Decisions on immunization policy, especially on the introduction of new vaccines into national programs, have important implications for program financing as well as for population health. Even when a vaccine is broadly recommended by the World Health Organization, it may not be a high priority in a particular setting, given local epidemiology, health system strengths and weaknesses, and immunization program capacity. Moreover, even if a vaccine would bring clear benefits, it may not be cost-effective or affordable at the price available to a particular country. Decisions on vaccine introduction are highly technical and require a range of epidemiological, economic, programmatic, and vaccine expertise. (See Brief 4.)
WHO recommends that countries establish an independent technical body, sometimes called a national immunization technical advisory group (NITAG), to advise the government on vaccine introduction and other aspects of immunization policy. Although 82 countries had set up NITAGS as of 2016, these groups vary greatly in their capacity, functioning, and influence.
Sri Lanka’s Advisory Committee on Communicable Diseases (ACCD) is an example of a long-established, well-functioning advisory committee, although its mandate differs in some respects from that of other NITAGs. This brief summarizes the ACCD’s functions and composition and highlights its role in important recent decisions concerning Sri Lanka’s immunization program.
Sri Lanka’s Immunization Program
Sri Lanka’s government launched its Expanded Programme on Immunization—now called the National Immunization Programme (NIP)—in 1978. The program rapidly achieved high coverage. The national immunization schedule now includes pentavalent vaccine, the measles-rubella-mumps combination, and Japanese encephalitis, as well as the basic vaccines provided from the start of the program. Inactivated polio vaccine (IPV) was introduced in July 2015, and the typhoid vaccine is given to high-risk groups. The country was among the first in South Asia to introduce several of these vaccines. Immunization
Even when a vaccine is broadly recommended by the World Health Organization, it may not be a high priority in a particular setting.
coverage is exceptionally high, reaching 99% for the third dose of diphtheria-tetanus-pertussis (DTP3) as well as for both doses of measles, according to WHO/UNICEF estimates for 2015. The program has contributed, as part of a strong health system, to low rates of vaccine-preventable diseases, a child mortality rate of 10/1,000, and a life expectancy of 76 years.
Advisory Committee on Communicable Diseases
The ACCD was established in the 1960s—before the launch of the Expanded Programme on Immunization—to review the status of communicable diseases in the country and make policy decisions related to their prevention and control. This mandate differs from that of NITAGs in most countries in two important respects. First, its scope includes all measures to control communicable disease, not just immunization. Second, its decisions are binding on the public sector—in this sense, it is more than an advisory body.
The ACCD meets quarterly and has 36 members, with a broad range of expertise in epidemiology, vaccinology, child health, health administration, and specific infectious diseases, among other disciplines. Most members are academics, physicians, or high-level government administrators. Its chair is the director general of health services; the chief of the Ministry of Health’s epidemiology unit serves as the committee’s secretary. Notably, as of 2016 it did not include members with economic expertise.
Approach to Vaccine Introduction
In considering the introduction of a new vaccine into the NIP, the ACCD assesses evidence on disease burden, vaccine safety and effectiveness, feasibility, cost, and cost-effectiveness. When data on disease burden from the routine surveillance system are insufficient, the ACCD sometimes recommends that special studies be done. In some cases, it has requested additional studies of vaccine safety and immunogenicity in the Sri Lankan population.
As a matter of policy, the ACCD will not recommend introducing a new vaccine unless sustainable financing is in place. It also considers cost-effectiveness, and the NIP has commissioned cost-effectiveness studies of several vaccines in recent years.
When a new vaccine is under consideration, the ACCD typically establishes a working group to gather and analyze the necessary information. The next step is discussion at a National Immunization Summit—a stakeholders’ forum attended by academic experts, representatives of professional associations, international organizations, and Ministry of Health officials. Although the ACCD is ultimately responsible for decisions on new vaccines, the immunization summits are important opportunities to seek broader input and build consensus.
The ACCD’s decision-making on the human papillomavirus (HPV) and rotavirus vaccines illustrates the committee’s approach.
Cervical cancer is the second most common cancer among women in Sri Lanka, accounting for 10% of female cancers. The country’s cervical cancer screening program currently reaches only 30–40% of women. Given the burden of cervical cancer and the high cost of treatment, a cost-effectiveness study carried out by a Ministry of Health expert concluded that introduction of the HPV vaccine would be cost-effective in Sri Lanka. Moreover, Sri Lanka has a well-established school-based immunization program to which the new vaccine could be added, making delivery less challenging than in many other developing countries.
In light of these analyses, in 2015 an expert group established by the director general of health services recommended nationwide introduction of the HPV vaccine for girls, along with efforts to expand coverage of cervical cancer screening to 80%. The ACCD endorsed this recommendation in 2016.
The rotavirus vaccine has been discussed at the annual National Immunization Summit, but an ACCD working group has not been established. The primary reason for the relatively low priority currently accorded to this vaccine is low disease burden. An ongoing hospital study has found low mortality and morbidity from rotavirus infection in Sri Lanka, presumably because of widespread access to safe water and sanitation (84% and 86%, according to UNICEF) and broad access to treatment for severe diarrhea.
Implications of Gavi Transition
At the end of 2015, Sri Lanka became one of the first countries to complete the transition from Gavi support. Compared to countries that introduced more vaccines, Sri Lanka faced a smaller increase in domestic vaccine financing during this transition. Nevertheless, it will now have to find domestic resources to pay for any new vaccines it introduces. The rigorous decision-making process led by the ACCD—including the requirement that assured financing be in place—puts Sri Lanka in a strong position to face these new challenges.
At the end of 2015, Sri Lanka became one of the first countries to complete the transition from Gavi support.
Sources and Further Reading
NITAG Resource Center [Internet]. NRC: About. Available from: http://www.nitag-resource.org/about
Wijesinghe PR, Palihawadana P, Peiris TS. Participatory decision-making through the Advisory Committee on Communicable Diseases: the Sri Lankan experience. Vaccine. 2010 Apr 19;28:A96-103.