PBM Surveillance Network Overview and Perspectives

1
PBM Surveillance Network Overview and
Perspectives

• netSPEAR Foundation Meeting
• 17-19 November, 2003
• Nairobi, KENYA
• WHO AFRO

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Objectives of AFRO PBM Surveillance

• Demonstrate the burden of Hib and other major
  childhood bacterial meningitis diseases, locally
• Sensitise the public health community and general
  population to the importance of Hib disease and
  use of the vaccine in routine infant immunization
• Measure impact of Hib (and any future) vaccine as
  it is introduced

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High
X-ray pneumonia surveillance
Vaccine trials
Population-based lab surveillance
Complexity, Cost, Rigor, Time
Sentinel site, Lab surveillance
Rapid Assessment Tool
Low
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Achievements between 2001 2003 (I)

• 26 countries trained for PBM sentinel site
  surveillance in June and November 2001
• 24 countries reporting in 2003
• 23 countries participating in External Quality
  Assurance (AFRO-CSR/HQ-Lyons) system for
  laboratories
• Intra-country expansion 2 countries (Uganda and
  Ghana)

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Achievements between 2001 2003 (II)

• Monthly profiles and indicators are posted in
  feedback table (AFRO bulletins)
• AFRO PBM web page posted
• Data manager recruited at AFRO
• 23/26 trained countries are eligible for
  GAVI/GFCV assistance for new vaccines
• 5 countries received Hib vaccine, 2001-2002
• 3 countries approved (2 received) in 2003

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AFRO PBM Surveillance Network Trained
Countries Hib vaccine introduction
Gambia (95) RSA (98) Ghana (01) Kenya
(01) Uganda (02) Rwanda (02) Malawi (02)
2003 Burundi Zambia (Senegal) Applications Benin
Burkina Faso Guinea Togo Zimbabwe
Trained not reporting
Trained, reporting
Hib vaccine introduced Hib vaccine in 2003/4
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AFRO PBM S-network Hib Disease Burden and
Vaccine Impact Estimation

• All 24 functioning PBM sites have cultured Hib
  but..
• Hib demonstrated as leading cause of bacterial
  meningitis at 7/18 PBM sites without Hib vaccine
  intro
• Evidence for Hib vaccine impact demonstrated at 1
  of 5 sites - Malawi

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AFRO PBM Impact Assessment Malawi 2002
Hib vaccine introduction
Industrial action
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AFRO PBM, Hib Vaccine Preliminary Impact
Assessment

• Uganda Jan02, little impact
• (vaccine stock out Jul-Dec03)
• Kenya Dec01, no impact (background of low
  isolation rates)
• Ghana Jan02, no impact (low isolation)
• Rwanda Jan02, no impact (low isolation)
• Malawi Jan02, yes impact (good data)

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AFRO PBM, Hib Vaccine Preliminary Impact
Assessment

• Hib is the leading cause of meningitis at 7/18
  (40) PBM sites Benin, Burkina Faso, Burundi,
  Cameroon, Cote dIvoire, Niger and Namibia.
• 6/24 countries are responsible for nearly 50 of
  all Hib, Pneumococcal and N. meningitidis
  cultures against 20 of CSF cultures with results
  in database
• Burkina Faso, Cameroon, Mali, Malawi, Niger and
  Senegal.
• Only Malawi has introduced vaccine

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Challenges

• Financial sustainability of PBM
• AFRO support to 26 PBM sites spread thin
• Regional Reference Laboratory layer still under
  development
• National support of the referral bacteriology
  laboratories is often inadequate
• Wide variation in quality of PBM site
  surveillance data within the network
• Weak link between PBM site surveillance data and
  national EPI planning (for most countries)
• Only 23/36 VF-eligible countries trained so far

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Some lessons learnt

• Start small and keep things simple
• Selection of sites crucial to success
• Keep data manager well motivated
• Regular (monthly) site meetings vital, especially
  at the beginning
• Plan for adequate support to the laboratories
• Link with EPI managers is critical to local
  ownership and utilization of data

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Strengths Opportunities

• Awareness of Hib as a VPD has been raised - high
  institutional and MOH interest
• Clinical and data/reporting mechanisms are in
  place and performing well
• With experience of first 2 years, we aim to focus
  site support/performance to better meet the needs
  of national plans for new vaccine introduction
• Collaboration/Decentralization netSPEAR East
• Next generation of new vaccines

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Annual Deaths Vaccine-Preventa
ble Diseases WHO Estimates 2001
Vaccines routinely used
Underused vaccines
NEW vaccines
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Pneumococcal Disease
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Pneumococcal vaccine

• Pneumococcal conjugate vaccine (7-valent)
  licensed and introduced in the USA in 2000
• Results so far promising (despite stock outs)
• 9-valent pneumococcal conjugate vaccine trail in
  Soweto, South Africa in children /- HIV
  infection
• Results published Oct 2003 (NEJM 34914)
• 83 and 65 reduction in 1st episode pneumonia
  due to the 7 serological groups, for HIV -/
  children respectively
• 25 reduction in x-ray confirmed pneumonia
• Incidence of invasive penicillin-resistant
  strains reduced by 67

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Pneumococcal vs Hib Disease

• Hib a warm-up for pneumococcal disease? Similar
  but even more challenging issues.
• Cost-challenge Financing and planning for
  sustainability of even more expensive vaccine
• Design/selection of appropriate vaccine (more
  than 90 serotypes!)
• Recognition Burden of disease data and advocacy
• Surveillance much more difficult for
  pneumococcal
• Significant adult disease for pneumo

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PBM S-Network and Pneumococcal Surveillance

• Collaboration with netSPEAR
• Introduction of surveillance using blood cultures
  (SOP development and training) strengthening
  surveillance
• Data sharing
• Feedback/Web page development
• Meetings and workshops
• Reference laboratory work
• Site visits and assessments

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PBM S-Network and Pneumococcal Surveillance

• CSF isolates from the rest of the network
• Enhanced pneumococcal surveillance at 5 selected
  sites (West , Central and Southern Africa) using
  blood cultures learning from the netSPEAR
  experience
• Results from netSPEAR/AFRO collaboration will
  guide activities elsewhere in the region for
  pneumococcal surveillance

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Conclusion

• A wonderful opportunity to contribute to the
  control of 2 major VPDs in Africa
• Many opportunities and challenges
• Capacity building at our respective institutions
  (Lab, data management, clinical practices)
• Generation of useful data, for guiding policy
• Developing (sustainable) surveillance systems
• Sharing information, problems and solutions