"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

IntroductionCOVID-19 vaccines are now being distributed to low- and middle-income countries (LMICs), with global urgency surrounding national vaccination plans. LMICs have significant experience implementing vaccination campaigns to respond to epidemic threats but are often hindered by chronic health system challenges. We sought to identify transferable lessons for COVID-19 vaccination from the rollout of three vaccines that targeted adult groups in Africa and South America: MenAfriVac (meningitis A); 17D (yellow fever); and rVSV-ZEBOV (Ebola virus disease). MethodsWe conducted a rapid literature review and 24 semi-structured interviews with technical experts who had direct implementation experience with the selected vaccines in Africa and South America. We identified barriers, enablers, and key lessons from the literature and from participants experiences. Interview data were analysed thematically according to seven implementation domains. ResultsParticipants highlighted multiple components of vaccination campaigns that are instrumental for achieving high coverage. Community engagement is an essential and effective tool, requiring dedicated time, funding and workforce. Involving local health workers is a key enabler, as is collaborating with community leaders to map social groups and tailor vaccination strategies to their needs. Vaccination team recruitment and training strategies need to be enhanced to support vaccination campaigns. Although recognised as challenging, integrating vaccination campaigns with other routine health services can be highly beneficial if well planned and coordinated across health programmes and with communities. ConclusionAs supplies of COVID-19 vaccines become available to LMICs, countries need to prepare to efficiently roll out the vaccine, encourage uptake among eligible groups, and respond to potential community concerns. Lessons from the implementation of these three vaccines that targeted adults in LMICs can be used to inform best practice for COVID-19 and other epidemic vaccination campaigns. O_TEXTBOXKEY QUESTIONSO_ST_ABSWhat is already known?C_ST_ABSO_LILow- and middle-income countries (LMICs) have substantial experience conducting vaccination campaigns as a part of epidemic responses. C_LIO_LIVaccination campaigns in LMICs are impacted by a number of systemic challenges, including poor infrastructure, limited resources, and an overstretched health workforce. C_LIO_LIMeningitis A, yellow fever and Ebola virus disease vaccines have been recently rolled out in LMICs to respond to epidemic threats. These campaigns share some of the same challenges anticipated for COVID-19 vaccination, including the focus on adult target groups. C_LI What are the new findings?O_LIExtensive community engagement is crucial when targeting adults for vaccination in LMICs to shift community perceptions that vaccination is only associated with children. C_LIO_LIWorking with community leaders to map social groups and plan effective vaccination strategies is vital to achieving high vaccination coverage. C_LIO_LIRecruiting local health workers who have established links to the community, can speak the local language, and can leverage existing rapport to increase vaccination uptake, is preferred over bringing in staff from other regions. C_LIO_LIVaccination training quality is reduced as information is transmitted down to lower levels using the cascade or training-of-trainers model. Training for vaccination campaigns in LMICs has been further affected by COVID-19 and the move to remote learning. Where access to training is limited, a greater emphasis is placed on resource-intensive supervision to ensure the effectiveness of vaccination campaigns. C_LI What do the new findings imply?O_LIPrevious vaccination campaigns conducted during epidemics are an important source of transferable lessons that can assist countries in their COVID-19 vaccine rollouts and future epidemic preparedness. C_LIO_LIOur findings suggest that countries can strengthen vaccination campaigns during epidemics by recruiting local health workers to assist vaccination teams, by providing operational funding for pre-campaign community engagement and social mobilisation activities, and by examining the effectiveness of vaccination training and developing new models where needed. C_LIO_LIImplementing these lessons for COVID-19, however, relies on countries having sufficient vaccine supply. C_LI C_TEXTBOX

Addressing disruptions in childhood routine immunisation services during the COVID-19 pandemic: perspectives and lessons learned from Liberia, Nepal, and Senegal

The COVID-19 pandemic has inflicted multifaceted disruptions to routine immunisation from global to local levels, affecting every aspect of vaccine supply, access, and demand. Since March 2020, country programmes have implemented a range of strategies to either continue vaccination services during COVID-19 measures like lockdown and/or resume services when risks of SARS-CoV-2 transmission could be appropriately mitigated. Through the Exemplars in Global Health partnership in Liberia, Nepal, and Senegal, we conducted interviews with immunisation programme managers and ministry of health leadership to better understand how they have addressed the myriad vaccination challenges posed by the ongoing pandemic. From establishing alternative modes of service delivery to combatting vaccine distrust and rumours via risk communication campaigns, many routine immunisation programmes have demonstrated how to adapt, resume, and/or maintain vital vaccination efforts during the COVID-19 crisis. Yet millions of children remain un- or under-vaccinated worldwide, and the same programmes striving to implement catch-up services for missed doses and postponed mass campaigns will also soon be tasked with COVID-19 vaccine deployment. As laid bare by the current pandemic, the worlds gains against vaccine-preventable diseases are fragile: enshrined by a delicate global ecosystem of logistics, supply, and procurement, the success of routine immunisation ultimately rests upon dedicated programme staff, the resources and support available to them, and then the trust in and demand for vaccines by their recipients. Our collective lessons learned during COVID-19 offer insights in programme adaptation and resilience that, if prioritised, could strengthen equitable, sustainable vaccine delivery for all populations. Summary boxO_LIKey message 1: As the COVID-19 pandemic affected routine immunisation services worldwide, country programmes have used a range of mitigation strategies to maintain vaccine delivery and/or resume interrupted programming. Interviews with immunisation programme managers and Ministry of Health staff provided key perspectives and lessons learned on how countries have approached routine immunisation services during the COVID-19 crisis. C_LIO_LIKey message 2: Key themes for mitigating COVID-19s effects on routine immunisation included prioritising continued services with strengthened infection prevention control; identifying alternative locations and approaches to providing vaccine services (e.g., conducting door-to-door vaccination if facility-based services were not possible); engaging in effective communications and mobilisation activities, especially to offset misinformation about COVID-19 and vaccines; setting up systems and strategies for reaching children who missed doses amid periods of disruption; and conducting catch-up campaigns as soon as SARS-CoV-2 transmission risks could be minimised. C_LIO_LIKey message 3: The ways in which COVID-19 has affected routine immunisation services have varied over time and across settings, underscoring the importance of contextually-tailored mitigation efforts and adaptation given evolving challenges amid an ongoing pandemic. As countries prepare and initiate roll-out COVID-19 vaccines, it will be vital to avoid one-size-fits-all implementation strategies and support the continuance of routine immunisation services through this next phase of COVID-19 response. C_LI