COVID-19 provides an opportunity to build a resilient and equitable immunization delivery system.

The COVID-19 pandemic has weakened the health systems in many countries particularly putting at risk efforts on the Immunization Agenda to make vaccination available to everyone, everywhere, by 2030. Immunization Agenda 2030 reconfirms the importance of reducing the absolute number of zero-dose children and increasing the proportion of children who complete their vaccinations on time. Despite the gains in promoting equity in immunization services, many children missed vaccination because of the COVID-19 pandemic that disrupted well planned strategies. The cancellation of outreach services following the COVID-19-motivated lockdown meant many children missed vaccination. The situation was further worsened by vaccination related rumors and fears. The collapse of the Primary Health Care (PHC) service provision during the epidemic may lead to higher under-five mortality similar to the Ebola Virus Disease epidemic in West Africa. The post COVID-19 recovery strategy should include strengthening the service delivery systems to remain resilient when threatened by emergencies. The recovery must therefore focus on rebuilding trust as the foundation for vaccine acceptance and demand which can only be achieved by appropriate community engagement.

Supporting national immunization technical advisory groups (NITAGs) in resource-constrained settings. New strategies and lessons learned from the Task Force for Global Health's Partnership for influenza vaccine introduction.

National Immunization Technical Advisory Groups (NITAGs) are multidisciplinary national experts who provide independent, evidence-informed vaccine policy recommendations to national health authorities. An essential NITAG function is to ensure that these decisions are grounded in the best available evidence generated through a systematic, transparent process. However, in many low- and middle-income countries (LMICs), experience with this decision making method is limited. The Task Force for Global Health manages the Partnership for Influenza Vaccine Introduction (PIVI) program in collaboration with the Centers for Disease Control and Prevention, Ministries of Health, corporate partners and others. During 2017, PIVI worked with its country partners and the World Health Organization regional and local offices to assess NITAG strengthening needs and to provide technical assistance in 7 LMIC countries (Laos Peoples Democratic Republic, Mongolia, Vietnam, Armenia, Côte d'Ivoire; Moldova and the Republic of Georgia). Our workshops supported general NITAG capacity building and the evidence-based review process using vaccines of interest to the country. For NITAGs reviewing evidence on seasonal influenza, we developed an influenza resource package to support their review and provide country-relevant information in an easy to use format. Of the seven NITAGs trained, six have applied some of the concepts learnt: revision or development of formal transparent, systematic procedures for their operations; preparation of recommendations on seasonal influenza vaccination using quality-assessed data from systematic searches and local data; and have applied the principles learned for making other new vaccine recommendations. Our experience confirms that LMIC NITAGs are considerably under-resourced without adequate technical support or access to global peer-reviewed literature. Ongoing support from NITAG partners must be secured and creative approaches might be needed to help countries achieve the GVAP 2020 target and support development of sustainable vaccine policies and programs.

Developing a seasonal influenza vaccine recommendation in Kenya: Process and challenges faced by the National Immunization Technical Advisory Group (NITAG).

BACKGROUND: In 2014 the Kenya National Immunization Technical Advisory Group (KENITAG) was asked by the Ministry of Health to provide an evidence-based recommendation on whether the seasonal influenza vaccine should be introduced into the national immunization program (NIP). METHODS: We reviewed KENITAG manuals, reports and meeting minutes generated between June 2014 and June 2016 in order to describe the process KENITAG used in arriving at that recommendation and the challenges encountered. RESULTS: KENITAG developed a recommendation framework to identify critical, important and non-critical data elements that would guide deliberations on the subject. Literature searches were conducted in several databases and the quality of scientific articles obtained was assessed using the Critical Appraisal Skills Programme tool. There were significant gaps in knowledge on the national burden of influenza disease among key risk groups, i.e., pregnant women, individuals with co-morbidities, the elderly and health care workers. Insufficient funding and limited work force hindered KENITAG activities. In 2016 KENITAG recommended introduction of the annual seasonal influenza vaccine among children 6 to 23 months of age. However, the recommendation was contingent on implementation of a pilot study to address gaps in local data on the socio-economic impact of influenza vaccination programs, strategies for vaccine delivery, and the impact of the vaccination program on the healthcare workforce and existing immunization program. KENITAG did not recommend the influenza vaccine for any other risk group due to lack of local burden of disease data. CONCLUSION: Local data are a critical element in NITAG deliberations, however, where local data and in particular burden of disease data are lacking, there is need to adopt scientifically acceptable methods of utilizing findings from other countries to inform local decisions in a manner that is valid and acceptable to decision makers.

The Role of National Immunization Technical Advisory Groups (NITAGs) in the Introduction of Inactivated Polio Vaccine: Experience of the Indonesia and Uganda NITAGs.

Background: National Immunization Technical Advisory Groups (NITAGs) are established by national authorities to provide them with independent, bias-free, objective, and evidence-based advice on vaccines and immunization challenges. As of December 2015, 125 countries have reported having set up an NITAG. The Health Policy and Institutional Development Center at the Agence de Médecine Préventive, a World Health Organization (WHO) Collaborative Center for evidence-informed immunization, through its Supporting Independent Immunization and Vaccine Advisory Committees (SIVAC) Initiative project, provides assistance to low- and middle-income countries in the establishment and strengthening of their NITAGs. The Indonesian NITAG (ITAGI) was formed in December 2006 and Uganda's (UNITAG) was formed in November 2014. Both Uganda and Indonesia have introduced inactivated polio vaccine (IPV) as part of the Global Polio Eradication and Endgame Strategic Plan (the Endgame plan). The authors reflect on the process and the role played by NITAGs in the introduction of IPV in the routine immunization program and the lessons learned. Methods: This commentary is a reflection of the authors' experience on NITAG's role as observed in 2 particular local settings and applied to a global public health issue, the polio eradication Endgame plan. The reflection is backed up by the relevant (policy and technical) documents on polio eradication, along with minutes and reports from countries' ministries of health, immunization programs, WHO, and NITAGs. Results: NITAGs are valuable tools for ministries of health to ensure sustainable, evidence-informed immunization policies that are trusted and accepted by their communities. Early engagement with NITAGs also ensures that the adoption of strategies addressing global public health threats at the country level reinforces the national immunization programs. On the other end, when NITAGs are proactive and forward-thinking, they can contribute to a smooth and effective introduction of the above-mentioned strategies. Time and resources are key factors to ensure optimal performance of NITAGs.

Policy analysis for deciding on a malaria vaccine RTS,S in Tanzania.

BACKGROUND: Traditionally, it has taken decades to introduce new interventions in low-income countries. Several factors account for these delays, one of which is the absence of a framework to facilitate comprehensive understanding of policy process to inform policy makers and stimulate the decision-making process. In the case of the proposed introduction of malaria vaccines in Tanzania, a specific framework for decision-making will speed up the administrative process and shorten the time until the vaccine is made available to the target population. METHODS: Qualitative research was used as a basis for developing the Policy Framework. Interviews were conducted with government officials, bilateral and multilateral partners and other stakeholders in Tanzania to assess malaria treatment policy changes and to draw lessons for malaria vaccine adoption. RESULTS: The decision-making process for adopting malaria interventions and new vaccines in general takes years, involving several processes: meetings and presentations of scientific data from different studies with consistent results, packaging and disseminating evidence and getting approval for use by the Ministry of Health and Social Welfare (MOHSW). It is influenced by contextual factors; Promoting factors include; epidemiological and intervention characteristics, country experiences of malaria treatment policy change, presentation and dissemination of evidence, coordination and harmonization of the process, use of international scientific evidence. Barriers factors includes; financial sustainability, competing health and other priorities, political will and bureaucratic procedures, costs related to the adoption and implementations of interventions, supply and distribution and professional compliance with anti-malarial drugs. CONCLUSION: The framework facilitates the synthesis of information in a coherent way, enabling a clearer understanding of the policy process, thereby speeding up the policy decision-making process and shortening the time for a malaria vaccine to become available.

Factors likely to affect community acceptance of a malaria vaccine in two districts of Ghana: a qualitative study.

Malaria is a leading cause of morbidity and mortality among children in Ghana. As part of the effort to inform local and national decision-making in preparation for possible malaria vaccine introduction, this qualitative study explored community-level factors that could affect vaccine acceptance in Ghana and provides recommendations for a health communications strategy. The study was conducted in two purposively selected districts: the Ashanti and Upper East Regions. A total of 25 focus group discussions, 107 in-depth interviews, and 21 semi-structured observations at Child Welfare Clinics were conducted. Malaria was acknowledged to be one of the most common health problems among children. While mosquitoes were linked to the cause and bed nets were considered to be the main preventive method, participants acknowledged that no single measure prevented malaria. The communities highly valued vaccines and cited vaccination as the main motivation for taking children to Child Welfare Clinics. Nevertheless, knowledge of specific vaccines and what they do was limited. While communities accepted the idea of minor vaccine side effects, other side effects perceived to be more serious could deter families from taking children for vaccination, especially during vaccination campaigns. Attendance at Child Welfare Clinics after age nine months was limited. Observations at clinics revealed that while two different opportunities for counseling were offered, little attention was given to addressing mothers' specific concerns and to answering questions related to child immunization. Positive community attitudes toward vaccines and the understanding that malaria prevention requires a comprehensive approach would support the introduction of a malaria vaccine. These attitudes are bolstered by a well-established child welfare program and the availability in Ghana of active, flexible structures for conveying health information to communities. At the same time, it would be important to improve the quality of Child Welfare Clinic services, particularly in relation to communication around vaccination.

Community perceptions of malaria and vaccines in two districts of Mozambique.

BACKGROUND: Malaria is a leading cause of mortality and morbidity in Mozambique, with nearly three-quarters of the country's malaria-related deaths occurring in children younger than five years. A malaria vaccine is not yet available, but planning is underway for a possible introduction, as soon as one becomes available. In an effort to inform the planning process, this study explored sociocultural and health communications issues among individuals at the community level who are both responsible for decisions about vaccine use and who are likely to influence decisions about vaccine use. METHODS: Researchers conducted a qualitative study in two malaria-endemic districts in southern Mozambique. Using criterion-based sampling, they conducted 23 focus group discussions and 26 in-depth interviews. Implementation was guided by the engagement of community stakeholders. RESULTS: Community members recognize that malaria contributes to high death rates and affects the workforce, school attendance, and the economy. Vaccines are seen as a means to reduce the threat of childhood illnesses and to keep children and the rest of the community healthy. Perceived constraints to accessing vaccine services include long queues, staff shortages, and a lack of resources at health care facilities. Local leaders play a significant role in motivating caregivers to have their children vaccinated. Participants generally felt that a vaccine could help to prevent malaria, although some voiced concern that the focus was only on young children and not on older children, pregnant women, and the elderly. Probed on their understanding of vaccine efficacy, participants voiced various views, including the perception that while some vaccines did not fully prevent disease they still had important benefits. Overall, it would be essential for local leaders to be involved in the design of specific messages for a future malaria vaccine communications strategy, and for those messages to be translated into local languages. CONCLUSIONS: Acceptance of routine childhood vaccines bodes well for a future malaria vaccine. Vaccinating children is a well-established routine that is viewed favourably in Mozambique. A communications strategy would need to build on existing immunization efforts and use trusted sources-including current government dissemination arrangements-to deliver health information.

Country planning for health interventions under development: lessons from the malaria vaccine decision-making framework and implications for other new interventions.

Traditionally it has taken years or decades for new public health interventions targeting diseases found in developing countries to be accessible to those most in need. One reason for the delay has been insufficient anticipation of the eventual processes and evidence required for decision making by countries. This paper describes research into the anticipated processes and data needed to inform decision making on malaria vaccines, the most advanced of which is still in phase 3 trials. From 2006 to 2008, a series of country consultations in Africa led to the development of a guide to assist countries in preparing their malaria vaccine decision-making frameworks. The guide builds upon the World Health Organization's Vaccine Introduction Guidelines. It identifies the processes and data for decisions, when they would be needed relative to the development timelines of the intervention, and where they will come from. Policy development will be supported by data (e.g. malaria disease burden; roles of other malaria interventions; malaria vaccine impact; economic and financial issues; malaria vaccine efficacy, quality and safety) as will implementation decisions (e.g. programmatic issues and socio-cultural environment). This generic guide can now be applied to any future malaria vaccine. The paper discusses the opportunities and challenges to early planning for country decision-making-from the potential for timely, evidence-informed decisions to the risks of over-promising around an intervention still under development. Careful and well-structured planning by countries is an important way to ensure that new interventions do not remain unused for years or decades after they become available.

Perceptions of malaria and vaccines in Kenya.

Malaria is a leading cause of morbidity and mortality in Kenya. To confront malaria, the Government of Kenya has been implementing and coordinating three approaches - vector control by distributing insecticide-treated bed nets and indoor residual spraying, case management, and the management of malaria during pregnancy. Immunization is recognized as one of the most cost-effective public health interventions. Efforts are underway to develop a malaria vaccine. The most advanced (RTS,S), is currently going through phase 3 trials. Although recent studies show the overwhelming support in the community for the introduction of a malaria vaccine, two issues - culture and the delivery of child immunization services - need to be considered. Alongside the modern methods of malaria control described above, traditional methods coexist and act as barriers to attainment of universal immunization. The gender dimension of the immunization programme (where women are the main child caretakers) will also need to be addressed. There is an age dimension to child immunization programmes. Two age cohorts of parents, caregivers, or family members deserve particular attention. These are the youth who are about to initiate childbearing, and the elderly (particularly mother-in-laws who often play a role in child-rearing). Mothers who are less privileged and socially disadvantaged need particular attention when it comes to child immunization. Access to immunization services is often characterized in some Kenyan rural communities in terms of living near the main road, or in the remote inaccessible areas. Should a malaria vaccine become available in the future, a strategy to integrate it into the immunization programme in Kenya should take into account at least two issues. First, it must address the fact that alongside the formal approach in malaria control, there exist the informal traditional practices among communities. Secondly, it must address particular issues in the delivery of immunization services.

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya.

BACKGROUND: Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level. METHODS: This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. RESULTS: Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. CONCLUSIONS: The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.

From evidence to action? Challenges to policy change and programme delivery for malaria in pregnancy.

This paper discusses the factors that influence whether strategies for preventing and treating malaria in pregnancy are successfully translated into national policy and programme implementation, and identifies key operational research issues. Countries require guidance on how to assess the effectiveness of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine in the context of increasing sulfadoxine-pyrimethamine resistance. At the same time, data on the safety and efficacy of alternatives to sulfadoxine-pyrimethamine for prevention and treatment are urgently needed. Systematic examination of the cultural and operational constraints to delivery and uptake of IPTp with sulfadoxine-pyrimethamine and use of insecticide-treated nets would provide a rational basis for strategies aimed at improving coverage. Standardised methodology must be used to monitor IPTp coverage and to compare different approaches for scaling-up the delivery of insecticide-treated nets to pregnant women. Adequate budgetary provision for the implementation of policy and for operational research to improve programme delivery should be included in national applications to the Global Fund to Fight AIDS, Tuberculosis and Malaria. The provision of clear policy guidance on malaria in pregnancy and its translation into evidence-based guidelines that are made widely available at a country level are central to improving malaria control in this particularly vulnerable group.