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Highlights from the Meeting of the Strategic Advisory Group of Experts (SAGE) on Immunization
31 March -1 April 2020
The full report with final recommendations will be published in the Weekly Epidemiological Record on 29 May 2020.
[Editor’s text bolding]
Global and Regional Reports
:: In the context of the COVID-19 pandemic and its impact on primary health and immunization services across the world, SAGE stressed the imperative to explore innovative approaches and to seize opportunities that may emerge from this crisis to move the global immunization agenda forward, as outlined within the Director’s report. These opportunities include using subnational data to drive vaccination coverage, tailoring local immunization programs, improving the design of clinics, accelerating the use of integrated campaigns and of life course immunization, addressing gender inequities, and overcoming fragmentation of vaccine-preventable disease surveillance. Implementing the strategic objectives of the Immunization Agenda 2030 will become even more important to address the challenges of and eventual recovery from the COVID-19 pandemic.

:: The Regional reports confirmed the challenges that countries will experience to sustain immunization activities in the current COVID-19 context. Furthermore, continued high numbers of measles cases and outbreaks were highlighted in various regions; these are likely to increase.

:: SAGE was updated on key COVID-19 modelling results for transmissibility, serial interval, incubation period, severity of the disease, risk groups, asymptomatic infections and role of public health interventions and social measures.

 

:: SAGE members stressed that safeguarding immunization services was of critical importance during the current pandemic and adequate catch-up activities should be planned at this stage to ensure that children receive all their needed vaccines.

:: Gavi expressed its concerns on the implications of COVID-19 on routine immunization, with an anticipated plummet of routine immunization coverage and emergence of outbreaks of VPD. Gavi outlined its engagement in response to the COVID-19 pandemic with providing immediate support to countries.

:: As a milestone in maintaining and enhancing the support to Gavi countries is the Gavi replenishment forum in June 2020. SAGE underlined its importance and the need to obtain adequate financial resources to enable the Alliance to continue its critical work. Gavi 5.0 objectives are more relevant than ever in light of the emerging crisis.

:: Industry from both developing and high income countries expressed concern that a prolonged COVID-19 crisis may impact its ability to manufacture and distribute live-saving vaccines.

 

Update on COVID-19 vaccine
:: SAGE acknowledged the unprecedent effort to develop a COVID-19 vaccine and requested that studies give due attention to vaccine performance in vulnerable populations and in low and middle income countries.

:: SAGE commended the early collaboration with key technical partners on consideration of use scenarios, access, availability and supply..

:: SAGE discussed the need to establish a SAGE Working Group on COVID-19 Vaccines to advise on strategies and use scenarios for investigational and licensed COVID vaccines. SAGE requested that the Working Group be constituted now to permit active involvement of SAGE in WHO processes to advise on product profile and target groups for vaccine evaluation.

 

Update on Ebola vaccine
:: The Eastern Democratic Republic of Congo (DRC) Ebola outbreak is coming to an end with no new cases reported since 17 February 2020, and more than 320 000 individuals vaccinated.

:: SAGE again acknowledged the huge efforts by the frontline workers to vaccinate large populations under extremely difficult conditions.

:: In a subsequent meeting, SAGE will discuss possible off-label recommendations for the licensed rVSV-ZEBOV vaccine to allow its appropriate use in future outbreaks.

:: SAGE recommended that a comprehensive review be conducted of the recent experience of Ebola vaccine implementation and policy development during an outbreak response in order to inform future processes for the development of recommendations, the use and the monitoring of un-licensed vaccines in emergency situations.

 

Measles outbreak epidemiology and WHO coordination
:: In the setting of the increased numbers of measles outbreaks throughout the world since 2019, SAGE expressed concern that the COVID-19 pandemic will further strain measles control efforts. Countries and immunization partners will need to re-double immunization efforts, guided by the recently published “WHO Guiding principles for immunization activities during the COVID-19 pandemic.”

:: SAGE was updated on newsworthy or graded measles outbreaks (e.g., Democratic Republic of Congo, European region) as well as on success stories (e.g., China, Colombia) and the WHO global response, including advice from the Strategic Technical Advisory Group – Infectious Hazards (STAG-IH) of WHO, and the development of the Global Strategic Response Plan and other measures.

:: An update on the ongoing measles and rubella policy and strategy work was provided, including the presentation of the Measles Eradication Feasibility Report to the Executive Board (EB) in February 2020 and World Health Assembly (WHA) in May 2020 with the Immunization Agenda 2030; the proposed M&E framework for measles and rubella; a benchmarking process to define an evidence based process to consider measles eradication; the Measles Rubella Strategic Framework.

 

Polio
:: SAGE expressed concern about the continuing upsurge in wild poliovirus cases and by the inability of the polio eradication program to effectively control outbreaks of vaccine derived polioviruses in Africa and Asia.

:: SAGE took note of the current reorientation of polio resources for country COVID-19 responses. In practice, this results in a halt of polio activities. The Global Polio Eradication Programme (GPEI) plans to monitor the COVID-19 situation and prepare scenarios for program restart vaccination activities.

:: SAGE reconfirmed the prioritization of available inactivated polio vaccine (IPV) supply for 2020: 1. Routine immunization, 2. Catch-up of missed children due to delayed introduction 3. Supplemental Immunization Activities for endemic countries and high-risk areas, based on risk assessment 4. Introduction of second dose of IPV into routine immunization. However, for 2021, SAGE agreed that the introduction of a second dose of IPV into routine immunization (currently 4th place) will be prioritized over IPV for SIAs for endemic countries and high-risk areas (currently 3rd place).

:: In terms of tOPV, SAGE endorsed that tOPV may be made available to countries for cVDPV2 outbreak response in subnational areas where there is co-circulation or high risk of co-circulation of cVDPV2 with cVDPV1, cVDPV3 or wild type 1 poliovirus in order to avoid the need for dual mOPV2 and bOPV campaigns. Use of tOPV will require the same authorizations and restrictions as required for use of mOPV2.

:: SAGE endorsed in principle criteria for initial nOPV2 use under emergency use listing (EUL) in cVDPV2 outbreak response and will continue to monitor and further review this in the future.

:: In the current epidemiological context, SAGE expressed caution over regions or countries moving from bOPV to an IPV-only schedule as a general principle and recommended that instead these regions or countries take a gradual approach, first introducing a 2nd dose of IPV into routine immunization.

 

:: SAGE concluded that a key lesson from the switch is that the GPEI cannot plan for complete cessation of OPV with the tools and knowledge that are currently available.

IA2030 Monitoring and Evaluation framework
:: SAGE was presented with initial framework of the monitoring and evaluation and accountability (M&E/A) framework for the immunization strategy for the new decade. The final framework is expected to be submitted to the WHO EB and WHA in 2021 for endorsement.

:: SAGE supports the proposed IA2030 ME&A Framework principles as well as the approach to defining indicators and targets in a lean and action-oriented manner.

:: SAGE stressed the need to concentrate ME&A efforts to enable country programme strengthening and continuous quality improvement resulting in community/facility level improvements.

 

Global Vaccine Safety Blueprint 2.0
:: SAGE acknowledged the significant progress made in strengthening the capacity of countries to address vaccine safety issues in all WHO regions since 2012 through the implementation of the Global Vaccine Safety Blueprint 1.0 (GVSB 1.0) and endorses the GVSB 2.0.

:: In order to make GVSB 2.0 more aligned with the Immunization Agenda 2030, SAGE suggested that the country ownership and country driven aspects be incorporated into the document with an emphasis on a bottom-up approach to mirror the IA2030 philosophy.

:: The role of Civil Service Organizations (CSO) in Adverse Events Following Immunization (AEFI) reporting from the family level should be emphasized. CSOs could have a role in vaccine safety by encouraging family level and community level reporting and by assisting in the design of governance systems as well as in the monitoring of AEFI’s and rumors.