How countries were chosen for TB vaccine readiness studies

Tuberculosis remains a global threat, and the arrival of promising new TB vaccine candidates has created urgency to understand where and how vaccines could be introduced fairly and effectively. To prepare for that moment, researchers developed a structured way to decide which countries should be examined first for vaccine demand and health system readiness. Led by Michelle M. Gill, the team focused on countries with high TB burdens and sought a transparent, stakeholder-driven process to set priorities before vaccine introduction. The goal was not to pick winners for procurement but to identify representative settings where research on readiness could reveal practical barriers and opportunities for equitable rollout. By concentrating efforts in a handful of countries, researchers and funders can gather the detailed, contextual evidence needed to guide policy and implementation strategies when a vaccine becomes available. The approach was designed to be inclusive of voices across government, civil society, and technical organizations, and to balance epidemiological need with health system capacity and political considerations.

The team used a self-administered electronic survey of TB vaccine stakeholders working across 23 of the 24 USAID TB priority countries. Stakeholders were recruited from an existing email list, a ‘snowball’ approach, and recommendations from TB experts. Of 427 stakeholders invited, 115 (26%) completed the survey; 88% of respondents 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%). The survey used best-worst scaling (BWS) to measure the relative importance of 17 criteria across 13 choice tasks, in which respondents picked the most and least important criteria from four randomly generated items. Weights from BWS were combined within an analytical hierarchy process (AHP) framework with country-specific scores drawn from publicly available data to produce overall prioritization scores. Sixteen of 17 criteria were deemed important, led by overall country TB burden (weight=11.1) and TB-related political will (weight=10.3); other top factors included burden of TB-related deaths (7.9), health systems strength (7.5), and adult COVID-19 coverage (7.4). The five highest-scoring countries were in sub-Saharan Africa, and the team selected three of them plus the top-scoring countries from South Asia, Europe and Central Asia, and East Asia to ensure regional diversity in follow-up research.

This work shows that combining BWS with an AHP framework offers a practical, transparent way to translate diverse stakeholder views into actionable research priorities. By explicitly weighting criteria such as disease burden, political will, and health system capacity, the method surfaces where readiness research could be most informative and where investments might have the greatest impact. Importantly, the approach is meant to be used alongside other contextual considerations rather than as a sole decision rule, allowing funders and planners to balance quantitative prioritization with on-the-ground knowledge. The authors suggest this stakeholder-centric, objective method can help guide evidence-based funding and research decisions in global public health, improving the chances that future TB vaccines will be deployed effectively and equitably when they become available.