Stories

Tag: vaccination

  • 50 years of the Expanded Programme on Immunization

    50 years of the Expanded Programme on Immunization

    In two articles published during the fiftieth year of the World Health Organization’s Expanded Programme on Immunization (EPI), Samarasekera and Shattock provide valuable insights into EPI’s remarkable impact on reducing childhood mortality and morbidity since its launch in 1974.

    Shattock et al. present a detailed quantitative analysis of the lives saved and health gains attributed to vaccination.

    They estimate that “since 1974, vaccination has averted 154 million deaths, including 146 million among children younger than 5 years of whom 101 million were infants younger than 1 year.” 

    The authors further emphasize the long-term benefits of vaccination, noting that “for every death averted, 66 years of full health were gained on average, translating to 10.2 billion years of full health gained.”

    These findings underscore the transformative impact of the Expanded Programme on Immunization on global health outcomes.

    Bill Moss of the International Vaccines Access Center (IVAC) calls this “one of humankind’s greatest achievements”.

    Inherent uncertainties based on the modeling approaches, data limitations and gaps, and challenges in attributing causality over a 50-year time horizon do not diminish their significance.

    Fresh challenges

    Samarasekera highlights several fresh challenges as EPI moves into its next 50 years:

    1. COVID-19 pandemic disruptions: The pandemic has led to 67 million children globally missing out on one or more vaccines. This has resulted in outbreaks of vaccine-preventable diseases, with measles outbreaks being reported in twice as many countries in 2023 compared to 2022. Due to pandemic disruption, many unimmunized children are now older than 2 years, requiring new approaches to reach them and prevent further outbreaks.
    2. Sustainable funding: Countries are facing challenges in sustaining funding for immunization programs due to debt crises, conflicts, and climate change.
    3. Improving collaboration during emergencies: There is a need for quicker access to vaccines and better coordination among stakeholders during humanitarian crises and outbreaks.
    4. Reaching the “last child”: Challenges persist in reaching children in conflict areas, active war zones, and those facing humanitarian crises, with immunization coverage in these settings being as low as 50-60%.

    While both articles recognize the urgent need to address these setbacks and reach underserved populations, they tend to emphasize the role of global agencies and donors in driving progress.

    For example, Samarasekera highlights the importance of initiatives like Gavi, the Vaccine Alliance, which was established in 2000 “to close the equity gap in access to vaccines,” and the Accelerated Development and Introduction Plans, which “expedited vaccine introduction in Gavi-supported countries.”

    While global plans and funding have been – and remain – undoubtedly crucial, this begs three questions:

    How to carry out such coordinated action and advocacy?

    Who will do it?

    What, if anything, should be different, compared to what was done in the past?

    Can we assume deployment?

    Both articles acknowledge that today’s challenges are different, and that immunization strategies should be grounded in local realities.

    Samarasekera’s report suggests exploring ideas such as involving community health workers more effectively, introducing newly approved vaccines (e.g., for malaria), and innovating vaccine delivery methods (e.g., microarray patches, single-dose vaccines).

    Ephrem T. Lemango, for example, emphasizes the role of health workers : “They are the most trusted source of information” for communities. “If we can skill these community health workers to vaccinate, provide them the required vaccines, then the likelihood of reaching the last child could be much more imminent”.

    Samarasekera also quotes O’Brien, who stresses that “every government that has had backsliding needs a plan, and most governments have made a plan and are starting to deploy. We have a very narrow window to get this completed.” 

    Neither article delves deeply into the specific strategies or mechanisms that connect global policy and funding to local action.

    Can “deployment” be assumed?

    There is wide recognition that local adaptation is a key challenge.

    This is most obvious in zones of armed conflict or when faced with the breakdown of trust in vaccines or government

    At the end of the day, it is health workers at the local levels that get the job of vaccination done.

    They are also the first to see epidemic outbreaks and to recognize changes in community trust.

    Does the future of vaccination require new ways of thinking and doing to adapt or invent strategies to lead to improved, sustained health outcomes?

    Global advocacy for community health workers to be paid is undeniably important.

    But paid to do what, how, and with what degree of recognition and support of their capacities, leadership, and expertise?

    This is where learning from the Movement for Immunization Agenda 2030 (IA2030) may offer useful insights that complement the top-down, global-level efforts emphasized in the articles.

    What is the Movement for Immunization Agenda 2030 (IA2030)?

    Launched by the Geneva Learning Foundation in March 2022, the Movement is a global network of over 10,000 health workers from 99 countries who have pledged to work together to achieve the goals of the Immunization Agenda 2030, the global strategy adopted by the World Health Assembly in 2020.

    Through peer learning and locally-led action, IA2030 members are sharing experiences, identifying root causes of immunization challenges, and implementing corrective actions tailored to their specific contexts.

    What does that actually mean?

    Wasnam Faye, a Senegalese midwife, moved the needle of vaccination coverage in a poor-performing remote health outpost from 8% to over 80%.

    How did she do it?

    At Teach to Reach, she met a doctor from the Democratic Republic of Congo who shared his EPI know-how with her, over WhatsApp.

    She then invited and trained caregivers to become peer educators, also building on what she heard at Teach to Reach.

    She then realized that she could speak about HPV vaccination for their daughters to mothers who came for cervical cancer screening.

    In global health, individual case studies and lived experience are often dismissed as anecdotal evidence.

    Each edition of Teach to Reach connects over 15,000 health workers, who share experience around their local challenges.

    At that scale, the cumulative insights gained take us beyond anecdotes and enable us to document how change happens at the local levels.

    Watch: Teach to Reach Insights Live with Orin Levine

    Rethinking immunization’s learning culture: Capacity for change, innovation, and risk

    To catch up and achieve the goals set for 2030, these articles suggest that a combination of increased funding, political commitment, and innovative strategies will be needed.

    It is important to recognize that top-down control and directive management appear to have been key to how immunization programmes achieved impressive results in previous decades.

    This explains why some EPI stakeholders may have an innovation challenge: why risk making changes or consider new models? 

    Addressing these underlying issues may require strengthening learning culture.

    “Learning culture” is a new concept in global health that provides the missing link between learning and performance.

    It measures the capacity for change and the leadership to recognize and support that capacity over time.

    That requires sustained financing, including specific funding required to test and scale new models and approaches. 

    But who will risk funding new ways to tackle the challenges facing immunization programs, such as weak health systems, inadequate infrastructure, and community trust?

    References

    Faye, W., Jones, I., Mbuh, C., & Sadki, R. (2023). Wasnam Faye. Vaccine angels – Give us the opportunity and we can perform miracles. (IA2030 Case study 18) (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7785244

    Jones, I., Eller, K., Mbuh, C., Steed, I., & Sadki, R. (2024). Making connections at Teach to Reach 8 (IA2030 Listening and Learning Report 6) (1.0). Teach to Reach: Connect 8, Geneva, Switzerland. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.8398550

    Jones, I., Sadki, R., Brooks, A., Gasse, F., Mbuh, C., Zha, M., Steed, I., Sequeira, J., Churchill, S., & Kovanovic, V. (2022). IA2030 Movement Year 1 report. Consultative engagement through a digitally enabled peer learning platform (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7119648

    Samarasekera, U., 2024. 50 years of the Expanded Programme on Immunization. The Lancet 403, 1971–1972. https://doi.org/10.1016/S0140-6736(24)01016-X

    Shattock, A.J., et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. The Lancet S014067362400850X. https://doi.org/10.1016/S0140-6736(24)00850-X

  • What works in practice to build vaccine confidence?

    What works in practice to build vaccine confidence?

    This is the content of a poster about vaccine confidence presented today by The Geneva Learning Foundation (LinkedIn | YouTube | Podcast | X/Twitter) at the International Social and Behavior Change Communication Summit 2022 (#SBCCSummit) held 5-9 December 2022 in Marrakech, Morocco. What is the Geneva Learning Foundation? Get the full report… Read the preface by Heidi Larson…

    Vaccine confidence: from responding to the initial shock of the pandemic to preparing COVID-19 vaccine introduction

    Over 6,000 health professionals joined the COVID-19 Peer Hub in July 2022, part of the Geneva Learning Foundation’s (TGLF) global immunization learning-to-action platform.

    • From August to October, they focused on developing and implementing recovery plans.
    • In November 2020, members of the COVID-19 Peer Hub decided to launch a reflective exercise to prepare COVID-19 vaccine introduction, after three months on early recovery implementation.
    • The exercise took place between 9 November and 18 December 2020.

    We asked a simple question in relation to vaccine confidence: Can you think of a time when you helped an individual or group overcome their initial reluctance, hesitancy, or fear about vaccination?

    • Each participant developed a case study to describe and analyze such a situation.
    • They then peer reviewed each other’s case studies, giving and receiving feedback to learn from each other.

    Who participated?

    Local practitioners from 86 countries joined this peer learning exercise about vaccine confidence:

    • 81% (n=591) in West and Central Africa
    • 11% (n=80) in Eastern and Southern Africa
    • 6% (n=43) in South Asia

    Health system levels:

    • 18% (n=131) national
    • 29% (n=213) sub-national
    • 29% (n=214) district
    • 20% (n=144) facility

    So what?

    What was the significance of the experience for participants?

    Transformation: “I can tell you this experience changed my life. It has changed my practice and made me think differently about the way I work, considering things I did not think about before.”

    Defying boundaries: “It was a opportunity like I have never had before… I have studied with peer from my country. Having a lot of people from other countries sharing their experience was something else.”

    What we learned from local practice about vaccine confidence

    1. Vaccine hesitancy is a complex problem that blanket recommendations or prescriptive guidelines are unlikely to solve.
    2. Instead, we should strive to recognize that solutions must be local to be effective, leveraging the ability of local staff to adapt to their context in order to foster confidence and acceptance of vaccines.
    3. Supporting health workers, already recognized as trusted advisors to communities, requires new ways of listening and learning.
    4. It also requires new ways of fostering, recognizing, and supporting the leadership of immunization staff who work at the local level under often difficult conditions.

    4 targeted intervention approaches that worked to strengthen vaccine confidence

    1. targeted individual counselling at the individual or household level;
    2. community outreach for larger groups;
    3. formal meetings (usually for community and religious leaders); and
    4. organized training sessions in which particular subgroups were involved (e.g., training for religious teachers, health workers, youth groups, women’s groups).

    2 key determinants that changed minds and behaviors about vaccine confidence

    1. The tone and delivery of the interventions were as critical to the success of the immunization as the activities themselves.
    2. The positive effect of using multiple approaches: high degree of understanding and compassion; navigating sensitive dynamics, grieving families, and issues related to vulnerable communities affected by displacement or war.

    Anthrologica performed the qualitative analysis of the case studies and developed the report for the Geneva Learning Foundation.

  • Heidi Larson: “So much remains determined by the capacity of people on the frontlines to explain, advocate, and respond in ways that are almost entirely dictated by context”

    This is the preface by Heidi Larson for the report “Overcoming barriers to vaccine acceptance in the community: Key learning from the experiences of 734 frontline health workers”. This report is presented today by The Geneva Learning Foundation (LinkedIn | YouTube | Podcast | Twitter) at the International Social and Behavior Change Communication Summit 2022 (#SBCCSummit) held 5-9 December 2022 in Marrakech, Morocco. What is the Geneva Learning Foundation? Get the full report… Read the preface by Heidi Larson…

    My own consciousness of the fragile equilibrium sustaining vaccine confidence came from working with immunization programmes and local health workers to defuse rumors that threatened to derail vaccination initiatives. Twenty years ago, this meant traveling to countries to meet, build relationships with, and work side-by-side with frontliners.

    Since that time, the corpus of research on the topic has grown tremendously. Elaborate behavioral science frameworks, supported by robust monitoring and evaluation, are now available to guide policy makers, donors, and other decision makers, for those who have the time and resources to implement them. 

    Nevertheless, there remains a gap in our understanding of how the complex dynamics of change actually happen, especially at the most local levels. For this we need to listen to the local experiences and voices of those at the front lines who can tell the real-life stories of how these complex dynamics are navigated.

    I found the idea of this report fascinating: 734 health professionals from all levels of the health system took time out from their demanding daily duties to reflect on their practice, describing and then analyzing a situation in which they successfully helped an individual or a group accept or gain confidence that taking vaccines would protect them from disease. Furthermore, they did this during four weeks of remote collaboration at a very crucial historical moment, months before the first doses of COVID-19 vaccine were to arrive in Ghana and Côte d’Ivoire.

    Reading this report, I experienced a sense of discovery. The stories shared reminded me of my early work with colleagues working at the local levels, and gave me renewed appreciation of   these health professionals who faced even greater challenges in the face of a deadly pandemic. I could feel how hard it is to remain that ‘most trusted adviser’ to communities, and how so much remains determined by the capacity of people on the frontlines to explain, advocate, and respond in ways that are almost entirely dictated by context, in this case a highly uncertain and evolving pandemic.

    I could also feel the tensions due to the imperfection of a participatory methodology that did not neatly fit the conventions and norms of expert-led research. Conventional research has seldom been able to access such local narratives, and even less so with such a large and diverse sample. Furthermore, the peer learning methodology used by the Geneva Learning Foundation meant that there was an immediate benefit for participants who learned from each other. Rather than research subjects or native informants, case study authors were citizen scientists supporting each other in the face of a common challenge. The scale, geographic scope, and diversity of contexts, job roles, and experiences are also strengths of this work. 

    Supporting health workers, already recognized as trusted advisors to communities, requires new ways of listening, new ways of supporting, new ways of measuring, documenting and learning.

    It also requires new ways of recognizing the leadership of immunization staff who work at local levels under often difficult conditions. 

    In some cases, it may actually be the lack of prescriptive guidelines that enabled local health staff to draw on their own creativity and problem-solving capabilities to respond to community needs.

    Rather than generalizations, we should therefore strive to recognize that solutions must be local to be effective, recognizing the ability of local staff to adapt to their context in order to foster confidence and acceptance of vaccines, and do all we can to support – letting them be the guide for future efforts.

    Heidi Larson, PhD
    Professor of Anthropology, Risk and Decision Science and
    Founding Director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine