in 2017. About 4.4 million of children in SEA Region did not receive DPT3 and 3.1 million of them were in India and 1 million were in Indonesia. As per the provisional WHO/UNICEF estimate, eight out of eleven countries, including Myanmar had achieved the target of more than 90 % national coverage of DPT3 in 2017. Another regional target is toachieve more than 80% DPT3 coverage in all districts of the country and Myanmar has not achieved this aim;only 88 % of the districts achieved this aim.7There are three hard to reach areas in Myanmar: geographically hard to reach areas such as Naga Lands; socially hard to reach areas like urban slums and mobile population and politically hard to reach areas like areas of arm conflicts. In 2017, 100,401 children were not vaccinated with the 3rd dose of DPT and 187,563 children were not vaccinated against 2nd dose of MR. The NIP has tried to solve this problem by many different ways including crash program, using additional immunizers and expansion of fixed-post immunization services in urban health centers and hospital-based immunization services in 98 hundred-bedded hospitals thorough out the country.8
Medical professionals, especially primary care physicians, can contribute by counseling the benefits of vaccinations, educate the public about the immunization schedules andindicate how and where to get immunizations.
Myanmar reported 68 suspected diphtheria cases and 1,293 measles cases during 2017.8The medical professionals should quickly report to public health authorities whenever they encounter a case of VPD, to take necessary preventive measures and for disease surveillance purposes.
Measles is eliminated and rubella/CRS controlled
The Region had observed a significant reduction in the incidence of reported measles cases and a 73% reduction in measles deaths during the period 2000 to 2016.9
Myanmar national immunization schedule include Measles containing vaccines (MCV) at 9 months and 18 months of age. Myanmar is currently given Measles Rubella vaccine (MR) at both ages. The possible presence of maternal immunity efficacy of measles vaccine given at 9 months has only 85 % efficacy. So it is important to receive both doses of MCV. The reported national coverage of MR1 and MR2 during 2017 was 83% and 80 % respectively, which were still far below the targeted coverage of >95 %. The low coverage is partly due to temporary suspension of MCV1 and MCV2 immunization during November and December 2017, during the mass Japanese Encephalitis (JE) immunization campaign.8 Medical professionals should advise their patients to complete the 2 doses of MR vaccines.
WHO-SEAR–ITAG (Immunization Technical Advisory Group) had advised to conduct supplementary immunization activities ( SIA ) to close immunity gap in Myanmar.10 Myanmar EPI has planned to conduct nationwide mass MR campaign covering 9 months to 5 years old children in 2019. The support and contribution of medical professionals in various aspects will be valuable in success of this mass campaign.
To certify for measles elimination, countries need to prove that there is no transmission of endogenous measles strain and proper disease surveillance indicators. Fever with maculopapular rash cases should be adequately surveillanced and tested for measles and rubella antibodies. Non-measles, non-rubella discard rate of 2 / 100,000 population is needed for certification. Medical practitioners can help by referring fever with maculo-papular rash cases to public health authorities.
In Myanmar, measles outbreak was reported inLahe township, Naga Self Administrative region in August 2016. Forty six children presented with fever with rashes who were later confirmed as measles by ELISA. The determined genotype was D8 and one new case of D9 was reported in other areas. Outbreak response vaccination was carried out and it was successfully controlled despite many logistic challenges. MR vaccine coverage in Lahetownshipwas only 71 % in the year 2015, the year before epidemic.
Polio-free status is maintained
The Southeast Asia Region was certified polio-free on 27th March 2014, and has remained polio-free up to now. Regional Certification Commission for Poliomyelitis Eradication (RCCPE) commented that wild poliovirus (WPV) importation remained at risk as long as there wasWPV circulation in some parts of the world, namely Afganistan, Parkistan and Nigeria. Countries are also still at risk of an outbreak due to circulating vaccine-derived poliovirus (cVDPV).11
In 2015, Myanmar reported an outbreak due to cVDPV (type 2) in Rakhine state, which was effectively controlled through an aggressive response undertaken by the country’s Ministry of Health and Sports and partners.10
Surveillance of Acute flaccid paralysis (AFP)is important for certification of polio-free status. Myanmar achievedthe non-polio AFP rate of 2.92 /100,000 under 15 population. There was no reported VDPVs in AFP cases in 2017 and 2018 in the whole region.11
Environmental surveillance (ES) has been included in National Plan for poliovirus surveillance since 2017.There are three sites for ES :Sittwe, Maungdaw and Yangon.8
Introduction of inactivated polio vaccine (IPV)
As no type 2 containing OPV has been used in the Region since April 2016, IPV was included in the national routine immunization schedules of all countries in the region. The SAGE strongly recommended using a fractional intradermal dose of inactivated poliovirus vaccine in a two-dose schedule, instead of a single intramuscular full dose12.
In Myanmar, IPV was introduced in 2015 and trivalent oral polio vaccine was replaced with bivalent oral polio vaccine in April 2016. However, because of global IPV shortage, IPV coverage dropped from 75% in 2016 to 12% in 2017.8
Elimination of maternal and neonatal tetanus (MNTE) is sustained
Maternal and neonatal tetanus has now been eliminated throughout the South-East Asia region since May, 2016. Myanmar and India achieved the goal in 2010 and 2016 respectively13.
It is extremely important to sustain this achievement. There are some challenges to maintain MNTE especially in areas with low vaccine coverage, and low antenatal attendance rate. These challenges could be overcome by coordination of programs for maternal and newborn health.Medical professionals should educate the public to get proper antenatal care, clean delivery and importance of vaccinations for pregnant women.Pregnancy vaccination will change from 2 doses of TT to Td in coming years. Routing vaccination of school children with 2 doses of TD (Tetanus and Diphtheria Toxoids) is in the future plan.8
Control of Japanese encephalitis( JE) is accelerated
Currently, 10 out of 11 countries in the SEA Region are endemic for JE except for the Maldives. In 2017, there were 2634 cases of confirmed JE in SEAR. Majority of cases were reported from Myanmar and India with 442 patients and 2045 patients respectively. Vaccination is the most cost-effective measure to prevent and control JE. Currently, 4 out of 11 countries including Myanmar, Nepal, Sri Lanka and Thailand have introduced JE vaccination nationwide while India has introduced immunization against JE in high-risk areas14.
Mass JE catch up immunization campaign for 9 months to 15 years old children was launched in two phases in Myanmar in 2017 before introduction of JE vaccines into National Immunization Schedule from 1StJanurary2018. The first phase was a school-based targeting children between 5 and 15 years of age. The second one was a community-based aiming children 9 months to 5 years and children who were not vaccinated in the first phase. Out of targeted around 14 million children, 92.5 % were successfully vaccinated in this campaign. Fear of some untrue rumors caused vaccine hesitancy and missed opportunities for some children. 8
Medical professionals should encourage the public to take this vaccine at 9 months of age and to get catch-up vaccinations for those who missed the opportunity in mass campaign to prevent this deadly infection.
Control of Hepatitis B is accelerated
In 2015, the prevalence of chronic hepatitis B in the SEAR was estimated around 3-5%. And HBsAg positive rate among Myanmar general population was reported as 6.5 % by DMR. The Global Health Sector Strategy on Viral Hepatitis (GHSSVH) set a 2020 goal of reaching a ≤1% prevalence of Hepatitis B surface antigen among 5 year old children. SEAR developed regional action plan on viral hepatitis control in accordance with the above goal.15
Myanmar has achieved the 89 % of Hepatitis B 3rd dose, just below the regional target of >90 % in 2017. 8
The Global advisory body, SAGE recommends that all infants should receive hepatitis B vaccine at birth, ideally within 24 hours. If this is not feasible, the birth dose can be given up to the time of the next dose of the primary schedule although efficacy is diminished especially after 7 days. The birth dose should be followed by two or three additional doses during infancy15. Although Myanmar has already introduced HepB-Birth dose in facility-based deliveries, only 1 % of newborn babies received HepB-BD within 24 hours. There are some challenges to achieve birth dose due to the high rate of home deliveries by unskilled birth attendants, limited political and financial support and difficulty in monitoring of vaccination in the private sector.8
Medical professionals should encourage for babies to receive birth dose as well as to get routine immunizations. As the HepB vaccine is very heat stable, the primary care physicians can give HepB-BD to newborns delivered in their local clinics.
Introduction of new vaccines and related technologies is accelerated
More new vaccines have become available in the last decade. These vaccines are targeted against diseases with high mortality such as pneumonia, diarrhoea and cervical cancer. Diarrhoea is also one of the leading causes of childhood mobility and mortality. Among eleven countries in SEAR, only six countries have introduced new vaccines in their NIP since 2016.16
Myanmar added two new vaccines, PCV and JE vaccine, in its EPI schedule in 2016 and 2018 respectively. Children in Myanmar are now getting 11 antigens beginning January 2018.There is an ongoing discussion regarding Rota and HPV vaccine to be added in the schedule in 2020. 8
Access to high quality vaccines is ensured
Access to affordable high vaccines is central to the performance of immunization programs. Vaccine development and production capacity in the Region is growing and playing an increasingly positive role both at regional and global levels. Three of the eleven countries of the SEAR, namely India, Indonesia and Thailand are WHO prequalified (PQ) vaccine-producing nations17.
Myanmar is one of the Gavi-eligible countries. Currently, the government is spending 7.6 million USD, which is 24% of total vaccine cost for 1 million birth cohort in 2017. Myanmar is classified as low middle income country and in the preparatory transition period to GAVI graduation, after which the government has to take the whole cost for vaccination. Vaccine cost for 13 antigens and service delivery expenditure are already included in increasing health budget allocation of National Health Plan (NHP) developed by MOHS.8
Vaccine hesitancy and approaches
Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of
vaccination services. It is the main barrier to successful immunization programs. It is very important to address the underlying factors. The interventions should address the specific determinants underlying vaccine hesitancy. Strategies may include engagement of religious or other influential leaders, social mobilization, mass media, improving convenience and access to vaccination, sanctions for non-vaccination, employing reminder and follow-up, communications training for HCWs, and non-financial incentives. 18
It is undeniable that each and every health professional is responsible to help the national immunization program in minimizing or removing the problem of vaccine hesitancy.
Summary
Vaccination is one of the great public health triumphs of human history. Each and every country is trying to improve its immunization program in line with GVAP. New safe, effective and affordable vaccines have become available globally. All health professionals should contribute by educating benefits of immunization, cooperate and collaborate with NIP, give correct information especially concerning adverse events following immunization (AEFI), participate in surveillance activities of vaccine preventable diseases They should be fully aware of current update and challenges of our national immunization program.
References:
- World Health Organization (WHO), United Nations Children’s Fund (UNICEF), World Bank. State of the world’s vaccines and immunization, 3rd ed, Geneva: WHO, 2009.p.4.
- World Health Organization (WHO). “Module 1: Introduction to vaccine safety” In: Vaccine safety basics, Geneva: WHO, 2013.p.11-13.
- World Health Organization (WHO). Global Vaccine Action Plan 2011-2020, Geneva: WHO, 2013.p.5-28.
- World Health Organization (WHO), Strategic Advisory Group of Experts on Immunization (SAGE). 2016 midterm review of the global vaccine action plan, Geneva: WHO, 2016.
- World Health Organization (WHO), Strategic Advisory Group of Experts on Immunization (SAGE). 2017 assessment report of the global vaccine action plan, Geneva: WHO, 2017.
- World Health Organization (WHO), Regional Office for South-East Asia. South-East Asia regional vaccine action plan 2016-2020, New Delhi: WHO, 2016.p.11.
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working Paper on immunization systems and services are strengthened, New Delhi: WHO, 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- National Immunization Technical Advisory Group / National Committee for Immunization Practice. Annual Report on monitoring of implementation of the National Immunization Program, Myanmar: MOHS, 2018.
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working Paper on Measles is eliminated and rubella/CRS controlled, New Delhi India: WHO.2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Regional Office for South-East Asia. South-East Asia Regional Immunization Technical Advisory Group (SEAR-ITAG) Report.New Delhi: WHO, 2017.
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Polio-free status is maintained, New Delhi: WHO, 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Strategic Advisory Group of Experts on Immunization (SAGE). Summary of conclusions and recommendations on vaccine hesitancy, Geneva: WHO, 2015.
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Elimination of maternal and neonatal tetanus is sustained, New Delhi: WHO 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Control of Japanese encephalitis is accelerated, New Delhi: WHO 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Control of hepatitis B is accelerated, New Delhi: WHO 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Introduction of new vaccines and related technologies is accelerated, New Delhi: WHO 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Regional Office for South-East Asia. ITAG Working paper on Access to high quality vaccines is ensured, New Delhi: WHO 2018. Available from: http://www.searo.who.int/immunization/meetings/ITAG/en/ (Assessed 30th July 2018).
- World Health Organization (WHO), Report of the SAGE Working Group on Vaccine Hesitancy. Geneva: WHO 2014.
Authors
Saw Win : Professor/Head (Rtd), Department of Pediatrics, University of Medicine 1, Yangon
: Member, Immunization Technical Advisory Group, WHO SEAR
Aung Khin Thein: Lecturer, Department of Pediatrics, University of Medicine 2, Yangon
