Expansion of seasonal influenza vaccination programs in low and middle income countries

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Each year, influenza results in the death of an estimated 250,000 to 500,000 people worldwide, along with millions of hospitalizations. In high-income countries, influenza is a common cause of hospitalization and death, and leads to substantial costs in terms of medical care and in lost productivity. As a result, annual influenza immunization programs have been conducted in most high-income countries for decades, generally targeting persons at the highest risk of severe complications. However, influenza vaccines are underused in most low and middle income countries. In 2015, fewer than half of countries had ongoing influenza vaccine programs, and only a few such programs existed in low-income countries. As more information has become available on the need for influenza prevention in low and middle-income countries and the efficacy and safety of vaccines in these settings, global health agencies have expressed increased interest in expanding influenza vaccination programs to all countries of the world, both as a disease reduction tool and a pandemic preparedness activity. CDC’s Influenza Division’s 2015 International Program Strategic Plan prioritized activites that would expand the use of seasonal influenza vaccines to greater numbers of middle and low-income countries. This FOA is intended to expand the use of influenza vaccines in low and middle income countries, to evaluate the effectiveness of vaccine introduction through a public-private partnership, and to establish an evidence base for global and regional influenza vaccine introduction decisions. In 2013, WHO’s Strategic Advisory Group of Experts voted to recommend influenza vaccination for high-risk groups worldwide. SAGE recommended that persons in five high-risk groups be targeted for vaccine, including children 6 months to 5 years, elderly persons, those with underlying health conditions, health care workers and pregnant women. Data clearly indicated that persons in these groups were either at higher risk of severe complications, including death, from influenza or were at risk of transmitting influenza to persons at high risk. This new policy, together with an increased appreciation of the burden of influenza globally as a by-product of pandemic preparedness, has led to increased interest in influenza prevention through vaccination in low and middle-income countries. In 2012, the Task Force for Global Health’s Center for Vaccine Equity collaborated with CDC and the Bill and Melinda Gates Foundation to create the Partnership for Influenza Vaccine Introduction (PIVI). PIVI is a public-private partnership that works to reduce morbidity and mortality associated with influenza in low- and middle-income countries (LMIC) by working with a wide range of global stakeholders to establish sustainable, national seasonal influenza vaccination programs. Development of robust seasonal influenza immunization programs are key elements in facilitating effective responses to pandemic influenza. PIVI supports the evaluation and sustainability planning of new and existing influenza vaccination programs in developing countries, focusing on supporting countries with programs that target vaccination of WHO SAGE-recommended priority groups. PIVI provides time-limited vaccine, supplies, and technical support to LMICs that lack those resources but are otherwise ready to create or expand seasonal influenza vaccination programs. To date, PIVI has assisted five countries in planning/introducing seasonal influenza immunization – Lao PDR, Nicaragua, Armenia, Morocco, and Moldova. This first group of projects were supported by a development grant from BMGF and a cooperative agreement with CDC. The project has had several notable successes, including advancing national discussions and policy development in partner countries, creation of partnerships with industry to obtain free or deeply discounted vaccines and with Ministries of Health to provide technical assistance to designing and delivering vaccines, and early signs that countries are accepting increasing financial responsibility for maintaining the vaccination programs once the PIVI donation ends. CDC’s Influenza Division has highlighted a goal of expanding seasonal vaccination programs as a global health security objective and a disease reduction tool. PIVI offers a novel approach to achieving his goal, but needs to continue in current countries to understand best methods for creating sustainable programs, and expand to new countries to understand the factors associated with achieving sustainability.

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