The world is still reeling under the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on public health and the economy. In many cases, the virus causes severe or even critical coronavirus disease 19 (COVID-19) and death. Vaccines are widely perceived to be the way back to resuming normal life.
However, the task of global vaccination is an enormous one. A new paper, available on the medRxiv* preprint server, presents lessons learned from the implementation of three adult vaccine programs in low- and middle-income countries (LMICs) in Africa and South America. The vaccines involved are MenAfriVac (meningitis A); 17D (yellow fever); and rVSV-ZEBOV (Ebola virus disease. The scientists feel that the insights obtained from these experiences could be of immense value in the current scenario as well.
There are multiple challenges to the successful rollout of vaccines in LMICs, such as the limited infrastructure, lack of resources and a skimpy healthcare setup. Despite these obstacles, the three vaccines mentioned above were distributed in such settings as part of the country’s response to local outbreaks of these diseases.
Important vaccination themes
The researchers examined the literature on these vaccination campaigns, as well as conducting interviews with experts to understand the issues and how they were overcome.
They classified the lessons by theme.
1.Planning at microlevel
The scientists found that early interactions with all the individuals and entities with a stake in the vaccination process were of great value in supporting the planning phase. This included, importantly, partnerships with government departments other than Health, such as Finance and Transport, which would be required to carry out the campaign.
The staff at the local centers were also important in understanding the setting behind the campaign, as well as the geographical and social context of the area each center covered. Microplans was thus an essential part of the successful campaign.
While external agencies and projects, both multinational and non-governmental organizations, such as the Meningitis Vaccine Project and the Eliminate Yellow Fever Epidemics strategy, were also central to the campaign, depending on external aid may hamper the future viability of these activities.
While initiatives such as COVAX help provide vaccines free of cost, operational funding is a constraint that is often overlooked. This is required for pre-campaign health awareness and promotional activities, as well as encouraging health workers to take the vaccines themselves. These preliminary steps play a major part in ensuring successful vaccine uptake in the community.
Coordination of efforts to avoid duplication and competition
Vaccination campaigns are multifaceted, requiring strong coordination and oversight. An incident management system (IMS) is important in defining the part played by different government and non-governmental agencies to avoid unnecessary overlap. Smaller working groups within the IMS will help the various partner organizations to coordinate their activities, speeding up the end result and averting unhealthy and divisive competition aimed at retaining the best-paying positions.
2.Target groups and vaccine delivery
A lot of time was required to explain the importance and relevance of vaccination in the outbreak situation to communities, requiring heavy investments in the form of time, staff, materials for education, transportation, training and financial compensation.
The location of each vaccination center was decided based on its proximity to a highly-frequented place such as a workplace, hotel, or transport hub. Known potential obstacles were worked around, such as social or cultural taboos, to ensure that subsets of the target population would be reached.
The entry of the vaccination teams into distant regions where primary healthcare is often missing was viewed as an opportunity to incorporate other health services into the community, such as childhood vaccinations, animal vaccinations, and health check-ups. Of course, this requires careful integration and coordination for efficient operation and documentation.
In the current situation, where COVID-19 vaccines are sometimes viewed with suspicion, care must be taken lest messages focusing on this vaccine produce counter-productive negativity towards other healthcare services as well. One participant said, “Some [community members] are really against COVID-19 vaccination, they say “No, you want to smuggle in the COVID-19 vaccine in the name of yellow fever.”
A clear demarcation should thus be made to prevent interference with other vaccine and healthcare interventions.
Meticulous assessments were required to define vaccine storage assessments at the facility level since this could lead to wastage. Test supplies were sent to each country to ensure the supply chain was working as designed, with correct handling at each step. Such simulations and planning can avoid wastage.
Vaccine storage and distribution hubs are essential facilities for a large-scale vaccination campaign, ensuring ultra-cold chain (UCC) storage where necessary, as for the COVID-19 mRNA vaccines. Expanding the storage network rather than using a central electrified depot is often important in a large country to prevent undue delay in distribution.
Qualified and hardworking staff are also key to running such facilities smoothly. The use of single-dose vs. multidose vials should also be deliberated, balancing the risk of wastage with the latter vs. speed of vaccination (not having to wait for the required number of recipients to arrive before opening the vial) with the former.
Local health workers with community rapport, who speak the language, are absolutely necessary to increase vaccine uptake. This may place an additional workload on already overworked local staff and compromise the healthcare services already operating at the local level.
Local workers may also opt for better-paid posts in the epidemic response teams rather than their normal posts.
Recruitment of new workers is desirable but should not exclude existing healthcare workers and should be smooth and efficient. Training quality should be ensured, especially if a trickle-down model is used, as newly trained workers are not always reliable trainers of other still newer staff.
Relying on field supervision to detect and correct mistakes could slow down the whole process by tasking supervisors unduly. Remote training during the current pandemic may introduce further delays and may even be impossible in some low-resource settings. Moreover, it may not be a good substitute for hands-on practical training.
Having to wade through reams of red tape and waste precious days before getting funding and resources can be dispiriting to the actual workers, who work hard but may not even be able to afford a bite or a cup of something during the day if they are not paid, in these settings.
5.Monitoring and safety
Vaccination must be accompanied by local accountability for required medical care and support in case of adverse events, as well as for breakthrough infections. This will promote community trust and transparency on the part of the vaccination initiative.
Monitoring of vaccine efficacy and safety may be difficult if manual recording into multiple different datasets is used. Electronic integrated surveillance systems are to be preferred, eliminating paper use and thus using a single standardized system across all organizations involved in the vaccine initiative to collect data. This will ensure swift analysis and surveillance of vaccine coverage, efficacy and safety.
The government should also be given due involvement in each of these areas to prevent friction in vaccination campaigns from this source.
6.Social and community involvement
Community engagement is crucial and can be promoted by public health messages explaining the disease, the vaccine, the reason for targeting certain groups, and adverse events. For example, the Meningitis Vaccine Project created a detailed plan for explaining the initiative to build up momentum for months before the campaign actually started.
The communication program in this case actually took years to arrive at its final, effective form, but the vaccine became immensely popular, underlining the need for the community to understand and become part of the program, no matter how urgent the need for vaccination appears, as in the COVID-19 pandemic. Persuasion, honesty, respect, understanding and responsiveness to fears and concerns about the vaccine are key to this process.
Moreover, ongoing engagement is necessary rather than relying on early favorable responses, with final feedback being given to the community at the end of the campaign. This will, it is felt, encourage community leaders by building sustainable relationships with them.
In the ongoing pandemic, the challenge is of promoting vaccine uptake in a situation where the community is not aware of the need to prevent the disease, and especially if there are other much more urgent felt needs. This may require collating data on the severity and impact of the infection in the target community.
When vaccine concerns are addressed in a timely and transparent manner, vaccine uptake will increase by quashing rumors about vaccine risks. Recognized leaders in the social, cultural, political or religious arenas are key to this process, especially when the misinformation comes from someone in these realms.
Medical refutations are important when rumors originate or are spread by medical professionals. National Immunisation Technical Advisory Groups are also central in providing independent information based on evidence.
Vaccine hesitancy is a bigger problem with COVID-19 than ever before due to the infodemic of misinformation and the intense publicity and political activity around the outbreak. While social media and technology platforms have sometimes been harnessed to beat this challenge, it is recognized to persist, and in-person interactions are more important than virtual messaging to convince community members about the falsity of such rumors.
What are the implications?
While the world still faces huge supply-demand gaps with respect to COVID-19 vaccines, the consequent delay faced by LMICs has a silver lining in that it allows for the preparatory steps to be undertaken, allowing for a vigorous vaccine uptake when it is available. Thus, these countries must now budget for such activities on a war footing, recognizing their urgency.
Recruitment and training of healthcare workers to meet the demand for an increased workforce on the ground must be monitored for efficiency and quality. Thirdly, it is important that COVID-19 vaccination not be lumped with other vaccination programs, though other healthcare programs may be offered independently at the time of vaccination. Attempts to integrate this with other vaccines may lead to rejection of already running projects as well due to the significant negative publicity already surrounding these vaccines.
The practical difficulties involved in using multidose vials without wastage should perhaps prompt the production and distribution of single-dose vials in low vaccine uptake areas. Alternatively, vaccine teams should be empowered to move outside prioritized target groups to use up the whole of the opened vial.
These lessons should be taken to heart, despite the localized geographical nature of the findings. The scientists urge a global effort to make COVID-19 vaccines available to LMICs.
As vaccine supplies increase, we encourage researchers to support countries in monitoring and documenting their COVID-19 vaccination campaigns to understand real-time responses to challenges and strengthen evidence around best practices during outbreak-related vaccination campaigns in low-resource settings.”
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.