In the face of dwindling health budgets, the World Health Organization’s (WHO) expert committee on immunisation has made several suggestions to enable countries to optimise existing vaccine supplies.
Countries can continue giving a single dose of the human papillomavirus (HPV) vaccine to girls aged 9-14 years to prevent cervical cancer – instead of two doses, the Strategic Advisory Group of Experts on Immunization (SAGE) advised.
This could enable resource-constrained countries to extend the vaccine to women aged up to 30 who have missed out, and routine vaccination to boys aged 9-14.
SAGE also recommends that countries can consider routine vaccination of girls aged 4-8 years with a single dose of HPV vaccine “if this is likely to result in increased vaccination uptake and coverage”.
“The global HPV vaccine coverage, at 33%, is far short of the global target we’re looking for, which is 90%,” SAGE chairperson Professor Anthony Scott told a media briefing on Tuesday.
“So, based on a review of updated evidence, SAGE decided the single dose schedule for girls aged 9 to 14 is now the most efficient approach to achieve this global target.”
Diphtheria booster during outbreaks
Countries may also consider a single diphtheria vaccination during an outbreak, although SAGE cautions that this must be followed by routine immunisation. Children under a year usually get three doses of a diphtheria-tetanus-pertussis (DTP3) vaccine.
“[Diphtheria] outbreaks have been increasing globally, particularly in West Africa, South[ern] Africa, and the Eastern Mediterranean region. The outbreaks clearly reflect gaps in immunity caused by low vaccine coverage,” Scott explained.
SAGE also confirmed that a one-fifth fractional dose of yellow fever vaccine can be used in outbreaks for people aged two and older “when vaccine demand exceeds supply”.
The same fractional dose can be used for preventive vaccination campaigns for people aged 2-59 “when vaccine supply, financial or other programme constraints would otherwise limit the timely implementation, scale or coverage of vaccination”, said Scott.
There should be no skimping on the polio vaccine, however. Countries giving fewer than three polio doses “should transition without delay to a three-dose infant schedule administered at 6, 10 and 14 weeks of age” and ensure 90% coverage.
However, fractional or full additional doses can supplement the three doses during outbreaks.
Gavi funding shortfall
SAGE executive secretary Professor Annelies Wilder-Smith said that all SAGE’s policy decisions are “focused on optimising the use of existing vaccines to achieve the greatest possible public health impact amid growing financial constraints”.
“Immunisation programmes now more than ever must maximise the impact of available vaccines, while safeguarding equity and still protecting the most vulnerable,” she stressed.
The key driver of SAGE’s new recommendations is the funds shortfall facing Gavi, the global vaccine platform. Gavi supports immunisation in the world’s poorest countries with a gross national income per capita of $2,300 or less – and 56 countries qualify this year.
However, Gavi has only secured $9.3 billion of its recalibrated $10.2 billion strategic budget.
SAGE noted that currently available Gavi funding is “insufficient to maintain use of vaccines currently included in national immunisation programmes, which jeopardises country gains achieved to date and may undermine trust in vaccine programmes”.
Dr Kate O’Brien, WHO’s director of Immunisation, Vaccines and Biologicals, acknowledged that domestic and Gavi funding shortfalls will require countries to make “difficult prioritisation decisions”.
“Countries must be “supported to make evidence-informed decisions” through strong national immunisation technical advisory groups (NITAGs), to ensure that existing immunisation gains are protected, said O’Brien.
“Against the funding constraints, SAGE has emphasised that maintaining vaccines already included in national programmes in GAVI eligible countries should be a top priority.”
Ebola and mpox
SAGE welcomed the accelerated development of vaccines that target Ebola Bundibugyo Virus Disease (BVD), and the establishment of the “single protocol, adaptive platform design of the TUMAINI randomised controlled trial (RCT)”.
This platform will enable the efficient evaluation of two BVD-specific vaccine candidates (Oxford University’s ChAdOx1 BDBV and Moderna’s mRNA-1469), and Ervebo, a vaccine already licensed for Ebola Zaire.
O’Brien said that the phase 1 trial for ChAdOx1 has been completed and a WHO technical advisory committee would be reviewing its data “in a short number of days or weeks”, and reviewing Moderna’s vaccine’s progress.
If the safety data is “sufficiently positive”, she expects the vaccines to move rapidly into phase 2 and phase 3 trials – possibly as early as the end of this month.
SAGE also recommended targeted mpox vaccination of people at risk of infection in communities affected by the virus, including children, people exposed through sexual networks, contacts of people with mpox and health workers with repeated exposure.
“Preventive mpox vaccination may be considered in those at high risk of infection or severe disease, while preventive vaccination for children in endemic areas may only be considered within a research setting,” SAGE noted.
Image Credits: Gavi.
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