Shaping meeting to explore the value of a coordinated work plan for epidemic and pandemic influenza vaccine preparedness

In March 2019, a group of global health leaders with expertise in influenza, vaccinology and pandemic preparedness was convened for a meeting titled “Shaping Meeting to explore the value of a coordinated work plan for epidemic and pandemic influenza vaccine preparedness.” Influenza epidemics occur annually in every country in the world, resulting in significant global burden of illness and deaths. While every country is effected, most deaths and severe disease occur in low- and lower middle-income countries (LIC and LMIC). Influenza immunization programs that limit the burden of disease, deaths, and reduce economic impact are a fundamental public health intervention for seasonal epidemics. In addition, they provide the experience, systems and infrastructure for the timely and efficient use of vaccines and other medical countermeasures critical for effective pandemic responses. Pandemic influenza response activities, including vaccination efforts, will be most effective if used and practiced regularly. Consequently, countries with seasonal influenza prevention and control programs should be better prepared for, and have more effective pandemic responses than countries without such programs. A decade after the 2009 pandemic, despite ongoing prevention efforts, most LICs and LMICs still lack access to robust seasonal influenza immunization programs. Given this current state, meeting participants concluded that there is critical need to advance the expansion and strengthening of seasonal influenza immunization programs in LICs and LMICs not only to reduce the economic and public health effects of annual influenza epidemics, but also to increase preparedness to mitigate the threat of future pandemics and improve global heath security. Many government and private sectors, in a whole of government approach, need to be working together to support and advance countries' epidemic and pandemic influenza capacities preparedness objectives. Accomplishment of these objectives can be achieved with a coordinated work plan developed and guided by an alliance of international stakeholders, to include, among others, government, and nongovernment organization representation, civil society representatives, vaccine manufacturers, international organizations, and health security and influenza experts.     

Country immunization policies for refugees across 20 low-middle income and 20 high-income countries

In 2020, 26 million refugees resettled in a new country—fleeing their homes due to conflict and persecution. Due to low immunization coverage and underlying health conditions, refugees commonly face an increased risk of contracting vaccine-preventable diseases. We collected and analyzed existing routine immunization policies for refugees across 20 low- and middle-income countries (LMICs) and 20 high-income countries (HICs), each with the highest number of refugees per 1000 residents. Primary and secondary data sources were used to collect policy evidence. Across 20 LMICs, 13 countries specified standing nationwide routine immunization policies for refugees, while 14 out of the 20 HICs included refugees in their national routine immunization programs. LMICs and HICs should include refugees in their national routine immunization policies and provide accessible and affordable immunizations. Such efforts would reduce vaccine-preventable diseases and protect the health of refugee populations—especially during the COVID-19 pandemic.     

Review of the epidemiological evidence for physical activity and health from low- and middle-income countries

Almost 80% of deaths from non-communicable diseases (NCDs) occur in low- and middle-income countries. Physical inactivity is a key risk factor for NCDs. Enhancing understanding of the scientific evidence linking physical activity and health in low- and middle-income countries is important for supporting national efforts to promote physical activity and reduce NCDs in these countries. A systematic review of three electronic databases was conducted in July 2013, including large population-based epidemiological studies with adult participants, conducted in low- and middle-income countries, and published in the past 30 years. Physical activity was consistently associated with a reduced risk of all-cause mortality, cardiovascular disease (CVD), diabetes and several types of cancer. Positive associations were also found between physical activity and body composition (including overweight and obesity), blood pressure, cholesterol, metabolic indices and bone mineral density. Overall, the results confirm that the epidemiological research into the health benefits of physical activity in low- and middle-income countries is consistent with previous research conducted in high-income countries. This summary of the available research can be used as an advocacy tool in low- and middle-income countries to support greater prominence of physical activity in NCD policies.     

Influenza epidemiology and immunization during pregnancy: Final report of a World Health Organization working group

From 2014 to 2017, the World Health Organization convened a working group to evaluate influenza disease burden and vaccine efficacy to inform estimates of maternal influenza immunization program impact. The group evaluated existing systematic reviews and relevant primary studies, and conducted four new systematic reviews. There was strong evidence that maternal influenza immunization prevented influenza illness in pregnant women and their infants, although data on severe illness prevention were lacking. The limited number of studies reporting influenza incidence in pregnant women and infants under six months had highly variable estimates and underrepresented low- and middle-income countries. The evidence that maternal influenza immunization reduces the risk of adverse birth outcomes was conflicting, and many observational studies were subject to substantial bias. The lack of scientific clarity regarding disease burden or magnitude of vaccine efficacy against severe illness poses challenges for robust estimation of the potential impact of maternal influenza immunization programs.     

Addressing the growing burden of trauma and injury in low- and middle-income countries

Low- and middle-income countries suffer disproportionately from reduced life expectancy and quality of life. Injuries are overlooked as contributors to global inequities in health, yet the long-term disabilities they frequently produce represent a significant burden.The Fogarty International Center of the National Institutes of Health convened a panel of experts in trauma and injury from the United States and low- and middle-income nations to identify research gaps in this area and opportunities to create new knowledge. Panel members identified sustainable programs of research established through stable linkages between institutions in high-income nations and those in low- and middle-income nations as a priority.The resulting benefits of addressing the growing burden of trauma and injury to communities in resource-constrained settings around the world would be substantial.     

Announcing the publication of the WHO immunological basis for immunization series module on influenza vaccines

In 2017, the World Health Organization (WHO) published a document aimed at facilitating influenza vaccine introduction and use in low- and middle-income countries. The document “The Immunological Basis for Immunization Series: Influenza Vaccines” is freely available on the WHO website. The main purpose of this document is to give immunization managers and vaccination professionals an authoritative but easily-understood overview of the scientific basis of influenza vaccination and the immunological basis for the WHO position on influenza vaccines. The influenza vaccine document comprises one module of the WHO Immunological Basis for Immunization series. We invite the immunization community to use these references, and we hope the influenza vaccine module will be a valuable resource for persons who manage and monitor influenza vaccine programs, particularly in low- and middle-income countries.     

Archetype analysis of older adult immunization decision-making and implementation in 34 countries

The global population of adults over 65 years of age is growing rapidly and is expected to double by 2050. Countries will face substantial health, economic and social burden deriving from vaccine-preventable diseases (VPDs) such as influenza, pneumonia and herpes zoster in older adults. It will be essential that countries utilize several public health strategies, including immunization. Understanding the different approaches countries have taken on adult immunization could help provide future learnings and technical support for adult vaccines within life-course immunization strategies. In this study, we describe the priorities and approaches that underlie adult immunization decision-making and implementation processes in 32 high-and-middle-income countries and two territories (“34 countries”) who recommend adult vaccines in their national schedule. We conducted an archetype analysis based on a subset of two dozen indicators abstracted from a larger database. The analysis was based on a mixed-methods study, including results from 120 key informant interviews in six countries and a landscape review of secondary data from 34 countries. We found four distinct archetypes: disease prevention-focused; health security-focused; evolving adult focus; and, child-focused and cost-sensitive. The highest performing countries belonged to the disease prevention-focused and health security archetypes, although there was a range of performance within each archetype. Considering common barriers and facilitators of decision-making and implementation of adult vaccines within a primary archetype could help provide a framework for strategies to support countries with similar needs and approaches. It can also help in developing context-specific policies and guidance, including for countries prioritizing adult immunization programs in light of COVID-19. Further research may be beneficial to further refine archetypes and expand the understanding of what influences success within them. This can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders.     

Improving immunization data quality in Peru and Mexico: Two case studies highlighting challenges and lessons learned

IntroductionThe Global Vaccine Action Plan and the Regional Immunization Action Plan of the Americas call for countries to improve immunization data quality. Immunization information systems, particularly electronic immunization registries (EIRs), can help to facilitate program management and increase coverage. However, little is known about efforts to develop and implement such systems in low- and middle-income countries. We present the experiences of Mexico and Peru in implementing EIRs.MethodsWe conducted case studies of an EIR in Mexico and of a population registry in Peru. Information was gathered from technical documents, stakeholder focus groups, site visits, and semi-structured interviews of national stakeholders. We organized findings into narratives that emphasized challenges and lessons learned.ResultsMexico built one of the world’s first EIRs, incorporating novel features such as local-level tracking of patients; however, insufficient resources and poor data registration practices led to the system’s discontinuation. Peru created an information system to improve affiliation to social programs, including the immunization program and quality of demographic data. Mexico’s experience highlights lessons in failed sustainability of an EIR and a laudable effort to reform a country’s information system. Peru’s demonstrates that attempts to improve health and other data may strengthen health systems, including immunization data. Major challenges in information system implementation and sustainability in Peru and Mexico related to funding, clear governance structures, and resistance among health workers.DiscussionThese case studies reinforce the need for countries to ensure adequate funding, plans for sustainability, and health worker capacity-building activities before implementing EIRs. They also suggest new approaches to implementation, including economic incentives for sub-national administrative levels and opportunities to link efforts to improve immunization data with other health and political priorities. More information on best practices is needed to ensure the successful adoption and sustainability of immunization registries in low- and middle-income countries.     

Report on WHO meeting on immunization in older adults: Geneva,Switzerland, 22–23 March 2017

Many industrialized countries have implemented routine immunization policies for older adults, but similar strategies have not been widely implemented in low- and middle-income countries (LMICs). In March 2017, the World Health Organization (WHO) convened a meeting to identify policies and activities to promote access to vaccination of older adults, specifically in LMICs. Participants included academic and industry researchers, funders, civil society organizations, implementers of global health interventions, and stakeholders from developing countries with adult immunization needs. These experts reviewed vaccine performance in older adults, the anticipated impact of adult vaccination programs, and the challenges and opportunities of building or strengthening an adult and older adult immunization platforms. Key conclusions of the meeting were that there is a need for discussion of new opportunities for vaccination of all adults as well as for vaccination of older adults, as reflected in the recent shift by WHO to a life-course approach to immunization; that immunization in adults should be viewed in the context of a much broader model based on an individual’s abilities rather than chronological age; and that immunization beyond infancy is a global priority that can be successfully integrated with other interventions to promote healthy ageing. As WHO is looking ahead to a global Decade of Healthy Ageing starting in 2020, it will seek to define a roadmap for interdisciplinary collaborations to integrate immunization with improving access to preventive and other healthcare interventions for adults worldwide.     

Global Efforts for Reducing the Burden of Smoking

Cigarette smoking and other tobacco use impose a huge and growing public health burden globally. Currently, approximately 4 million persons are killed annually by tobacco use; by 2030, estimates based on current trends indicate that this number will increase to 10 million, with 70% of deaths occurring in low- and middle-income countries. Numerous studies from high-income countries, and a growing number from low- and middle-income countries, provide strong evidence that increases in tobacco tax, dissemination of information about health risks from smoking, restrictions on smoking in public places and in workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies are all effective in reducing tobacco use and its consequences. Despite this evidence, tobacco control policies have been unevenly applied, partly because of political constraints.When the tobacco control policies that have been adopted by individual governments were reviewed, upper-middle-income countries had significantly higher total legislative scores than low- and middle-income countries. This suggests a relationship between the comprehensiveness of tobacco control policies and income level. However, there are other factors that may contribute.A key political tool for addressing political opposition to tobacco control policies is an earmarked tobacco tax. In addition, a key pillar to help overcome some of the constraints against implementing effective tobacco control policies is the Framework Convention on Tobacco Control (FCTC). The FCTC aims to be an international treaty that would commit countries to adopting strong, effective tobacco control policies. The treaty was recently unanimously adopted by the 192 member states of the WHO.     

Economic barriers to better mental health practice and policy

Mental health systems in many countries are seriously under-developed, yet mental health problems not only have huge consequences for quality of life, but--particularly in low- and middle-income countries--contribute to continued economic burden and reinforce poverty. This paper discusses economic barriers to improving the availability, accessibility, efficiency and equity of mental health care in low- and middle-income countries. Six sets of barriers are identified: an information barrier, resource insufficiency, resource distribution, resource inappropriateness, resource inflexibility and resource timing. Overcoming these barriers will be a major task, although there is no shortage of suggestions for action. The paper discusses broadening the evidence base, improving mental health literacy, tackling stigma, improving financing mechanisms, prioritizing and protecting mental health care budgets, emphasizing mental health promotion through the development of resilience, exploring routes to improved equity, experimenting with new arrangements for purchasing and delivering services, improving coordination between agencies and professionals at both macro- and micro-levels, building alliances between public and private sectors, and training and mobilizing primary care services to improve identification and treatment of mental health problems.     

Road traffic injuries: a major global public health crisis

Evidence suggests that the present and projected global burden of road traffic injuries is borne disproportionately by countries that can least afford to meet the health service, economic and societal challenges. Although the evidence base on which these estimates are made remains somewhat precarious in view of the limited data systems in most low- and middle-income countries, these projections highlight the essential need to address road traffic injuries as a public health priority. Most well-evaluated effective interventions do not focus directly on efforts to protect vulnerable road users, such as motorcyclists and pedestrians. However, these groups comprise the majority of road traffic victims in low- and middle-income countries, and consequently the majority of road traffic victims globally. Responding appropriately to the disparities in available evidence and prevention efforts is necessary in order to address this global public health crisis comprehensively.     

WHO Expert Committee on Problems Related to Alcohol Consumption. Second report

The disease burden attributable to alcohol consumption is significant and, in many countries, public health problems caused by harmful use of alcohol represent a substantial health, social and economic burden. Reduction of the alcohol-attributable burden is becoming a priority area for international public health. Alcohol-related harm can be reduced through the implementation of proven alcohol strategies, including at a global level. This report of a WHO Expert Committee reviews the health and social consequences of alcohol consumption and disease burden attributable to alcohol in the context of alcohol-related harm and recent trends in alcohol consumption worldwide. Based on the reviews of available evidence, including the latest data on the contribution of alcohol consumption to the global disease burden, the Committee makes several recommendations emphasizing WHO's role in coordinating a global response, and the need for global action to reduce alcohol-related harm through effective mechanisms of international action and country support. The Committee recommends a range of strategies and policy options that have a sound evidence base and global relevance for reducing alcohol-related harm, emphasizing that their adaptation and implementation at the national and sub-national levels should take into account specific cultural and legal contexts and the local configuration of alcohol problems. The Committee also recommends that WHO should support governments, particularly in low- and middle-income countries, in developing, implementing and evaluating national and sub-national evidence-based policies, action plans and programmes. The Committee's conclusions and recommendations have significant implications for future developments in this area.     

How can we achieve global equity in provision of renal replacement therapy?

There is a significant emerging burden of chronic and end-stage kidney disease in low- and middle-income countries, driven by population ageing and the global epidemic of type 2 diabetes. Sufferers of end-stage kidney disease require ongoing dialysis or kidney transplantation to survive; however, in many low- and middle-income countries, treatment options are strictly limited or unaffordable. Low numbers of maintenance dialysis patients and transplant recipients reflect profound economic and service provision challenges for health-care systems in low- and middle-income countries in sustaining renal replacement therapy programmes. Underdeveloped organ donor and transplant programmes, health system and financing issues, ethical regulation of transplantation and the cost of pharmaceuticals commonly pose additional barriers to the delivery of efficient and cost-effective renal replacement therapy. Development of locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need. Select low- and middle-income countries demonstrate more equitable provision of renal replacement therapy is possible outside high-income countries. For other low- and middle-income countries, education, the development of good public policy and a supportive international environment are critical. Prevention of end-stage kidney disease, ideally as part of an integrated approach to chronic vascular diseases, must also be a key objective.     

Treatment of common mental disorders in primary care in low- and middle-income countries

Common mental disorders are responsible for up to 10% of the total global disease burden. The growing evidence base for the efficacy and cost-effectiveness of treatments for these disorders raises the possibility of delivering huge health and economic benefits. However, delivering these treatments in resource-constrained settings is challenging. At least one-third of all patients seen in primary care in low- and middle-income countries present with common mental disorders. The majority are not recognised or are ineffectively treated. To address this problem, WHO advocates integrating mental health in primary care. However, the limited evidence base has impeded efforts to develop such services.     

Evaluating the cost-effectiveness of maternal pertussis immunization in low- and middle-income countries: A review of lessons learnt

This issue of Vaccine is devoted to papers from a research project that developed two types of simulation models, static and dynamic transmission, to evaluate the cost-effectiveness of maternal immunization to prevent pertussis in infants in low- and middle-income countries (LMICs). The research was conducted by a multinational team of investigators and funded by the Bill & Melinda Gates Foundation to gain an understanding of when and where maternal immunization might be a good public health investment for LMICs. Here we review the project’s central lessons for vaccine policy and research. Models require a lot of data. As most LMICs lack good data, the models were built using pertussis disease burden data from Brazil, a middle-income country with three long-established, independent information systems (disease surveillance, hospitalization, and mortality), on the hypothesis that the disease process is similar across countries. Values for key parameters, particularly infant mortality, infant vaccine coverage, and costs of vaccination and treatment, were then varied to represent other LMICs. The results show that coverage levels of infant whole cell pertussis (wP) vaccine are key to the cost-effectiveness of maternal pertussis immunization. In settings where infant wP coverage is below the threshold thought necessary to eliminate pertussis in the population, 90–95%, maternal immunization is cost-effective, even cost-saving. By contrast, it is very expensive in countries capable of maintaining infant vaccination in or above the threshold range. The research also suggests that, while static models may serve to explore an intervention’s cost-effectiveness initially, dynamic transmission models are essential for more accurate estimates. These findings can help guide policies toward maternal pertussis immunization, but also show that developing better data on neonatal pertussis mortality burden and infant vaccine coverage in LMICs, and on the duration of immunity of currently available pertussis vaccines, are key priorities to support better vaccine policy.     

Role of the private sector in the provision of immunization services in low- and middle-income countries

The authors conducted a literature review on the role of the private sector in low- and middle-income countries. The review indicated that relatively few studies have researched the role of the private sector in immunization service delivery in these countries. The studies suggest that the private sector is playing different roles and functions according to economic development levels, the governance structure and the general presence of the private sector in the health sector. In some countries, generally low-income countries, the private for-profit sector is contributing to immunization service delivery and helping to improve access to traditional EPI vaccines. In other countries, particularly middle-income countries, the private for-profit sector often acts to facilitate early adoption of new vaccines and technologies before introduction and generalization by the public sector. The not-for-profit sector plays an important role in extending access to traditional EPI vaccines, particularly in low-income countries. Not-for-profit facilities are situated in rural as well as urban areas and are more likely to be coordinated with public services than the private for-profit sector. Although numerous studies on non-governmental organizations (NGOs) suggest that the extent of NGO provision of immunization services in low- and middle-income countries is substantial, the contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels. Studies on quality of immunization service provision at private health facilities suggest that it is sometimes inadequate and needs to be monitored. Although some articles on public-private collaboration exist, little was found on the extent to which governments are effectively interacting with and regulating the private sector. The review revealed many geographical and thematic gaps in the literature on the role and regulation of the private sector in the delivery of immunization services in low- and middle-income countries.     

Costs of Immunization Programs for 10 Vaccines in 94 Low- and Middle-Income Countries From 2011 to 2030

ObjectivesUnderstanding the level of investment needed for the 2021-2030 decade is important as the global community faces the next strategic period for vaccines and immunization programs. To assist with this goal, we estimated the aggregate costs of immunization programs for ten vaccines in 94 low- and middle-income countries from 2011 to 2030.MethodWe calculated vaccine, immunization delivery and stockpile costs for 94 low- and middle-income countries leveraging the latest available data sources. We conducted scenario analyses to vary assumptions about the relationship between delivery cost and coverage as well as vaccine prices for fully self-financing countries.ResultsThe total aggregate cost of immunization programs in 94 countries for 10 vaccines from 2011 to 2030 is $70.8 billion (confidence interval: $56.6-$93.3) under the base case scenario and $84.1 billion ($72.8-$102.7) under an incremental delivery cost scenario, with an increasing trend over two decades. The relative proportion of vaccine and delivery costs for pneumococcal conjugate, human papillomavirus, and rotavirus vaccines increase as more countries introduce these vaccines. Nine countries in accelerated transition phase bear the highest burden of the costs in the next decade, and uncertainty with vaccine prices for the 17 fully self-financing countries could lead to total costs that are 1.3-13.1 times higher than the base case scenario.ConclusionResource mobilization efforts at the global and country levels will be needed to reach the level of investment needed for the coming decade. Global-level initiatives and targeted strategies for transitioning countries will help ensure the sustainability of immunization programs.     

A critical review of priority setting in the health sector: the methodology of the 1993 World Development Report

The 1993 World Development Report, Investing in Health, suggests policies to assist governments of developing countries in improving the health of their populations. A new methodology to improve government spending is introduced. Epidemiological and economic analyses from the basis for a global priority setting exercise, leading to a recommended essential public health and clinical services package for low- and middle-income countries. Ministries of Health in many countries have expressed an interest in designing a national package of essential health services, using the methodology. Given the apparent importance attached to the study and its far reaching potential consequences, this article provides an overview of the method, the main issues and problems in estimating the burden of disease as well as the cost-effectiveness of interventions. Strengths and weaknesses in the databases, value judgements and assumptions are identified, leading to a critical analysis of the validity of the priority setting exercise on the global level.