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Report of the regional immunization technical advisory group meeting

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Executive Summary

The second 2017 meeting of the Regional Immunization Technical Advisory Group (RITAG), the principal advisory group to the WHO Regional Offce for Africa took place at the Protea Balalaika Hotel Sandton, in Johannesburg, South Africa, on 5–7 December 2017. The meeting focused on progress towards regional immunization goals, maternal & neonatal tetanus elimination, polio eradication & end-game strategy, challenges facing middle-income countries, cholera control and immunization research in the African Region.

The annual progress report on immunization in the African Region highlighted some progress in 2017 but concluded that much remains to be done if regional 2020 immunization targets are to be met. The ten countries that collectively account for 80% of under-immunized children present a particular challenge. Furthermore, national data can mask signicant variation in vaccination coverage within countries, highlighting the need to map and respond to variation in service provision at a more granular subnational level.

Despite commitments made in the Addis Declaration on Immunization, and although some countries have invested significantly in new vaccine introductions, the proportion of countries supporting financially their immunization programmes wholly or mostly through domestic resources remains virtually unchanged since the previous year. With external funding declining as the Global Polio Eradication Initiative (GPEI) winds down and countries transition out of Gavi support, it is increasingly important that countries honour their investment commitments, and explore the use of innovative approaches to boost domestic funding.

The mid-term review of the Regional Strategic Plan for Immunization, carried out by an independent expert panel, was presented to the RITAG meeting. The Regional Strategic Plan seeks to energize efforts to bring the benets of immunization to all target groups of the African region, particularly those in underserved and hard-to-reach populations. The mid-term review highlighted areas of progress but concluded that the region was not on track to achieve most of its 2020 targets. The review was well received by RITAG and, once feedback from RITAG members has been incorporated, it will be adopted by RITAG and its recommendations endorsed.

Middle-income countries (MICs) are home to two-thirds of the world's poorest people and two-thirds of vaccine-preventable deaths occur in these countries. Gavi-ineligible MICs and Gavi-graduating countries, including those in the African Region, face particular challenges. These were addressed in a Middle-Income Country Strategy developed by WHO and partners which was endorsed by the WHO's Strategic Advisory Group of Experts on Immunization (SAGE) but has not been adequately funded or implemented.

Pooled procurement mechanisms may be one approach for facilitating vaccine access in such countries. There is also a need to address regulatory issues that may affect timely access to vaccines for routine and emergency use and evaluation in clinical trials.

The implications of Gavi transitions are of concern, including the risk that countries enter transitions ill-prepared to absorb increasing co-financing commitments and eventually to assume full responsibility for immunization systems. This could potentially lead to reversals of new vaccine introductions.
There is real hope that polio can soon be eradicated in the region. No new cases of wild poliovirus have been detected in the African Region since August 2016. RITAG applauds the emergency response launched in Nigeria and the countries surrounding Lake Chad. Technologies and approaches applied here may have application in control of other infectious diseases. Nevertheless, concerns remain about the possible continued transmission of wild polioviruses and the emergence of vaccine-derived polioviruses in areas where insecurity constrains high-quality surveillance and high vaccination coverage.

As GPEI funding declines, it is vital that polio transition plans safeguard essential surveillance functions for polio and other vaccine-preventable diseases and routine immunization activities, to protect national populations and regional health security. Declining levels of human and nancial resources for surveillance in the region may potentially compromise the quality and completeness of data and jeopardize the regional certification of polio eradication, as well as complicate efforts to achieve measles and rubella elimination.

Affordable oral cholera vaccines (OCVs) combined with water, sanitation and hygiene (WaSH) and other control strategies represent a valuable new tool for cholera control, and it is essential that they are used effectively in the region. It is important that procedures for accessing the OCV global stockpile facilitate rapid access in emergency situations, and in particular do not impose impractical data collection requirements on countries. Countries also need to ensure that their vaccine regulatory policy frameworks enable the rapid importation of OCV when required, to establish effective surveillance systems to underpin timely disease control, and to collect and analyse the data required to develop evidence-driven policies and programmes, including the use of OCVs, to mitigate the risk of cholera outbreaks.

Great progress has been made towards achieving and maintaining maternal and neonatal tetanus elimination (MNTE). Nevertheless, the region is off-track to reach its elimination target in 2020. The seven countries yet to achieve MNTE face significant challenges, including civil conflicts and infectious disease outbreaks, and require support during a final push towards elimination. Although it has been suggested that MNTE could be accelerated through greater use of compact pre-filled auto-disable devices, which can be used by individuals with minimal training and enhance access to hard-to-reach populations, question marks remain about the true demand and appropriateness of this technology and the likelihood of reliable supply.

A further important theme was research – particularly the need for research driven by local priorities and involving or led by African researchers. These are core principles of the draft Strategic Framework for Research on Immunization in the African Region. Once finalized, the Strategic Framework will provide a key resource to support the generation and use of evidence required to prioritize and support new vaccine development, in order to strengthen national immunization programmes and bring its benets to larger numbers of people, including those currently being missed