The Global Vaccines and Immunization Research Forum was held in Incheon, Republic of Korea, 28-30 March, 2023. The following is an expanded summary of my meeting reflections during the final panel, which was chaired by Professor Noni MacDonald.
Equitable access to vaccines was a major theme during the forum, with a dedicated panel focused on zero dose children and communities. What we measure reflects what is valued. In 2021, there were 18.2 zero dose children worldwide. This is deeply concerning and many of these children live in communities at the intersection of multiple forms of disadvantage. Yet when we focus on reducing the sheer number of zero dose children and prioritise interventions accordingly, we also need to think about those in smaller population groups who miss out but don’t occupy big numbers. As Samir Sodha from WHO stated, there is a need to focus, not just on heavily populated urban slums, but smaller rural and remote communities of zero dose children.
What we measure and prioritise brings in assumed values, since evidence is facts plus values. So when policies and global priorities are made, we should ask how the perspectives and values of communities can also be included? I have been fortunate to learn from colleagues at the University of Wollongong who specialise in community juries and other deliberative methods, to see how it is possible to rigorously capture these values.
The R&D of human factors
We heard a lot in the meeting about the need to invest in research and development (R&D) for vaccines. We also need to invest in the R&D of human factors – sociology, political science, psychology, ethnography, ethics, history, implementation science, and innovations in interventions. Bringing such knowledges into vaccination means integrating them. I have benefited from training in public health and epidemiology, nursing and midwifery as background to a specialisation in vaccination-focused social science. Knowing about vaccinology, vaccine systems, policies and global arrangements enhances the capacity of social researchers in the field and helps guide and prioritise our investigations. That is why it’s important to integrate technical and social disciplines, either through collaborations or within people who have the combined expertise.
We need investment to sustain expertise in this growing field, particularly in low- and middle-income countries. That could involve training up program staff and local epidemiologists to do social research and/or training local social scientists in the vaccines field. That would need to be combined with an ongoing plan for building competencies with mentoring and ongoing support (something I’m looking into at present). This integration also happens within communities of practice. As Cathy Ndiaye from PATH empahised in the Implementation Research workshop, communities of practice can also share and learn from each other how they managed a particular challenge in rolling out a vaccine.
A major challenge is not enough published evidence on increasing uptake in low-and middle-income countries, including how to reduce dropouts, such as for measles-containing vaccines and newer vaccines like the RTS,S malaria vaccine which requires four doses to be effective. One solution is in having to only give one dose. Here, we learnt of the body of evidence that showed just one HPV dose was needed – a gift for program delivery.
Technologies can help programmatic challenges too – the promise of single-dose pulse-delivered vaccine is one exciting technology being trailed by Ana Jaklenec and team at MIT.
Other technological solutions to program implementation include thermostable vaccines and patches. When new technologies are used by health care workers, we learn things that we didn’t anticipate. That is why design thinking and user-testing needs to be incorporated into how the technologies are developed and implemented.
Since new vaccine technologies were such a focus, safety also came up. As Peter Dull from the Bill and Melinda Gates Foundation said, “We can do the safety and regulators can be assured, but receivers of the message need to trust what we are doing.”
As a vaccination professional, I’m in awe of the notion of micromolded particles giving a pulse of release over time via a single injection. As a social scientist, I know that vaccine safety concerns affect uptake and that this technology will generate concerns and conspiracies. Careful social research can understand and better anticipate how this plays out.
Scientists have a role to play in communicating this science well. As technologies advance and vaccines seem more mysterious to people, plain language explanations and good communication are even more essential. For me, knowing that the pulse-delivered antigen was put into tiny cubes made from a biodegradable material akin to dissolvable suture material was reassuring. This came from good science communication by Dr Jaklenec.
Demand and supply – a false binary
Vaccine safety concerns are often grouped under the label, “demand issues”. But a worry about safety isn’t the same as a lack of motivation to have a vaccine. It’s often a competing motivation for protection… from the vaccine. Equally, everyone knows at these meetings that uptake goes well beyond demand and nor is it all represented by the term ‘supply’. Demand and supply are a false binary in vaccination.
For example, Edson Utazi’s population modelling showed that highest risk of having zero dose children is where there is 3 hours or more travel time to the nearest health facility. A vaccine may be in good supply in that facility. So when we call everything else a ‘demand problem’, are we implying that the woman who must travel a day on foot across perilous terrain to reach the facility isn’t sufficiently demanding? She needs to be better represented in the language around the drivers of uptake.
The Global Vaccine Action plan in 2011 put “Demand” on the agenda largely to ensure that citizens in countries who switched from GAVI funding to self-funding were demanding their governments ensure vaccine purchase and supply.
“Strategic objective 2: Individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility.”
“Significant improvements in coverage and programme sustainability are possible if individuals and communities understand the benefits and risks of immunization; are encouraged to seek services; are empowered to make demands on the health system; and have ownership of the planning and implementation of programmes within their local communities. Although there has generally been a high demand for vaccination services, accessing hard-to-reach populations, attaining higher coverage levels and achieving equity objectives may require additional approaches to stimulate demand for vaccination.”
Now, “demand” is used as a catch-all for any of the human factors related to uptake and global agencies have entire departments under this banner. Those working in these units equally feel the pain of its limitation and some have written about the complexities.
Demand is a valid concept, but should be used as per its intentions – demanding governments commit to vaccines which are cost effective and prevent disease and death.
For the drivers of uptake, we need to talk about uptake. As Amaya Gillespie from UNICEF reflected during our Vaccine Uptake workshop from her work in the Middle East and North Africa during the COVID-19 vaccine rollout, the unvaccinated were often not hesitant. Similarly, as Katie Attwell, Adam Hannah and I noted in our 2022 article, “COVID-19: talk of ‘vaccine hesitancy’ lets governments off the hook”. There are many factors driving vaccine uptake and even hesitancy is in the realm of governments to prevent and address.
The focus on individuals as the unit of responsibility for low uptake is too heavily embedded in the current language. The WHO/UNICEF Behavioural and Social Drivers of Vaccination guidebook is one way to give a more holistic lens on uptake barriers with tools to assess them from a caregiver’s or adult vaccinee’s perspective. Other approaches help to assess system-level problems.
This forum was a privilege to attend. Since I had to listen so intently as a final wrap-up panellist, I learnt a great deal and came away feeling inspired by all that is being done to improve and innovate with vaccines by some of the world’s brightest minds.
As we continue to recover from the emergency years of COVID-19, there are some major challenges ahead on local and global scales with ensuring that all people everywhere have access to safe and effective vaccines. We can look to strengths locally and globally to not feel too overwhelmed with the tasks ahead.