'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

"Community engagement and social mobilisation are vital components of a successful vaccination campaign."

Vaccination campaigns in low- and middle-income countries (LMICs) are impacted by a number of systemic challenges, including poor infrastructure, limited resources, and an overstretched health workforce. As COVID-19 vaccines are distributed to LMICs, this study sought to identify transferable lessons from the literature on prior rollouts of three vaccines that, like COVID-19 vaccination, sought to reach adult groups: MenAfriVac (meningitis A); 17D (yellow fever), and rVSV-ZEBOV (Ebola virus disease - EVD).

This research took place as the first doses of COVID-19 vaccines arrived in LMICs in Africa and South America. The researchers conducted a rapid literature review (early February 2021) and 24 semi-structured interviews via Zoom (from late February to late April 2021) with technical experts who had direct implementation experience with the selected vaccines in Africa and South America. Interview data were analysed thematically and are illustrated by representative quotations. Key lessons emerged around:

• Engaging early with diverse stakeholders to support campaign planning - Successful vaccination campaigns engage early with a broad network of stakeholders to support detailed pre-campaign planning. Interview participants considered collaboration with other government departments (e.g., Ministries of Education, Finance and Transport) and involvement of staff at the health facility level to be crucial. Insufficient funding has impaired some countries' capacity to conduct preparatory activities for COVID-19 vaccination campaigns, such as raising awareness and encouraging vaccine uptake among health workers; participants were apprehensive about vaccine uptake in the absence of such activities.
• Establishing strong coordination mechanisms - Participants highlighted the benefits of an incident management system (IMS) that delineates roles and responsibilities. In relation to COVID-19, some participants outlined how they were drawing on the strength of previously established technical working groups; they emphasised the need for effective communication both within and between working groups.
• Considering groups to be reached by vaccination and community perceptions - Because vaccination is traditionally associated with children, perceptions and suspicions around adults as a focal population need to be recognised and accounted for in vaccination planning. For example, the inclusion of adults of reproductive age was frequently associated with concerns that vaccines affected fertility. Meaningful engagement with communities is critical to facilitate a better understanding of the disease and address community concerns around vaccination "target" groups. However, participants noted that time and resources (e.g., for development of messages) are required for this process.
• Tailoring delivery strategies - Tailored strategies are required for groups that experience physical or social barriers to accessing vaccination. For example, during meningitis A campaigns in West Africa, sociocultural norms sometimes prevented men from attending vaccination centres at the same time as women and children. Similarly, one participant described how young married women (in East and West Africa) might not be able to attend a public vaccination site without authorisation from their spouses. Engaging with community leaders to map social groups and identify when, where, and how vaccination teams can most effectively reach subgroups is vital to achieving high vaccination coverage.
• Integrating vaccination campaigns with other health services - Integrating multiple vaccination campaigns can minimise time burdens on both communities and health workers and can potentially increase uptake by offering additional health services that the community prioritises. However, participants outlined how vaccination teams have had to differentiate between vaccines for COVID-19 and vaccines for other pathogens, which was seen to be the only way to ensure that the uptake of other vaccines was not compromised; this need for reassurance adds to the complexity of messaging for COVID-19 vaccines.
• Dealing with vaccine storage and transportation - For example, in-depth logistical planning exercises and simulations can help identify and mitigate potential areas of vaccine wastage.
• Recruiting, training, and resourcing vaccination teams - Participants consistently referred to the importance of recruiting local health workers who have established links to the community, can speak the local language, and can leverage existing rapport to increase uptake. However, local recruitment depends on the availability of skilled workers and may place additional workload on already overburdened staff. The transition to remote training to comply with COVID-19 physical distancing guidelines has introduced additional barriers to training delivery; many settings have limited access to hardware and stable internet. Participants also raised concerns about the quality of practical skills training through virtual methods.
• Monitoring vaccination in a way that is locally led and integrated - Providing organised, accurate information on the progress of the campaign can increase community confidence. However, outside of clinical trials, most interview participants described complex data aggregation processes and highlighted how limited access to data held by different organisations negatively affects response efforts. They described tensions when governments were not sufficiently supported in the ownership, storage, access, and analysis of vaccination data, highlighting the importance of these elements for the success of campaigns.
• Appraising the timing and approach of community engagement - Some key points:
  • Participants repeatedly raised the importance of having a clear strategy for engaging with communities, with consistent messaging around the disease, the vaccine, vaccination group(s) to be reached, and adverse events following immunisation. They insisted that community engagement should precede vaccination campaigns by a minimum of 1-2 months to allow for development of relationships with community members and time to respond to vaccination queries and tailor delivery strategies.
  • Ensuring continuous engagement with communities, as well as reconnecting with communities and providing feedback at the end of the campaign, was deemed essential for enhancing trust and building sustainable relationships that would support future vaccine uptake.
  • Respect, honesty, and meaningful discussion were stressed as principles crucial to building trust.
  • Providing community members with an opportunity to ask questions and query points about the disease or vaccine is a crucial enabler for vaccination success.
  • Social mobilisation was much more difficult if diseases were not known or prioritised by communities.
  • Generating demand for vaccination where communities had other priorities outside the health sector was particularly challenging. Addressing this challenge, participants said, required detailed and focused communication about the disease beyond simple vaccine uptake advocacy.
  • Participants outlined how engaged community members often became champions for the campaign.
  • Stimulating demand in the face of limited supply (as is the case for COVID-19 vaccines in many LMICs) requires careful balancing of risks; some participants spoke of how they had not yet employed previously used demand generation methods, such as short message service (SMS) alerts, for COVID-19 for fear of overwhelming their limited vaccine supply.
• Responding to vaccine concerns - Swift, transparent, and trusted responses are needed to address vaccine concerns, such as this one: "Early on in the COVID-19 outbreak [the Central African population] said, 'well, we're not willing to be guinea pigs for this one because it's not our problem...we are probably not going to die of COVID-19'." Participants stated that the longer a rumour circulates, the greater the risk to a vaccination campaign. Influencers - political, religious, and traditional leaders or heads of social groups (e.g., women's groups, youth groups, or sporting groups) - can play an important role in counteracting negative rumours. Rumours spread by health professionals were especially difficult to address and were best responded to by other health professionals. Vaccine hesitancy in the COVID-19 response was perceived as particularly challenging compared with previous campaigns. Participants attributed this to the global nature of the pandemic and the propagation of rumours through social media. Several participants described how social media tracking and online rumour debunking were incorporated into their COVID-19 response activities. At the same time, they stressed the importance of continued face-to-face interaction with communities to understand and respond to rumours in person rather than relying on information distributed online.

Selected recommendations for the implementation of COVID-19 vaccines in LMICs, based on lessons from earlier vaccination campaigns, include, for example:

• Develop a community engagement strategy that emphasises the principles of community involvement, co-development, and iterative adaptation.
• Engage local, trusted health workers to support vaccination activities, ensuring a continued connection between communities and the vaccination campaign.
• Ensure national ownership, access, and capacity to analyse vaccination campaign data, including the use of electronic data capture systems.
• Bring together response pillar leads and routine health programme leads to discuss opportunities to integrate health services during vaccination campaigns.

In 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."

Finally, the researchers encourage the provision of support countries in monitoring and documenting their COVID-19 vaccination campaigns to understand real-time responses to challenges and strengthen evidence around best practices during outbreak-related vaccination campaigns in low-resource settings.