The independent European Technical Advisory Group of Experts on Immunization (ETAGE) has advised countries to increase efforts to achieve high COVID-19 vaccination coverage (primary and booster dose) among high-risk groups and to plan for the integration of COVID-19 vaccination into routine health-care strategies. These are among the recommendations provided by ETAGE at its 22nd meeting in Copenhagen, Denmark, on 6–7 December 2022.
ETAGE meets regularly to provide independent review and expert technical recommendations to national immunization programmes and WHO/Europe’s vaccine-preventable diseases and immunization programme (VPI).
At its 22nd meeting, ETAGE received a report on conclusions of the global Strategic Advisory Group of Experts on
Immunization (SAGE) from its October 2022 meeting, as well as, for the WHO European Region, updates on implementation of the European Immunization Agenda 2030, COVID-19 vaccination, paediatric diarrhoeal disease surveillance, WHO/Europe activities to strengthen national immunization technical advisory groups (NITAGs), and the role of NITAGs in the WHO European Region in guiding the agenda of ETAGE meetings.
Based on in-depth presentations and discussion of the agenda topics, ETAGE made the recommendation listed below. A full report of the meeting will be posted on the WHO/Europe website.
Rotating membership
In line with its terms of reference, the 22nd ETAGE meeting marked a change in its leadership and membership, with Dr Ole Wichmann taking over the Chair position from Professor Adam Finn. Dr Wichmann thanked Professor Finn for his dedicated leadership, as well as fellow outgoing members Professor Alenka Kraigher and Professor F. Nur Baran Aksakal, for their important contributions to ETAGE in recent years. Dr Wichmann also welcomed three new members: Dr Arman Badalyan, Dr Fedir Lapii, and Dr Marianne A. Riise Bergsaker.
In taking over as Chair, Dr Wichmann noted, “There are many challenges ahead for immunization programmes in the Region to recover from the pandemic and incorporate COVID-19 vaccines in their immunization agenda. I look forward to working with ETAGE members as we together support WHO and national immunization programmes throughout the Region to equitably protect the health of the population.
ETAGE recommendations
COVID-19 vaccination
Background summary
In the WHO European Region, 1.7 billion COVID-19 vaccine doses have been administered so far, but inequitable uptake has left many high-risk individuals vulnerable to serious outcomes of the disease. The rate of immunization coverage with the primary series and at least one booster dose among adults aged 60 years and older is much higher in high-income countries than in lower-middle-income countries in the Region.
Recommendations
- ETAGE reiterates its recommendation that achieving high vaccination coverage with the primary series and booster doses in high-risk populations should remain the highest priority. Countries should undertake additional efforts to ensure that all eligible people are up to date on COVID-19 vaccinations according to national recommendations.
- ETAGE concurs with the SAGE recommendation that countries may use ancestral virus vaccines or new variant-containing COVID-19 vaccines for booster doses according to product availability.
- Countries should plan for the integration of COVID-19 vaccination into routine health-care strategies using lessons learned from the COVID-19 vaccine rollout.
- Countries should sustain systems to monitor COVID-19 vaccination and adapt them as vaccination policies and reporting requirements evolve. If applicable, they should consider leveraging reporting mechanisms and digital platforms that were developed for COVID-19 vaccination to monitor routine immunization uptake through the life course.
Strengthening NITAGs
Background summary
Notable progress has been made in establishing NITAGs: 50 out of 53 countries of the WHO European Region reported having a NITAG established. However, when considering the six performance indicators identified by WHO , the performance of NITAGs varies considerably. WHO/Europe, in collaboration with the Robert Koch Institute (RKI), has been providing guidance and support to NITAGs in defining their maturity level; developing and implementing improvement plans; and building their capacities to develop evidence-based recommendations following a systematic approach. The newly developed WHO/Europe “Guidance on an adapted evidence to recommendation process for National Immunization Technical Advisory Groups” has been pilot tested in a few countries with positive results. In addition, a European Union (EU)/European Economic Area (EEA) NITAG Collaboration Network has been established recently with activities to enhance the exchange between EU/EEA NITAGs and strengthen NITAG capacities.
Recommendations
- WHO/Europe should continue advocating for the establishment of NITAGs in the three remaining countries in the Region. Ministries of health should prioritize support for and recognize the important role of NITAGs and their secretariats in making independent, informed recommendations on immunization in their countries.
- ETAGE encourages NITAGs to use the WHO/Europe “Guidance on an adapted evidence to recommendation process for National Immunization Technical Advisory Groups” to improve their recommendation-making processes, and NITAG partners to use it as part of the capacity building of NITAGs in the Region.
- Building upon the efforts to strengthen the work of NITAGs in the WHO European Region, WHO/Europe and partners should further strengthen ongoing collaboration towards capacity building of NITAGs. Such enhanced coordination between partners will increase efficiency and create synergies.
- ETAGE encourages NITAG partners to further enhance their collaboration by:
- ensuring that documents, tools and training materials are shared and made available to all NITAGs in the Region and globally, including tools developed by WHO and RKI and reviews of scientific evidence conducted by/for the EU/EEA NITAG Collaboration Network; and
- conducting joint meetings for NITAGs, whenever possible, to facilitate peer-to-peer learning and the exchange of experiences between all NITAGs in the Region.
- The enhanced exchange between ETAGE and NITAGs in developing COVID-19 recommendations should continue in the future when ETAGE develops recommendations on other immunizations and vaccine-preventable diseases. WHO/Europe should develop a process to collect NITAG requests for regional guidance and consider them when defining future ETAGE meeting agendas.
Paediatric diarrhoeal disease surveillance
Background summary
The WHO-coordinated Global Rotavirus Surveillance Network (GRSN) coordinates hospital-based sentinel surveillance, using hospital sites in multiple countries to conduct rotavirus surveillance in a standardized and quality-assured manner. Data from GRSN
have been instrumental in supporting decision-making for the introduction of rotavirus vaccination in WHO/Europe countries. The Global Pediatric Diarrhea Surveillance (GPDS) network analyses diarrhoeal specimens collected through GRSN sites, thereby
leveraging the existing GRSN to conduct broader testing for enteropathogens. GPDS data are used to estimate pathogen-specific attributable burdens of diarrhoeal hospitalizations and deaths, at site, country, regional, and global levels. GPDS is used
to guide the development of new enteric vaccines and will support decision-making on their introduction. Due to the small and decreasing number of countries and sites in the European Region with continued and consistent participation in GPDS, as well
as GRSN, pooled data are unlikely to describe the disease burden and genotype circulation for rotavirus and other enteropathogens in the Region.
Recommendations
- Considering availability of data, status of rotavirus vaccine introduction and challenges in sustaining sentinel surveillance in the European Region, WHO support in this area should focus on GPDS surveillance, building upon efforts already made to develop capacity for GRSN.
- The valuable data on rotavirus epidemiology and vaccine effectiveness generated by GRSN should be further used to develop investment plans to support policy decisions on rotavirus vaccine implementation.
- Countries are encouraged to continue conducting rotavirus surveillance using their own resources. Countries should consider increasing ownership and domestic funding for GPDS surveillance within overall investments in immunization and vaccine-preventable disease surveillance.
- WHO should consider supporting more countries in conducting paediatric diarrhoea surveillance based on common standards, regardless of income level, eligibility for specific donor funding or participation in the GPDS network, by:
- providing guidance on a minimum set of pathogens to be included in paediatric diarrhoea surveillance, a case definition for enrolment of cases in the surveillance, handling of specimens, laboratory testing, data management and analysis; and
- enabling access to laboratory testing through TaqMan Array Card (TAC) or similar testing platforms and standards, and building needed technical laboratory capacity.
- WHO should consider conducting a landscape analysis to better understand the surveillance gaps in paediatric diarrhoea surveillance at regional level and liaise with existing regional networks to coordinate use of the data to estimate disease burden due to enteropathogens.