5th Global Meeting on Implementing New and Under-utilized Vaccines, 22-24 June 2011
Workgroup 1. Prioritization of vaccines at country level
Many countries are in the process of introducing new vaccines into their national immunization schedule. In some settings, consideration is being given to introducing more than one vaccine at the same time. Thus, countries and partners would benefit from practical guidance on the vaccine introduction decision-making process. In developing such guidance, lessons learned from countries that have completed this process can provide important information. In particular, determining the process used by advisory bodies within the country, and the use of any specific decision-making tools, may be useful to identify the key components in decision making.
Main Topics of Discussion
- Issues to consider in the new vaccine decision-making and prioritization processes at the country level include burden of disease and cost-effectiveness analyses, the capacity of the immunization programme to introduce a new vaccine, vaccine introduction logistics/cold chain, political and legal aspects, and financial sustainability. These issues can vary not only from country to country but within country over time.
- Country experiences were shared by:
- Colombia, a non-GAVI country, described the legal framework for EPI, and took stock of the economic conditions in the country, and the financial support for EPI. The country conducted analyses that assisted in the comparison of options for vaccine introduction. Major issues considered included information on disease occurrence, the cost effectiveness of the intervention, political priorities, and sustainability.
- Nigeria considered introducing new vaccines in the context of conducting polio eradication activities. The country considered the stakeholders in the decision-making process, used information from a visit by WHO and partners, formed a new vaccines introduction committee, and received input from the Interagency Coordinating Committee (ICC). Additionally, information on disease burden, cost of vaccines, operational issues and sustainability was also assessed. It was noted that the focus on polio eradication activities helped putting more emphasis on immunizations overall and impact of vaccines, as well as strengthening immunizations systems, which actually helped moving forward decisions for new vaccine introduction.
- Rwanda considered many factors including progress towards the Millennium Development Goals (MDGs), other leading causes of child mortality (such as malaria), the existing capacity to introduce a new vaccine based on their experience of PCV introduction, and other potential interventions such as education, nutrition, and sanitation. It was noted that the large proportion of women in the parliament (53%) played an important role in moving forward the country’s maternal and child health agenda including immunization.
- Lao PDR considered the burden of disease (Japanese Encephalitis), the geographic distribution of cases, MDGs, experience of EPI staff, cost of the vaccine, vaccine schedule (i.e. single dose), and operational issues. The country also noted that the disease was highly visible to the population, and that this was another key consideration.
- It was emphasized several times that other factors such as efforts needed to achieve the MDGs, other leading causes of child mortality in the country, advocacy groups, technical bodies such as National Immunization Technical Advisory Groups (NITAGs), and other ongoing public health activities such as polio eradication, influence the prioritization process.
- NITAGS in particular have a critical role in guiding policy makers and programme managers in making evidence-based immunization-related policy decisions by providing technical recommendations. However, NITAGs should not serve as an implementing nor a regulatory body. A specific example of the important role of the NITAG in Mozambique was shared.
- Tools and resources can assist decision making and prioritization. For example, the WHO Region of America's ProVAC initiative and tool assists countries in making evidence-based decisions. This includes TriVac, a cost-effectiveness analysis tool for Hib, pneumo and rotavirus vaccine which can be adapted to include other vaccines. TriVac can also be used to estimate the impact of the vaccines on morbidity and mortality. PAHO is available to assist countries in the use of the tool and in these efforts. The elements of a cost effectiveness analysis were discussed and include the vaccination programme costs, health services costs prevented, and health benefits.
- The Lives Saved Tool (LiST) was reviewed (www.CHERG.org or www.jhsph.edu/IIP), which can assist in country planning or to estimate impact and costs of scaling up interventions. Within LiST, each intervention is introduced separately (for example, a cause of death) and then the impact of increasing the coverage of an intervention (such as vaccination) is calculated.
- The existing tools could be further refined. It was noted that currently similar tools can produce different results, e.g. TriVac and LiST. Additionally, tools sometimes produce information difficult to present to decision makers.
- Overall, given the diversity between and within countries over time, the vaccine community should not try to identify a standardized decision-making process. Rather, the conclusion was that it is important for countries to have a systematic process for decision making.
- LMICs are likely to differ from GAVI eligible countries in their decision-making process since there are no external GAVI resources to support vaccine introduction, but similar processes to prioritize vaccines and guide decision making (such as with NITAGs) can be followed.
- Ensure each country follows a systematic decision-making process that is suitable to its needs. Sharing experiences among countries is helpful.
- Decision-making tools need to be simplified and harmonized where practical, and made easily accessible.
- LMICs should be supported in their decision making through the provision of tools and technical support by WHO and other immunization partners.