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Synthesis

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This research was conducted by the UK Public Health Rapid Support Team. The UK Public Health Rapid Support Team is funded by UK aid from the Department of Health and Social Care. It is jointly run by the UK Health Security Agency and the London School of Hygiene & Tropical Medicine.

Introduction

Vaccines have been in use for over 200 years, and improvements in medical research and health care delivery infrastructure have led to dramatic improvements in patient outcomes against some of the world’s most lethal pathogens. There are lessons to be learned from this history that may inform the successful delivery of vaccines to control COVID-19, as well as future epidemics. The recent use of the ring vaccination methodology during Ebola vaccine trials in West Africa, drawn from smallpox eradication methods used 50 years earlier, highlights the value in learning from history.1, 2 As COVID-19 vaccination campaigns gathered momentum in low- and middle-income countries, this project sought to identify transferable lessons from previous rollouts of vaccines with similar characteristics.

The information provided below is drawn from the published article titled 'Learn from the Lessons and Don’t Forget Them’: Identifying Transferable Lessons for COVID-19 from Meningitis A, Yellow Fever and Ebola Virus Disease Vaccination Campaigns,” which is available at BMJ Global Health at https://gh.bmj.com/content/6/9/e006951.
Collins et al.
Click here to see key milestones in the development and delivery of the selected vaccines.

Research Scope and Methodology

This project included a rapid literature review, followed by 24 semistructured interviews with technical experts who had direct implementation experience with the selected vaccines in Africa and South America. Barriers, enablers, and key lessons were identified from the literature and from participants’ experiences. Data were analyzed thematically according to seven implementation domains.

Thematic Framework Used to Guide the Rapid Literature Review and Semistructured Interviews

Collins et al.

The thematic framework was developed using existing vaccine readiness assessment tools and gap analyses developed for implementing Ebola virus disease vaccines3,4 and COVID-19 vaccination guidelines developed by the World Health Organization.5

Recommendations

Following are the key recommendations for the implementation of COVID-19 vaccines in low- and middle-income countries, based on lessons from meningitis A, yellow fever, and Ebola virus disease vaccination campaigns.

Recommendation
 Domains
  • Prioritize the availability of operational funds to support community engagement and social mobilization well in advance of vaccination activities.
  • Planning and coordination
  • Community engagement and social mobilization
  • Develop a community engagement strategy that emphasizes the principles of community involvement, co-development, and iterative adaptation. Vaccination teams should meet iteratively with community members, actively seek their questions and input on strategy development, and adapt vaccination strategies accordingly. 
  • Community engagement and social mobilization
  • Target groups and delivery strategies
  • Vaccine confidence
  • Engage local, trusted health workers (including community health workers) to support vaccination activities and to ensure a continued connection between communities and the vaccination campaign.
  • Vaccination teams
  • Community engagement and social mobilization
  • Develop rapid processes to recruit and manage an expanded vaccination workforce for the response. Care should be taken to balance response staffing requirements with the need to maintain existing services.
  • Vaccination teams
  • Evaluate and refine training strategies to ensure vaccination teams are well equipped to conduct vaccination activities. Identify teams who are not able to access remote training and design suitable alternatives.
  • Vaccination teams
  • Provide vaccination teams with clear guidance on the management of multidose vaccine vials, including which population groups should be offered leftover vaccine doses where the vial cannot be stored appropriately and used at a later time.
  • Vaccination teams
  • Logistics and supply
  • Ensure national ownership, access, and capacity to analyze vaccination campaign data, including the use of electronic data capture systems.
  • Vaccination monitoring and safety surveillance
  • Work with technical leads across the outbreak response (e.g., surveillance, vaccination) to streamline the collection, aggregation, and analysis of different indicators to support vaccination campaign monitoring.
  • Vaccination monitoring and safety surveillance
  • Bring together response pillar leads and routine health program leads to discuss opportunities to integrate health services during vaccination campaigns. Any integration of services should be well resourced, and well coordinated between services and with communities, to mitigate potential adverse impacts.
  • Target groups and delivery strategies

Key Findings by Domain

The key lessons from previous vaccination campaigns are shown according to the domains in the thematic framework developed for this research. These domains align with the Exemplars in Global Health vaccine delivery framework , which has been used to understand the drivers of routine immunization.

  • Engaging early with a broad network of stakeholders is critical to detailed precampaign planning.
  • Gaps in operational funding can prevent vaccination teams from conducting necessary precampaign activities, such as community engagement.
  • Incident management systems and technical working groups can promote collaboration and prevent the duplication of response efforts. 

[The incident management systems] helped us to coordinate the partners, because at the beginning of Ebola in West Africa, everybody took the money, went into the community without asking the others. [It was a] nightmare, until we found this coordination mechanism, this harmonization of all the priorities in one single strategic response plan.”

- Multilateral organization, West and Central Africa (see published manuscript)
  • Vaccinating adults requires a shift in community understanding of vaccination (which traditionally is associated with children). More time is needed to engage with adult groups and convince them of the benefits of vaccination.
  • Vaccination campaigns can be used to provide other important health services that are prioritized by communities. However, health service integration requires careful planning with other health programs and communities to ensure that it is both appropriate and effective.
Families wait for vaccines during a meningitis vaccination campaign in Kaolack, Senegal on November 14, 2012. Photo was not taken for this research project.
© Bill & Melinda Gates Foundation / Frederic Courbet
  • Vaccine storage assessments and logistic planning exercises should be conducted prior to each vaccination campaign to identify and mitigate potential areas of vaccine wastage.
  • Multidose vaccine vials simplify vaccine transport and storage; they can, however, lead to hesitancy to open vaccine vials among vaccination teams who fear wasting doses, thereby affecting vaccination coverage.
  • Local health workers help maintain a connection between communities and the vaccination campaign and may be able to leverage existing rapport to increase vaccine uptake.
  • Training vaccination teams is a vital precampaign activity, but training quality decreases at lower levels of the cascade or training-of-trainers model, leading to dependency on resource-intensive supervision to correct errors in the field.
  • Vaccination campaigns often involve complex data aggregation processes where indicators held in different data sets across the response need to be collated and compared. Limited access to data held by different organizations negatively affects response efforts.
  • Community engagement should precede vaccination campaigns by one to two months to allow sufficient time to build relationships and conduct social mobilization.
  • Continual engagement with communities throughout the campaign is necessary to monitor vaccine acceptance and respond to community concerns.

“There are many things that the communities need to understand. . . . One of the keys is to never hide the truth. Be frank and honest with them, because when they trust you, they trust you forever. But when you lose [their] confidence, it’s difficult.”

- Multilateral organization, West and Central Africa  (see published manuscript)
  • Swift, transparent, and trusted responses are needed to address vaccine concerns; the longer a rumor circulates, the greater the risk to a vaccination campaign.
  • Influencers (political, religious, and traditional leaders or heads of social groups) play an important role in counteracting negative rumors.

Conclusion

The key recommendations generated from this research include prioritizing resources for operational activities and community engagement, identifying effective and sustainable training strategies for improved service delivery to upskill vaccination teams, streamlining response coordination and vaccination monitoring functions, and exploring opportunities for health service integration.

These recommendations rely on low- and middle-income countries having sufficient vaccine supply to conduct vaccination campaigns for COVID-19, which has not been the case in most settings. We implore the global community to prioritize COVID-19 vaccine supply for low- and middle-income countries.

Additional Context

Geographic Regions for Yellow Fever, Meningitis A, and Ebola Virus Disease Vaccines

CDC and WHO

Key Milestones in the Development & Delivery of the Yellow Fever Vaccine (17D)

Key Milestones in the Development & Delivery of the Meningitis A Vaccine (MenAfriVac)

Key Milestones in the Development & Delivery of the Ebola Vaccine (rVSV-ZEBOV)

  1. 1
    Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. Lancet. 2015;386(9996):857-866. https://doi.org/10.1016/s0140-6736(15)61117-5 
  2. 2
    Calain P. The Ebola clinical trials: a precedent for research ethics in disasters. J Med Ethics. 2018;44(1):3-8. https://doi.org/10.1136/medethics-2016-103474
  3. 3
    World Health Organization (WHO). Global Ebola Vaccine Implementation Team (GEVIT) Practical Guidance on the Use of Ebola Vaccine in an Outbreak Response. Geneva: WHO; 2016. Accessed December 13, 2021. https://www.who.int/csr/resources/publications/ebola/gevit_guidance_may2016.pdf?ua=1
  4. 4
    Ebola Vaccine Deployment, Acceptance and Compliance (EBODAC) Consortium. Ebola Vaccine Communication, Community Engagement and Compliance Management (3C) Gap Analysis Tool. [Publisher location]: EBODAC; 2019. Accessed December 13, 2021. https://www.worldvision.ie/media/3madylmi/ebodac-3c-gap-analysis-tool.pdf
  5. 5
    Guidance on Developing a National Deployment and Vaccination Plan for COVID-19 Vaccines. Geneva: World Health Organization; 2020. Accessed December 13, 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-Vaccine_deployment-2020.1