Undersecretary of Prevention and Health Promotion

Advantages of Vaccination in the Americas “Mexican Vaccination Model” Pablo Kuri Morales M.D. February, 2016

Vaccination history Presidential Decree for vaccination against smallpox

Dr. Francisco Balmis Mexico introduces smallpox vaccination 1804

1908

Combined Diphtheria and Pertussis Vaccine 1926

1948

Creation of the National Institute of Bacteriology in infectious diseases and vaccines

1951

Last case of Polio Oral Polio vaccination begins

1962

BCG vaccination begins

Last case of smallpox in Mexico

1970

CONAVA and Universal Vaccination Program creation

National Immunization Program: 5 vaccines 7 diseases

1973

Measles vaccination begins

National Immunization Record (Cartilla de vacunación)

1979

1980

1986

Intensive Workshops, National Days and National Immunization Week

1990

1991

Last case of Diphtheria

Universal Vaccination

Vaccination history Congenital Rubella Syndrome Elimination

Neonatal Tetanus Elimination

VPH vaccination begins

Evolution of scheme 2 new Immunogens

1991

1993

National Health Weeks

Pneumococcal Vaccine Introduction 1996

1997

2003

2006

2008

VPH Vaccine Universalization

2009

Evolution of scheme 5 new Immunogens

2010

AH1N1 Influenza Vaccine

Rubella Elimination

Pneumococcal Vaccine Universalization

2012

2016

Possible introduction of Dengue Vaccine

Milestones

Vaccination Universal Program The Universal Vaccination Program is a public policy to reduce preventable vaccine diseases, the goal is to aim specific protection to the population. This will allows us to control, eliminated or eradicated diseases through the universal and free vaccination schedule. The beneficiaries of this policy are children, adolescents, elderly and vulnerable groups of all the country. Mexican Government through all it’s health institutions invests more than 6 mmdp (328 million of dollars*) in this program.

Characteristics Public Good *1 dollar = 18.20 Mexican peso

Universal

Free

Goals The national and international commitments of the Universal Vaccinate Program are: Achieve and maintain the vaccination coverage on 90% with the basic Vaccinate Schedule on children under one year, four and six years. Achieve and maintain the coverage vaccination on 95% for each biologic. Maintain the Poliomyelitis eradication and Measles, Rubella, Congenital Rubella Syndrome and neonatal tetanus elimination. Keep epidemiological control of Diphtheria, whooping cough, meningeal and miliary Tuberculosis, Rotavirus diarrhea, invasive pneumococcal infection, influenza and human papilloma virus. Detection, reporting and timely study of events supposedly associated to vaccinate immunization (ESAVI) .

National immunization schedule 2012-2016 - 14 vaccines / 14 diseases 2004 -- 6 diseases 1999 10 diseases 2007 11 diseases 1973 1998 8 diseases 2011 13 diseases BCG (Tuberculosis)

BCG(Tuberculosis) (Tuberculosis) BCG Hepatitis B Polio (Sabin) Polio (Sabin) DPT + Hib + Polio (Diphtheria, Pertussis y Tetanus, DPT (Diphtheria, (Diphtheria, Pertussis Pertussis y Tetanus) y Tetanus) DPT Haemophilus influenzae b and Polio) SRP (Measles, (Measles, Rubella Rubella and Mumps) and Mumps) Measles SRP Rotavirus DPT + Hib +Polio + HepB whole cell vaccine (Diphtheria, + Polio(Diphtheria, (Diphtheria, Pertussis y Tetanus, DPT + Hib Pertussis y Tetanus, Pneumococcal Pertussis y Tetanus, Haemophilus Haemophilus influenzae b and Polio) b and Polio) influenzae b and Haemophilus influenzae MRM (Measles, Rubella and Mumps) Hepatitis B) Influenza Influenza DPT (Diphtheria, Pertussis y Tetanus) Influenza Hepatitis B Hepatitis B Influenza Hepatitis B Rotavirus Polio (Sabin) Pneumococcal VPH (Human papillomavirus) MR (Measles and Rubella) Pneumococcal Adult Td (Tetanus and Diphtheria) Tdpa acelular (Tetanus and Diphtheria)

Vaccination Coverage Mexico Vaccines BCG Hepatitis B DPT + HiB + Polio Rotavirus Pneumococcal Complete Schedule < 1 year Measles/mumps/rubella 1 year DPT + HiB + Polio (18 months) Pneumococcal Complete Schedule 1 year Diphtheria, tetanus, & pertussis DPT 4 years Measles/mumps/rubella 6 years Human Papilloma virus vaccine Seasonal Influenza Information Source: Subsystem of services benefit (SIS)

Coverage 2013 91.3 79.1 82.6 81.4 84.5

Coverage 2014 95.6 84.6 89.9 84.6 89.8

88.7 62.5 84

97.8 89.4 93.6

83.8

88.9

85.3

91.8

99 79 90 98.7

97.9 96.4 91 99

Vaccine Program Impact Thanks to coverages of the Universal National Vaccination Program and the National Health Weeks:

Eradicated Smallpox - 1951 Poliomyelitis - 1990

Eliminate Measles- 1996 Rubella - 2008 Congenital Rubella Syndrome - 2010 Neonatal Tetanus - 1994 minus one case for each 1000 live births for municipality

Under Control: Tetanus Meningeal tuberculosis Pertussis Invading diseases for Haemophilus influenzae b (Meningitis, pneumonia and septic arthritis) Rotavirus diarrhea and mumps Diphtheria (last case in 1991)

Protection against: Influenza Human Papilloma virus Hepatitis B

Impact on reducing the mortality rate of children under 1 year PVU Campaign against measles Clean Water Program

National Vaccination Days

Oral Hydration

60 51.0

45

48.5

45.9

44.3

National Vaccination Week

42.0 41.2

39.7

15

0

38.5 38.5

(Seguro Medico Nueva Generación)

DPT + Hib + Hep B

Rotavirus Universalization

Even Start in life

National Vaccination Week MRM

36.3

30

Medical Insurance for a New Generation

Introduction of Rotavirus And 7Pneumococcal

Influenza Vaccine

PCV-7 Universalization

32.5 31.1 29.7 28.4 27.2 26.0 Every Children, 24.9 23.8 Seguro 22.8 21.8 Every Cancer Popular 20.8 20.0 19.1 18.3 17.6 16.9 16.3 15.7 15.1 14.6 14.1 13.7 13.2 12.9

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Mortality rate: General Direction of Information System in Health “Methodology for adjust new born and child mortality in < 5 years for indicators use.

Immunization Record (cartilla de vacunación) By Presidential Decree since 1979, it is mandatory that children under 6 years old have this immunization record were basic vaccines included in the Vaccination National Program were registred. This immunization record was issue by the Civil Registry.

From 1979 to 1990, the National System for the Integral Development of the Family (DIF) was in charged for the administration operation of this vaccine record.

Immunization Record (cartilla de vacunación) 38 years of successful experienced Mandatory official document since 1979 by Presidential Decree. Applied vaccines, and other health actions like length and weight in children and adolescents. This record is for free in all the National Health System facilities. Allows the following of the vaccination schedule in all age groups. Official document for national and international process. This document has allow to validate the inmmunization coverage by rapid surveys and validate the records by the information system.

From Immunization record to National Health Card 2008 Immunization record (Cartilla de vacunación) Population < 5 years old

Policy continuity of a social right. It’s used in all the healthcare facilities of the National Health System.

National Health Card All ages

National Council of Vaccination (CONAVA) In 1991 the National Health Council was created, this council is responsible for the public policy in vaccination and publish to all the National Health System. Members: National Health System leaders Academy and collegiate member National Health Institutes States Health departments Civil Society

National Health Weeks Since 1980 Mexico has been delivering health promotion and prevention actions to the population like: Intensive Workshops National Health Days National Immunization Week National Health Weeks (1993) These weeks aims to bring health actions to the population Vaccine Preventable Diseases Distribution of oral hydration Diarrheas and acute respiratory infections prevention and Nutritional supplements

Vaccine introduction and Implementation Policy Criteria for deciding on the introduction of new vaccines

PLAN FOR INTRODUCING THE VACCINE Vaccine program development Goals and technical justification

Technical and politics aspects

Programmatic and feasibility aspects

Impact Assessment

Scope and beneficiares Introduction strategy Plan costs and activities schedule Evaluation

Coverages

Epidemiologic surveillance Reduction burden of disease

Vaccine Introduction Phases 1. Review of technical and politics aspects for priority definitions a) Burden of diseases, incidence, prevalence, disability, hospitalizations, mortality b) Efficacy, quality and safety vaccines c) Other interventions d) Financial and economics criteria's i. Budget analysis impact ii. Budget analysis cost benefit and cost effectiveness 2. Programmatic aspects a) Vaccine formulation b) Cold chain capacity c) Vaccination, supervision, training and follow up inputs

Interinstitutional work group

Inclusion Groups of experts from the National Council of Immunization National Council of Immunization

Universal Vaccination Program Process CONAVA Operational Research

COEVAs Interinstitution al Work Group

Group of experts Surveillance of ESAVI and EPV

Universal Vaccination Program

National Health Weeks

Population Distribution

Supervision

Permanent Program

Training Cold Chain

Information System

Dengue vaccine, implementation process Vaccine Sanitary Registration

Security COFEPRIS

Efficacy Quality

Two clearly differentiated processes Vaccine Public Policy Where are we now?

NHS CONAVA Dengue Expert Group

Cost / Benefit Cost / Effectiveness

Dengue vaccine, implementation process On December 9th, 2015, Mexico was the first country of the world to obtained the sanitary registration to the dengue vaccine. World Health Organization (WHO) recognized the Federal Commission for Protection against Health Risks (COFEPRIS) as Functional Regulatory Agency for the 2014-2017 period. Mexico is for the first time part of a select group of 28 countries with an agency capable of manufacturing, distributing, reviewing and commercializing vaccines worldwide.

Challenges Keep high vaccination coverage in all municipalities. Fortify the cold chain net. Implement of the Electronic Immunization Record. Implement of the Web Vaccination Supplies Stock Management Sistem (wVSSM)

Conclusions Mexico has one of the most complete vaccination schedule of the world, this schedule is free and universal. Mexico has been working since 1804 in vaccination and has a strong commitment with the population health, vaccination is a priority on the National Health Agenda. Although we don’t have a strong anti vaccination movement we are always expectant. Vaccination is an essential component of every health system, and is responsibility of people, community and governments. Vaccines and immunization are essential investment for the future of the country and even the world. Mexico is one of the countries to promote the global initiative in favor of vaccines.

One time event Pope Francis vaccinated against polio in his recent visit to Mexico

Undersecretary of Prevention and Health Promotion

Advantages of Vaccination in the Americas “Mexican Vaccination Model” Pablo Kuri Morales M.D. February, 2016