Closing the pneumococcal conjugate vaccine (PCV) introduction gap: an archetype analysis of last-mile countries

Figures & data

Table 1. Global pneumococcal conjugate vaccine (PCV) introduction status as of March 2023.

	Number of Countries
Total countries	194
Introduced PCV into National Immunization Program*	155 (80%)
Not introduced PCV into National Immunization Program (including partial introduction for risk groups and/or certain regions of the country)	39 (20%)
High-income countries	6
Upper-middle-income countries	19
Lower-middle-income countries	7
Low-income countries	6
Temporarily unclassified by World Bank (Venezuela)	1

*Including Indonesia, Tajikistan and Timor-Leste who introduced PCV into their National Immunization Programs between November 2022 and January 2023.

Table 2. Domains, indicators and scoring framework for country archetype classification related to PCV introduction decision-making.

Domains	Indicators	Score^a
		0	1	2	3	4
Health characteristics	(1) Pneumococcal incidence rate (2015) (cases per 100,00 children)^b	<199	200 to 1,000	1,001 to 2,000	2,001 to 3,000	>3,001
	(2) Child mortality rate (U5 child deaths per 1,000 live births)^c	<10	11 to 39	40 to 69	70 to 99	>100
	(3) National health expenditure (% of national gross domestic product – GDP)	<2.5	2.6-5.0	5.1-7.5	7.6-10.0	>10.1
Immunization systems	(4) Vaccine coverage: DTP3 (%)	less than 25%	26–50%	51–74%	75 to 89%	>90%
	(5) Vaccine coverage: MCV1 (%)	less than 25%	26–50%	51–74%	75 to 89%	>90%
	(6) Current usage of ‘new’ vaccines (RV, HPV, IPV, MCV2)	None	1 vaccine introduced	2 vaccines introduced	3 vaccines introduced	4 vaccines introduced
	(7) PCV partial introduction	PCV not introduced (including available only in the private sector)	PCV was introduced previously but currently suspended	PCV introduced to risk groups and/or certain regions in the country (subnational introduction)	-	-
Policy framework	(8) Presence of a National Immunization Technical Advisory Group (NITAG)^d	No NITAG or no information	Yes: Interagency coordinating committee (ICC) that functions in lieu of NITAG	Yes: NITAG which meets 1-3 WHO criteria	Yes: NITAG which meets 4-5 WHO criteria	Yes: NITAG which meets all 6 WHO criteria
	(9) Political will pertaining to PCV introduction^e	No Information	Political interest present, along with strong political challenges to vaccine introduction	Expression of interest via reports and interviews of stakeholders	-	Official statement of intent from the government
	(10) Gavi-eligibility and support	Non-Gavi	MIC^e approach: Never Gavi-eligible	MIC^f approach: Former Gavi- eligible	Gavi-eligible	Gavi-eligible (fragile and conflict segment)^g

^aThe greater the score, the lower the barriers to vaccine introduction.

^bEstimated incidence (2015) of pneumococcal disease including pneumonia, severe pneumonia, meningitis and invasive non pneumonia non meningitis (NPNM).

^cWorld Bank Child Mortality Data. Available at: https://data.worldbank.org/indicator/SH.DYN.MORT.

^dThe six process indicators for NITAGs are the presence of: (1) a legislative or administrative basis, (2) formal terms of reference, (3) five or more areas of expertise represented among its membership, (4) at least one meeting per year, (5) distribution of the agenda and background documents at least one week prior to meetings and (6) mandatory disclosure of conflict of interests.

^eSourced from government reports, public announcements, published accounts.

^fGavi’s MICs Approach supports selected middle-income countries to drive sustainable introduction of key missing vaccines in select former- and never Gavi-eligible countries. [Eligible country list, July 2022 https://www.gavi.org/sites/default/files/programmes-impact/support/Countries-and-economies-eligible-for-support-under-Gavi-MICs-Approach.pdf].

^gGavi has identified a set of countries that face chronic fragility to provide more flexible and tailored support – these countries in our scoring received a score of 4, considering that Gavi will prioritize these countries with bespoke interventions to adopt within the conflict affected environment.

Table 3. Scoring and categorisation of last-mile countries yet to introduce PCV.

Country	Pneumococcal incidence rate (2015)	U5 child mortality rates per 1,000 live births	National health expenditure (% of GDP)	Vaccine coverage: DTP3^1	Vaccine coverage MCV1^2	Recent new vaccine introductions (RV^3, HPV^4, IPV^5, MCV2^6)	Partial PCV introduction	Presence of a NITAG	Political will pertaining to PCV introduction	Gavi eligibility & support	Score	Country Category based on score (Low-Barriers, Moderate -Barriers, High-Barriers)
Cuba	1	0	4	4	4	2	0	4	2	2	23	Low
Comoros	3	2	2	3	3	2	0	4	0	3	22	Low
Iran (Islamic Republic of)	2	1	2	4	4	2	2	4	0	1	22	Low
South Sudan	2	3	2	1	1	1	0	4	4	4	22	Low
Viet Nam	2	1	2	3	3	2	0	3	4	2	22	Low
Chad	2	4	1	2	2	1	0	1	4	4	21	Low
Dominica	2	1	2	4	4	3	0	4	0	1	21	Low
Jordan	2	1	3	3	3	3	0	2	4	0	21	Low
Maldives	2	0	3	4	4	3	0	4	0	1	21	Low
Sri Lanka	2	0	1	4	4	3	0	4	1	2	21	Low
Guinea	2	3	1	1	1	1	0	4	4	3	20	Low
Jamaica	1	1	2	4	3	3	2	4	0	0	20	Low
Moldova, Republic of	1	1	2	3	3	2	2	4	0	2	20	Low
Somalia	4	4	0	1	1	1	0	1	4	4	20	Low
Thailand	2	0	1	4	4	4	0	3	2	0	20	Low
Belarus	1	0	2	4	4	2	2	4	0	0	19	Moderate
Belize	2	1	2	3	3	3	0	4	0	1	19	Moderate
China	1	0	2	4	4	2	0	4	2	0	19	Moderate
Egypt	1	1	1	4	4	2	0	3	2	1	19	Moderate
Iraq	2	1	1	3	3	3	1	3	2	0	19	Moderate
Saint Lucia	1	1	1	3	3	3	2	4	0	1	19	Moderate
Saint Vincent and the Grenadines	1	1	1	4	4	3	0	4	0	1	19	Moderate
Ukraine	1	0	2	3	3	2	0	4	1	2	18	Moderate
Syrian Arab Republic	2	1	1	1	2	2	0	4	0	4	17	Moderate
Cabo Verde	2	1	1	4	4	3	0	0	0	1	16	Moderate
Grenada	1	1	1	2	3	3	0	4	0	1	16	Moderate
Suriname	1	1	3	2	2	3	0	4	0	0	16	Moderate
Bosnia and Herzegovina	1	0	3	2	2	2	2	3	0	0	15	High
Democratic People’s Republic of Korea	2	1	0	1	1	2	0	4	0	3	14	High
Venezuela	1	1	2	2	2	2	1	0	2	1	14	High
Equatorial Guinea	2	3	1	2	2	2	0	0	0	0	12	High
Gabon	2	2	1	3	2	2	0	0	0	0	12	High
Montenegro	1	0	3	3	0	2	0	3	0	0	12	High

DTP3 – Three doses of diphtheria, tetanus and pertussis; MCV1 – The first dose of measles-containing vaccine; RV – Rotavirus vaccine; HPV – human papillomavirus vaccine; IPV – Inactivated poliovirus vaccine; MCV2 – Second dose of measles-containing vaccine

Figure 1. Map of 33 LMICs yet to introduce PCV with their respective archetypes.

*Venezuela is currently unclassified by the World Bank, but for the purposes of this exercise and categorisation process, it is considered as a LMIC (source: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups)

Table 4. LMICs that have not yet introduced PCV, categorised as per their archetypes for potential PCV introduction.

Category	Countries
Low barriers to introduction (Score 20 to 25)	Cuba Comoros Iran (Islamic Republic of)^a South Sudan Viet Nam Chad Dominica Jordan Maldives Sri Lanka Guinea Jamaica^a Moldova, Republic of^a Somalia Thailand
(2) Moderate barriers to introduction (Score 15 to 19)	Belarus^a Belize China Egypt Iraq^b Saint Lucia^a Saint Vincent and the Grenadines Ukraine Syrian Arab Republic Cabo Verde Grenada Suriname
(3) High barriers to introduction (Score 8 to 12)	Bosnia and Herzegovina^a Democratic People’s Republic of Korea Venezuela^b Equatorial Guinea Gabon Montenegro

^aCountries that have partially introduced PCV among certain regions of the country and/or to specific risk groups.

^bIraq and Venezuela both previously introduced PCV in 2017 and 2014 respectively, however halted its use in the national routine schedule (19).

Table 5. List of countries with opportunities that lower barriers to PCV introduction.

Archetype	Gavi-eligible (Fragile and conflict segment^a)	Gavi MICs^b Approach		Non-Gavi countries
		Never Gavi-eligible	Former Gavi-eligible
Low-barrier countries	Chad^a Comoros Guinea Somalia^a South Sudan^a	Dominica Iran (Islamic Republic of) Maldives	Cuba Moldova, (Republic of) Sri Lanka Viet Nam	Jamaica Jordan Thailand
Moderate- barrier countries	Syrian Arab Republic^a	Belize Cabo Verde Egypt Grenada Saint Lucia Saint Vincent and the Grenadines	Ukraine	Belarus China Iraq Suriname
High-barrier countries	Democratic People’s Republic of Korea	Venezuela		Bosnia and Herzegovina Equatorial Guinea Gabon Montenegro

^aFragility, emergencies and displaced populations policy, Gavi. https://www.gavi.org/programmes-impact/programmatic-policies/fragility-emergencies-and-displaced-populations-policy.

^bMIC: Middle Income Countries; Gavi’s approach to engaging with middle-income countries. https://www.gavi.org/types-support/sustainability/gavi-mics-approach.

Data availability statement

All data generated or analysed during this study are included in this published article [and its supplementary information files].