Seventy-third Regional Committee for Europe: Astana, 24–26 October 2023: progress report: European Immunization Agenda 2030

Regional Committee for Europe 73rd session Astana, Kazakhstan, 24–26 October 2023 EUR/RC73/15 20 September 2023 | 230702 ORIGINAL: ENGLISH Provisional agenda items 2(c) and 10 European Immunization Agenda 2030 Progress report This report provides an overview of the progress in the WHO European Region during the first two years of implementation of the European Immunization Agenda 2030, through to December 2022. While the Region maintained its polio-free status, vaccine-derived polioviruses were detected in environmental samples and in cases of paralytic disease. Based on the reported data for 2021, the European Regional Commission for the Certification of Poliomyelitis Eradication identified several Member States as at either high or intermediate risk for the spread of polioviruses in the Region following the importation of wild poliovirus or the emergence of vaccine-derived polioviruses. In 2021 and 2022, the verification process for elimination of measles and rubella was disrupted due to low reporting by Member States. Notification of measles and rubella cases also declined during 2020 until 2022, partly because of suboptimal performance of vaccine-preventable disease (VPD) surveillance in Member States due to the COVID-19 pandemic. An increasing number of Member States have reported a decline in coverage with measles- and rubella-containing vaccines in 2022 compared with 2019. Five Member States were validated in 2021 and 2022 as having achieved the regional hepatitis B control target, setting the path towards achieving regional hepatitis elimination. By the end of 2022, only four Member States had achieved the global target of 90% coverage with the human papillomavirus vaccine among girls 15 years of age. Over 1900 episodes of VPD outbreak in 36 Member States that met predefined thresholds for outbreaks were reported in 2019, and only 10 VPD outbreaks were reported in six Member States in 2022. The data on the reported VPD outbreaks during 2020 until 2022 should be treated with caution because of the impact of the COVID-19 pandemic on VPD surveillance and the impact of pandemic-related social and public health measures on the transmission of infection. The number of Member States with less than 90% of districts (third administrative level) with at least 95% coverage of the third dose of diphtheria, tetanus and pertussis-containing vaccines decreased from 27 (55%) in 2019 to 23 (47%) in 2022. Coverage with the third dose of diphtheria, tetanus and pertussis-containing vaccines, the second dose of measles-containing vaccine, and the final dose of human papillomavirus and pneumococcal conjugate vaccines provides an indication of the breadth of protection provided by vaccines in the national immunization schedule. There was only a marginal change in the breadth of protection provided by these vaccines between 2019 and 2022. This report is submitted to the WHO Regional Committee for Europe for its consideration at its 73rd session in October 2023. EUR/RC73/15 page 2 Contents Introduction ............................................................................................................................................. 3 Progress against the EIA2030 impact indicators ..................................................................................... 3 Impact indicator 1: sustained polio-free status in the European Region........................................... 4 Impact indicator 2: percentage of countries that have achieved and sustained measles and rubella elimination ............................................................................................................................. 4 Impact indicator 3: percentage of countries that have achieved the regionally established hepatitis B control target ................................................................................................................... 5 Impact indicator 4: percentage of countries that have achieved the global HPV immunization target ................................................................................................................... 5 Impact indicator 5: trend in number of reported vaccine-preventable disease outbreaks .............. 6 Impact indicator 6: percentage of countries with evidence of under-immunized populations at subnational levels ........................................................................................................................... 6 Impact indicator 7: coverage with vaccines included in national immunization schedules (DTPc3, MCV2, HPVc, PCV3) ............................................................................................................... 7 Conclusions .............................................................................................................................................. 7 EUR/RC73/15 page 3 INTRODUCTION 1. The European Immunization Agenda 2030 (EIA2030), adopted at the 71st session of the WHO Regional Committee for Europe (resolution EUR/RC71/R4), outlines a vision and strategy for realizing the full benefits of immunization in the WHO European Region over the decade ending 2030. It is one of the flagship initiatives of the European Programme of Work, 2020–2025 – “United Action for Better Health in Europe” and aims to support Member States in their commitments towards the 2030 Agenda for Sustainable Development and the Global Action Plan for Healthy Lives and Well-being for All. 2. Aligned with the principle of co-creation for effective implementation, through extensive consultation with Member States and regional stakeholders, an operational framework for EIA2030 is being finalized by the WHO Regional Office for Europe (WHO/Europe). This operational framework outlines the context-specific national and subnational actions needed to operationalize the strategic objectives of EIA2030. 3. This report provides a concise overview of the progress made against the impact indicators and targets in EIA2030 through to December 2022, using 2019 as the base year. The base year for the progress measurement is 2019 instead of 2020 (the last year of the European Vaccine Action Plan 2015–2020) as the performance of Member States’ immunization programmes in 2019 (that is, before the impact of the COVID-19 pandemic) better depicts their progress towards regional goals and targets. 4. This overview of progress is based on a review of data reported by Member States to WHO/Europe through the annual WHO/United Nations Children’s Fund (UNICEF) Joint Reporting Form on Immunization, as well as other documents and reports, including (i) the WHO/UNICEF estimates of national immunization coverage and human papillomavirus (HPV) vaccine coverage, (ii) the reports of the European Regional Commission for the Certification of Poliomyelitis Eradication, the European Regional Verification Commission for Measles and Rubella Elimination, and the European Technical Advisory Group of Experts on Immunization hepatitis B working group, and (iii) vaccine-preventable disease (VPD) surveillance data. 5. The impact of the COVID-19 pandemic on routine immunization service delivery has been variable in the Region. The disruption in the provision of health services, including vaccination, led to a backslide in regional immunization coverage in 2020. But in 2021, the Region as a whole was able to prevent any further backsliding in coverage. There has been a decline in the performance of VPD surveillance, which has impacted the assessment of progress towards regional disease control goals. 6. The programmatic innovations and the lessons learned in rolling out COVID-19 vaccines in the Region will serve as a springboard to better operationalize vaccination across the life course in the Region and to enhance the resilience of national immunization programmes and their preparedness to respond to future epidemics and pandemics. PROGRESS AGAINST THE EIA2030 IMPACT INDICATORS 7. The monitoring, evaluation and accountability framework of EIA2030 outlines action-based indicators to monitor and evaluate progress towards EIA2030 goals and strategic priorities. The framework includes seven indicators that monitor progress against two impact goals: goal 1 – disease control, and goal 2 – equity and strengthening of primary health care. In addition, 16 indicators monitor progress against seven strategic priorities. 8. A compendium of indicators has been developed by WHO/Europe in consultation with all stakeholders in the Region, including Member States, partners and non-State actors. The compendium outlines the definition, rationale, programmatic relevance and intended use of the indicators as well as the data sources. 9. During the first two years of implementation of EIA2030, while some successes have been observed, national immunization programmes have experienced constraints linked to service delivery because of the COVID-19 pandemic. This points to the need for resilience in national immunization programmes to sustain EUR/RC73/15 page 4 routine vaccination service delivery during periods of public health emergency while concurrently mounting an effective response to contain the crisis. Impact indicator 1: sustained polio-free status in the European Region 10. At its 36th meeting, held in October 2022, the European Regional Commission for the Certification of Poliomyelitis Eradication concluded, based on the available evidence, that there was no wild poliovirus (WPV) transmission in the Region in 2021. This confirmed that the Region was able to maintain its polio- free status for a 20th year. Despite this success, the Regional Commission concluded that Bosnia and Herzegovina, Montenegro, Romania and Ukraine are at high risk and 14 other Member States are at intermediate risk of sustained transmission in the event of importation of WPV or the emergence of circulating vaccine-derived polioviruses (cVDPV) due to suboptimal immunization programme performance, low surveillance quality, low population immunity and inadequate preparedness. 11. The regional coverage with three doses of polio vaccine remained steady at 94% between 2020 and 2022, after experiencing a 1% drop in coverage in 2020 from 2019. However, the number of Member States with less than 90% coverage with three doses of polio vaccine increased from seven in 2019 to 13 in 2020 and 11 in 2022, indicating a build-up of immunity gaps in several Member States. 12. The widespread use of oral polio vaccine has led to increasing prevalence and spread of cVDPV in several parts of the world, including the European Region. An outbreak circulating vaccine-derived poliovirus type 2 (cVDPV2) occurred in Tajikistan in 2021, resulting in 34 paralytic cases; the outbreak was declared closed on 29 April 2022. An outbreak of cVDPV2 occurred in Ukraine in 2021, resulting in two paralytic cases, and was genetically linked to the outbreak in Tajikistan. Polioviruses of concern with varying divergence from the polio vaccine strains were detected in Germany, Israel, Poland and the United Kingdom of Great Britain and Northern Ireland in 2022. In Germany, three vaccine-derived poliovirus type 1 (VDPV1) isolates were detected with no genetic link to any outbreak and were classified as ambiguous VDPV1. In the United Kingdom, 26 isolates of cVDPV2 were detected in sewage samples. Israel experienced an outbreak of cVDPV3 in 2021 and 2022, with the virus isolated from one paralytic case, seven healthy contacts and 58 environmental samples. Israel also had 27 environmental samples classified as cVDPV2 in 2022, and these were linked to the virus isolated in the United Kingdom. 13. To manage poliovirus (PV)-associated risks, all Member States are required to perform a national inventory of all facilities that handle PV materials, to destroy all unneeded PV materials (with primary focus on all type 2 PV and type 3 WPV materials), and to certify all facilities that retain PV as PV-essential facilities (PEFs). To date, all Member States but one (Romania) have confirmed the destruction of type 2 PV materials and all but two (France and Romania) have confirmed the destruction of type 3 WPV materials in all non-PEFs in their country. In 2022, nine out of 10 Member States that expressed intention to host a total of 33 designated PEFs had initiated the certification process for their PEFs, and 19 certificates of participation had been awarded. The next step towards the issuance of the Interim Certificate of Containment has already begun, and this certification has been issued to two PEFs in France. Impact indicator 2: percentage of countries that have achieved and sustained measles and rubella elimination 14. Elimination of measles and rubella is defined as the absence of endemic transmission in a defined geographical area (such as a country) for at least 12 months in the presence of a well-performing surveillance system, maintained for three consecutive years. Verification of elimination at country level can therefore be declared after at least 36 months of absence of endemic disease in the Member State. The number of Member States in the Region that were verified by the European Regional Verification Commission for Measles and Rubella Elimination as having eliminated endemic transmission of measles and of rubella in 2019 was 30 (57%) and 45 (85%), respectively. In 2020, the number declined to 29 (55%) and 41 (77%), respectively, but recovered to 33 (62%) and 48 (91%), respectively, in 2021. The COVID-19 EUR/RC73/15 page 5 pandemic disrupted the verification process during 2020 and 2021 due to low reporting from Member States. Review of elimination status of Member States for 2022 will be conducted in the second half of 2023. 15. Globally, the number of reported cases and the incidence per million population of measles and rubella declined in 2020 and 2021 in comparison with 2019. Several factors may have contributed to this decline, including decreased virus transmission because of the non-pharmaceutical public health and social measures of the COVID-19 pandemic response, the decline in the performance of VPD surveillance, and an increase in population immunity in certain Member States from the outbreaks of measles between 2017 and 2019. The same was observed in the European Region, with a dramatic decline in reported cases and incidence of both measles and rubella in 2020 and 2021. Alongside factors related to the COVID-19 pandemic, the decline in measles cases during this period was also the result of improved coverage with measles-containing vaccines (MCVs) during the years preceding the pandemic. Between 2016 and 2019, coverage with the first dose increased from 93% to 96%, while coverage for the second dose increased from 88% to 92%. The number of measles cases in 2018 and 2019 was substantially higher than in the previous years in the decade, representing epidemic years. Although the number of reported cases increased in 2022 compared with 2020 and 2021, the incidence of measles and rubella in 2022 remained lower than in 2019. With the limited routine data available, measles surveillance sensitivity in most Member States in the Region dropped from 3.1 per 100 000 in 2019 to 0.7 per 100 000 in 2021 and did not attain the pre-pandemic level in 2022. 16. Regional coverage with the first and second doses of MCV (MCV1 and MCV2) declined by 3% and 1%, respectively, between 2019 and 2022. The number of Member States with MCV1 coverage below 90% increased from eight in 2019 to 14 in 2022. This indicates a build-up of immunity gaps in several Member States in the Region, which could potentially lead to outbreaks of measles unless catch-up vaccination is carried out in 2023 and 2024 to fill these gaps. Impact indicator 3: percentage of countries that have achieved the regionally established hepatitis B control target 17. A working group of the European Technical Advisory Group of Experts on Immunization is tasked with assessing achievement of the hepatitis B control goal by Member States in the Region. 18. Since 2019, through to the end of 2022, five Member States in the Region (Georgia, Italy, Netherlands (Kingdom of the), Republic of Moldova and the United Kingdom) have been validated by the working group as having achieved the control target. In early 2023, four additional Member States (Belarus, Kyrgyzstan, Turkmenistan and Uzbekistan) were validated as having achieved the regional target. These Member States, which had high endemicity of hepatitis B in the past, demonstrated that successful implementation of hepatitis B vaccination can lead to significant reduction of chronic hepatitis among children and adolescents and thereby to reduction in liver cancer caused by hepatitis B. 19. As more Member States reach the regional targets set for hepatitis B control, an effort supported by WHO/Europe and other regional partners, the Region will move closer to achieving the ultimate goal of eliminating viral hepatitis as a public health threat by 2030. Impact indicator 4: percentage of countries that have achieved the global HPV immunization target 20. The Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem outlines the strategic actions and sets 2030 targets for Member States to achieve to be on the path towards cervical cancer elimination. The vaccination-related target is for Member States to ensure 90% of girls are fully vaccinated with the HPV vaccine by the age of 15 years. EUR/RC73/15 page 6 21. By the end of 2019, 38 Member States (72%) in the Region had introduced HPV vaccination. This number increased to 44 (83%) in 2022. There was no major change in the regional coverage with HPV vaccine during this period: 27% in 2019 and 29% in 2022. 22. By 2022, four Member States (Iceland, Norway, Portugal and Turkmenistan) had achieved the global target of 90% coverage among girls 15 years of age, compared to one (Portugal) in 2019. By 2022, 24 Member States had achieved coverage of 50% or more among girls 15 years of age. 23. In 2022, through to the first quarter of 2023, seven additional Member States introduced HPV vaccination to the national immunization schedule, taking the total number of Member States in the Region with HPV vaccine to 45 (85%). Approximately 58% of the Region’s population of girls between 9 and 15 years of age live in Member States that implement routine HPV vaccination. In addition, 20 Member States also provide HPV vaccination to boys. Impact indicator 5: trend in number of reported vaccine-preventable disease outbreaks 24. The detection, reporting and timely response to VPD outbreaks in the Region measures the impact of multiple strategic priorities of EIA2030: strengthening of primary health care and universal health coverage, including enhanced VPD surveillance; achieving high and equitable vaccination coverage; delivering immunization through the life course; and improving outbreak and emergency response. 25. In 2019, around 1920 episodes of VPD outbreak in 36 Member States met predefined outbreak thresholds for the reported cases of poliomyelitis, measles, rubella and meningococcal diseases. In 2022, only 10 such episodes of VPD outbreak were reported by six Member States in the Region, a significant decline compared with 2019. Around 80% of the episodes in 2019 that met predefined outbreak thresholds were reported from four Member States in the Region: Italy, Kyrgyzstan, Russian Federation and Ukraine. The decline in the episodes of VPD outbreak that met predefined thresholds in 2021 and 2022 should be treated with caution. Measles cases between 2017 and 2019 in the Region were significantly higher than in previous years. The COVID-19 pandemic has impacted the performance of VPD surveillance, and the public health and social measures implemented to respond to the COVID-19 pandemic may have also resulted in a reduction in transmission of other respiratory infections, including measles. 26. The reported outbreaks of cVDPV2 in Israel, Tajikistan, Ukraine and the United Kingdom and of cVDPV3 in Israel during 2021 and 2022, together with an increase in the number of Member States with coverage of less than 90% with three doses of polio vaccine between 2020 and 2022, highlight the risks of sustained polio transmission within the Region. In addition, coverage with the third dose of diphtheria, tetanus and pertussis- containing vaccines (DTPc3) also declined in several Member States in the Region during the COVID-19 pandemic, which increases the risk of outbreaks of epidemic-prone VPDs such as diphtheria and pertussis. The coverage of both MCV1 and MCV2 has also declined since 2019, indicating an accumulation of vulnerable populations and an increased risk of outbreaks if these immunity gaps are not filled. 27. The detection of VPD outbreaks between 2020 and 2022, despite a decline in the performance of VPD surveillance, points to existing immunity gaps in Member States and the need to improve and maintain high vaccination coverage to address such gaps. It also highlights the need to strengthen and sustain high- quality VPD surveillance and mechanisms for rapid response should cases of measles, polio or meningococcal disease be detected in the Region. Impact indicator 6: percentage of countries with evidence of under-immunized populations at subnational levels 28. Assessment of progress towards achieving immunization equity, one of the core principles of EIA2030, will be evaluated through annual reporting of subnational vaccination coverage data by Member States. EUR/RC73/15 page 7 29. Evidence of under-immunized populations at subnational levels (third-level administrative unit), an indicator of immunization inequity, is defined as less than 90% of third-level administrative units in a country with at least 95% coverage for DTPc3. In addition, even if at least 90% of subnational units in a country report coverage of 95% or more for DTPc3, there must not have been any outbreaks or ongoing transmission of measles, rubella or polio from the reporting subnational units among residents under five years of age in the past three years. This indicator is applicable for 49 Member States in the Region that report having a subnational level. 30. The reporting of subnational immunization coverage by Member States has declined in the Region. In 2022, 32 Member States reported DTPc3 coverage for their third-level administrative units, compared with 40 in 2019. 31. Assessment of DTPc3 coverage of the third-level administrative units in the Region indicates that in 2022, 23 Member States (47%) had evidence of under-immunized populations at subnational levels compared with 28 (57%) in 2019. Impact indicator 7: coverage with vaccines included in national immunization schedules (DTPc3, MCV2, HPVc, PCV3) 32. A composite coverage with vaccines against diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenzae type b, measles, poliomyelitis, rubella, pneumococcus and HPV reflects the breadth of protection offered to the population by the national immunization schedule. The target is for countries to achieve at least 90% coverage for four selected vaccine doses: DTPc3, MCV2, the last dose of HPV vaccine (HPVc) and the final dose of pneumococcal conjugate vaccine (PCV3). 33. Not all Member States in the Region have introduced PCV and HPV vaccines in their national immunization programmes for the entire population, and as of the end of 2022, six Member States (11%) and 11 Member States (21%) were yet to include PCV and HPV vaccines, respectively, in their national immunization schedule. 34. There has been only a marginal change in the coverage of these four vaccines and the breadth of protection provided by these vaccines between 2019 and 2022. In 2022, only three Member States had at least 90% coverage with all four vaccines, and 20 had at least 90% coverage with three of the four vaccines. CONCLUSIONS 35. Amid the roll-out and scale-up of COVID-19 vaccination in 2021 and 2022, the Member States in the Region have demonstrated resilience in the delivery of routine immunization services to their populations. Since the adoption of EIA2030 in September 2021, the Region has made considerable progress in its implementation. The Region has maintained its polio-free status, despite the occurrence of VDPV cases and detection in the environment. The progress in the Region towards achieving hepatitis B control is creditable, with an increasing number of Member States continuing to reach the regional target. While regional coverage of HPV vaccine remains lower than the globally established vaccination target, more than half of the Member States that have introduced HPV vaccination have now achieved coverage of 50% or above in girls 15 years of age, paving the path towards achieving the regional elimination of cervical cancer. 36. Despite these commendable successes, concerns remain over the stagnant breadth of protection with key vaccines since 2019 and the occurrence of the VDPV, measles and diphtheria outbreaks in the Region. Unless action is taken immediately to close the immunity gaps, achieving the vision of a Region free of VPDs, as outlined in EIA2030, remains unlikely. 37. Achieving and maintaining high and equitable vaccination coverage in every community in the Region will be central to achieving and maintaining the VPD eradication, elimination and control goals outlined in EUR/RC73/15 page 8 EIA2030. Coordinated and urgent action by all Member States and stakeholders in the Region is needed to systematically address immunization inequity by closing population immunity gaps through catch-up vaccination, constant vigilance and preparedness to detect outbreaks, and a timely outbreak response thereby ensuring regional health security. 38. The innovations and lessons learned from the COVID-19 vaccination of varied age groups provide the architecture for Member States and stakeholders to integrate COVID-19 vaccination into the broader health system, including paving the way to institutionalizing vaccination across the life course in the Region. = = =