key: cord-0427792-jona4dgz authors: Collins, J.; Westerveld, R.; Nelson, K. A.; Rohan, H.; Bower, H.; Lazenby, S.; Ikilezi, G.; Bartlein, R.; Bausch, D. G.; Kennedy, D. S. title: "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 date: 2021-07-19 journal: nan DOI: 10.1101/2021.07.15.21260439 sha: 96158c370c4395c4e5e488c2a8885db1be6b0806 doc_id: 427792 cord_uid: jona4dgz Introduction: COVID-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). Methods: We 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. Results: Participants 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. Conclusion: As 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. What is already known? • Low-and middle-income countries (LMICs) have substantial experience conducting vaccination campaigns as a part of epidemic responses. • Vaccination campaigns in LMICs are impacted by a number of systemic challenges, including poor infrastructure, limited resources, and an overstretched health workforce. • Meningitis 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. • Extensive community engagement is crucial when targeting adults for vaccination in LMICs to shift community perceptions that vaccination is only associated with children. • Working with community leaders to map social groups and plan effective vaccination strategies is vital to achieving high vaccination coverage. • Recruiting 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. • Vaccination 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. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 What do the new findings imply? • Previous 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. • Our 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. • Implementing these lessons for COVID-19, however, relies on countries having sufficient vaccine supply. 55 56 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Target group inclusion and exclusion criteria; prioritisation of groups; communication of target groups; delivery strategies for vaccination (e.g., house-to-house, fixed post, mobile fixed post); tailoring of delivery strategies to reach sub-groups. 3) Logistics and supply Supply chain; infrastructure; vaccine storage; cold chain (and ultra-cold chain) management; transportation; equipment (including personal protective equipment); waste disposal. Team composition and roles; recruitment; training techniques and processes; team coordination and communication. Identifying cases of disease and differentiating between similar pathogens; recording, reporting and monitoring vaccination coverage; identification, reporting and management of adverse events following immunisation; use of technology. Developing relationships with communities and working together to conduct vaccination activities; strategies to increase vaccine demand and uptake, including communication strategies. Vaccine confidence 2 Perceptions and attitudes toward the vaccine; factors contributing to confidence or resistance; types of rumours and misinformation; strategies to address rumours and misinformation. 1 World Health Organization definitions of community engagement and social mobilisation were used in this 99 research, however it was noted that these terms were often used interchangeably by key informants. [67, 68] 100 2 Vaccine confidence was not identified in articles retrieved in the literature review but was discussed in the key 101 informant interviews. 102 103 104 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Participants 116 Using a purposive sampling approach, we identified technical experts through the 117 professional networks of the research team and via "snowball sampling." Participants had 118 either 1) involvement in the rollout of one or more of the selected vaccines through global 119 initiatives or organisations, or 2) implementation experience with one or more of the selected 120 vaccines at either a regional, national, or sub-national level. Data collection 123 We developed a semi-structured interview guide, based on preliminary findings from the 124 literature review and using the thematic framework ( Table 2 ). The interview guide helped 125 elicit specific information across the domains but was sufficiently flexible to allow the 126 interview to be guided by the participants' experiences. While the interviews focused on the 127 three selected vaccines, interviewers did not dissuade participants from drawing on their 128 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 experiences from other campaigns. Participants were given the opportunity to reflect on their 129 experiences with the initial COVID-19 vaccination rollout, where appropriate. Interviews were conducted virtually via Zoom and were in either English or French. Interviews were digitally recorded, professionally translated to English when required, and 133 transcribed. The interviewers verified each transcript to ensure accuracy before commencing 134 data analysis. Data analysis 137 We analysed the qualitative data thematically, using deductive and inductive coding in Nvivo 138 12 Plus. A coding framework was developed based on the seven domains in the thematic 139 framework (Table 2) , along with additional themes emerging from the data. Key trends, 140 barriers, enablers, and lessons shared by participants were identified across each theme. Literature review 144 Thirty-seven studies met the inclusion criteria ( Figure 1 African countries [11-35, 40, 44, 46, 47] ; two on South American countries [41, 43] ; and six 148 studies did not specify a region [36-39, 42, 45] (Table 3) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. For the success of the campaign, we must have a strong microplan, originating from 176 the health facility itself that is going to be involved. … [without this] you may still 177 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. International partners, such as multilateral organisations, NGOs, and civil society 184 organisations, play a key role in supporting campaign resourcing and implementation. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10. 1101 Establishing strong coordination mechanisms 204 Robust coordination mechanisms are necessary to provide direction and oversight over 205 campaign activities. Participants highlighted the benefits of an incident management system 206 (IMS) that delineates the roles and responsibilities of government departments (e.g., disease 207 control, routine immunisation, national drug authorities) and partner organisations and 208 prevents the duplication of response efforts. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. East and West Africa) described how young married women might not be able to attend a 259 public vaccination site without authorisation from their spouses. Engaging with community 260 leaders to map social groups and identify when, where, and how vaccination teams can most 261 effectively reach sub-groups is vital to achieving high vaccination coverage. Integrating COVID-19 vaccination with other services requires careful planning with 276 communities to prevent potential spillover of COVID-19 vaccine hesitancy to other services. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. Participants consistently referred to the importance of recruiting local health workers who 324 have established links to the community, can speak the local language, and can leverage 325 existing rapport to increase uptake, rather than bringing in staff from other regions. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. Inadequate resourcing of vaccination teams and lengthy processes for distributing funding 358 were identified as additional barriers, with participants stating that it was unfair to expect 359 teams to perform without funding. [The resources] must be available, and that is very key, available and handed to the 361 people that actually get involved, because if you are going to keep the team in the 362 field for the whole day and they don't have support or any money to get themselves a 363 drink or something to eat, it is going to have a negative effect. (National health 364 agency, East Africa) 365 CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101/2021.07.15.21260439 doi: medRxiv preprint centres opened at 8 am, but at 5 am people were already queuing to get the vaccine. The feedback to the community leaders is very, very important, because we always 416 seek their permission, their help, their assistance, but we never give them feedback. 417 (Multilateral organisation, West Africa) 418 419 Respect, honesty, and meaningful discussion were stressed as principles crucial to building 420 trust: There are many things that the communities need to understand. They may not be 422 intellectual … but they are not stupid. They observe and ask relevant questions. So one 423 of the keys is to never hide the truth. Be frank and honest with them, because when they 424 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. The current limited supply of COVID-19 vaccines presents a paradox for LMICs in terms of 448 community engagement and social mobilisation. While delayed vaccine delivery means 449 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 countries have more time to plan mobilisation activities, they lack the operational funding 450 required to design and deliver these activities. Further, generating demand in the face of 451 limited supply requires careful balancing of risks; some participants spoke of how they had 452 not yet employed previously used demand generation methods, such as SMS alerts, for 453 COVID-19 for fear of overwhelming their limited vaccine supply. The problem is that COVID-19 is too publicised, which is already a major obstacle to 472 acceptance. … Unfortunately today, the world cannot control [the information] 473 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. Participants noted that rumours around 'vaccine testing' were prevalent in both the EVD and 486 COVID-19 responses, but that community risk perceptions were different between the 487 campaigns. [During the EVD response] there was lots of talk about being guinea pigs and 489 [people] would say, "yeah, we're guinea pigs", but a lot of people went, "actually, I'd 490 rather be a guinea pig and get vaccinated than get Ebola." … Early on in the COVID-491 19 outbreak [the population] said, "well, we're not willing to be guinea pigs for this 492 one because it's not our problem … we are probably not going to die of COVID-19." 493 (NGO, Central Africa) 494 Participants spoke of how they explained the vaccine regulatory and approval processes to 495 communities, highlighting that COVID-19 vaccine trials had already been conducted in other 496 countries outside of Africa. However, changing community perceptions was considered 497 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; difficult due to misinformation and the absence of high disease incidence or severity that 498 might increase the prioritisation of COVID-19 vaccination within communities. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 • Prioritise the availability of operational funds to support community engagement and social mobilisation well in advance of vaccination activities. • Planning and coordination • Community engagement and social mobilisation • Develop a community engagement strategy that emphasises 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 mobilisation • Target groups and delivery strategies • Vaccine confidence Health Workers) to support vaccination activities, ensuring a continued connection between communities and the vaccination campaign. • Vaccination teams • Community engagement and social mobilisation • 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 multi-dose vaccine vials, including which population groups should be offered leftover vaccine doses where the vial cannot be appropriately stored and used at a later time. • Vaccination teams • Logistics and supply • Ensure national ownership, access and capacity to analyse 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 programme 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 513 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 19, 2021. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 has been a global recognition of frontline worker burnout, the effect of a protracted pandemic 564 on key personnel in countries' incident management systems should also be considered. [60] 565 Countries need to explore ways to streamline coordination processes and upskill additional 566 staff to fulfil IMS functions to ensure continuity in the response. These recommendations rely on LMICs having sufficient vaccine supply to conduct 578 vaccination campaigns for COVID-19, which has not been the case in most settings. We 579 implore the global community to prioritise COVID-19 vaccine supply for LMICs. As vaccine 580 supplies increase, we encourage researchers to support countries in monitoring and 581 documenting their COVID-19 vaccination campaigns to understand real-time responses to 582 challenges and strengthen evidence around best practices during outbreak-related vaccination 583 campaigns in low-resource settings. 584 585 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 19, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 Data sharing statement 621 The qualitative data generated through this study are not suitable for sharing beyond that 622 contained within the manuscript in order to protect participants' anonymity. Further 623 information can be obtained from the corresponding author. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 19, 2021. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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