Pneumococcal conjugate vaccine implementation in middle-income countries

Pneumonia Tricarico et al. Pneumonia (2017) 9:6 DOI 10.1186/s41479-017-0030-5 REVIEW Open Access Pneumococcal conjugate vaccine implementation in middle-income countries Serena Tricarico1,2,3†, Hannah C. McNeil1,2,3†, David W. Cleary1,2, Michael G. Head1,2,4, Victor Lim5, Ivan Kok Seng Yap5, Chong Chun Wie5, Cheng Siang Tan6, Mohd Nor Norazmi7, Ismail Aziah7, Eddy Seong Guan Cheah8, Saul N. Faust1,2,9,10, Johanna M.C. Jefferies1,2,9, Paul J. Roderick1, Michael Moore1,2, Ho Ming Yuen1,2, Marie-Louise Newell1,4, Nuala McGrath1,2,11, C. Patrick Doncaster12, Alex R. Kraaijeveld12, Jeremy S. Webb12 and Stuart C. Clarke1,2,3,4,5,13* Abstract Background: Since 2000, the widespread adoption of pneumococcal conjugate vaccines (PCVs) has had a major impact in the prevention of pneumonia. Limited access to international financial support means some middleincome countries (MICs) are trailing in the widespread use of PCVs. We review the status of PCV implementation, and discuss any needs and gaps related to low levels of PCV implementation in MICs, with analysis of possible solutions to strengthen the PCV implementation process in MICs. Main body: We searched PubMed, PubMed Central, Ovid MEDLINE, and SCOPUS databases using search terms related to pneumococcal immunization, governmental health policy or programmes, and MICs. Two authors independently reviewed the full text of the references, which were assessed for eligibility using pre-defined inclusion and exclusion criteria. The search terms identified 1,165 articles and the full texts of 21 were assessed for suitability, with eight articles included in the systematic review. MICs are implementing PCVs at a slower rate than donor-funded low-income countries and wealthier developed countries. A significant difference in the uptake of PCV in lower middle-income countries (LMICs) (71%) and upper middle-income countries (UMICs) (48%) is largely due to an unsuccessful process of “graduation” of MICs from GAVI assistance, an issue that arises as countries cross the income eligibility threshold and are no longer eligible to receive the same levels of financial assistance. A lack of country-specific data on disease burden, a lack of local expertise in economic evaluation, and the cost of PCV were identified as the leading causes of the slow uptake of PCVs in MICs. Potential solutions mentioned in the reviewed papers include the use of vaccine cost-effectiveness analysis and the provision of economic evidence to strengthen decision-making, the evaluation of the burden of disease, and post-introduction surveillance to monitor vaccine impact. Conclusion: The global community needs to recognise the impediments to vaccine introduction into MICs. Improving PCV access could help decrease the incidence of pneumonia and reduce the selection pressure for pneumococcal antimicrobial resistance. Keywords: Immunization, Streptococcus pneumoniae, Pneumonia, Pneumococcal vaccines, Middle-income countries, GAVI, Health policy * Correspondence: ; † Equal contributors 1 Faculty of Medicine, University of Southampton, Southampton, United Kingdom 2 Institute for Life Sciences, University of Southampton, Southampton, United Kingdom Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tricarico et al. Pneumonia (2017) 9:6 Background Pneumonia is the leading infectious cause of mortality among all age groups, especially among children. It accounts for 15% of all deaths of children under five years old worldwide, and killed an estimated 922,000 children in 2015 [1]. Streptococcus pneumoniae is the major cause of morbidity and mortality associated with childhood bacterial pneumonia and is responsible for at least 18% of severe episodes and 33% of pneumonia deaths in children worldwide [1, 2]. It is also responsible for other invasive infections such as meningitis, sepsis and peritonitis, as well as non-invasive diseases including acute otitis media [3] with a severe burden of associated morbidity. Since 2000, the widespread adoption of pneumococcal conjugate vaccines (PCVs) has had a major impact on the prevention of pneumonia. PCVs are projected to prevent 1 million deaths among children worldwide by 2020, and 7 million by 2030 [4]. Two conjugate vaccines are currently available: the 10-valent (PCV10) and the 13-valent (PCV13), conferring protection against ten and 13 of the most prevalent and pathogenic serotypes, respectively [5]. The most recent estimate of serotypes implicated in the global burden of pneumococcal disease in children under five years of age attributed ≥70% of the disease burden to serotypes included in both the PCV10 and PCV13 vaccines [6]. The worldwide recommendation that PCVs be included in national immunization programmes (NIPs) for children aged less than two years was renewed by the World Health Organization (WHO) in 2012, with prioritization of PCV introduction given to countries with high child mortality rates [5]. However, five of the world’s 7 billion people live in middle-income countries (MICs)1 [7, 8], where the majority of vaccine preventable deaths occur [7]. As of 2014, just 31% of the global target population for PCV had been immunized, with only 14 more countries adding PCV to their NIP in 2014, after it was added by 103 countries in 2013 [9]. It is the authors’ contention that in the dynamic and challenging vaccine environment, MICs may be struggling with PCV implementation without the international financial and technical support from which many low-income countries (LICs) benefit [10]. As a consequence, an opportunity to reduce a massive burden of mortality and morbidity is potentially being overlooked. Given the number of countries where infant PCV immunization is still yet to be widely adopted, the authors undertook a systematic review into the status of PCV implementation in MICs. The review identifies potential impediments to PCV uptake and analyses possible solutions to improve PCV uptake in MICs that have yet to include PCVs in their NIP. Page 2 of 15 Methods Search strategy Literature on the implementation of the PCV in MICs was systematically reviewed, with contributions from peer-reviewed journals and institutional websites. The following databases were searched: PubMed, PubMed Central, Ovid MEDLINE 1946, and SCOPUS. The Cochrane Library (the Cochrane Database of Systematic Reviews an (...truncated)