How to accelerate the supply of vaccines to all populations worldwide? Part I: Initial industry lessons learned and practical overarching proposals leveraging the COVID-19 situation.

The COVID-19 pandemic has shown itself to be an unprecedented challenge for vaccines which are widely recognized as the most important tool to exit this pandemic. We have witnessed vaccine scientists, developers, manufacturers, and stakeholders deliver several vaccines in just about a year. This is an unprecedented achievement in an environment that was not ready to manage such a global public health crisis. Indeed, the pandemic has highlighted some hurdles that need to be addressed in the system in order to streamline the regulatory processes and be in a situation where life-saving pharmaceutical solutions such as vaccines can be delivered quickly and equitably to people across the globe. More precisely, trade-offs had to be made between the need for regulatory flexibility in the requirements for manufacturing and controls to enable rapid availability of large volumes of vaccines vs the increased stringency and the lack of harmonization in the regulatory environment for vaccines globally. It is also characterized by a high heterogeneity in terms of review and approval processes, limiting equitable and timely access. We review and highlight the challenges relating to several topics, including process validation, comparability, stability, post-approval-changes, release testing, packaging, genetically modified organisms and variants. We see four areas for accelerating access to vaccines which provide solutions for the regulatory concerns, (1) science- and risk-based approaches, (2) global regulatory harmonization, (3) use of reliance, work-sharing, and recognition processes and (4) digitalization. These solutions are not new and have been previously highlighted. In recent months, we have seen some progress at the health authority level, but still much needs to be done. It is now time to reflect on the first lessons learnt from a devastating pandemic to ultimately ensure quick and wide access to medicines and vaccines for the citizens and patients.

How to accelerate the supply of vaccines to all populations worldwide? Part II: Initial industry lessons learned and detailed technical reflections leveraging the COVID-19 situation.

Vaccine discovery and vaccination against preventable diseases are one of most important achievements of the human race. While medical, scientific & technological advancements have kept in pace and found their way into treatment options for a vast majority of diseases, vaccines as a prevention tool in the public health realm are found languishing in the gap between such innovations and their easy availability/accessibility to vulnerable populations. This paradox has been best highlighted during the unprecedented crisis of the COVID-19 pandemic. As part of a two series publication on the vaccine industry's view on how to accelerate the availability of vaccines worldwide, this paper offers a deep dive into detailed proposals to enable this objective. These first-of-its-kind technical proposals gleaned from challenges and learnings from the COVID-19 pandemic are applicable to vaccines that are already on the market for routine pathogens as well as for production of new(er) vaccines for emerging pathogens with a public health threat potential. The technical proposals offer feasible and sustainable solutions in pivotal areas such as process validation, comparability, stability, post-approval changes, release testing, packaging, genetically modified organisms and variants, which are linked to manufacturing and quality control of vaccines. Ultimately these proposals aim to ease high regulatory complexity and heterogeneity surrounding the manufacturing & distribution of vaccines, by advocating the use of (1) Science and Risk based approaches, (2) global regulatory harmonization, (3) use of reliance, work-sharing, and recognition processes and (4) digitalization. Capitalizing & collaborating on such new-world advancements into the science of vaccines will eventually benefit the world by turning vaccines into vaccination, ensuring the health of everyone.

Alignment in post-approval changes (PAC) guidelines in emerging countries may increase timely access to vaccines: An illustrative assessment by manufacturers.

A comparison of the regulations and guidelines from 33 countries, across different regions, on the requirements and procedures for the management of chemical, manufacturing and control (CMC) changes for vaccines, also known as post- approval changes (PACs), reveals significant variability and lack of predictability of timelines for regulatory review and approval. These shortcomings imply that multiple data packages have to be prepared for submission to different authorities, generating a complex regulatory environment. Moreover, the timelines for approval by individual national regulatory authorities are variable, which results in manufacturers keeping various stocks of vaccines produced in accordance with the various approved specifications and procedures, in the different countries. This can seriously affect timely availability of vaccine in those countries. The World Health Organization (WHO) guidelines on procedures and data requirements for changes to approved vaccines provide a consensual framework for alignment, but are still underused. Reliance on both the review and approval by the regulatory authority in the country of manufacturing, or on the review performed by other national regulatory authorities, recognized by WHO as stringent, or on WHO prequalification dossier, offer alternative ways forward. These and other options to improve the management of post-approval changes during the product lifecycle of vaccines are discussed in this report, and aimed at improving guidelines alignment and regulatory convergence to advance immunization equity and coverage.

Opportunities for improving access to vaccines in emerging countries through efficient and aligned registration procedures: An industry perspective.

Vaccines play an essential role in preventing infectious diseases. Their registration in importing countries is often cumbersome and unpredictably lengthy, leading to delays in vaccine access for populations that need them most. This report builds on a previous publication identifying challenges for registration of vaccines in emerging countries. As a matter of social responsibility, it was judged necessary to address the challenges and offer a set of solutions for open dialogue. Based on regular exchange of information and experiences, a group of regulatory experts from the vaccine industry developed three sets of proposals for consideration by vaccine stakeholders, with a view to improving the situation, by fostering regulatory convergence, with viable options for streamlining registration procedures through reliance on other experienced regulators or international agencies. Further, it offers options for alignment of structure and contents of Common Technical Document modules and presents a harmonized template application form that could potentially be used by all countries.

Joint evaluation of marketing authorization files of inactivated polio vaccines in countries of the Eastern Mediterranean Region.

BACKGROUND: In 2012, the World Health Assembly declared ending polio a "programmatic emergency for global public health". In response, the Global Polio Eradication Initiative developed "The Polio Eradication and Endgame Strategic Plan 2013-2018" to address the eradication of all types of poliomyelitis. AIMS: The World Health Organization invited selected countries in the Eastern Mediterranean Region to take part in a joint evaluation of the marketing authorization files of candidate standalone inactivated poliovirus vaccines (IPVs), aimed to facilitate the evaluation process and expedite the timelines for registration. METHODS: This report describes the planning, organization and execution of the joint meeting among 6 countries of Eastern Mediterranean Region. RESULTS: Participants prepared a joint list of questions and concerns which was shared and discussed with the respective manufacturers on the last day of the review. Manufacturer provided answers to the questions. The questions that could not be responded to immediately by the manufacturer remained to be addressed after the meeting directly between the manufacturer and the national regulatory authoritys. A final joint evaluation report was prepared before the end of the meeting by the participating countries. CONCLUSIONS: The report focuses on the benefits of the exercise and highlights its shortcomings as a sole strategy to secure the timely registration of the vaccine in target countries. We discuss additional aspects to be addressed to effectively accelerate registration, and hence access to priority vaccines.

Challenges for the registration of vaccines in emerging countries: Differences in dossier requirements, application and evaluation processes.

The divergence of regulatory requirements and processes in developing and emerging countries contributes to hamper vaccines' registration, and therefore delay access to high-quality, safe and efficacious vaccines for their respective populations. This report focuses on providing insights on the heterogeneity of registration requirements in terms of numbering structure and overall content of dossiers for marketing authorisation applications for vaccines in different areas of the world. While it also illustrates the divergence of regulatory processes in general, as well as the need to avoid redundant reviews, it does not claim to provide a comprehensive view of all processes nor existing facilitating mechanisms, nor is it intended to touch upon the differences in assessments made by different regulatory authorities. This report describes the work analysed by regulatory experts from vaccine manufacturing companies during a meeting held in Geneva in May 2017, in identifying and quantifying differences in the requirements for vaccine registration in three aspects for comparison: the dossier numbering structure and contents, the application forms, and the evaluation procedures, in different countries and regions. The Module 1 of the Common Technical Document (CTD) of 10 countries were compared. Modules 2-5 of the CTDs of two regions and three countries were compared to the CTD of the US FDA. The application forms of eight countries were compared and the registration procedures of 134 importing countries were compared as well. The analysis indicates a high degree of divergence in numbering structure and content requirements. Possible interventions that would lead to significant improvements in registration efficiency include alignment in CTD numbering structure, a standardised model-application form, and better convergence of evaluation procedures.

Improving safety, quality and efficacy of medicines in the Americas / Mejora de la seguridad, calidad y eficacia de los medicamentos en la Región de las Américas

In the Region of the Americas, access to medicines and other health technologies constitutes a priority for countries as they continue to move towards universal access to health and universal health coverage. Ensuring the availability of affordable medicines and health technologies within health services is required as part of the comprehensive approach to disease prevention and control. Through the adoption of pharmaceutical policies and strategies at the national level, governments establish the framework that will ensure equitable access and affordability of medicines and health technologies, while promoting their rational use. Core to such policies and strategies is the principle of quality, safety and efficacy. The pharmaceutical and health technology sector plays a critical role in the health promotion and protection by ensuring that those products and technologies made available through the health systems respond to international norms of quality and safety. The role of the government, and in particular the ministry of health, jointly with interested stakeholders, is to create a regulatory environment that guarantees the quality of the product throughout its life cycle, to ensure patient safety and optimize health outcomes. As globalization continues, with an ever increasing flow of people and products across borders, product quality and safety becomes a co-responsibility between countries and interconnected regulatory systems—nationally, regionally and globally. The regulatory landscape for medicines and health technologies is complex, given the multiple different types of product (medicines, biologicals, medical devices, etc.), the co-existing of single, limited and multiple source products within the market, the increasing technological complexity of new products entering the market (genomic, biotechnical products, etc.), and the critical array of regulatory functions (clinical studies, manufacturing, distribution, post marketing surveillance, etc.)...

Mejora de la seguridad, calidad y eficacia de los medicamentos en la Región de las Américas

En la Región de las Américas, el acceso a los medicamentos y otras tecnologías sanitarias constituye una prioridad para los países en su avance hacia el acceso universal a la salud y la cobertura universal de salud. Es necesario asegurar la disponibilidad de medicamentos y tecnologías sanitarias asequibles dentro de los servicios de salud como parte del abordaje integral de la prevención y el control de las enfermedades. Mediante la adopción de políticas y estrategias farmacéuticas a nivel nacional, los gobiernos establecen el marco que garantizará el acceso equitativo y la asequibilidad de los medicamentos y las tecnologías sanitarias, al tiempo que promueve su uso racional. El principio de calidad, seguridad y eficacia ocupa un papel central en tales políticas y estrategias. El sector farmacéutico y de la tecnología sanitaria desempeña una función crucial en la promoción y protección de la salud al asegurar que los productos y tecnologías que se ponen a disposición de las personas por intermedio de los sistemas de salud respondan a las normas internacionales de calidad y seguridad. La función del gobierno y en particular del ministerio de salud, conjuntamente con los interesados directos, es crear un entorno de regulación que garantice la calidad del producto a lo largo de toda su vida útil, garantizar la seguridad para el paciente y optimizar los resultados en materia de salud...

Regulatory Pathways That Facilitated Timely Registration of a New Group A Meningococcal Conjugate Vaccine for Africa's Meningitis Belt Countries.

BACKGROUND: Through its normative and public health leadership roles, the World Health Organization (WHO) plays a key role in the availability of vaccine products in low-and middle-income countries. The recent introduction of a new group A meningococcal conjugate vaccine, PsA-TT (MenAfriVac), in Africa exemplifies this process. WHO requires that any new vaccine to be introduced in countries for public health reasons and supplied through United Nations centralized mechanisms be licensed by the national regulatory agency (NRA) in the producing country, then prequalified and given a marketing authorization in the user countries. METHODS: PsA-TT was manufactured by the Serum Institute of India, Ltd (SIIL), which submitted a license application in April 2009 to the Drug Controller General of India (DCGI), the Indian NRA responsible for licensing vaccines. WHO encouraged the DCGI to establish a collaboration with Health Canada's Centre for Vaccine Evaluation for the review. Through this collaborative effort, registration was facilitated and in December 2009 an export license was granted to SIIL, which subsequently submitted an application for WHO prequalification. RESULTS: Given the importance of the vaccine, WHO "fast tracked" the prequalification review, and after a detailed review and site visit, WHO prequalification was granted to PsA-TT in June 2010. Country use of the new vaccine could not occur until the vaccine was a registered product in each country seeking its use. WHO facilitated country reviews by conducting regulatory training exercises (in French and English) for country NRA staff, which used the PsA-TT registration as a case study. CONCLUSIONS: PsA-TT was gradually registered in African countries as vaccine introduction proceeded. The regulatory pathway for this new group A meningococcal conjugate vaccine proved to be a useful training opportunity both in India and Africa, because the availability of the vaccine was a high African public health priority, as well as for WHO as a case study to facilitate registration of vaccines based on reliance on other regulatory bodies.

Twenty-five years of the WHO vaccines prequalification programme (1987-2012): lessons learned and future perspectives.

The World Health Organization (WHO) vaccines prequalification programme was established in 1987. It is a service provided to United Nations procurement agencies to ensure that the vaccines supplied through these agencies are consistently safe and effective under conditions of use in national immunization programmes. This review describes the purpose and aims of the programme, its evolution during 25 years of existence, its added value, and its role in the context of the WHO strategy to ensure the global availability of vaccines of assured quality. The rationale for changes introduced during the implementation of the programme is provided. The paper also discusses the resources involved, both human and financial, its performance, strengths and weaknesses and steps taken to maximize its efficiency. This historical perspective is used to inform proposed future changes to the service.

Vaccine quality--can a single standard be defined?

To analyze the current global situation with respect to vaccine quality and to monitor progress in attaining it, it is first necessary to define what this means. While acknowledging that manufacturers are responsible for the quality of the vaccines they produce, World Health Organization (WHO) proposes a definition for "vaccines of assured quality" which depends on the existence of a competent and fully functional regulatory authority as assessed by an external expert team using widely agreed indicators to regulate the product. A vaccine of assured quality is defined as one that consistently meets appropriate levels of purity, potency, safety and efficacy as judged through an independent review system competent to take an evidence-based decision on the product for a specified population in a specific context. Such a review system would make use of all available information, such as licensing dossiers, surveillance of field performance, lot-by-lot scrutiny, appropriate laboratory testing, cGMP inspection of manufacturers, and evaluation of clinical trials, generally assumed by a fully functional regulatory authority. This definition implies that, faced with the same risk/benefit, any competent group would come to the same decision. The definition also indicates clear pathways to improve vaccine quality by strengthening national regulatory authorities and WHO is actively engaged in this task. By insisting on competent regulatory oversight, while recognizing the role of risk analysis in the selection of vaccines for use, WHO strongly reiterates the need for a single standard of quality. Only vaccine of assured quality should be considered for use in national immunization programs on the basis of the risk/benefit ratio for the particular population.

Vacuna antirrabica de cerebro de raton lactante: Composicion antigenica y capacidad inmunogena / Suckling mouse brain rabies vaccine: Antigenic composition and immunogenic capacity

Suckling mouse brain (SMB) rabies vaccine is the preparation most widely used in the countries of Latin América and the Caribbean. This vaccine, prepared according to the Fuenzalida and Palacios method, consists of three fixed rabies virus strains (CVS, 51, and 91). However, the World Health Organization recommends that rabies vaccines for human use be prepared using only a single strain of this virus. In order to determine whether any one of the antigens of the SMB vaccine could be eliminated from the preparation, the immunogenic capacity of the standard trivalent SMB vaccine was compared with that of experimental bivalent (CVS-51, CVS-91, and 51-91) and monovalent (CVS, 51, and 91) SMB vaccines. The study was conducted using adult and suckling albino mice provided by the laboratory at the Pan Américan Zoonoses Center, Buenos Aires, Argentina, and different strains of fixed and street rabies virus. The experimental vaccines were prepared using the Fuenzalida-Palacios method. Potency and cross-immunity tests were conducted. The result showed that the trivalent vaccine was the most effective in protecting the mice againg both fixed and street rabies virus infections and also in inducing rapid development of neutralizing antibody at high titers

La técnica de contrainmunoelectroforesis para la determinación de anticuerpos antirábicos / Counterimmunoelectrophoresis technique for the detection of rabies antibodies

Se evalúa reproducibilidad técnica de contrainmunoelectroforesis (CIE) para la deteminación de anticuerpos antirrábicos. En el estudio participaron cuatro laboratorios que utilizaron los mismos reactivos estandarizados y sueros codificados en el Centro Panamericano de Zoonosis (CEPANZO). Los títulos de los sueros obtenidos en pruebas de seroneutralización en ratón que se realizaron en el CEPANZO se compararon con aquellos obtenidos por CIE en los otros laboratorios. Los resultados demostraron que la sensibilidad y especificidad de la técnica fueron adecuadas. Los títulos del antígeno y del suero indicador fueron reproducibles. No se pudieron demostrar diferencias estadísticamente signicativas entre las pendientes de las rectas de regresión. Los coeficientes de correlación oscilaron entre 0,6 y 0,85. Se pudo confirmar que es posible estimar los títulos de anticuerpos neutralizantes en función de los que se obtienen por CIE. Esta técnica puede resultar útil a aquellos laboratorios de diagnóstico de rabia que necesiten realizar controles serológicos rápidos y económicos