Identifying research questions for HIV, tuberculosis, tuberculosis-HIV, malaria, and neglected tropical diseases through the World Health Organization guideline development process: a retrospective analysis, 2008-2018

OBJECTIVES

World Health Organization (WHO) guidelines for health programmes and healthcare delivery are the foundation of its technical leadership in public health and essential to decision-making globally. A key function of guideline development is to identify areas in which further evidence is needed because filling these gaps will lead to future improvements in population health. The objective of this study was to examine the knowledge gaps and research questions for addressing those gaps generated through the WHO guideline development process, with the goal of informing future strategies for improving and strengthening the guideline development process.

STUDY DESIGN

We did a systematic, retrospective analysis of research questions identified in the published guidelines.

METHODS

We analyzed guidelines published between January 1, 2008, and December 31, 2018, by the Communicable Diseases Cluster in five disease areas: tuberculosis (TB), HIV, malaria, TB-HIV, and neglected tropical diseases (NTDs). Research questions were extracted independently by two researchers. We analyzed the distribution of research questions by disease and by topic category and did a qualitative assessment of optimum practice for research question generation during the guideline development process.

RESULTS

A total of 48 guidelines were included: 26 on HIV, 1 on malaria, 11 on TB, 5 on TB/HIV, and 5 on NTDs. Overall, 36 (75%) guidelines encompassed a total of 360 explicit research questions; the remainder did not contain specific research questions. The number of research questions that focused on TB was 49, TB/HIV was 38, HIV was 250, and NTDs was 23. The number of research questions that focused on diagnosis was 43 (11.9%) of 360, prevention was 62 (17.2%), treatment was 103 (28.6%), good practice was 12 (3.3%), service delivery was 86 (23.8%), and other areas was 54 (15%). Research questions were often not formulated in a specific or actionable way and were hard to identify in the guideline. Examples of good practice identified by the review team involved the generation of specific and narrowly defined research questions, with accompanying recommendations for appropriate study design.

CONCLUSIONS

The WHO must strengthen its approach to identifying and presenting research questions during the guideline development process. Ensuring access to research questions is a key next step in adding value to the guideline development process.

Vaccination status of migrant populations in EU/EEA countries and implications for VPD control

Background

Migrant populations in the EU/EEA are increasingly being associated with outbreaks of vaccine-preventable diseases (VPDs), including the large-scale measles outbreak currently ongoing across Europe; however, it is unclear to what extent migrants represent an under-immunised group in the European context and implications for VPD control. Ensuring high levels of vaccination coverage is a key priority for all countries through the European Vaccine Action Plan, with EU/EEA Member States committed to eliminating measles and rubella, sustaining polio-free status, and controlling hepatitis B infection. We synthesised existing EU/EEA data to assess under-immunisation in migrants (defined as foreign born) residing in EU/EEA countries.

Methods

We did a systematic review and meta-analysis (PROSPERO CRD42018103666) in accordance with PRISMA guidelines. Inclusion criteria were primary research studies pertaining to vaccination status (measles, mumps, rubella, diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b [Hib]) in migrants residing in all EU/EEA countries. Pooled prevalence (95% CIs) were calculated for the meta-analysis using a random effects model.

Results

56 studies met our criteria (14 EU/EEA countries); 36 studies, which included data from 80,432 migrants, were included in the meta-analysis. Vaccination status of migrants for key VPDs varied substantially, with pooled immunisation coverage well below the herd immunity threshold (HIT) targets for measles 80% (95% CI: 73-87%; HIT 92-95%), mumps 65% (95% CI: 48-82%; HIT 75-86%), and diphtheria 51% (95% CI: 29-73%; HIT 83-86%). Polio type 1 and 2 coverage was high (97% [95% CI: 95-98%]; 95 [95% CI: 92-97%], respectively).

Conclusions

Migrants represent an under-immunised group in Europe, thus a high priority group for catch-up vaccination. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and/or control of key VPDs.

Key messages

Migrants represent an under-immunised group in Europe and a high priority group for catch-up vaccination campaigns. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and control of vaccine-preventable diseases.