Dalhousie University (MacDonald); World Health Organization, or WHO (Duclos, Henaff); Robert Koch Institute (Wichmann); University of Oxford (Harnden); Alyamamah Hospital (Alshammary); Ministry of Health, Costa Rica (Tijerino); Royal Brisbane and Women's Hospital (Hall); Universidade Eduardo Mondlane (Sacarlal); BP Koirala Institute of Health Sciences (Singh)
National Immunization Technical Advisory Groups (NITAGs) provide independent, evidence-informed advice to assist their governments in immunisation policy formation. In 2016, recognising that NITAGs could potentially benefit from intercountry collaboration, 26 countries met to discuss the formation of a Global NITAG Network (GNN), whose purpose is to nurture development of inter-country NITAG relationships, to facilitate voluntary sharing information of technical expertise, and to provide a venue to discuss NITAG immunisation decision-making and implementation concerns. This conference report summarises the proceedings of the second GNN meeting, held June 28-29 2017 in Berlin, Germany, at which the GNN was formally launched.
During the meeting, the following 10 areas were addressed:
- GNN governance and formalisation of the GNN - Countries voluntarily participate in the GNN, and there is not fee. Each member country determines what NITAG-relevant information, processes, and lessons learned will be shared and how this will be done - i.e., what materials added to the NITAG Resource Centre, what shared directly with another country or countries, and what not shared. The GNN is not prescriptive to WHO regional NITAG network functions nor in individual country NITAG decisions. The WHO announced that it accepted the role of secretariat and would provide for the main secretariat support. This is reflected in the five-page Strategic Document of the Global NITAG Network.
- Reflection on the WHO's Strategic Advisory Group of Experts (SAGE) April 2017 conclusions concerning strengthening of NITAGs - For example, SAGE recognised the importance of regional and global NITAG collaboration and recommended continuous support for the GNN and the NITAG Resource Centre (NRC), which is an interactive collaborative web platform that is a gathering place for all NITAG-related information. During the second GNN meeting, participants underlined the value of information-sharing amongst NITAGs, especially via the NRC and of funding support of NITAGs for their formation and for support of their work in country. Potential solutions raised by participants for the countries with small populations included the use and adaptation of recommendations from a neighbouring country's NITAG that they can relate to, partnership with another NITAG, or the formation of a sub-regional group of small countries where recommendations could be developed jointly and then shared in the member countries.
- Sharing of NITAG experiences in evaluation and inter-country collaborations - During a moderated discussion, Mozambique, Cote d'Ivoire, and Armenia each shared their experiences with external evaluation of their NITAG using the NITAG Evaluation tool. The Australian NITAG participant noted that their NITAG has endorsed a strategic document [PDF] stating that international collaboration was an asset and that they were committed to foster it and work with NITAGs in other countries. Saudi Arabia noted that with the approval of their Ministry, the NITAG is planning to post documents on a website to promote the work of the committee. These are in Arabic and may well be helpful to other Arabic speaking countries.
- Discussion on the role of Regional Technical Advisory Groups on Immunization (RTAGs) and regional networks - Following break out and then plenary discussions, the participants highlighted that the GNN should help regions access resources, share data, and make links between the regions, while Regional NITAG Networks should encourage collaboration between NITAGs in the region, mobilise resources, share challenges and information with the GNN, and participate in envisaged annual GNN meetings. To date, only one WHO Region has a formally established regional NITAG Network, the South East Asia Region. NITAGs need to be encouraged to link with other countries in their region (and beyond) to work on the same topics and identify training opportunities. Virtual meetings could be set up for NITAGS in a region. Participants emphasised the importance of collaboration beyond the regions, through sharing materials and information via the NRC as well as through direct country-to-country collaborations.
- Sharing of NITAG experiences on independence - In a panel discussion, representatives from Belgium, Costa Rica, Nepal, and Canada shared how their NITAG functions, highlighting how their committees balance independence from government and integration of the NITAG decisions into government policy. The models in the four countries showed marked contrasts, emphasising how one size does not fit all.
- Reflection on NITAG off-label recommendations - During the Canada NITAG presentation, it was noted that NITAGs, based upon evidence, often make off-label recommendations on the use of vaccines that can be in conflict with those of the National Regulatory Authorities for drugs including vaccines. This discussion culminated with a proposal that it would be beneficial if GNN members shared experiences and the evidence on which off-label recommendations are based (e.g., systematic reviews or single studies on alternative schedule or specific populations).
- Discussion of NITAG roles in communications, dissemination of recommendations, and vaccine implementation - Representatives from Mozambique, the United Kingdom (UK), Australia, and Germany shared their lessons learned on communications and dissemination of recommendations with respect to building credibility and trust in their NITAG. For example, in Germany, the NITAG meeting minutes are published online and since September 2016 as a pocketbook to be purchased in bookstores and on a smartphone app that had been downloaded by more than 40,000 users as of June 2017. It contains recommendations and guidelines on how to implement the recommendations and communication messages. The app also includes around 230 frequently asked questions with answers, push messages to inform about new recommendations and warn about rumours, an algorithm on catch-up vaccination, and a resource centre (e.g., advice on how to address vaccination arguments). Following this panel presentation, participants stimulated lively a discussion on vaccine hesitancy, something NITAGs play an important role in addressing. In Australia, a web page has been developed for the public (parents), presenting the risks of not vaccinating and comparing this to the risks of vaccinating. In Australia, the legislation supports the NITAG in reinforcing "No jab, no pay"/"no play" policies. Jordan raised the issue of bloggers who increase anti-vaccine sentiments. Panelists noted that engaging with conspiracy theorists may increase anti-vaccine issue. However, giving access to experts that the media can trust can enable the press to prevent the media from publishing overt lies and having them cross-check their information. The UK NITAG does contact the press and are in regular touch with journalists.
- Alert on evidence assessment and sharing of resources - The SYSVAC, a database of systematic reviews on vaccines and immunisation developed by the London School of Hygiene & Tropical Medicine, has been integrated in the media centre of the NRC. The SYSVAC database collects a list of all systematic reviews on human vaccines registered on Prospero, Embase, and Cochrane; this integration within the NRC should make it easier for NITAGs to search for systematic reviews.
- Discussion on GNN funding and development of an action plan - Participants emphasised that more countries need to be apprised of the GNN; it needs to be discussed at RTAG meetings so more countries are alerted to it. Also, conversations should be initiated about the establishment of regional networks and the role of RTAGs in such networks.
- Selection of the steering committee members, alternates, chair, and deputy chair, and identification of priority activities for the GNN and its global partners - Participants emphasised the importance of growing advocacy for the GNN and NRC in different settings as GNN functions, stating that NRC work must become a priority of WHO, partners, donors, and also for countries.
In conclusion, the GNN was formally launched in June 2017, with a membership of 35 countries coming from all WHO Regions. As participants emphasised, the GNN provides a forum for networking, sharing lessons learned and NITAG documents, developing partners for NITAG evaluations, and wrestling with complex issues such as how to manage conflicts of interest and off-label use of vaccines. The 3rd GNN meeting is tentatively scheduled for June 26-27 2018.
Vaccine, Volume 35, Issue 50, 15 December 2017, Pages 6925-6930. Image caption/credit: The NITAG Resource Centre (NRC) - ScienceDirect.com