The burden of JE in Southeast Asia The
The burden of JE in Southeast Asia: The role of NGOs in the fight against the disease Julie Jacobson Director, JE Project
Overview n Introduction to PATH n Brief introduction into JE epidemiology n Discuss the barriers to JE control n Introduce the JE project n Review the strategy for vaccine introduction n Discuss recent success in India
PATH n Program for Appropriate Technologies in Health n 25 years of working with women’s and children’s health n Program areas Advancing technologies n Strengthening health systems n Encouraging healthy behaviors n
Overall Program Goal n To assure the availability of lifesaving vaccines to children in the developing world. n Immunization program strengthening n New and underutilized vaccine introduction n Vaccine development for the developing world
Immunization program strengthening n Training n Financial sustainability n Technical support n Advocacy and communication plans n New vaccine introduction planning n Technologies that support immunization
Description of Vaccine Vial Monitors (VVMs) ©Lifelines Technologies, Inc. A VVM contains a heat sensitive material that registers cumulative heat exposure over time. VVMs on Oral Polio Vaccine path June 2002
New and underutilized vaccine introduction n Hib, Yellow Fever, and Hep B Training materials n Disease burden n Vaccine introduction plans n Cold chain assessments n Japanese encephalitis (JE) n
Vaccine development for the developing world n Epidemic Mening in patrnership with WHO (MVP) n Malaria (MVI) n Rotavirus (RVP) n Pnemococcus (PVS) n JE n HPV
JE in Asia
Age groups affected by JE n Children 1 to 15 years of age are mainly affected in endemic areas. n But people of any age can be infected. Adult infection most often occurs in areas where the disease is newly introduced. Photo credit: Carib Nelson, PATH
Japanese Encephalitis n Leading cause of viral encephalitis in Asia n Leading neurologic infection in Asia n 50, 000 cases annually reported throughout Asia n severely under-reported n 10, 000 -15, 000 deaths annually (5 -35% CFR) n JE-related disability 30 -75%
Different patterns of age distribution of cases Data supplied by Government of Andhra Pradesh Data supplied by WHO, Nepal
JE Transmission Cycle
Slide from Dr PN Rao
Barrier 1: Poor recognition n Surveillance n Diagnostics
Under-reporting JE cases • Poor surveillance • Diagnostics not easily available
Two patterns of transmission of JE JE may be spread: 1. 2. Seasonal, called an epidemic pattern (e. g. , southern China) Year-round, called an endemic pattern (e. g. , Bali, Indonesia) Data supplied by International Vaccine Institute
Barriers to Effective JE Control Patient presents poor recognition Syndromic diagnosis no lab tests Laboratory confirmation of JE weak reporting JE case reported Data compiled analyzed poor communication Vector Control poor communication poor coordination Vaccine Program
Barrier 2: Misconceptions of effective disease control
JE transmission cycle and possible control points Control options n Mosquito control? n Pig control? n Human interventions?
Mosquito control ? n Spraying mosquito habitats with insecticide n Time consuming, expensive, it is difficult to cover all mosquito habitats, and causes environmental pollution n Bednets n Mosquitoes bite at dusk before people are in bed NOT THE BEST SOLUTION Photo credit: Julie Jacobson
Pig control ? n Segregating, slaughtering, or vaccinating pigs n n Photo credit: Susan Hills Economically not feasible and difficult Other animals, like birds, may also act as amplifying hosts so even if pigs are eliminated JE will not disappear NOT THE BEST SOLUTION
Evolution of JE control in Thailand Number of provinces JE Cases EPI-based 8 17 21 28 34 34 34 76 Catch-up Vector control and personal protection 10 16 23 28 Outbreak response and social mobilization JE vaccine phased into routine immunization 1970 1980 1997 2000 Year Source: Division of GCD, CDC, MOPH Annecy, June 2002
Scientific evidence for JE immunization There is compelling evidence that human immunization is effective for controlling JE. Studies in Korea and Japan showed >99% reduction in JE cases after immunization. Source: Igarashi A. “Control of Japanese Encephalitis in Japan: Immunization of humans and animals and vector control” Current Topics in Microbiology and Immunology 2002. 267: 139 -152
Barrier to Vaccination n Most widely available vaccine: mouse brain derived n Responsible for much of the success to date with JE control n Unfortunately there are limitations in its use Limited supply due to production process n Expensive to produce n Difficult schedule n Side effect profile needs to be considered n
JE Project n 5 -years, funded by the Bill & Melinda Gates Foundation n Early focus on data for decision-making (surveillance, dissemination, advocacy) n Vaccine access of product with defined product profile n Later shift to activities for vaccine introduction
JE Project Vision To eliminate clinical JE and avoid the unnecessary death and disability caused by this disease
JE Project Strategy To routinely vaccinate all the atrisk population with a safe, efficacious and affordable vaccine
How do we support country level disease control and decision making? n Countries must understand their disease burden and develop the will to fight JE n They need an available, affordable vaccine n They need increased support from international public health partners n They need the advice and experience of other countries that have excelled in JE control
JE Project Goals Improve disease surveillance, including available simple diagnostics 2. Advance an improved vaccine- tailored for the needs of the developing world 3. Introduce and integrate the vaccine 4. Promote JE control nationally and internationally 1.
Strategy Country support: n Support data for decision making and the most cost effective and high impact strategies for JE control in different national settings n Assist vaccine introduction by providing technical support to countries and partners and distill lessons learned n Integrate all activities into routine mechanisms so that control program activities are sustained and continued to be expanded by partners
Surveillance and laboratory work: n WHO JE surveillance standards available n 2 countries with new evidence of endemic disease (Indonesia and Bangladesh) n 3 new commercialized ELISA diagnostic tests in field trials n WHO lab network under development
Surveillance n Indonesia n Nepal n Philippines n Cambodia n Vietnam n China n India
Strategy Vaccine development: n Ensure a safe, efficacious, affordable supply of JE vaccine for use in routine immunization for all endemic countries (particularly GAVI-eligible countries) that is fundable by international agencies with a reliable supply.
Vaccine development n Reviewed available vaccine candidates against the target product profile n n n Safe, efficacious Few or single dose Fits into EPI schedule Sufficient affordable supply Can be used in routine EPI and campaigns n One licensed vaccine- Live attenuated SA 14 -14 -2 vaccine met the criteria n Two candidate vaccines- Intercell inactivated vero cell SA-14 -14 -2 and Acambis Chimeri. Vax. JE
Vaccine Introduction in India n Full technical support in areas needed n Vaccine introduction planning n n Vaccine introduction n n Introduction plan, operational guidelines, training materials, procurement timing Monitoring and evaluation, AEFI monitoring Post licensure studies n Immunogenicity, safety, viremia
Vaccination in India n Started May 15 th, 2006 n Over 9 million children vaccinated n 4 states, 11 districts n First phase of 5 year plan
Vaccination in India
Results!
Important Update n Bad press in India n No deaths or serious adverse events have been associated with the live attenuated vaccine used in India n Great deal of misinformation n Highlights one of the challenges of working in the developing world (particularly India)
General support: Providing key resources to countries and partners n Pamphlet for parents on JE n Generic informational posters for JE n Generic Powerpoint presentations n Many topics- JE disease, diagnosis, lumbar puncture, JE vaccine n AIM e-learning JE vaccine introduction module to be updated this year with a new planning tool n Immunization training modules n Web resources at www. path. org/je
Providing key resources to countries and partners with WHO n WHO JE Surveillance Standards n Encephalitis Clinical Care Guidelines n JE Vaccine Introduction Guidelines n 2006 WHO position paper on JE
Julie Jacobson, MD DTMH Scientific Director, Immunization Solutions Director, JE Project PATH
- Slides: 44