Ensuring Healthy Populations through a New Era of Global Immunization: Rapporteur's Report

"With new leadership for immunizations at the World Health Organization (WHO), revised global strategies spearheaded by the WHO, UNICEF, and Gavi, the Vaccine Alliance, and a focus on vaccination as a cornerstone of universal health coverage and global health security, the world is entering a new era of global immunization."

On September 27 2019, the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) convened a day-long conference to discuss innovations being developed globally to address gaps in immunisation coverage. Among pressing challenges are: completing polio eradication; reaching the disenfranchised, including those in fragile and disordered settings; supporting governments as they develop their own sustainable immunisation systems; and addressing vaccine hesitancy. This report captures the deliberations of the day (see also the video from the event, below).

Communication elements highlighted in the report include:

• Introductory remarks - Key points made by J. Stephen Morrison (CSIS): Sustained high-level leadership and funding are fundamental to success in immunisation; equitable access to vaccines is critical to achieving universal health coverage; and a decline in trust and a "weaponisation" of social media to promote anti-vaccine messages pose a major challenge.
• Opening plenary, moderated by Nellie Bristol (CSIS):
  • Kate O'Brien (WHO) described WHO's leading of a collaborative effort to devise Immunization Agenda 2030 (IA2030), which is the successor to the Global Vaccine Action Plan (GVAP). Expected to be implemented starting in 2021, IA2030 will draw on the perspectives of immunisation partners at all levels, tailor implementation to country contexts, address inequities, take a life course approach to immunisation, and work to build partnerships beyond the health sector.
  • Seth Berkley (Gavi) described Gavi 5.0's focus on developing real-time data and other tools to ensure vaccines are reaching children in urban slums and isolated rural communities, as well as those displaced by climate change. In creating demand for vaccine services, Gavi will explore increasing involvement of women decisionmakers and in enhancing political will. In recent successes, Berkley cited programmes in Liberia and Pakistan that improved reach through mobile phones.
• Panel 1: A Renewed Focus on Vaccine Equity, moderated by Amanda Glassman (Center for Global Development):
  • Edna Yolani Batres (Government of Honduras) talked about the Salud Mesoamérica Initiative, a public-private partnership aimed at reducing health equity gaps in Mexico and Central America. According to Batres, in areas working under the model, vaccine coverage has reached 90%, and localities have a greater sense of ownership. Moving funding decisions closer to the community and ensuring services are provided in a way that people understand are critical to expanding health equity, she said.
  • Muhammad Ali Pate (World Bank and Global Financing Facility for Women, Children, and Adolescents - GFF) called for a rethinking of primary care delivery to ensure those implementing programmes are trusted by the community. To achieve equitable and sustainable health services, international organisations should put the onus on country systems and governments - working with them to empower and strengthen them, not to undermine them.
  • Kerry Pelzman (United States Agency for International Development - USAID) discussed her agency's role in improving vaccine equity. USAID's approach has 4 components: decreasing missed opportunities for vaccination, strengthening healthcare delivery systems, improving disease surveillance, and increasing communication. She urged greater focus on trust and better understanding of supply and demand in different contexts.
  • Anne Schuchat (U.S. Centers for Disease Control and Prevention - CDC) noted that achieving vaccine equity is complicated and expensive. The CDC's primary strengths are providing high quality data, building solid relationships and trust with ministries of health in more than 50 countries (along with multilateral organisations), creating partnerships with civil society groups, and promoting innovation.
• Video message - Key points made by Henrietta Fore (UNICEF): UNICEF's Immunization Roadmap 2030 provides renewed commitment to vaccinations and calls for new approaches to reach children now missing out. Fore urged using networks and systems for vaccine delivery to scale up other services such as nutrition screening, maternal and newborn care, and adolescent health.
• Panel II: Restoring Trust in Vaccines:
  • Morrison (CSIS) introduced the panel, which he moderated, by noting that barriers to increasing coverage include geography, urban poverty, violent conflict, and lack of pollical will and cultural acceptance. He said social media now drives the spread of misinformation about vaccines across the globe, urging the involvement of experts in technology, social media, behaviour patterns, cybersecurity, and group behaviour to help combat the problem.
  • US Congressman Adam B. Schiff relayed in an opening video message that he wrote letters earlier in 2019 to social media organisations asking them to take steps to limit vaccine misinformation available on the internet. At the same time, he said a balance must be struck between public health necessity and the protection of free speech. In summer 2019, the House passed his amendment to fund an educational campaign focused on the importance of vaccination and the advent of rampant misinformation.
  • Emilie Karafillakis (London School of Hygiene and Tropical Medicine) discussed the work of the Vaccine Confidence Project, which "looks at a variety of data from qualitative to media messages to detect changes in vaccine confidence throughout the world. One finding is that when trust erodes for one vaccine in a region, mistrust tends to spill over to all vaccines in the area. Overall, the project is discovering that vaccine confidence is emotion-based and can erode very quickly. Further, emotions are not an individual factor but can be contagious and spread among individuals in a group. Decisions about vaccination are not made in a linear fashion, and decisionmaking is volatile, Karafillakis said. This is important, she added, because social media has changed the dynamics between science and the general public. The public now is more engaged and is looking for information, but removing negative information may not be the answer. She suggested improved methods for engaging patients, listening to their concerns, warning them against the dangers of social media, and teaching them how to distinguish between information sources. She said it is important to begin teaching children at an early age how to be internet savvy and to teach health care professionals to communicate with patients to reduce vaccine hesitancy."
  • Rina Dey (CORE Group Polio Project) shared her experience in the area of vaccine confidence. "When the Indian polio eradication program started house-to-house vaccination in 1999, Dey said, the program met stiff resistance from many communities....Dey said the program learned that mass awareness campaigns were ineffective and that the program had to look at attitudes and needs at the community level. The CORE Group established a social mobilization network in concert with UNICEF in 2003. Successful approaches included hiring vaccinators from within local communities and developing a better understanding of the religious and social norms in each community. CORE Group communicators invested time in listening to community concerns and addressing them. They involved local influencers and allowed vaccinators the opportunity to try new approaches. CORE Group is now working on social mobilization for routine immunization services across India, where Dey said sharing the approaches and lessons from the polio program will help to build India's system. Dey added that engaging local politicians in building immunization coverage as a positive accomplishment has been successful in India."
  • David Broniatowski (George Washington University) reported that, while Americans generally view vaccination positively, there is growing concern about vaccine confidence and misinformation. "In studying the content of tweets, Broniatowski said his group discovered that many vaccine-related messages, both pro- and anti-vaccine, were coming from Russian internet trolls. The purpose of the tweets was to make people angry, encourage the dissemination of conspiracy theories, and foment social divisions. Vaccine messages are also being used to encourage people to click on specific sites to drive up ad revenues....Broniatowski urged additional research on which messages are amplified through retweeting and other methods and on ensuring those messages do not drown out more positive messages. He added that he and his colleagues found in a recent study that just two buyers are responsible for the majority of anti-vaccine Facebook ads. In distinguishing between types of social media, Bronistowski said that while Twitter is prone to disseminating automatic content because of its structure, Facebook is more hierarchical and allows for the spread of misinformation within groups. Administrators should perhaps be held more accountable for the content they allow, he suggested."
• Panel III: Global Health Security and Vaccination in Disordered Settings, moderated by Katherine Bliss (CSIS):
  • US Senator Roger Wicker opened the session with a video message in which he described American leadership and investment in the Global Polio Eradication Initiative (GPEI) as critical to its success, and he urged continued congressional support.
  • Nahid Bhadelia (Boston University School of Medicine) noted that gaining trust from populations with which one hopes to interact is critical to all endeavours, such as research and data collection, in fragile and conflict-affected settings. She pointed to the importance of longstanding research partnerships with countries that are most affected by infectious diseases. Bhadelia talked about the success of the Stop Transmission of Polio Program (STOP) at the CDC, which trains international and local staff to oversee surveillance and programme implementation at the local level.
  • Rebecca Martin (CDC) emphasised one of the recommendations from a report by the WHO/World Bank-convened Global Preparedness Monitoring Board, released in September 2019: "[A]ll parts of a society need to be part of outbreak and disaster preparedness, from national governments to communities. Community engagement is important to health security and polio eradication work as well, she added. Martin discussed the importance of understanding and involving people at the community level to understand what they need and want. She also noted the importance of training people from the community to respond to diseases,...noting that mapping and satellite imagery have been critical for finding where remote populations are located."
  • Violaine Mitchell (Bill & Melinda Gates Foundation) discussed the importance of international partners in improving global vaccine coverage. "Strengthening and sustaining global partnerships and ensuring government ownership of immunization systems are essential for increasing vaccine coverage, she added. Mitchell cited Nigeria as an example, noting that after 25 years of concerted effort by the government, WHO, Gavi, CDC, Gates Foundation, and other partners, immunization coverage is starting to improve."

"In wrapping up the day, CSIS's Bristol thanked participants and noted that immunization is a vital health intervention that should be accessible to and trusted by all. She noted the role in this endeavor of all the organizations speaking, those present in the audience, and of the U.S. government." (Editor's note: With regard to the latter entity, another CSIS report may be of interest: Enhancing U.S. Leadership in a New Era of Global Immunization", by Nellie Bristol, Michaela Simoneau, and Katherine Bliss, September 27 2019.)