Prioritizing countries for TB vaccine readiness research using a global stakeholder-centric approach

Background: The promise of new tuberculosis (TB) vaccine candidates prompts the need for research on vaccine demand and health system readiness in diverse country settings with high TB burdens to help ensure effective and equitable vaccine deployment. Prior to vaccine introduction, we developed a structured approach to prioritizing countries for TB vaccine readiness research by combining stakeholder preferences, elicited through best-worst scaling (BWS) with an analytical hierarchy process (AHP) framework. Methods: We conducted a self-administered electronic survey targeted to TB vaccine stakeholders involved in vaccine development, advocacy, and implementation across 23 of the 24 USAID TB priority countries. The survey included BWS to determine the relative importance of 17 criteria for country selection. Stakeholders were recruited using an existing email list, a ‘snowball’ approach, and recommendations from TB experts. In a series of 13 choice tasks, respondents selected what they felt were the most and least important criteria from four randomly generated criteria. The weights derived through BWS for each criterion were combined with country-specific scores for each criterion using publicly available data to determine the overall prioritization score for each country. Results: Of 427 stakeholders, 115 (26%) completed the survey; 88% were from TB priority countries. Participants represented civil society/advocacy groups (34%), international nongovernmental organizations (21%), national TB Programs (13%), and academic/research institutions (17%). Sixteen of 17 criteria were identified as ‘important’ using BWS.  Overall country TB burden (weight=11.1) and TB-related political will (weight=10.3) were the most important, followed by burden of TB-related deaths (weight=7.9), health systems strength (weight=7.5), and adult COVID-19 coverage (weight=7.4).  The five countries with the highest prioritization scores were in sub-Saharan Africa. Three of them were selected alongside the highest-scoring country from South Asia, Europe and Central Asia, and East Asia as priority research settings in pursuit of regional diversity. Conclusion: This study demonstrates the successful use of an inclusive, objective approach to be considered alongside other contextual factors for prioritizing countries for future TB vaccine readiness research. The AHP, especially when combined with BWS, is a practical and transparent approach that can be applied to support evidence-based funding decisions in the global public health field.