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Invasive pneumococcal disease (IPD) surveillance in the South-

East Asia Region : Successes and challenges

Dr. Pushpa Ranjan Wijesinghe Medical Officer ( Emerging Vaccine Preventable Disease

Surveillance)Immunization and Vaccine Development (IVD)

WHO - SEARO

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WHO supported Invasive Bacterial Vaccine Preventable Disease surveillance network in SEAR

Source: IVD/SEARO

Independent County sites/networks

??

33

1. Decisions were made and plans are underway for introduction of Pneumococcal conjugated vaccine (PCV) in the SEARa. Bangladesh : 2014b. Nepal: 2014 c. Myanmar : 2016

2. Usefulness of locally/regionally/globally generated evidence at the National Technical Advisory Group of Immunization (NTAGI) for decision makinga. Bangladesh : Introduction and selecting PCV10 over PCV 13b. Nepal: Introduction and selecting PCV10 over PCV 13c. Sri Lanka : based on available evidence, decision to introduce was

deferred in 2010 considering other public health priorities d. Myanmar : No surveillance mechanism; Regional and global

evidence use for decision making

Successes : vaccine introduction

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Successes: Generating evidence from sentinel surveillance data

a. Bangladesh : Annual incidence risk of invasive pneumococcal disease

– 447 per 100000 under five (unadjusted )– 3058 per 100000 under five (adjusted for low sensitivity of cultures)

Conservative estimates of the impact of the PCV 10

b. Sri Lanka : Annual incidence risk of invasive pneumococcal disease

– 40.9 (95% CI- 29.4-54.5 ) per 100000 under five (unadjusted)– 204.3(95% CI - 177.9-233.3 ) per 100000 under five (adjusted for low

sensitivity of cultures) Estimates of direct medical cost for different outcomes Estimates of cases, DALYs and medical cost prevented by

immunizing with PCV 7. Estimates of cost-effectiveness and incremental cost effectiveness

ratio of PCV-7 introduction

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Transparent decision making processes through NTAGIs:Bangladesh/Nepal Reviewing surveillance data for introduction

Myanmar Reviewing global and regional evidence forintroduction

Sri Lanka Reviewing surveillance data for priority setting

India Demanding solid, representative evidence base

Country owned /financed networks of surveillance:

India 11 sentinel sites( five to be added)

Bhutan 3 regional sites , 1 district site, Reference lab in Bangkok

Bangladesh Acute-Meningo-Encephalitis (AMES) network

Success: Contribution of IPD surveillance to health system strengthening

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Successes: Contribution of IPD surveillance to health system strengthening

a. Establishing impact assessment mechanisms Bangladesh:

– using the sentinel sites in urban, Dhaka – Using the population based surveillance in rural , Mirzapur

Nepal:– Monitoring dynamics of multiple pneumococcal serotype

carriage change following vaccine introduction b. Feasibility assessment of integrated surveillance

India and Bangladesh :– Expansion of Acute Meningo-encephalitis surveillance(AMES)

to the existing polio and measles surveillance networks c. Changes in antibiotic prescription policy

Sri Lanka :– Based on Antibiotic sensitivity data generated in

pneumococcal surveillance

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Challenges : Sustainability of the WHO supported network

a. Current dependence of surveillance sites on external funding

b. Ensuring full ownership of the national governments

c. Forging new alliances and partnerships for supplementation by countries

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Challenges: Integration to the existing VPD surveillance networks

a. Complexity of pneumococcal surveillance from measles or Acute Flaccid Paralysis surveillance

b. Using the well established regional polio and measles network

c. Learning lessons from successful stories d. Development of best practices for

reference

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Challenges: Sustaining surveillance in the post-introduction period

a. Sustainability for impact assessmentincluding sero-type replacement

b. A paradigm shift to post-introductionsurveillance objective

c. Supporting planned impact assessments inpost-introductory settings Bangladesh Nepal :

d. Establishing sero-type epidemiology inpost-introductory settings

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Challenges: Increasing the yield, improving quality and maximum use of data

a. Adopting high sensitive diagnostic methodsb. Using the reference laboratory for better yield

Difficulties with material transfer across borders Budgetary limitations

c. Where feasible establishment of PCR facility and capacity development

d. Standardization of surveillance practice , laboratory diagnosis and data management

e. Maximizing use of existing evidence for decision making

Meningitis/Pneumonia/Sepsis surveillance 2009-2012

Country # enrolled Suspectedbacterial

meningitis (%)

SPn(%)

# enrolled sepsis &

Pneumonia

SPn(%)

Bangladesh 11423 1531(13)

269(18)

48085 97(0.2)

Nepal - Kanti 209 198(95%)

6(3)

2615 3(0.1)

Nepal-Patan 862 84(9.7)

6(7)

2791 23(0.8)

Sri Lanka 506 140(28)

2(1.4)

1699 26(1.5)

Coverage of detected serotypes by PCV types 2009-2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nepal Sri Lanka Bangladesh

OthersPCV13PCV10PCV7

N=35 N=57N=22

Improvement of yield of IPD (1994 to 2012) in Bangladesh with Gradual Addition of Improved Diagnostics (N=1,167)

2754

33 4129 33

13 22 2816

28 30 29 3547

30 28 32 2487

1212

19 13 26 22

30

23 32 1513

3

32

66

77

25 2266

39

12

1

3

3 4

2

1

0

20

40

60

80

100

120

140

160

180 PCR ICT Latex Culture

LATEX

ICT

PCR

Saha et al J Clin Microbiol 1993, 1997, 1999; 2003; Saha et al Clin Infect Dis, 2009, Saha et al PLoS One 2008, Arifeen et al Clin Infect Dis 2009; Saha et al PLoS One 2012

Slide courtesy : Professor Samir K Saha

Unit cost (GAVI) per an enrolled suspected IBVPD case ( US $), 2009-2012

Country Unit cost per an enrolled IBD case ( US$)

2009 2010 2011 2012

Bangladesh 20.4 12.1 19.2 21.4

Nepal (Patan) 70.9 26.6 71.7 159.8

Sri Lanka 49.6 35.6 63.4 144.7

Nepal (Kanti) 19.9 36.6 Surveillance discontinued

USD

Need for higher technical efficiencyIn resource use

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Challenges : Supporting networks beyond the WHO support

1. Providing technical support to sentinel sites/laboratories beyond the WHO network

2. Standardization of surveillance , laboratory diagnosis and data management in sites beyond the WHO network

3. Reporting data from other networks to the WHO a. for regional and global decision making

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Conclusion1. At the beginning, lack of epidemiological and

economic evidence for priority setting and decision making in SEAR

2. Establishment of sentinel surveillance in the SEAR3. Vaccine introduction decision making using local,

regional and global evidence4. Usefulness of generated evidence, despite the

limited scope of sentinel surveillance5. Potential higher performance and usefulness of the

network with more enthusiastic national interests

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Thank you

Is the risk of abandoning the network Without being integrated into existing

in-country surveillance networks worth taking

after years of hard work ?