Nonstructural barriers to adult vaccination.

Adult vaccination coverage remains low, despite vaccine recommendations, improved access, and reimbursement. Low vaccination coverage and an aging population at higher risk from vaccine-preventable diseases lead to preventable disability and deaths, straining healthcare systems. An Advisory Board meeting was, therefore, held to identify non-structural barriers to adult vaccination and discuss potential solutions to increase uptake. Many non-structural factors can influence vaccine uptake, such as heterogeneity in the population, (fear of) vaccine shortages, incentives, or mandates for vaccination, understanding of disease burden and personal risks, time and opportunity for healthcare providers (HCPs) to discuss and deliver vaccines during general practice or hospital visits, trust in the health system, and education. To address these barriers, push-pull mechanisms are required: to pull patients in for vaccination and to push HCP performance on vaccination delivery. For patients, the focus should be on lifelong prevention and quality of life benefits: personal conversations are needed to increase confidence and knowledge about vaccination, and credible communication is required to build trust in health services and normalize vaccination. For providers, quality measurements are required to prioritize vaccination and ensure opportunities to check vaccination status, discuss and deliver vaccines are not missed. Financial and quality-based incentives may help increase uptake.

What is the context?● As populations age, healthcare systems are increasingly struggling with the burden of adult disease. Multiple vaccines are already recommended for adults throughout their lifetime, and more are coming soon, however, even in countries with subsidized programs, few adults are fully vaccinated, leading to frequent cases of illness, disability, hospitalization, or death, which could have been prevented.What is new?● Experts from Europe and the US joined an Advisory Board meeting to find out what is stopping people from getting vaccinated, particularly when vaccines are free, and how this can be helped in future.● The decision to get vaccinated can vary for different subgroups of the population, and can be influenced by vaccine shortages, rules about vaccination, and understanding the disease severity and need for vaccination. In addition, doctors may not have enough time and opportunity to discuss and provide vaccines during visits or may not feel comfortable raising the issue of vaccination with their patients.● To overcome these issues, both patients and doctors must change. Patients need: greater awareness of how illness impacts overall health and quality of life; better conversations with their doctors to address vaccination concerns; and trustworthy information from health services. For providers, vaccination prioritization should be linked to quality measurements, with collaboration from trusted community members to reinforce the importance of prevention, thus ensuring opportunities are not missed to discuss prevention and vaccinate. Normalizing adult vaccination is important for this.What is the impact?● Taking a patient centered prevention approach will help protect adults and ease the burden of vaccine-preventable disease.

Supporting evidence-based rotavirus vaccine introduction decision-making and implementation: Lessons from 8 Gavi-eligible countries.

Despite the 2009 World Health Organization recommendation that all countries introduce rotavirus vaccines (RVV) into their national immunization programs, just 81 countries had introduced RVV by the end of 2015, leaving millions of children at risk for rotavirus morbidity and mortality. In response, the Rotavirus Accelerated Vaccine Introduction Network (RAVIN) was established in 2016 to provide support to eight Gavi-eligible countries that had yet to make an RVV introduction decision and/or had requested technical assistance with RVV preparations: Afghanistan, Bangladesh, Benin, Cambodia, Democratic Republic of Congo, Lao People's Democratic Republic, Myanmar, and Nepal. During 2016-2020, RAVIN worked with country governments and partners to support evidence-based immunization decision-making, RVV introduction preparation and implementation, and multilateral coordination. By the September 2020 program close-out, five of the eight RAVIN focus countries successfully introduced RVV into their routine childhood immunization programs. We report on the RAVIN approach, describe how the project responded collectively to an evolving RVV product landscape, synthesize common characteristics of the RAVIN country experiences, highlight key lessons learned, and outline the unfinished agenda to inform future new vaccine introduction efforts by countries and global partners.

COVID-19 vaccines and the pandemic: lessons learnt for other neglected diseases and future threats.

Through the experiences gained by accelerating new vaccines for both Ebola virus infection and COVID-19 in a public health emergency, vaccine development has benefited from a 'multiple shots on goal' approach to new vaccine targets. This approach embraces simultaneous development of candidates with differing technologies, including, when feasible, vesicular stomatitis virus or adenovirus vectors, messenger RNA (mRNA), whole inactivated virus, nanoparticle and recombinant protein technologies, which led to multiple effective COVID-19 vaccines. The challenge of COVID-19 vaccine inequity, as COVID-19 spread globally, created a situation where cutting-edge mRNA technologies were preferentially supplied by multinational pharmaceutical companies to high-income countries while low and middle-income countries (LMICs) were pushed to the back of the queue and relied more heavily on adenoviral vector, inactivated virus and recombinant protein vaccines. To prevent this from occurring in future pandemics, it is essential to expand the scale-up capacity for both traditional and new vaccine technologies at individual or simultaneous hubs in LMICs. In parallel, a process of tech transfer of new technologies to LMIC producers needs to be facilitated and funded, while building LMIC national regulatory capacity, with the aim of several reaching 'stringent regulator' status. Access to doses is an essential start but is not sufficient, as healthcare infrastructure for vaccination and combating dangerous antivaccine programmes both require support. Finally, there is urgency to establish an international framework through a United Nations Pandemic Treaty to promote, support and harmonise a more robust, coordinated and effective global response.

Factors, enablers and challenges for COVID-19 vaccine development.

The COVID-19 pandemic triggered a sense of vulnerability and urgency that led to concerted actions by governments, funders, regulators and industry to overcome traditional challenges for the development of vaccine candidates and to reach authorisation. Unprecedented financial investments, massive demand, accelerated clinical development and regulatory reviews were among the key factors that contributed to accelerating the development and approval of COVID-19 vaccines. The rapid development of COVID-19 vaccines benefited of previous scientific innovations such as mRNA and recombinant vectors and proteins. This has created a new era of vaccinology, with powerful platform technologies and a new model for vaccine development. These lessons learnt highlight the need of strong leadership, to bring together governments, global health organisations, manufacturers, scientists, private sector, civil society and philanthropy, to generate innovative, fair and equitable access mechanisms to COVID-19 vaccines for populations worldwide and to build a more efficient and effective vaccine ecosystem to prepare for other pandemics that may emerge. With a longer-term view, new vaccines must be developed with incentives to build expertise for manufacturing that can be leveraged for low/middle-income countries and other markets to ensure equity in innovation, access and delivery. The creation of vaccine manufacturing hubs with appropriate and sustained training, in particular in Africa, is certainly the way of the future to a new public health era to safeguard the health and economic security of the continent and guarantee vaccine security and access, with however the need for such capacity to be sustained in the interpandemic period.

Vaccine access, equity and justice: COVID-19 vaccines and vaccination.

Although significant progress has been made in achieving goals for COVID-19 vaccine access, the quest for equity and justice remains an unfinished agenda. Vaccine nationalism has prompted calls for new approaches to achieve equitable access and justice not only for vaccines but also for vaccination. This includes ensuring country and community participation in global discussions and that local needs to strengthen health systems, address issues related to social determinants of health, build trust and leverage acceptance to vaccines, are addressed. Regional vaccine technology and manufacturing hubs are promising approaches to address access challenges and must be integrated with efforts to ensure demand. The current situation underlines the need for access, demand and system strengthening to be addressed along with local priorities for justice to be achieved. Innovations to improve accountability and leverage existing platforms are also needed. Sustained political will and investment is required to ensure ongoing production of non-pandemic vaccines and sustained demand, particularly when perceived threat of disease appears to be waning. Several recommendations are made to govern towards justice including codesigning the path forward with low-income and middle-income countries; establishing stronger accountability measures; establishing dedicated groups to engage with countries and manufacturing hubs to ensure that the affordable supply and predictable demand are in balance; addressing country needs for health system strengthening through leveraging existing health and development platforms and delivering on product presentations informed by country needs. Even if difficult, we must converge on a definition of justice well in advance of the next pandemic.

Factors Affecting SARS-CoV-2 Vaccination Intent and Decision Making Among African American, Native American, and Hispanic Participants in a Qualitative Study.

Limited studies are available on how decisions and perceptions on SARS-CoV-2 vaccination have changed since the start of vaccination availability. We performed a qualitative study to identify factors critical to SARS-CoV-2 vaccination decision making and how perspectives evolved among African American/Black, Native American, and Hispanic communities disproportionately affected by COVID-19 and social and economic disadvantage. We conducted 16 virtual meetings, with 232 participants in wave 1 meetings (December 2020) and with 206 returning participants in wave 2 meetings (January and February 2021). Wave 1 vaccine concerns in all communities included information needs, vaccine safety, and speed of vaccine development. Lack of trust in government and the pharmaceutical industry was influential, particularly among African American/Black and Native American participants. Participants showed more willingness to get vaccinated at wave 2 than at wave 1, indicating that many of their information needs had been addressed. Hesitancy remained greater among African American/Black and Native American participants than among Hispanic participants. Participants in all groups indicated that conversations tailored to their community and with those most trustworthy to them would be helpful. To overcome vaccine hesitancy, we propose a model of fully considered SARS-CoV-2 vaccine decision making, whereby public health departments supply information, align with community values and recognize lived experiences, offer support for decision making, and make vaccination easy and convenient.

The intersection of gender and race in older adults' decision to receive COVID-19 vaccines.

COVID-19 vaccines are essential public health tools for protecting older adults, who are at high risk of severe outcomes associated with COVID-19. Little is known, however, about how older adults approach the decision to receive a COVID-19 vaccine. We hypothesized that intersections between gender and race may provide unique insight into the decision-making process and the factors that lead to vaccine uptake among hesitant individuals. We performed in-depth interviews with 24 older adults who had been vaccinated against COVID-19 and used the framework approach with an intersectional lens to analyze data. Two typologies emerged: eager compliers did not question the need to vaccinate, whereas hesitant compliers were skeptical of the vaccine and underwent a thorough decision-making process prior to vaccination. For eager compliers, the vaccine offered protection from a disease that posed a serious threat, and few risks were perceived. In contrast, hesitant compliers perceived risks associated with the vaccine product or mistrusted the infrastructure that led to rapid vaccine development. Hesitancy was greater among Black participants, and only Black participants reported mistrust in vaccine infrastructure. At the intersection of gender and race, a 'White male effect' was observed, whereby White men perceived the fewest risks associated with the vaccine, and Black women were the most fearful of serious side effects. Nearly all hesitant compliers ultimately got vaccinated due to the threat of COVID-19. Convenient access through vaccine clinics in senior's buildings was pivotal for hesitant compliers and external and internal influences had differential impacts by race and gender. Emphasizing the risk of COVID-19, convenient and accessible opportunities for vaccination, and messages that are targeted to specific groups are likely to increase vaccine uptake among older adults.

The Promise of Disease Detection Dogs in Pandemic Response: Lessons Learned From COVID-19.

One of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the utility of an early, flexible, and rapidly deployable disease screening and detection response. The largely uncontrolled spread of the pandemic in the United States exposed a range of planning and implementation shortcomings, which, if they had been in place before the pandemic emerged, may have changed the trajectory. Disease screening by detection dogs show great promise as a noninvasive, efficient, and cost-effective screening method for COVID-19 infection. We explore evidence of their use in infectious and chronic diseases; the training, oversight, and resources required for implementation; and potential uses in various settings. Disease detection dogs may contribute to the current and future public health pandemics; however, further research is needed to extend our knowledge and measurement of their effectiveness and feasibility as a public health intervention tool, and efforts are needed to ensure public and political support.

Assessing vaccine introduction and uptake timelines in Gavi-supported countries: are introduction timelines accelerating across vaccine delivery platforms?

BACKGROUND: Previous studies identified factors influencing regulatory approval to introduction timelines for individual vaccines. However, introduction and uptake timelines have not been comprehensively assessed across the portfolio of Gavi-supported vaccines. METHODS: We analysed median times between introduction milestones from vaccine licensure to country introduction and uptake across six vaccine-preventable diseases (VPDs), three delivery platforms and 69 Gavi-supported countries. Data were gathered from public, partner and manufacturer records. VPDs and prequalified vaccines analysed included Haemophilus influenzae type b (DTwP-HepB-Hib, pentavalent), pneumococcal disease (pneumococcal conjugate vaccine, PCV), rotavirus diarrhoea (rotavirus vaccine, RVV), cervical cancer (human papillomavirus vaccine, HPV), polio (inactivated polio vaccine, IPV) and meningococcal meningitis (meningococcal group A conjugate vaccine, MenA). RESULTS: Median time from first vaccine licensure to first Gavi-supported country introduction across VPDs at a 'global level' (Gavi-supported countries) was 5.4 years. Once licensed, MenA vaccines reached first introduction fastest (campaign=0.6 years; routine immunisation (RI)=1.7 years). Most introductions were delayed. Country uptake following first introduction was accelerated for more recently Gavi-supported RI vaccines compared with older ones. CONCLUSION: Factors accelerating timelines across delivery platforms included rapid product prequalifications by WHO, strong initial recommendations by the WHO Strategic Advisory Group of Experts (SAGE) on Immunization, achieving target product profiles on first vaccine licensure within a VPD and completing several VPD milestones at a global level prior to licensure. Milestones required for introduction in Gavi-supported countries should start prior or in parallel to licensure to accelerate uptake of vaccines delivered through diverse delivery platforms.

Supply and delivery of vaccines for global health.

Vaccines developed in high-income countries have been enormously successful in reducing the global burden of infectious diseases, saving perhaps 2.5 million lives per year, but even for successful cases, like the rotavirus vaccine, global implementation may take a decade or more. For unincentivized vaccines, the delays are even more profound, as both the supply of a vaccine from developing country manufacturers and vaccine demand from countries with the high disease burdens have to be generated in order for impact to be manifest. A number of poverty-associated infectious diseases, whose burden is greatest in low-income and middle-income countries, would benefit from appropriate levels of support for vaccine development such as Group A Streptococcus, invasive non-typhoid salmonella, schistosomiasis, shigella, to name a few. With COVID-19 vaccines we will hopefully be able to provide novel vaccine technology to all countries through a unique collaborative effort, the COVAX facility, led by the World Health Organization (WHO), Gavi, and the Coalition for Epidemic Preparedness Innovations (CEPI). Whether this effort can deliver vaccine to all its participating countries remains to be seen, but this ambitious effort to develop, manufacture, distribute, and vaccinate 60-80% of the world's population will hopefully be a lasting legacy of COVID-19.

Situational assessment of adult vaccine preventable disease and the potential for immunization advocacy and policy in low- and middle-income countries.

By 2050, the number of adults over 65 years of age will be double the under-5 population, and heavily concentrated in low- and middle-income countries. Population growth and increasing life expectancies call for effective healthy aging strategies inclusive of immunization to reduce the burden of vaccine-preventable diseases, improve quality of life, and mitigate antimicrobial resistance. Based on a review of available literature on the pneumococcal disease, influenza, and herpes zoster epidemiology and economic burden, and the health systems and policy barriers for adult immunization, we identified evidence gaps and considerations for prioritizing adult immunization. The body of evidence for adult immunization and the health and economic burden of adult disease is heavily concentrated in high-income countries. The few countries reporting adult immunization policies generally focus on high-risk groups. Despite robust child immunization programs in most countries, adult immunization programs and policies lag far behind and there is a general lack of appropriate delivery platforms. Global adult disease burden and economic costs are substantial but evidence from low- and middle-income countries is limited. There is a need for a strengthened evidence base and political commitment to drive a comprehensive, global technical consensus on adult immunization.

Determinants of policy and uptake of national vaccine programs for pregnant women: results of mixed method study from Spain, Italy, and India.

An important strategy for addressing maternal and newborn risks of disease is through vaccinating pregnant women. We conducted a mixed-methods study including a narrative literature review of drivers of maternal vaccination and key informant interviews in Spain, Italy, and India to characterize different approaches to national maternal immunization programs. Fifty-nine respondents participated in the study conducted between November 2018 and January 2019. Policies in Spain and Italy both reflect a life-course approach to vaccination, but recommendations and how they ensure uptake differs. Italy was focused on tracking of progress and mandates to ensure compliance in all regions, while Spain, an early adopter, relied more on advocacy and building provider acceptance. India includes Td in their national program, but the political will and advocacy for other vaccines are not seen. Needs for improving rates of maternal vaccination include education of health-care providers and pregnant women, use of central registries to track progress, stronger global guidance for use of vaccines, and engagement of champions, particularly obstetrician-gynecologists (ob-gyns). Health security concerns can also be leveraged to build political priority and needed platforms to detect disease and deliver vaccines in some countries. Understanding what drives a country's maternal immunization program decisions and the success of implementation is useful in designing strategies to share best practices and guide support to strengthen platforms for maternal vaccination.

The public's role in COVID-19 vaccination: Human-centered recommendations to enhance pandemic vaccine awareness, access, and acceptance in the United States.

Given the social and economic upheavals caused by the COVID-19 pandemic, political leaders, health officials, and members of the public are eager for solutions. One of the most promising, if they can be successfully developed, is vaccines. While the technological development of such countermeasures is currently underway, a key social gap remains. Past experience in routine and crisis contexts demonstrates that uptake of vaccines is more complicated than simply making the technology available. Vaccine uptake, and especially the widespread acceptance of vaccines, is a social endeavor that requires consideration of human factors. To provide a starting place for this critical component of a future COVID-19 vaccination campaign in the United States, the 23-person Working Group on Readying Populations for COVID-19 Vaccines was formed. One outcome of this group is a synthesis of the major challenges and opportunities associated with a future COVID-19 vaccination campaign and empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against SARS-CoV-2. While not inclusive of all possible steps than could or should be done to facilitate COVID-19 vaccination, the working group believes that the recommendations provided are essential for a successful vaccination program.

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action.

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.

Archetype analysis of older adult immunization decision-making and implementation in 34 countries.

The global population of adults over 65 years of age is growing rapidly and is expected to double by 2050. Countries will face substantial health, economic and social burden deriving from vaccine-preventable diseases (VPDs) such as influenza, pneumonia and herpes zoster in older adults. It will be essential that countries utilize several public health strategies, including immunization. Understanding the different approaches countries have taken on adult immunization could help provide future learnings and technical support for adult vaccines within life-course immunization strategies. In this study, we describe the priorities and approaches that underlie adult immunization decision-making and implementation processes in 32 high-and-middle-income countries and two territories ("34 countries") who recommend adult vaccines in their national schedule. We conducted an archetype analysis based on a subset of two dozen indicators abstracted from a larger database. The analysis was based on a mixed-methods study, including results from 120 key informant interviews in six countries and a landscape review of secondary data from 34 countries. We found four distinct archetypes: disease prevention-focused; health security-focused; evolving adult focus; and, child-focused and cost-sensitive. The highest performing countries belonged to the disease prevention-focused and health security archetypes, although there was a range of performance within each archetype. Considering common barriers and facilitators of decision-making and implementation of adult vaccines within a primary archetype could help provide a framework for strategies to support countries with similar needs and approaches. It can also help in developing context-specific policies and guidance, including for countries prioritizing adult immunization programs in light of COVID-19. Further research may be beneficial to further refine archetypes and expand the understanding of what influences success within them. This can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders.

Community-based Strategies to Engage Pastors Can Help Address Vaccine Hesitancy and Health Disparities in Black Communities.

In an era of Freddie Gray and Black Lives Matter, a long history of structural racism, combined with disproportionate rates of COVID-19, the African American community has seen a lot of reasons to demand social justice, equal treatment and immediate access to solutions to health disparities. Despite the promise of COVID-19 vaccines, the community is highly distrustful of the vaccine and institutions given a history of mistreatment and many other current concerns. Trusted messengers such as Black pastors are crucial to protecting the community that faces a disproportionate amount of disease. We present a framework to build trust and acceptance including understanding history and context; listening and empathy; engaging pastors as trusted messengers; creating partnerships with shared responsibility and power; and co-creation of solutions with faith leaders and their community, governments and institutions to create sustainable, long-term change. Efforts to support vaccine acceptance must be customized to the variety of needs and realities of the African American community, not just the topic of concern to the institution. Evaluations are needed to help ensure the community is engaged and feeling heard. Pastors and other religious leaders can work with government and institutions to bring information, facilitate discussion, build trust and develop measurable improvement efforts. Although acceptance of COVID-19 vaccines may not be achieved overnight, the process of focusing on issues that are important to the community is an important step in laying the foundation for both COVID-19 vaccines and future interventions.

Cholera control and prevention: Role of evidence-based advocacy and communications.

Evidence-based communications and policy outreach are critical elements in building awareness about a disease, build public momentum and decision making and resource mobilization. In India, communications and advocacy played an important role in managing diseases like HIV/AIDS, pneumonia, tuberculosis, etc. and addressing barriers to adoption of new health interventions. These learnings from the past, can help India manage cholera more effectively through a strong advocacy and communications strategy involving multiple stakeholders and partners, with a focus on engaging decision makers. The article discusses strategic communications and advocacy programs for cholera that can be instrumental in paving the way for cholera vaccine use to combat this public health problem and its social and economic impact.

One size does not fit all: The impact of primary vaccine container size on vaccine distribution and delivery.

BACKGROUND: While the size and type of a vaccine container (i.e., primary container) can have many implications on the safety and convenience of a vaccination session, another important but potentially overlooked consideration is how the design of the primary container may affect the distribution of the vaccine, its resulting cost, and whether the vial is ultimately opened. METHODS: Using our HERMES software platform, we developed a simulation model of the World Health Organization Expanded Program on Immunization supply chain for the Republic of Benin and used the model to explore the effects of different primary containers for various vaccine antigens. RESULTS: Replacing vaccines with presentations containing fewer doses per vial reduced vaccine availability (proportion of people arriving for vaccines who are successfully immunized) by as much as 13% (from 73% at baseline) and raised logistics costs by up to $0.06 per dose administered (from $0.25 at baseline) due to increased bottlenecks, while reducing total costs by as much as $0.15 per dose administered (from $2.52 at baseline) due to lower open vial wastage. Primary containers with a greater number of doses per vial each improved vaccine availability by 19% and reduced logistics costs by $0.05 per dose administered, while reducing the total costs by up to $0.25 per dose administered. Changes in supply chain performance were more extreme in departments with greater constraints. Implementing a vial opening threshold reversed the direction of many of these effects. CONCLUSIONS: Our results show that one size may not fit all when choosing a primary vaccine container. Rather, the choice depends on characteristics of the vaccine, the vaccine supply chain, immunization session size, and goals of decision makers. In fact, the optimal vial size may vary among locations within a country. Simulation modeling can help identify tailored approaches to improve availability and efficiency.