Meeting Report MEETING OF NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUPS FOR ASEAN COUNTRIES - World Health Organization

 
Meeting Report MEETING OF NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUPS FOR ASEAN COUNTRIES - World Health Organization
Meeting Report

MEETING OF NATIONAL IMMUNIZATION
 TECHNICAL ADVISORY GROUPS FOR
        ASEAN COUNTRIES

       23–24 September 2019
       Kuala Lumpur, Malaysia
Meeting Report MEETING OF NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUPS FOR ASEAN COUNTRIES - World Health Organization
Meeting of National Immunization Technical Advisory Groups for ASEAN Countries
                           23–24 September 2019
                           Kuala Lumpur, Malaysia
WORLD HEALTH ORGANIZATION
            REGIONAL OFFICE FOR THE WESTERN PACIFIC

RS/2019/GE/49 (MYS)                                             English only

                               MEETING REPORT

MEETING OF NATIONAL IMMUNIZATION TECHNICAL ADVISORY GROUPS
                    FOR ASEAN COUNTRIES

                                  Convened by:

                 WORLD HEALTH ORGANIZATION
            REGIONAL OFFICE FOR THE WESTERN PACIFIC

                             Kuala Lumpur, Malaysia
                              23–24 September 2019

                                   Not for sale

                            Printed and distributed by:

                           World Health Organization
                      Regional Office for the Western Pacific
                               Manila, Philippines

                                   March 2020
NOTE

The views expressed in this report are those of the participants of the Meeting of National
Immunization Technical Advisory Groups for ASEAN Countries and do not necessarily reflect the
policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific
for Member States in the Region and for those who participated in the Meeting of National
Immunization Technical Advisory Groups for ASEAN Countries in Kuala Lumpur, Malaysia
from 23 to 24 September 2019.
CONTENTS

SUMMARY ........................................................................................................................................................... 1
1. INTRODUCTION .......................................................................................................................................... 3
  1.1      Meeting organization ............................................................................................................................ 3
  1.2      Meeting objectives ................................................................................................................................ 3
2. PROCEEDINGS ............................................................................................................................................. 4
  2.1      Opening ................................................................................................................................................. 4
  2.2      Overview of immunization programmes and VPD control in the Western Pacific Region: evaluation,
           progress and achievements ................................................................................................................... 4
  2.3      Overview of immunization programmes and VPD control in the South-East Asia Region .................. 5
  2.4      Population movement and migration in Asia and their impact on immunization programme .............. 6
  2.5      Evidence-based decision for immunization programme and roles of NITAGs..................................... 7
     2.5.1 Global updates on NITAG establishment and strengthening activities ............................................. 7
     2.5.2 Experience on evidence-based decision-making process from the Australian Technical Advisory
             Group on Immunization .................................................................................................................... 7
     2.5.3 Brunei Darussalam ............................................................................................................................ 8
     2.5.4 Cambodia .......................................................................................................................................... 9
     2.5.5 Indonesia ........................................................................................................................................... 9
     2.5.6 Lao People’s Democratic Republic ................................................................................................... 9
     2.5.7 Malaysia .......................................................................................................................................... 10
     2.5.8 Myanmar ......................................................................................................................................... 10
     2.5.9 Philippines ....................................................................................................................................... 11
     2.5.10 Singapore ........................................................................................................................................ 11
     2.5.11 Thailand .......................................................................................................................................... 12
     2.5.12 Viet Nam’s National Immunization Technical Advisory Groups: membership, functions and mode
             of operation ..................................................................................................................................... 12
  2.6      Capacity-building and networking among NITAGs ........................................................................... 12
     2.6.1 Updates from recent NITAG meeting from the South-East Asia Region ....................................... 12
     2.6.2 Study tour experience from the Lao People’s Democratic Republic............................................... 13
     2.6.3 Group work: discuss ways of synergistic interaction and mutual collaboration and priority actions
             for strengthening NITAGs of ASEAN countries ............................................................................ 14
  2.7      Feasibility of pooled procurement of vaccines .................................................................................... 16
     2.7.1 Revolving Fund – experience from the Pan-American Health Organization: vaccine planning,
             financing and pooled procurement in Latin America and the Caribbean ........................................ 16
     2.7.2 Updates from workshops on ASEAN Vaccine Security and Self-Reliance (AVSSR).................... 16
     2.7.3 Survey on pooled procurement of vaccines in the Western Pacific Region .................................... 17
     2.7.4 Vaccine production capacity ........................................................................................................... 18
3. CONCLUSIONS AND RECOMMENDATIONS ....................................................................................... 19
  3.1      Conclusions ......................................................................................................................................... 19
  3.2      Recommendations ............................................................................................................................... 20
     3.2.1 Recommendations for Member States ............................................................................................ 20
     3.2.2 Recommendations for WHO ........................................................................................................... 20
ANNEXES ........................................................................................................................................................... 23
  Annex 1. Agenda
  Annex 2. List of participants, temporary advisers, observers and Secretariat

  Immunization / Vaccines / Regional health planning / Southeast Asia
ABBREVIATIONS

ASEAN   Association of Southeast Asian Nations
EPI     Expanded Programme on Immunization
GNN     Global NITAG Network
HPV     human papillomavirus
JE      Japanese encephalitis
NIP     National Immunization Programme
NITAG   National Immunization Technical Advisory Group
PAHO    Pan-American Health Organization
PCV     pneumococcal conjugate vaccine
RITAG   Regional Immunization Technical Advisory Group
TAG     Technical Advisory Group
VPD     vaccine-preventable disease
VDPV    vaccine-derived poliovirus
WHO     World Health Organization
SUMMARY

Participants from nine Member States and territories along with representatives from four partner
agencies attended a two-day meeting in Kuala Lumpur, Malaysia on 23–24 September 2019 to discuss
National Immunization Technical Advisory Groups (NITAGs) of countries within the Association of
Southeast Asian Nations (ASEAN) region. Participants shared the status of their NITAGs, or equivalent
advisory bodies, and identified strengths and challenges. Using the information shared, participants
identified common immunization programme issues and proposed priority action points for
strengthening the NITAGs of ASEAN countries.

Functioning as a technical advisory group, NITAGs provide evidence-based immunization-related
recommendations to national policy-makers and programme managers. The establishment of a
functional NITAG in each Member State is one of the strategies to achieve the goals of the Global
Vaccine Action Plan, which was endorsed by the World Health Assembly in 2012. Since then, the
World Health Organization (WHO), in collaboration with other development partners, has been
supporting Member States to establish and strengthen NITAGs. ASEAN’s Post-2015 Health
Development Agenda also serves as a solid foundation to strengthen NITAGs by promoting resilient
health systems as well as prevention and control of communicable diseases within its 10 Member States.

The independence of ASEAN NITAGs allows ministries to make decisions using evidence-based
advice for increased public credibility on immunization-related issues. Some NITAGs are able to
separate their technical advice on safety, efficacy, and need for new vaccine introduction from financial
considerations. All countries demonstrated ongoing efforts to strengthen NITAGs through ongoing
staff trainings and regular meetings. Most NITAGs have diverse membership and demonstrate that
they consider conflicts of interest of members but not a process for the management of such.
Accountability for evidence sits with NITAGs, and they are responsible to the health ministries for
providing appropriate advice.

WHO will continue to advocate with national governments to ensure adequate funding support for
NITAGs. Efforts will be geared towards strengthening ASEAN NITAGs through self-assessment,
external evaluations and peer-to-peer trainings. Multilevel communication between national and
regional advisory groups will continue to be coordinated by WHO with the purpose of monitoring the
implementation of regional strategic frameworks and country-specific priorities. WHO will also
continue its cross-collaboration and coordination with ASEAN’s Vaccine Security and Self-Reliance
initiative while exploring opportunities for pooled procurement, harmonization of regulatory standards,
and vaccine research and development with UNICEF’s Vaccine Independence Initiative. Efforts to
develop a network of ASEAN NITAGs in cooperation with the ASEAN Secretariat and other partners.

Member States will advocate for funding to support a strong NITAG secretariat. Technical groups
should be established to assemble evidence to support the NITAG’s advice on immunization-related
policies. Member States are instructed to operationalize NITAG workplans while incorporating
monitoring and evaluation mechanisms that assess the implementation of recommendations.
Self-assessments and/or external assessments should also be considered. Annual NITAG workplans
should also be aligned with national, regional and global strategic frameworks and goals.

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1.    INTRODUCTION

1.1     Meeting organization

National immunization technical advisory groups (NITAGs) provide advice and guidance to national
policy-makers and programme managers to enable them to make evidence-based decisions for
immunization-related policy and programmes while promoting country ownership. Establishing a
functional NITAG in each Member State is one strategy to achieve the goals of the Global Vaccine
Action Plan, which was endorsed by the World Health Assembly in 2012. Since 2012, the World Health
Organization (WHO), in collaboration with other development partners, has been providing support to
Member States to establish and strengthen NITAGs.

The Association of Southeast Asian Nations (ASEAN) was established to promote regional peace and
stability through active collaboration and mutual assistance in technical and scientific matters.
To promote a healthy and caring ASEAN community, countries have adopted the ASEAN Post-2015
Health Development Agenda (2016–2020), which aims to promote resilient health system as well as
prevention and control of communicable diseases. This platform and shared agenda among the
10 ASEAN countries provides WHO with a solid foundation to strengthen the NITAGs in the
South-East Asia and Western Pacific regions. Considering common immunization policy and
programme issues, particularly immunization service delivery and vaccine-preventable disease (VPD)
notification among cross-border and migrant populations in countries of the South-East Region, the
Expanded Programme on Immunization (EPI) teams from the Western Pacific Region, in collaboration
with the team from the South-East Asia Region, organized a two-day meeting of NITAGs for
ASEAN countries in Kuala Lumpur, Malaysia, on 23–24 September 2019.

1.2     Meeting objectives

The WHO Regional Office for the Western Pacific convenes annual meetings of its Technical Advisory
Group (TAG) on Immunization and VPDs. The conclusions and recommendations of the TAG meeting
in June 2019 included: (1) Member States to strengthen the functionality and effectiveness of NITAGs
or equivalent immunization decision-making bodies to support the formulation of evidence-based
immunization policy; and (2) WHO to continue to provide technical support and capacity-building for
the development of national plans for evidence‐based introduction of new vaccines. Establishment of
a functional NITAG in each Member State is a step towards achieving the goals of the Global Vaccine
Action Plan, and WHO in the Western Pacific Region has been supporting the strengthening of NITAGs.
The ASEAN health promotion initiative on control of communicable diseases provides a good
opportunity for the WHO Western Pacific and South-East Asia regional offices to work together to
support strong NITAGs.

The participants of the two-day meeting presented on evidence-based decision-making and the roles of
NITAGs for each country. Discussions on the second day included capacity-building and networking
among NITAGs. Experiences and feasibility of pooled procurement of vaccines were also considered.

The objectives of the meeting were:
   1)   to review the current status of NITAGs, identify common immunization policy and programme
        issues, and share experience between NITAGs of ASEAN countries; and
   2)   to discuss ways of synergistic interaction and mutual collaboration and priority actions for
        strengthening NITAGs of ASEAN countries.

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2.      PROCEEDINGS

2.1     Opening

Dr Ying-Ru Lo, WHO Representative for Malaysia, Singapore and Brunei Darussalam, in her opening
remarks communicate the importance of NITAGs in supporting evidence-based decision-making by
providing advice that is independent and credible. She encouraged attending members to share
experiences on ways to create synergies and strengthen NITAGs with the common goal of preventing
VPDs throughout the ASEAN region. Following these remarks, Dr Sahib, Deputy Director of
Communicable Diseases, Malaysia Ministry of Health, welcomed participants to the meeting.

2.2     Overview of immunization programmes and VPD control in the Western Pacific
        Region: evaluation, progress and achievements

Dr Yoshihiro Takashima, EPI Coordinator, WHO Regional Office for the Western Pacific

The Western Pacific Region consists of 37 countries and areas, of which seven are ASEAN countries.
Between 1988 and 2018, the Region has achieved much progress. The polio eradication initiative was
started in 1988, with South Asia and East Asia recording 6000 polio cases in 1990. Thanks to strong
efforts by Member States, however, rates were reduced. In 1997, Cambodia reported the last cases of
wild poliovirus, and the Region became polio-free in 2000.

In 2003, the regional measles elimination initiative was started. In 2018, nine countries and areas in the
Western Pacific Region had been verified as having achieved measles elimination (Australia,
Brunei Darussalam, Cambodia, Hong Kong SAR (China), Japan, Republic of Korea, Macao SAR
(China), New Zealand and Singapore). In 2018, five countries and areas (Australia, Brunei Darussalam,
Republic of Korea, Macao SAR (China) and New Zealand) had been verified as having achieved rubella
elimination. Before 2000, six countries (Cambodia, China, Lao People’s Democratic Republic,
Papua New Guinea, Philippines and Viet Nam) had high mortality due to maternal and neonatal tetanus,
but they have now achieved elimination through their strong efforts in implementing the strategies of
WHO and the United Nations Children’s Fund (UNICEF). To date, only Papua New Guinea needs
support to reach this goal.

Chronic hepatitis B affects more than 8% of the Region’s population. Prevalence of hepatitis B surface
antigen among 5-year-old children was less than 1% in 2012, reaching target goals. Pneumococcal
conjugate vaccine (PCV) has been introduced in 17 countries, and 13 countries have included human
papillomavirus (HPV) vaccine. To accelerate the control and elimination of VPD, the Western Pacific
has developed a regionwide laboratory network, which started with the polio regional network in 1990;
since 1998, the measles and rubella network has been developed. In 2008, Japanese encephalitis (JE)
and rotavirus were added to the network. In addition to VPD laboratory data, Member States in the
Region have established shared case-based surveillance systems for acute flaccid paralysis (AFP),
measles and rubella, JE, invasive bacterial vaccine-preventable diseases (IB-VPD), and rotavirus.
The Regional Framework for Implementation of the Global Vaccine Action Plan in the Western Pacific
has eight immunization goals: sustaining polio-free status; maternal and neonatal tetanus elimination;
measles elimination; accelerated control of hepatitis B; rubella elimination; introduction of new
vaccines; meeting regional vaccination coverage targets; and accelerated control of JE.

As of 2019, six of the eight goals have been achieved, with measles elimination and meeting regional
immunization coverage rates are still lagging. Challenges to be addressed during the next decade
will include measles resurgence with increased importations of measles; diphtheria outbreaks
(Lao People’s Democratic Republic, Viet Nam, Malaysia and Philippines); and vaccine-derived
poliovirus (VDPV). In 2000, the Western Pacific Region was declared polio-free; this has been
sustained with the exception of a large wild poliovirus outbreak in China that was imported from
Pakistan in 2011. From 2001 to 2012, there were small-scale outbreaks due to circulating VDPV in the

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Region, but the large-scale outbreaks in the last four years have been due to wild types of poliovirus.
Two months ago, there was circulation of wild poliovirus type 2 in the Philippines and China.

Future challenges in the Region include: growing population; expanding urbanization; increases in
immigration and non-state citizens; vaccine hesitancy; countries transitioning from financial support
granted by Gavi, the Global Fund and the Global Polio Eradication Initiative; new global eradication
initiatives; repeated outbreaks; increased VPD incidence among other children and adolescents; fewer
new vaccines; increased needs and unstable global vaccine supply (i.e. stock-outs) and interrupted
immunization services; and diversifying country needs and goals. Immunization programmes will play
important roles in reaching the Sustainable Development Goals (SDGs), such as SDG3 to “ensure
healthy lives and promote well-being for all at all ages”, and in achieving universal health
coverage (UHC) over the next decade.

WHO headquarters is working with global immunization partners towards developing an agenda for
2020–2030 that will be submitted and reviewed by Member States at the next World Health Assembly.
The South-East Asia and Western Pacific regions are also in the process of developing a regional plan
for 2030. Member States and the WHO Secretariat will consider the strategic direction, which must
sustain gains and achieve the immunization goals while strengthening preparedness for public health
emergencies related to VPDs and promote integration of service delivery and the strategy for disease
elimination initiatives along with financing and laboratory surveillance. Expanding immunization
services along the life course will provide immunization for adolescents, adults and older people and
will also address demographic changes that promote a differentiated approach for different
immunization issues, such as minority groups in middle-income countries. National country ownership
of financing will be promoted with enhanced partnership and synergy between the health ministry,
WHO and other partners. Strategic objectives for the next decade aim to achieve existing goals and
strengthen and expand immunization systems and programmes and to manage health intelligence on
VPD and immunization and prepare for and respond to public health emergencies related to VPD, with
the outcome to control and eliminate more VPDs by 2030. These will be reached through synergy in
three areas: universal health coverage, healthier populations/noncommunicable diseases and ageing,
and health security and emergencies/environment and climate change.

Questions and answers related to the role of social media in promoting vaccine hesitancy and recent
concerns in Muslim countries regarding the requirement that vaccines be certified halal. The solution
could involve understanding parents’ views and working with religious groups. Hesitancy will be a
core focus in the upcoming regional strategic framework. It was also noted that reporting of adverse
events following immunization (AEFI) can potentially cause a public health emergency (for example
the dengue vaccine in the Philippines).

2.3     Overview of immunization programmes and VPD control in the South-East Asia Region

Dr Sudhir Khanal, Technical Officer, Immunization and Vaccine Development                       (IVD),
WHO Regional Office for South-East Asia

The WHO South-East Asia Region comprises 11 Member States that have endorsed the South-East
Asia Regional Vaccine Action Plan 2016–2020. The annual review of the Plan’s eight goals in 2019
showed that all goals are on track, except for measles elimination and rubella/congenital rubella
syndrome (CRS) control, which is off track.

An overview of progress towards all eight goals was presented. In terms of the routine immunization
goal, there has been significant progress on immunization systems strengthening in the Region. As a
result, most Member States have reached coverage with the diphtheria–tetanus–pertussis (DTP3)
vaccine of above 90%. Out of all routine vaccines, coverage of inactivated polio vaccine (IPV) and
second dose of measles-containing vaccine (MCV2) has been suboptimal for multiple reasons, but
efforts to improve these coverage levels are ongoing. Global coverage of DTP3 is stagnant, but the
Region’s coverage is improving. There have been more than 18 000 cases of diphtheria in the Region
due to waning immunity and vaccination gaps.

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Over the last 18 years, coverage for measles-containing vaccine (MCV) has increased. As a result, the
number of measles cases has decreased, although Myanmar and Thailand saw increased numbers in
2018. Five countries (Bhutan, Democratic People’s Republic of Korea, Maldives, Sri Lanka and
Timor-Leste) have been verified as having eliminated measles. Regional coverage of rubella-
containing vaccine (RCV) has reached 83%, and six countries have been verified as having controlled
rubella/congenital rubella syndrome. In 2017, a midterm review of the Strategic Plan for Measles
Elimination and Rubella and Congenital Rubella Syndrome Control in the South-East Asia Region,
2014–2020 concluded that, while significant progress has been made, the Region is off track for measles
elimination and rubella control.

Polio-free status has been maintained, and no wild poliovirus type cases have been reported since 2011.
Vaccine-derived poliovirus type 1 (VDPV1) was detected in Myanmar in June 2019. A polio transition
plan has been developed in five countries (Bangladesh, India, Indonesia, Myanmar and Nepal), and
work is being conducted with partners and countries to mobilize resources for these efforts. JE vaccine
was introduced nationwide in four countries (Myanmar, Nepal, Sri Lanka and Thailand), while
two countries (India and Indonesia) have introduced it in high-risk areas. All countries have introduced
hepatitis B vaccine in their national immunization programme (NIP) schedules, and eight countries are
providing hepatitis B birth dose. A regional expert panel has verified hepatitis B control in four
countries (Bangladesh, Bhutan, Nepal and Thailand) in the Region. All 11 countries have introduced
at least one new vaccine either at national or subnational levels or to high-risk areas/populations.
Three out of the 11 countries manufacture WHO prequalified (WHO-PQ) vaccines; another
three countries self-procure and two have mixed procurement processes. All countries report vaccine
pricing data to the WHO through the WHO/UNICEF Joint Reporting Form (JRF) for the Vaccine
Product, Price and Procurement (V3P) database/Market Information for Access to Vaccines (MI4A).

2.4     Population movement and migration in Asia and their impact on immunization
        programme

Dr Leena Bhandari, Chief Migration Health Officer, International Organization for Migration

Migration patterns in the South-East Asia and Western Pacific regions are unprecedented, and the
population is likely to grow due to political and economic circumstances. It is estimated that East Asia
will require 275 million immigrants aged 15–64 years by 2030 to maintain a steady working-age
population. These circumstances, along with environmental impacts caused by climate change, will
promote more migration in the ASEAN region. At the World Health Assembly in 2019, Member States
advocated the promotion of health of refugees and migrants. Health threats in remote parts of the world
can spread, and many countries are not prepared for such threats. Immunization is the most
cost-effective public health intervention, annually preventing 1.5 million deaths, although global
vaccine coverage has stagnated in recent years. There have been achievements in the region, including
the cessation of wild poliovirus and a reduction in measles, JE and hepatitis B transmission.
High-quality in-country and regional surveillance systems have been established, improving the
measurement of the burden of VPDs and providing information for effective disease outbreak responses
and vaccine effectiveness.

The United Nations High Commissioner for Refugees (UNHCR), UNICEF and WHO have
recommended that refugees and migrants be immunized following the schedule of their host countries,
but there have been large gaps in providing and financing targeted health services for such populations.
One of the main health challenges is the lack of comprehensive health policies. Given the high
transmissibility of VPDs combined with the harsh living condition of migrants, children are especially
vulnerable to infections. Genetic sequencing in India has shown an association between VDPV
infections and migration. Information gaps related to immunization schedules coupled with language
barriers affect the health care of migrants. Undocumented status does not allow them to access health
services, resulting in poor health outcomes among migrant children. Health promotion in schools to
migrant children should therefore be considered. Non-exclusive policies through cross-border
collaboration should be in place to better serve the health needs of vulnerable migrant populations.

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Critical areas for investment, such as strengthened human resources, implementation costs, vaccine cold
chain and storage should be considered by partners and UN agencies. Immunization services should be
tailored for groups that have suboptimal coverage.

2.5     Evidence-based decision for immunization programme and roles of NITAGs

2.5.1   Global updates on NITAG establishment and strengthening activities

Ms Louise Henaff, Technical Officer, Department of Immunization, Vaccines and Biologicals,
WHO headquarters

In 2010–2018, the number of countries with NITAGs fulfilling all Global Vaccine Action Plan
requirements almost tripled from 41 to 114. As a result, around 85% of the world’s population resides
in countries with well-functioning NITAGs. Throughout the years, their role has expanded from
providing evidence-based recommendations on new vaccine introduction to general recommendations
on NIPs. As a result, trainings have been a major component for NITAG strengthening. Guidelines
with training materials are made available to all country NITAGs through the NITAG Resource Center
(NRC), an online resource platform.

WHO headquarters supports regional initiatives where NITAGs can network and collaborate via
subregional trainings. Recommendations and workplans of other countries are shared to strengthen
NITAGs and to build capacity. The preliminary results of a scoping exercise by WHO headquarters
show that a three-day workshop is sufficient for a successful NITAG training. Materials should be
tailored to each country’s context, and follow-up is critical for capacity-building. Creative approaches
are also encouraged for post-training workshops.

Future WHO efforts at the global level include revamping the NITAG Resource Center, which was first
launched in 2015 with the purpose of centralizing information related to guidelines, trainings, and
information on NITAGs. A new website will be available in January 2020.

The 4th Annual Global NITAG Network (GNN) Meeting is scheduled to take place in February 2020.
The network’s main objective is to function as a global platform to efficiently share knowledge while
liaising with regional NITAG networks to address country-specific needs that strengthen processes for
evidence-based decision-making. The Meeting will be co-organized with the United States Centers for
Disease Control and Prevention (US CDC) and will take place back to back with the US Advisory
Committee on Immunization Practices (US ACIP) meeting, allowing GNN participants to also attend
the American NITAG meeting. GNN membership allows NITAG members to have access to policy
updates, engage with other NITAG members, and participate in GNN and regional meetings to
contribute on strategic issues. As a GNN member, responsibilities include participating in surveys,
providing input to GNN documents, attending GNN-organized meetings and actively communicating
updated information on country NITAGs to the GNN secretariat. There are four areas of work outlined
in the GNN workplan: knowledge sharing, evaluation, capacity-building and meeting structures.

Moving forward, WHO headquarters will work on revamping the NITAG Resource Center, establishing
a GNN working group on training, revising training materials, and developing new guidelines and
training materials.

2.5.2   Experience on evidence-based decision-making process from the Australian Technical
        Advisory Group on Immunization

Professor Ross Andrews, Epidemiologist, Global and Tropical Health Division, Menzies School of
Health Research, Darwin, Australia

Australia has a birth cohort of 300 000 children who are offered protection against 17 VPDs across
eight states and territories through a government-funded vaccination programme. The Australian

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Technical Advisory Group on Immunization (ATAGI) provides advice on whether vaccines should be
included in the NIP based on evidence of vaccine safety, efficacy, disease burden and other
considerations. Its function is to equip the Minister for Health with necessary advice to improve the
uptake and equity of access to vaccines. The ATAGI recommendations are an output of two processes:
the preparatory phase and the pre-submission phase, which requires the participation of
manufacturers/suppliers, an independent ATAGI Working Group and the Pharmaceutical Benefits
Advisory Committee (PBAC). A key pillar of the new vaccine introduction recommendation process
is ATAGI’s annual meeting with manufacturers. A working group is established and supported by the
National Centre for Immunisation Research and Surveillance (NCIRS). This advice pathway identifies
key questions and gathers data from the review of published and unpublished literature. Knowledge
gaps are identified, and evidence is provided for discussion, but ATAGI provides the final
recommendation. There are typically nine steps in generating recommendations: key questions,
gathering data, epidemiological review, vaccine characteristics, important factors, identify gaps, draft
recommendations, discuss at ATAGI and profile output. Vaccines are not introduced into the NIP
unless there are positive recommendations from the PBAC, which is a separate decision-making body.

As an ATAGI member, responsibilities include providing technical advice and clinical guidance on the
medical administration of vaccines, review of ATAGI publications and its operational procedures. The
PBAC decides whether the cost of the vaccine will be reimbursed by the government based on an
internal tendering process with industry. The recently established Australian Regional Immunisation
Alliance (ARIA), for example, is another independent group that collaborates with governments and
global immunization partners, nongovernmental organizations and other partners with the aim of
strengthening immunization to reduce the impact of VPDs in Australia and the WHO South-East Asia
and Western Pacific regions.

2.5.3   Brunei Darussalam

Dr Linda Lai, Senior Medical Officer, Child Health Immunization, EPI Manager, Ministry of Health

Brunei Darussalam is a small nation located in northern Borneo that is divided into four main districts.
Childhood immunization is routinely conducted through the child and maternal health services where
95% of immunizations are carried out. Brunei Darussalam’s NIP offers routine vaccines nationwide,
while some newer vaccines are available through the private sector. Several vaccines have been
introduced in the country with the most recent change taking place in 2012/13 with the introduction of
the hexavalent (DTaP-IPV and HPV) vaccine. To date, there is no formal advisory body or NITAG
providing recommendations on immunization to the Ministry of Health. In 2011, when changes were
made to the NIP, an ad hoc committee chaired by director general of the Ministry of Health was created
to make decision on the programme. However, there are no formal procedures or guidelines for the
committee, which is mainly comprised of Ministry staff. Brunei Darussalam’s Vaccine Committee was
responsible for implementing the NIP schedule changes in 2011/12, and their recommendations were
presented to an executive committee of the Ministry and the Minister of Health and was later approved
by the Ministry of Finance for budgetary purposes. Although there is no NITAG, there is recognition
of the need for a committee to specialize in immunization-related recommendations.

In 2017, the World Health Assembly recognized NITAGs as a basis for strong and effective
immunization programmes, motivating Brunei Darussalam’s interest to establish such a group. No
changes have been made to the country’s EPI since 2012, but there are plans to introduce new vaccines
in the near future. Establishing a NITAG will support evidence-based recommendations that will
endorse immunization-related issues to higher management levels. Having a NITAG will also improve
the relationship of the Ministry of Health with other departments and engage other relevant members
that support immunization (the private sector and so on). A 2019 working paper has been drafted, which
is under review by the Minister of Health, and the terms of reference will be shared with potential
NITAG members. The terms of reference outline the technical advice to the government on the control
of VPDs, policy analysis and advice on the evidence related to new vaccines and their effectiveness.
Members will be elected by the chairperson, and meetings will be held at least once a year. Possible

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challenges include trying to ensure that the committee keep up to date with the latest evidence and the
lack of resources to collect local data.

2.5.4   Cambodia

Mr Ork Vichit, Manager, National Immunization Program, Ministry of Health

Cambodia has a population of 15 million and a birth cohort of 368 000 within its 100 operational
districts. A Technical Working Group for Health (TWGH) was established in 2006 under
circular no. 519 which was signed by the Health Minister with the purpose of improving aid
effectiveness in Cambodia. The Working Group has four main roles and functions: information sharing
among key stakeholders, providing advice to the Ministry of Health on immunization strategies and
policies, monitoring the performance of immunization, and facilitating intra- and intersectoral
harmonization and alignment of immunization activities. There are 45 members within the Working
Group, mainly Ministry of Health staff, bilateral and multilateral partners as well as paediatricians and
gynaecologists. Members are mandated to ensure effective coordination in responding to health
challenges, to be achieved by identifying priorities for discussion and improving mobilization of
resources. The Working Group facilitates the implementation, monitoring and evaluation, and, where
necessary, modification of the Health Strategic Plan. It is chaired by the Minister of Health or, in the
event of his absence, by the Secretary of State. Their responsibilities include implementing the
objectives of the Working Group and disseminating the minutes of the monthly meetings to all attending
members. It also prepares and agrees on the annual workplan.

2.5.5   Indonesia

Professor Sri Rezeki Hadinegoro, Head of Indonesia Technical Advisory Group on Immunization,
Ministry of Health

Indonesia is made up of five main islands that are subdivided into 34 provinces and 514 districts, with
2632 hospitals serving an infant population of 4.8 million. Since 1999, the Government’s system has
been decentralized. The NITAG provides technical guidance to make evidence-based immunization-
related and programme decisions. The Indonesian Technical Advisory Group on Immunization (ITAGI)
received its formal name when it was established in 2007. Two members were replaced after a decree
in 2016. The office is located under the directorate of the CDC. Core members are independent experts
without conflicts of interest, most from academic organizations, appointed for a three-year term.
ITAGI’s function is to provide technical advice on immunization schedules for both the private and
public sectors, review articles for evidence-based decision-making and provide technical advice to help
the government make decisions on immunization issues.

Meetings are not open to the public, and vaccine manufacturers might be invited on an ad hoc basis.
A summary of the discussion is used as information and shared, but the minutes of the meeting remain
confidential. Items for the meeting agenda can be submitted by committee members and other
stakeholders. Recent topics include changes of the epidemiology of VPDs, new vaccine introduction
and new evidence on existing vaccine products. ITAGI plays a small role in the introduction of new
vaccines, the most important factor being availability, cost and financial sustainability. It might take
years to operationalize an ITAGI recommendation once accepted by the Ministry of Health. In the case
of PCV, introduction was recommended in 2011, but the actual implementation only took place in 2017.

2.5.6   Lao People’s Democratic Republic

Dr Phimmasone Sirimanotham, Core Member of Lao NITAG, Ministry of Health

The Lao People’s Democratic Republic has a population of 7.1 million, of which 25% live below the
poverty line and 71% in rural areas. Since 2013, the country’s NITAG has provided independent
technical recommendations on immunization, but it was restructured and its terms of reference revised

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in 2017. The terms of reference include providing technical advice to the Ministry of Health as well as
presenting information to the inter-country committee (ICC) on a biannual basis. The secretariat must
cooperate and coordinate with every party, and materials are disseminated along with the meeting
invitations as instructed by the NITAG chair. A budget and annual plan is developed for
implementation by the NITAG. It can establish working groups that are dedicated to assessing new
vaccine introductions, for example for PCV, rotavirus and HPV vaccines. There have been
three national meetings and workplans developed that have generated recommendations to introduce
the HPV, rotavirus and influenza vaccines. NITAG members have attended three Strategic Advisory
Group of Experts (SAGE) meetings for capacity-building and training.

2.5.7   Malaysia

Dr A’Aisah Senin, Head of Sector, Vaccine Preventable, Food and Waterborne Diseases, Disease
Control Division, Ministry of Health

Malaysia’s NITAG equivalent is known as the National Immunization Policy and Practice Committee
(NIPPC). It is the highest decision-making body on immunization. Members are appointed by the
Director General of Health for a three-year term. There are four subcommittees that support NIPPC
which are chaired by different national health divisions. Each subcommittee discusses different
immunization-related topics, including a vaccine’s use and cost, the implementation of the national
child immunization programme, pharmacovigilance and vaccine safety, and health education and
promotion. They then report back to the NIPPC. Subcommittees can have more than one meeting a
year. NIPPC meetings are held annually to discuss national reports on measles and rubella elimination
and the maintenance of polio-free status. Any new proposal of vaccine introduction or changes in the
current NIP is discussed in these meetings. Updates on WHO position papers and other relevant
information on vaccines are also presented.

Malaysia achieved polio-free status in 2000, and the decision to include PCV in the NIP was discussed
and made in 2018. The elements considered for recommending introduction of a new vaccine include
a disease burden assessment, cost-effectiveness analysis, vaccine-specific service delivery strategies,
surveillance, monitoring and evaluation, and vaccine regulation and registration. Vaccination is not
mandatory in Malaysia, but there is interest in passing an immunization law due to growing vaccine
hesitancy, although the Government has preferred efforts geared towards immunization advocacy.
Since 2009, PCV introduction has been frequently included in the NITAG agenda, and it was finally
approved for introduction in 2018.

2.5.8   Myanmar

Dr Yee Cho, National Professional Officer, WHO Country Office, presenting on behalf of NITAG
members

Myanmar is divided into 14 administrative states and regions and 330 townships with functional units
for health-care services. To date, the Government financially supports 26% of vaccine costs while 74%
is covered by Gavi. By 2025, the Government intends to finance all its vaccine costs. All vaccines are
procured through UNICEF and are part of the essential health package of the universal health coverage
(UHC) platform. There are plans to expand the NIP by introducing two more vaccines by 2020.
Myanmar’s NITAG is the highest technical advisory group and is an independent body providing
recommendations to the Ministry of Health and Sports on immunization policies. In 2017, the NITAG
was re-established and further strengthened from its 2012 function and structure. Members are retired
technical experts in paediatrics, microbiology and public health. The nomination process is led by the
country’s EPI and officially nominated by the Ministry of Health and Sports. Member’s declare
potential conflicts of interest verbally. The terms of reference are similar to other countries in region,
including providing recommendations on vaccine-specific regulations, policies and strategies that are
based on evidence. Decisions are made by consensus and discussion of the current epidemiology of
VPDs. Meeting minutes are drafted by the secretariat and shared with NITAG members for review and

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endorsement. Recent recommendations have included targeting the uncovered population in
non-government-controlled areas (NGCA) as well as switching back from RotaVac to Rotarix.
Accessibility to international network and local evidence-based data provide strengths and opportunities
for NITAG members.

2.5.9   Philippines

Dr Maria Wilda Silva, Medical Specialist II, Disease Prevention and Control Bureau, Department of
Health

The Philippines has more than 7000 islands, which are subdivided into three main geographic regions.
From 1990 to 2008, its population has increased by 45% and half reside in the island of Luzon. The
National Immunization Committee (NIC) was established in 1986 and was reconstituted following the
dengue vaccine controversy in 2018. Its function serves as a forum to coordinate all aspects of the NIP
where its core members have voting rights. There are 10–15 NITAG core members with voting rights;
they are independent and do not represent a particular group or stakeholder. Experts in vaccinology,
health economics, epidemiology, infectious diseases and other fields are all represented. There are
biannual as well as ad hoc meetings. Potential conflicts of interest are declared in every meeting, and
those with conflicting interests are not allowed to vote. Those who are employed by pharmaceutical
companies or have consultancies, relatives and/or financial interests with pharmaceutical companies are
not allowed to vote. The agenda items of the NIC are determined by the Department of Health or by
members. Preparation takes place 3–12 months before the meeting, with documents circulated to
members. The NIC decision-making process starts by selecting health issues presented by the Family
Health Department which are then communicated by the NIC Chair to its members. A technical
working group is formed with the function of gathering and appraising the evidence. Background
documents are drafted along with a summary of all the evidence collected. A plenary presentation is
conducted among the NIC, and recommendations are drafted and submitted to the Family Health
Department. Examples of recent recommendations include the introduction of the JE vaccine, a booster
dose of DTP during the second year of life, a shift from PCV13 to PCV10 and immunization of senior
citizens against dengue.

2.5.10 Singapore

Mr Yuske Kita, Senior Public Health Officer (Strategy and Prevention), Communicable Diseases
Division, Ministry of Health, Singapore

Singapore’s Expert Committee on Immunization (ECI) was established in 1975. Its key responsibilities
focused on providing recommendations on the control of VPD among children through immunization,
but priorities have shifted to include vaccines through the entire life course. There are 17 members,
made up of eight core members, eight institutional representatives and a secretary. Each member has a
renewable three-year term. Members are appointed by the Director of Medical Services and are all
asked to declare their conflicts of interest at the beginning of each term and during face-to-face meetings.
Core members are three paediatricians, two infectious disease specialists, two vaccine
researchers/immunologists and a microbiologist. Roles of the secretariat include preparing background
materials as well as collating and determining the agenda of the meeting in consultation with the ECI
Chair. There are one or two face-to-face annual meetings and multiple consultations via email. ECI
meetings are closed and exclude the participation of the pharmaceutical industry, only allowing selected
internal and external stakeholders as observers. During the decision-making process, documents are
circulated prior to the meeting and the decision is made through consensus, taking into consideration
three factors: disease burden, vaccine safety and efficacy, and the cost-effectiveness of the vaccine.
Communication is part of the implementation of recommendations following its approval.
Recommendations are issued to doctors and health-care institutions through a circular. Future activities
include enhancing and establishing a more standardized and robust economic evaluation of vaccines for
inclusion of national programmes along with clearer governance.

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2.5.11 Thailand

Dr Piyanit Tharmaphornpilas, Senior Medical Advisor, Office of the Senior Expert Committee,
Department of Disease Control, Ministry of Public Health

Thailand’s advisory committee was initially established in 1970. In 2018, under the vaccine security
act, the NITAG became one of the four subcommittees under the national vaccine committee (NVC).
The NVC usually does not intervene in the decision-making process of the NITAG. Its
recommendations are communicated to the Ministry of Public Health, which is responsible for its
implementation. The NITAG composition includes academicians and technical experts on
immunization, epidemiology, vaccine research, financing and quality assurance, and other specialties.
The NITAG’s main function as a subcommittee is to provide advice and recommendations on vaccines
for people of all ages as well as the vaccine’s administration to successfully reach its target population.
The implementation of recommendations is beyond the NITAG’s scope of work and expertise. New
vaccines are only introduced if they are cost-effective, have an acceptable budget impact and are
included in the essential drugs list. If the National Health Security Office does not have funds in its
budget, then the NITAG recommendations will be postponed. This was the case with HPV vaccine
introduction where the NITAG had provided recommendations for its introduction since 2014. Due to
lack of funds, the vaccine’s use was piloted as a school-based provincewide programme until 2017,
since when the vaccine has been used nationwide for grade 5 schoolgirls.

2.5.12 Viet Nam’s National Immunization Technical Advisory Groups: membership, functions
       and mode of operation

Professor Nguyen Tran Hien, Senior Researcher, National Institute of Hygiene and Epidemiology,
Chair of Viet Nam’s NITAG

Viet Nam has a population of 94 million that reside in four regions. The country’s EPI offers
eight vaccines to children less than 1 year old. Viet Nam’s first immunization advisory committee was
established in 1998 by the Ministry of Health. The committee’s TOR encompasses four main
responsibilities: providing guidance on targeted immunization delivery, conducting assessments and
research on immunization effectiveness, review of national immunization-related policies, and the
development of standard operating procedures for its operation and function. As of 2017, the committee
has been re-established with 16 committee members comprising paediatricians, epidemiologists,
microbiologists, immunologists, and public health and other specialists. Eight members make up the
committee’s secretariat. Members are selected through a nomination process for a five-year term and
are required to declare any conflict of interest. NITAG members meet twice a year, and additional
meetings can take place following requests from the Ministry of Health. The decision-making process
is initiated by the secretariat, which collects, synthesizes and compiles background information and
disseminates it to NITAG members. Decisions are made by consensus with approval from more than
50% of members. Working groups are established depending on the discussion topic. Summary of
recommendations are prepared by the secretariat and are submitted to the Chair for approval. Potential
activities for strengthening Viet Nam’s NITAGs include the development of operational regulations
and the organization of workshops on specific issues with the purpose of sharing and updating
information.

2.6     Capacity-building and networking among NITAGs

2.6.1   Updates from recent NITAG meeting from the South-East Asia Region

Dr Sudhir Khanal, Technical Officer, Immunization and Vaccine Development (IVD), WHO Regional
Office for South-East Asia

The World Health Assembly’s 2017 and 2018 resolutions urge countries to strengthen country
ownership and credibility through NITAGs, with the goal of improving national evidence-based

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recommendations through a transparent process from an independent body. The WHO South-East Asia
Regional Vaccine Action Plan 2016–2020 includes strengthening NITAGs as one of its strategic priority
areas. Thailand was the first country to establish one in 1960, while Timor-Leste was the latest in 2015.
Most NITAGs in the Region were established between 2007 and 2008. The scope of work in the Region
includes providing guidance on immunization, introducing new vaccines and technologies, and
updating information on safety and quality of vaccines. There are six indicators measuring NITAG
functions: formal terms of reference, legislative mandate, representatives from five technical areas,
agenda distributions, declarations of conflict of interest and at least two meetings annually. When
measured against these indicators, all 11 countries in the Region had well-functioning and strong
NITAGs.

The question remains: Why measure and work on capacity-building if the Region’s NITAGs are already
well established and functional? In response, there have been discussions on expanding this list of
indicators to assess its functional effectiveness. There have been efforts to enhance collaboration and
coordination between NITAGs and the South-East Asia Regional Immunization Technical Advisory
Groups (SEAR-ITAG). In 2016, NITAGs started providing reports to the SEAR-ITAG and a year later
the format of these reports were revised to include country-specific reporting on the eight goals of the
Regional Vaccine Action Plan. Country NITAG reports are assigned two reviewers by the
SEAR-ITAG chair. This report is then presented by the NITAG chairs in their respective annual
meeting. Conclusions presented by NITAG chairs are compiled and then presented in the SEAR-ITAG.

In March 2019, the WHO Regional Office for South-East Asia organized a regional meeting on
strengthening the capacity of NITAGs to guide and monitor NIPs. Recommendations from this meeting
included the review of the current terms of reference by health ministries and NITAG members,
formalization of processes for policy briefs and members’ declaration of interest. Progress has been
made since this meeting. Orientation meetings following the regional recommendations and format
were conducted in Bhutan and Bangladesh, and Nepal has a similar meeting planned for
November 2019. All NITAGs in the Region revisited workplans to include essential activities, and an
external evaluation of NITAGs commissioned by the Regional Office is currently in progress.

2.6.2   Study tour experience from the Lao People’s Democratic Republic

Dr Panome Sayamoungkhoun, Deputy Director, Mother and Child Center and EPI Manager,
Ministry of Health

The Lao NITAG was established in 2013, comprising experts and professionals from several
departments. Its initial functioning was suboptimal because of limited expertise in the committee.
In 2017, five senior officials travelled to Canberra to learn from ATAGI with the objective of studying
its terms of reference and member selection, as well as learning how to organize and manage NITAG
meetings, generate recommendations, and coordinate with other committees. These experiences were
then communicated to the Lao Health Minister. As a result of this study tour, the NITAG was reformed
in 2017 with new members recruited based on their technical expertise, reflecting improved and revised
terms of reference. Recommendations are now successfully generated by the NITAG. In
February 2020, the HPV vaccine will be introduced, although there are still issues related to funding
gaps despite the government’s plan to co-finance the vaccine with Gavi’s support. The introduction of
the rotavirus vaccine is being postponed due to a global shortage. Typhoid vaccines were also discussed,
but the NITAG has requested stronger evidence to support introduction. As a result, the US CDC will
support the collection of more data on typhoid disease burden. This will be further discussed by the
NITAG in the coming months. There have been issues in procuring influenza vaccine through UNICEF
after its price more than doubled from US$1.50 to US$3.50 per dose. The NITAG must now provide
strong recommendations for the vaccine’s continued procurement and whether financing this more
expensive vaccine is worth it.

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