Covid-19 disrupted just about every aspect of healthcare, including routine vaccination. While the global healthcare community was racing to roll out the new Covid-19 vaccine, the pandemic was fueling the largest backslide in childhood vaccinations in three decades, according to a July 2022 report from WHO and UNICEF – dropping 5 percent between 2019 to 2021.
That means that 25 million children, most living in low to middle income countries, didn’t receive one or more doses of the DPT3 vaccine (for diphtheria, tetanus, and pertussis), with India, Nigeria, Indonesia, Ethiopia, and the Philippines recording the highest declines. Additionally, a quarter of HPV vaccination coverage was lost from already low 2019 levels, leaving adolescent girls vulnerable to human papillomavirus, which can cause cervical cancer. Under vaccination has also led to measles and polio outbreaks in the last year that otherwise could have been prevented.
As countries play catch-up in their vaccination efforts, organizations like Jhpiego, an international non-profit and Johns Hopkins University affiliate, are examining what lessons from the Covid-19 vaccine rollout can be applied to support life course vaccination — meaning immunizations received from birth through early childhood, to adolescence and adulthood. That includes stalwart shots like tuberculosis and influenza, emerging immunizations like malaria, and ones that could come in the future, such as new and improved TB or flu vaccines, and one to prevent HIV.
Doing so will first require a shift in thinking. While in high-income settings it’s common to have a primary care provider, in low to middle income countries in Africa, Asia, and Latin America where Jhpiego works, that isn’t the case. Many adults there tend to seek care only when they’re sick or in pain, not preventatively.
“The immunization program has traditionally been focused on pregnant women and one- or two-year-old infants,” says Dr. Chris Morgan, Jhpiego’s head of immunization. “It’s also been a challenge just to get that side of things running well, so vaccinating adults against things like influenza have felt like extras that will come later. The whole idea of preventive and promotive medicine for adults is not strong in many of these countries.”
Meeting people where they are
For the last five decades, Jhpiego has been working to bring preventative health services to lower-income countries through its work in maternal and child health, HPV immunization, and HIV testing and treatment, among other services. Like all healthcare organizations, it had to adapt when Covid-19 hit, but Morgan says that Jhpiego’s experience was unusual in that it was asked to pivot its existing preventative programs for adults, especially for HIV, first to do Covid-19 diagnosis and treatment, then roll out vaccines when available.
“The standard approach... has been to go to the country’s immunization program that normally works with pregnant women and the under fives and say, ‘Okay, you’ve just got to expand and do all of these adults as well,’” Morgan says. “You look at how many families they were being asked to reach normally in routine immunizations, and then compare with what the Covid-19 vaccination response was requiring, it’s between a 10- and 20-fold scale-up that was being asked of these programs. So, it’s just not possible for them to suddenly manufacture 10 times the number of staff.”
Many still tried, of course, but Morgan explains that it led to long days, burned out staff, and the shelving of other preventative services, like measles vaccinations for children, to accommodate the Covid-19 immunization response. Jhpiego’s alternative approach meant that the same nurses and staff who do HIV education and male circumcision, for example, were doing coronavirus prevention and vaccination. That also gave them a crucial advantage in vaccinating local populations: the trust of the community.
“Jhpiego is actually uniquely placed, because we have boots on the ground,” says Sarah Wanyoike, Jhpiego’s senior technical advisor for immunization, naming epidemiologists, clinical officers, nurses, and program managers, among others. “They’ve already been on the ground working on HIV. So when Covid came and they were asked to support Covid vaccinations, the communities they were serving already knew who they were. It was very easy to get buy-in... These are not new faces. These are people who have a track record in the work they’ve doing.”
Instead of asking patients to go to a different site or center, where they don’t know any of the people working there, Jhpiego has found the more effective path is trying to meet those patients where they are anyway. Take Cote d’Ivoire, whose HPV vaccination rates in girls actually went up during the pandemic when other countries’ rates were going down, according to Wanyoike.
“The difference is that Cote d’Ivoire identified very quickly that there is a whole health department within their education sector that takes care of girls and we could partner together with those professionals to vaccinate girls in schools,” Wanyoike says. “As opposed to going in with a fully developed campaign plan with dates... and we’ve completely left out the nurse who’s working in that school.”
Fighting inequity and distrust
In September 2021, 60 percent of people in high-income countries had been vaccinated against Covid-19, compared to just 3 percent in low-income countries, according to the UN. As of August 2022, coverage in low-income countries had risen to 17 percent, according to Gavi, an improvement but still far below its rich peers. While organizations like Jhpiego were expecting to get much-needed vaccines for countries in Africa by mid-2021, the rise of the delta variant meant that wealthy countries started prioritizing booster doses, which soaked up supply.
“The vaccine supply really only opened up in December last year,” Morgan says. “By that time, some countries and communities were, I guess, so disgruntled and discouraged with the whole process that there’s been much loss of trust… That lack of trust means we’re nine months into having enough vaccine supplies to these countries and it’s not getting used because it’s hard to get people to actually agree.”
Hesitancy surrounding vaccines has proved a huge hurdle for Covid immunization in low- to middle-income countries, just as it has in the US. Distrust, misinformation, and a history of medical racism all play a role. In Africa, Wanyoike witnessed hesitancy to take the western-developed Covid-19 vaccine based on fears that they were being targeted for vaccine trials or depopulation.
“Vaccine hesitancy has existed from the beginning of vaccines and it’s going to continue to the end. We just have to learn how to manage it,” she says. Wanyoike has seen success in involving nontraditional players like religious institutions in the coordination of vaccine rollouts. “You bring them to the table, because those are the same people who will go and talk against the vaccine because they don’t know enough because you didn’t… tell them what you’re doing.”
One potential solution Wanyoike sees to hesitancy surrounding “outside” vaccines, particularly in Africa, is manufacturing them locally. Such moves are already being made by Moderna, which announced plans to build an mRNA vaccine manufacturing facility in Kenya and BioNTech’s plan to build one in Rwanda.
“You address the issue of availability, but more critically, acceptance,” she says. “If you have the vaccine manufactured locally, the local regulatory authorities can go and inspect the place. Everybody has more confidence because they have a little bit more control if it’s locally produced. It’s ours. It also will create employment for people in the area.”
Taking an integrated approach to care
Even though vaccine hesitancy is a big deal, when it comes to immunization, “convenience is the big factor, perhaps more so than the rumors and misinformation and myths,” Morgan says.
“We’re trying to really document what went right in the pivots made by our HIV programs so that we can look at where and from whom do adults actually prefer to get preventive care services,” he adds. “We’ve shown that it’s not necessarily the traditional immunization clinics or mother-and-child clinics. They may often be with either NGO or for-profit private providers that adults are accustomed to using. So, we need to make sure that future adult vaccination is available in those mechanisms.”
What Jhpiego has seen work for HIV is making primary health care a more common paradigm in communities by building familiarity in the health system and local providers so that people visit to get their blood pressure checked, tested for diabetes, and tested for HIV. It’s also about asking people where and how they would like to receive care. Though girls are usually vaccinated for HPV in school, Morgan notes that some say they would prefer to go to a clinic where they could talk to someone about other health concerns such as menstrual hygiene, sexual health, and family planning.
“For both adolescents and adults, having this integrated approach is critical, partly because vaccination programs have done it alone in relation to reaching under ones, but they can’t do it alone in relation to reaching the 14-year-old girl or the young or older adult,” he says. “They really have to integrate with other programs to join forces.”
With it now clear that Covid-19 will become a routine vaccination, just like polio or influenza, the hope is that the sense of urgency demanded by the pandemic response can be channeled to other vaccines needed over the course of a person’s life. The need is great, especially for “zero-dose children,” those who have not received a single dose of a vaccine to prevent disease (a number that reached 17 million worldwide in 2020). And the upside is huge: Vaccines against 10 diseases — including measles, meningitis, and hepatitis — prevented 37 million deaths in low- and middle-income countries over the last 20 years.
“Covid was a wake-up call for global health leaders to continue to prioritize vaccinating their populations. We saw how quickly… national governments moved with partners to make sure people are getting vaccinated,” Wanyoike says. “That means people believe that vaccines work and there’s a willingness to invest, so it shouldn’t stop there. That willingness and those resources should continue to be channeled towards broader immunization outside of just Covid.”