The pharmaceutical company GSK was awarded a contract for the first supply of a malaria vaccine by UNICEF in 2022. The contract, with a value of up to $170 million, is expected to lead to 18 million doses of a vaccine over the next 3 years.
According to the WHO, at least 30 countries have “moderate-to-high” areas of malaria transmission. Malaria is one of the “biggest killers of children under 5”. In Africa alone, nearly half a million children died from the disease, with a rate of “one death every minute”.
The RTS,S malaria vaccine is the world’s first vaccine against a parasitic disease. It acts against Plasmodium falciparum, the deadliest malaria parasite and the most common in Africa. Although approved by the EMA in 2015, there were concerns about the efficacy of RTS,S. However, in 2019 a pilot was launched by the WHO in Ghana, Kenya, and Malawi. The “experience and evidence generated” encouraged the WHO’s recommendation of RTS,S in October 2021.
In December 2021 Gavi elected to provide funding for the malaria vaccine programmes across eligible countries. CEO Seth Barkley reported that the “application window” for funding requests was open, saying “thanks to UNICEF’s procurement” they had “more certainty on supply”. The hope is that “increasing volumes will also lead to more sustainable, lower prices”.
Etleva Kadilli, director of UNICEF’s supply division, believes that the vaccine rollout “gives a clear message to malaria vaccine developers to continue their work”. She wants to impress upon them that “malaria vaccines are needed and wanted”. Her intention is that “continued innovation” will “increase available supply” and promote a “healthier vaccine market”.
“This is a giant step forward in our collective efforts to save children’s lives and reduce the burden of malaria”.
Dr Kate O’Brien, WHO director of the department of immunisation, vaccines, and biologicals, said that the WHO “welcomes the progress” made through this contract. She reflected that “lives are at stake, every day”, and that securing “supply and timely access” will contribute to wider malaria prevention efforts. The demand for the vaccine will be high among affected countries, warned UNICEF. However, with increasing manufacturing capacity supply will increase over time.
Malawi’s cholera outbreak in March 2022 came at the end of rainy season. However, as the disease continues to claim lives it is thought that the damage caused by tropical storms is partly to blame. Head of Public Health at Kamuzu University of Health Sciences, Professor Adamson Muula, stated that “climate change” is increasing the “problem”.
Ministry of Health spokesperson, Adrian Chikumbe, emphasised that access to clean water is central to the outbreak, particularly for Blantyre. “Only 37% of the district’s population has access to safe water”, he said. Despite advising people to “treat their water before usage”, he observed that “many areas are congested” with “no space between wells and pit latrines”.
According to Chikumbe, the fatality rate is particularly concerning. “The standard is only 1 person per 100 but we have close to 5 fatalities per 100”. Blantyre has suffered 351 cases and 18 deaths so far. Dr Neema Rusibamayila Kimambo, the WHO country representative, says the 4.77% national fatality average needs to be reduced. She identifies “several factors” such as “poor community knowledge” that mean people seek health support too late.
The local District Environmental Health officer (DEHO), Penjani Chunda, stated that many cases are emerging in “slum townships” with 10- to 29-year-olds worst affected.
“Even though vaccines are a reactionary approach, in places where vaccines have been administered, we have seen cases slowing down.”
He is positive about the effect and uptake of vaccines but concerned about the “challenge” of reaching certain areas. Tactics to increase uptake include WhatsApp groups, says Fedson Kansiyamo, Chairperson for Naperi Development Committee.
“I personally believe in prevention rather than curing a disease, which is why I was one of the first residents to receive the cholera vaccine during the campaign”.
Kansiyamo believes that poor sanitation is “reversible”. He identifies waste-dumping and “diaper disposal” as significant contributors that need to be addressed.
Gavi’s report on the situation states that a cholera vaccination campaign launched in May 2022. With support from WHO, Gavi, and UNICEF, Malawi is targeting 1.9 million people. Consequently, the Ministry of Health received 3.9 million doses of oral cholera vaccines from the “global stockpile” funded by Gavi. Professor Muula is grateful for the vaccines; however, they “don’t remove the fact that people are drinking water that is mixed with human faeces”.
“We should be working towards a country where vaccines are not needed. We need to get back to basics, ensure that our people have safe water for drinking”.
To hear about recent cholera vaccine technology at the World Vaccine Congress in October 2022 click here to get your tickets.
A study published in The Lancet in August 2022 concluded that Covid-19 vaccinations had a “good safety profile” for pregnant people. This was concluded during an attempt to “determine the frequency and nature of significant health events among pregnant females after Covid-19 vaccination”. The “observational cohort study” was conducted across Canada as part of the Canadian National Vaccine Safety (CANVAS) network study.
The Covid-19 pandemic “disproportionately affected pregnant people” according to the investigators, who explored out higher risks of hospital admission, intensive care unit admission, requirement for ventilation, and death. Furthermore, infection also “increases risk of adverse pregnancy outcomes”, which include impaired foetal growth or preterm birth. In a previous article we explored some of the reasons behind low maternal immunisation rates, suggesting that a lack of data complicated public health communication. Thus, this research is an important step in encouraging pregnant people to come forward when vaccines are available to them.
Overall, “pregnant vaccinated females had a decreased odds of a significant health event compared with non-pregnant vaccinated females” after both doses of “any mRNA vaccination”. One of the most pressing concerns among pregnant women might be miscarriage or stillbirth, as the most “frequently reported adverse pregnancy outcome”. However, this was “reported at similar rates” between the control group and the vaccinated group. Additional outcomes such as bleeding or reduced foetal movement were “rarely reported” following mRNA vaccination.
The authors of the study acknowledge the strengths and limitations of their results. One such limitation is that CANVAS is “based on self-reports” and does not feature specific medical verification. This is highly subjective but has been “shown to be reliable for short time periods”. Further limitations can be found in the profile of patient selected, as an email address was required and fluency in French or English was also a prerequisite.
Despite the handful of limitations, the data provide “reassuring evidence” that mRNA vaccines are “safe in pregnancy”. The study recommends “high vaccine coverage” to protect both pregnant individuals and their infants. Going forward, further research will be required to demonstrate longer-term data.
Dr Flor Munoz wrote in 2021 that it is “imperative to better understand the potential of immunisation during pregnancy”.* She insisted on data collection to answer the multitude of questions about immunity in pregnancy and beyond. This study is a step in the right direction towards providing the pregnant community with detailed, accurate information on the benefits of receiving vaccines.
*Dr Flor Munoz-Rivas led the World Vaccine Congress maternal immunity workshop in Washington 2022. To book your place at the congress in 2023 click this link.
In August 2022 Professor Peter Hotez of the Centre for Vaccine Development at Texas Children’s Hospital wrote an article in Nature exploring the dire consequences of America’s “anti-vaccine activism”. If Professor Hotez’s name is unfamiliar, a twitter search will reveal him to be a highly respected and hugely empathetic source of vaccine information in the face of abuse and misinformation.
Professor Hotez begins his article with a reflection that “declining immunisation rates” across the world are being driven in many cases by anti-vaccine movements. He considers his own home of Texas, the source of a “false assertions linking vaccines to autism”. Further to these assertions, a “libertarian framework of health freedom” is promoted by elected officials, and he identifies the links between far-right movements and anti-vaccine beliefs.
Health freedom might sound like a reasonable expectation to many, but Professor Hotez unpacks it for us to explore its more worrying tenets. These do not correlate to the “principles” identified by a health freedom organisation but are a summary of some of the core beliefs. For readers of these “principles”, emotive language such as “hope” and “healing” effectively mask undercurrents of scientific ignorance or denial.
The effects of anti-vaccine activism’s security within “health freedom” are “tragic and even deadly”. Since 2021, “200,000 unvaccinated” Americans have died. Professor Hotez reflects on analyses that show these deaths and low vaccination rates are “overwhelmingly along a partisan divide and in Republican-majority states”. Health, as always, is a deeply political issue.
However, Professor Hotez’s concern is that this anti-vaccine movement is “now linked to health freedom politics” that have enabled greater “anti-vaccine sentiment in other countries”. Hence “freedom convoy” protests in Canada, and anti-vaccine rallies across Europe. This has further consequences for routine vaccinations, which are reportedly dropping. The effect on LMICs is another troubling concern for Professor Hotez. He states that “tremendous strides” have been made against measles, polio, pertussis, and other “dangerous illnesses” against which we have effective vaccines. Anti-vaccine movements pose a threat to this progress.
The WHO has long identified “vaccine hesitancy” as a top ten global health threat, and as routine childhood vaccinations are “backsliding”, this is more pertinent than ever. Alongside this, Professor Hotez acknowledges that “access accounts for most of the vaccine inequality”. Although “evidence that links US anti-vaccine activism to vaccine refusal in LMICs remains fragmented and often elusive” it does emerge. Professor Hotez states that anti-vaccine materials, memes as well as more structured resources, “circulate widely”. This international reach of social media “disproportionately” provokes vaccine hesitancy according to the African CDC.
“Confirming the adverse impact of American Covid-19 anti-vaccine activism is challenged by the paucity of culturally relevant on-the-ground reporting and the fact that data are often unsearchable in the biomedical science literature.”
However, these “activists” are increasingly turning their attention to vaccines other than the Covid-19 vaccines. Among the “disinformation dozen” is a US-based organisation “claiming a tetanus immunisation programme is a WHO ‘population-control experiment’ that sterilised African women”. Further attacks include “claims around injuries as a result of polio and other vaccine campaigns in India and elsewhere”.
Hotez’s conclusion is that vaccine refusal must not be permitted to permeate borders and must be addressed within the US. His recommendations include exploring “anti-vaccine activities in LMICs” and creating an “observatory for collecting and analysing disinformation”. Further to this, he suggests seeking support external to the US to address internal movements.
“We must recognise the depth and breadth of anti-vaccine activism and its detriment to global security”.
To hear from Professor Peter Hotez at the World Vaccine Congress in Washington 2023, click here to get your tickets.
Malaria threatens almost half of the world’s population, with the WHO estimating a 2020 death toll of 627,000. However, it is a preventable and treatable disease. In August 2022 the Financial Times suggested that “partnerships with governments and NGOs can help advance efforts for future generations”. The article stated that a child dies from malaria each minute, with children under 5 being the most vulnerable population group.
In June 2022 the Rwandan government hosted the Kigali Summit on Malaria and Neglected Tropical Diseases (NTDs). Discussions addressed the “urgency of ending malaria and NTDs”. Ahead of this Summit, SC Johnson announced a partnership with The Global Fund to “accelerate the elimination of malaria”. The Chairman and CEO of SC Johnson, Fisk Johnson, stated that his company has been “working for decades on preventative interventions and innovative solutions” but “can’t tackle this insidious disease alone”. SC Johnson has been developing Mosquito Shield for almost a decade. The “low-cost, effective indoor spatial repellent” is ideal for use where “core interventions may be constrained”. This development, with public health partners, is another sign of SC Johnson’s commitment to the cause.
Peter Sands, Executive Director of The Global Fund, believes that SC Johnson’s “strong expertise in entomology” will be a “key asset” against malaria. He is glad to see the private sector contributing “innovative solutions and technical expertise” to the fight. The Financial Times described the partnership as an “example of how private and public sectors can work together” through “entomological surveillance, end-user behavioural research, and product acceptability and use research”.
Throughout the last decade SC Johnson has committed more than $100 million to public health efforts in Africa. With this most recent partnership it will dedicate another $10 million. In 2021 the company joined the Society for Family Health Rwanda and East African Community leaders by signing a Memorandum of Understanding to tackle malaria. The goal is the reduction of mortality by 50% in 2025, ultimately eradicating it completely.
This partnership comes just ahead of The Global Fund’s Seventh Replenishment Conference 2022. Hosted by the US President, the target is “to raise at least US$18 billion to fund its next three-year cycle of grants”. This would contribute to life-saving treatments and preventions for 20 million people. Looking ahead to a “brighter future”, this partnership may be a step in the right direction to eliminate one of the world’s most prolific diseases.
To hear about progress towards malaria vaccines at the World Vaccine Congress in Europe 2022 click here to buy tickets.
In August 2022 a study in Nature concluded that 58% of infectious diseases we face are “aggravated by climatic hazards”. The authors identify “global distress” caused by “human vulnerability to pathogenic diseases”.
This literature study describes how “empirical cases revealed 1,006 unique pathways in which climate hazards, via different transmission types, led to pathogenic diseases”. Among the research were different links between climate hazards and disease, some of which are highlighted below.
Climate hazards bringing pathogens closer to people:
The study reflects that “shifts in the geographical range of species are one of the most common ecological indications of climate change”. For example, “warming and precipitation changes” can be linked to the “range expansion” of a variety of vectors. These include “mosquitoes, ticks, fleas, birds and several mammals” as well as “bacteria, animals and protozoans”. Expansions were also perceived in aquatic systems.
Disruptions to natural habitats caused by factors such as drought, wildfires, floods, and land cover change are also “bringing pathogens closer to people”. Viral spillovers were linked to wildlife moving over “larger areas” in search of resources or habitats. In a dystopian conclusion, warming was related to “melting ice and thawing permafrost exposing once-frozen pathogens”.
Climate hazards bringing people closer to pathogens:
Climate hazards push the global population closer to pathogens in a variety of ways. For example, heatwaves increase instances of “recreational water-related activities”, associated with “rising cases of several waterborne diseases”. Human displacement, caused by floods and storms, has seen an increase in cases of Lassa fever, typhoid, and pneumonia, among others. Furthermore, land use changes provoke “human encroachment into wild areas”. This brings people “into closer proximity to vectors and pathogens”.
Pathogens strengthened by climatic hazards:
Climatic hazards also provide enhancement to certain aspects of pathogens. These include “improved climate suitability for reproduction, acceleration of the life cycle, increasing seasons/length of likely exposure, enhancing pathogen vector interactions, and increased virulence”. For mosquitoes, increased temperatures saw positive effects on population development and viral replication. Consequently, the “transmission efficiency” of West Nile virus was increased.
Virulence is also linked to climatic hazards in the study. The researchers consider heat, which was “related to upregulated gene expression of proteins affecting transmission, adhesion, penetration, survival, and host injury by Vibrio spp”. Furthermore, heatwaves are considered a “natural selective pressure” towards viruses that are heat resistant. These viruses are thought to then be better able to respond to fever in the human body.
People impaired by climatic hazards:
Our ability to respond to pathogens has been affected by climatic hazards as well. The study identifies “stress from exposure to hazardous conditions”, weakened infrastructure, unsafe conditions, and reduced access to treatment. Citing “body malnutrition and condition” as an example, it reflects that “immunocompetence” is greatly impaired by increased exposure to hazards.
Although the examples above paint a very alarming picture, the study includes some diseases that were “diminished” by climatic hazards: 16%. For example, warming “appears to have reduced the spread of viral diseases probably related to unsuitable conditions for the virus or because of stronger immune system in warmer conditions”. However, many diseases that were “diminished by at least one hazard” were sometimes “aggravated by another and sometimes even the same hazard”. The is exemplified in malaria, which was reduced through drought decreasing breeding grounds. At the same time, drought can lead to “increased mosquito density” in bodies of water.
The conclusion is overwhelmingly negative, and the authors conclude that collaborative and proactive efforts must be increased. As attempts to tackle climate change continue, some are preparing for the many pathogens that follow.
“The sheer number of pathogenic diseases and transmission pathways aggravated by climatic hazards reveals the magnitude of the human health threat posed by climate change and the urgent need for aggressive actions to mitigate GHG emissions.”
After woeful statistics of global vaccine uptake decreases, and the news from UNAIDS that the AIDS response is “under threat”, Gavi published an analysis of 2021 immunisation rates. As 2020 saw the “biggest drop in routine immunisation coverage”, we had little reason to be hopeful.
In the years before the Covid-19 pandemic, lower-income countries demonstrated “two decades of skyrocketing vaccine coverage”. This was revealed in the increase of DTP3 doses from 59% in 2000 to 82% in 2019. Unfortunately, the pandemic “reversed these gains” with a total drop of 5% over 2 years. With this drop came a rise in the number of zero-dose children to 12.5 million. The consequences of this could be “felt for a generation”.
However, there were some positive changes across the world. Over half of the 57 countries supported by Gavi “managed to stabilise or even increase coverage” in 2021.
“Amidst the gloom there are signs of recovery and resilience.”
Cheers to Chad and Pakistan
A highlight in the report was the strong performance by Chad and Pakistan. Chad increased vaccine coverage throughout the pandemic. The percentage of children immunised with “basic vaccines” rose from 50% in 2019 to 58% in 2021. Although Pakistan experienced a setback during the 2020 lockdowns, it was able to return “both vaccine coverage and the number of zero-dose children close to pre-pandemic levels”.
Covid-19 vaccination successes
The report also highlights the fact that vaccine programmes were pretty preoccupied during 2021 with the distribution of Covid-19 vaccines.
“In fact, taking into account the two billion Covid-19 vaccines rolled out by the 57 Gavi-supported countries, 2021 saw more vaccines administered by lower-income countries than any other year in history.”
Thanks to the persistence of health officials and volunteers across the globe, routine and Covid-19 vaccination programmes were delivered in 2021. Covid-19 vaccine coverage rose “in the 92 lower-income countries eligible for the COVAX AMC” to 48%.
So perhaps, as we head into 2023 beset by stories of failure and fatigue, let’s consider the positive changes that were brought into effect, and push to build on these in the future.
To hear from Anuradha Gupta, Deputy CEO of the Gavi Alliance, at the World Vaccine Congress in Washington, 2023, click here!
WHO member states can expect an update from an Intergovernmental Negotiating Body in August 2022 on an “initial draft” of a treaty to “break the pandemic cycle”. In July 2022, Drs Alexandra Phelan and Colin Carlson published a recommended 12 elements for this treaty.
According to Drs Phelan and Carlson, we are “trapped in a positive-feedback loop” of disease spillovers that become outbreaks, then pandemics. These then reduce resilience and promote the “socioecological drivers” of further spillovers. The consequences are social, political, environmental, and economic. Therefore, the development of a treaty will be difficult, as “stakeholders lobby for [it] to be all things for all interests”.
The primary purpose of this treaty is: “preventing, preparing for, and responding to pandemics”. Drs Phelan and Carlson identify 12 elements that they believe would comprise a “cohesive, transformative, and evidence-based treaty”.
Reduce Spillover Risk
Planetary health solutions
One health solutions
Zoonotic risk assessment
Reduce Pandemic Risk
Surveillance and assessment
Biomedical R&D and production
Health systems strengthening
Reduce Pandemic Impacts
Equitable access to global goods
Emergency legal preparedness
Least restrictive measures
Recovery and Resilience
Accountability and transparency
Reduce inequalities and injustice
If a treaty can balance these aims, it will “move global health governance beyond the limited scope of the International Health Regulations” offering “clarity and complementarity to other relevant international legal regimes”.
To discuss pandemic preparation after lessons from Covid-19 at the World Vaccine Congress in Washington in 2023, click here to get your tickets!
DrPh Jennifer Nuzzo, Professor at Brown University School of Public Health and speaker at the World Vaccine Congress 2022, warned that we’re not ready to prevent another pandemic. Unless public health officials take concrete steps, she fears we will experience more waves of disease.
“This pandemic is not a one-off. It’s not a once-in-a century event. The likelihood of new pathogens emerging means we should expect a future filled with infectious disease threats that we must be ready to fight.”
Dr Nuzzo says that governments at every level must treat this as a fundamental threat to national peace and prosperity. We should expect to encounter more respiratory viruses. Thus, we must match safety measures to these pathogens. She recommends concrete steps such as improving ventilation in buildings.
“The progress made during Covid-19 must not be followed by quiet time in which we forget rather than work hard to prepare for the next one. We went through this hideous experience and failing to strengthen our readiness is the biggest mistake we could make.”
Home testing was clearly beneficial in detecting and fighting Covid-19. It would be extremely valuable if we developed this for other infectious diseases, such as strep throat and influenza, Dr. Nuzzo said. This might help the public understand isolation requirements. “Simple behaviour changes” will be key to reducing the spread of other pathogens.
“I think in some ways we will be better prepared for the next pandemic, but that is partially shaped by education and awareness. I am optimistic. There’s a tremendous number of things that we can do, and we are at that moment.”
*To hear DrPH Nuzzo at the World Vaccine Congress in Washington in 2023, click here to get your tickets!
Dr David Kaslow, Chief Scientific Officer of PATH and speaker at the World Vaccine Congress 2022, suggested the successful deployment of vaccines against future pandemics relied on leaders developing a better system for vaccinating people.
“It’s deplorable that at the start of the second year of the COVID-19 pandemic we were at 40%, 50%, 60% vaccine coverage in high-income settings yet still at single-digit percent coverage in low-resource settings. That is not global equity nor global access and coverage. So, we need to figure out what went wrong and how we can do much better.”
He cited the importance of years of research and vaccine technology advances but admitted this does us no good if the vaccines remain “sitting on a tarmac or in a warehouse”.
“All this amazing science has no impact unless there’s some way and someone to deliver that vaccine. Healthcare workers and systems are critical in turning all that amazing technology into amazing protective interventions.”
He believes that it is “foolhardy to think we can go from zero doses administered one day and the next day we will have hundreds of millions of vaccine doses in the arms of the U.S. population, not to mention the billions needed globally.” He called on global leaders to develop strategies for the inevitable next health crisis.
“We need to learn as much as we can from the current pandemic to prevent another huge setback of trillions of dollars in the global economy and the misery caused by hundreds of millions of disrupted lives and millions of preventable deaths. Because no matter what you may wish, the next pandemic will affect you, your family, your community, your state, your country, the whole globe. We just have to be better prepared.”
To see Dr David Kaslow at the World Vaccine Congress in 2023 click here to get your tickets!
It appears that lessons from the Covid-19 pandemic have been ignored, certainly regarding vaccine distribution. Africa is the only continent where monkeypox is endemic. Yet according to Dr Ahmed Ogwell Ouma, the acting director of Africa CDC, it hasn’t received vaccines for the virus, which is now taking hold in non-endemic countries.
It was hoped that the declaration of a public health emergency by the WHO would encourage more active distribution of resources. However, this hope has not been realised, says Dr Ouma. He stated that the continent should be the first to receive vaccines, to “stop monkeypox at its source”.
Since 1970s Africa has been subject to monkeypox with little support, but as it spreads across the rest of the world it is beginning to gain international interest. According to Dr Ouma the Africa CDC is in talks to get vaccines “as soon as possible”. However, this may already be too late, for Africa and the rest of the world.
There have been 70 suspected monkeypox deaths in Africa. This number is likely underestimated due to limited diagnostic capabilities. Yet public attention is concentrated in nations with increasing cases and no deaths. That is not to say that these unexpected case numbers should be taken lightly, but recalls recent pandemic experience.
As we have seen from the Covid-19 pandemic, when countries are unable to vaccinate their populations, the risk of new variants and infections is increased. However, it seems that the selfish tendency for a kind of vaccine nationalism and self-preservation prevails.
Members of the WHO have pledged over 31 million doses of the smallpox vaccine to be used in smallpox emergencies. These have not been offered to African countries for use against smallpox. Dr Rosamund Lewis of WHO says that some of these are “first generation” vaccines not recommended for monkeypox. She cites “regulatory issues” for some of the member states.
The lack of demonstrable progress from Covid-19 to monkeypox feeds a decidedly pessimistic instinct to wonder what will happen in the next pandemic. We will have to see if international efforts will become more equitable or remain inward-looking.
The warning from UNAIDS released in July 2022 features an alarming front cover, with the words “in danger” repeated across the page. This might seem dramatic to some, until one opens the document and examines the startling statistics presented by Winnie Byanyima, UNAIDS Executive Director. She reports the sobering fact that a life was lost to AIDS each minute in 2021. Although the number of people with access to HIV treatment increased throughout the year, she insists that it grew more slowly in 2021 than previous years. ¼ of people with HIV have access to antiretroviral treatment, and only 52% of children with HIV have access to medicine.
“The global AIDS response is under threat”.
Thus begins the introduction, reflecting that a series of global crises disrupted and distracted from the global HIV response. Resources available to lower income countries continues to decline consequently; it is estimated that current HIV responses will be $8 billion below the target by 2025. Official development assistance from bilateral donors excluding the US has dropped by 57% in a decade, making the 2022 replenishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) “more critical than ever”. UNAIDS describes how “indifference has slid towards neglect” and a “morally wrong and harmful” absence of solidarity ignores the lesson we should be taking from the Covid-19 pandemic: “pandemics can’t be ended anywhere until they are ended everywhere”. This is reflected in the HPV statistics: 9/10 girls in higher income countries are vaccinated, whereas only 3/10 girls in lower income countries are vaccinated.
What is lacking, then according to UNAIDS?
“Shared science, strong services, and social solidarity”
The pamphlet offers advice as well as sibilant criticism, with suggested “key actions” to get back on track for 2030 eradication:
Make a new push for HIV prevention.
Realise human rights and gender equality.
Support and effectively resource community-led responses.
Ensure sufficient and sustainable financing.
Address inequalities in HIV prevention, testing, and treatment access and outcomes, and close the gaps that exist in specific localities and for certain groups.
The key message from the publication is of an urgent need to increase intellectual and financial investment to resume progress in the fight against AIDS. With targets set for as soon as 2025 and 2030, we will need to see immediate action to realise the goals.
We’ve pushed against vaccine hesitancy, encouraged increased uptake of dose after dose, booster after dose. Booster after booster. What next? Although general acceptance of Covid-19 vaccinations has been positive, vaccine hesitancy towards these and other routine vaccinations continues, with the WHO declaring that the number of children receiving three doses of their DTP3 vaccines decreased 5% between 2019 and 2021. Experts are describing this widespread reluctance as “vaccine fatigue”, implying that exposure to information about and promotion of vaccines has overwhelmed the public as they become more conscious of the number of vaccines that are recommended for them.
In 2021 the Mayor of London stated his intention to address this so-called “vaccine fatigue” through collaboration with the NHS, PHE, and local governments to “engage with communities” in schemes such as the “Community Champions” and “Youth Community Champions”. He emphasised the importance of enabling people to discuss vaccines and “wider health concerns”. However, some might argue that this repeated insistence on vaccination and increased investment in information sharing is the root of the problem; before the pandemic people gave a lot less thought to the numerous vaccine expectations of them, whereas scrutiny of the development process and encouragement to participate in vaccination schemes by policymakers might have undermined this complacency.
A 2022 study, Mind the “Vaccine Fatigue”, found that “effective and empathetic vaccine communications” are promising in “eliminating preventable vaccine fatigue across sectors in society”. As we explored in our article on vaccine hesitancy, communication is, as always, key. What does “empathetic” communication look like, then, and how can we achieve it? Solutions might include more humanisation of the vaccine development process; for example, patients may feel more inclined to accept a vaccine if they know a little about the people who designed and produced it and could be confident in their motives. At a time when conspiracy theories about political agendas are complicating vaccine uptake, this might be a key aspect of future communication.
“Empathetic” communication might also look a little more like listening than talking, with the opportunities for communities to share fears and concerns in the presence of someone who can assuage them without dismissing them; too often we are expected to accept scientific fact without understanding the processes behind it, creating a harmful divide between those who know and those who don’t, and aren’t able to then learn. Whatever communication looks like going forward, it is certain that a kind of vaccine invigoration will be essential to protecting the public from health threats.
The Covid-19 pandemic has swept across the world with impunity over the past three years, bringing to light its fair share of hard pills to swallow. After that terrible trend of celebrities suggesting that everyone was in the same boat it is abundantly clear that health inequalities ensure that some of us enjoy a well-sheltered gin-palace while others struggle to stay afloat on driftwood, if you will forgive the extended metaphor.
One of the clearest examples of this inequality is the distribution of the various Covid-19 vaccines. In October 2021 the WHO posited a 70% vaccination target for mid-2022. Many countries have been unable to come even remotely close, with others steaming far ahead. The Director General Dr Tedros Adhanom Ghebreyesus stated that if equitable access to vaccines, among other things, could be achieved, Covid-19 might cease to be a global health emergency. In low-income countries just 21% of the population has received one dose of a vaccine, compared to a striking 81% in higher income countries, as reported by the New York Times in July 2022.
Africa has the slowest vaccination rate of any continent with 25.5% of the population at the single dose stage. The continent produces only 1% of the vaccines it requires. Data from February 2022 revealed that 0.05% of Burundi’s population and 0.4% of the Democratic Republic of Congo had received one dose. To dredge the boat metaphor back up, these small and unseaworthy vaccination boats are dangerous for the whole fleet.
Considering factors that affect vaccination rates consistently brings war and civil unrest to the fore. This is exemplified by conflict-stricken countries like Yemen and South Sudan, with vaccination rates of 2%. Issues aren’t specific to these countries, however; global vaccine inequality is exacerbated by vaccine nationalism, stockpiling, and accessibility issues.
The word stockpiling marked its place the public vocabulary thanks to its increased used during the Covid-19 pandemic. From secret personal stashes of hand sanitiser or self-raising flour to national hordes of PPE, we have come to associate it with greed and selfishness rather than forethought. Although it could be argued that vaccine stockpiling will protect a nation, or specific group of people, the evidence from recent years demonstrates that unless global herd immunity can be achieved through vaccine equity, further strains will evolve from those not privileged with access.
Vaccine Nationalism is described by WHO Director-General Dr Tedros Adhanom Ghebreyesus as a ‘me-first approach’. Putting the interests of a single nation above a global goal is a decidedly unfriendly but, more importantly, it leaves the poorest people in the poorest countries vulnerable. This is a clearly a tragedy of inequality, but it is surprising to note that even the global consequences – potential for increased numbers of variants and infections – are not enough to dissuade policymakers in higher income countries from signing exclusive deals and stockpiling.
In 2021 Human Rights Watch reported that 75% of Covid vaccines had gone to 10 countries. According to Airfinity, the world’s richest countries were withholding 1.2 billion doses from countries who needed them. Dr Linley, lead researcher at Airfinity, said that 241 million vaccines were at risk of going to waste, not because these countries were greedy, but they didn’t know which would work.
Vaccine nationalism is a hugely unsustainable and impractical approach to a pandemic, as has become evident in the multiple variants springing out of unvaccinated populations. How can we encourage the wealthier or more dominant countries to change tack to divide and conquer? Unfortunately, it seems as though Monkeypox might ask us to explore this sooner than previously imagined.
The Covid-19 pandemic presented the scientific community with one of the fastest changing challenges of the 21st century. Scientists responded with agility, producing a vaccine that was effective, safe, and as close to universally available as possible. However, for one group in particular the vaccine encountered hesitancy and fear.
Despite assurances that maternal and perinatal heath were vulnerable to infection, the maternal community was disproportionately underrepresented at vaccination stations across the world. In late 2021, data revealed that 98% of women in the UK admitted with symptoms in pregnancy had not received the vaccine. This was despite recommendations from the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. Of the 235 pregnant women in intensive care, on 3 had received their first dose, and none the second. Why, despite recommendations, were women reluctant to get their jabs?
Sebghati and Khalil reflected in October 2021 that there was “no safety data” on the covid vaccine’s effect in pregnancy. This was a result of their exclusion from early research into a covid vaccine. This happened despite the acknowledgement that pregnant women were at greater risk of “severe disease” after infection. A consequence of this exclusion was that healthcare professionals and government advisors had no concrete evidence that the benefits outweighed the risks. At a time when the world tuned in to daily news broadcasts to see graphs and figures, the need for data was greater than ever.
Dr Flor Munoz stated in January 2021 that in order to “inform and implement safe and effective maternal and infant vaccination strategies” information needed to be collected through clinical studies. Maternal immunisation, she said, is “likely the best available option to protect both pregnant and lactating mothers as well as their infants”.*
Facts and figures, however, are not the only influential factor in a person’s decision to accept a vaccine. Wider vaccine rejection of the influenza and tetanus jabs, among others, resulted in a lower likelihood of vaccine uptake. The covid vaccine was no exception to a wider problem. Mistrust and safety concerns associated with maternal immunisation are not assuaged by public health advice. This mistrust was enforced by exclusion from vaccine research due to “heightened safety concerns in this population”, a self-fulfilling prophesy.
*Dr Flor Munoz-Rivas led the World Vaccine Congress maternal immunity workshop in Washington 2022. To book your place at the congress in 2023 visit the website.
World Hepatitis Day is on July 28th, marking the birthday of Dr Baruch Blumberg, the Nobel-prize winning scientist who discovered HBV and developed a diagnostic test and initial vaccine. The theme for World Hepatitis Day 2022 is “Bringing hepatitis care closer to you”, with calls for simplified service delivery.
According to the WHO, a patient dies every 30 seconds from hepatitis B or C. Although Hepatitis B kills more people each year than AIDS-related illnesses, an effective vaccine does exist. Four years after the 1965 discovery of the virus in 1965 Drs Blumberg and Millman developed a heat-treated vaccine. In 1981 the FDA approved a plasma-derived vaccine, involving the collection of blood from infected donors, since discontinued. In 1986 fresh research resulted in a second generation of DNA recombinant vaccines. These are synthetically prepared and approved in the United Sates. Looking at the different strains of hepatitis we can explore the vaccination options available across the world.
Hepatitis A: there are several inactivated vaccines available to people over the age of 1. In China a live-attenuated vaccine is also available.
Hepatitis B: the WHO recommends that infants receive the current vaccine, a protein-based subunit vaccine that contains the HBV surface antigen, immediately after birth. This protection lasts at least 20 years, possibly for life. This initial dose coverage is relatively low, at 43% globally. The key issue here is accessing mothers whose births are not supervised by medical professionals. However, there was a significant increase in the number of children getting all three doses from 1990, around 1%, to 2019, closer to 85%. This has reduced transmission in early years but is globally unequal. In 2019 around 296 million people were living with chronic hepatitis B, with 1.5 million infections a year.
Hepatitis C: there is currently no effective vaccine, so prevention relies on reduced exposure to the virus in healthcare settings and high-risk populations, including those who inject drugs. Described by Dr Jeffrey Glenn of Stanford University as a “huge problem” HCV faces little opposition from current treatments, which are often toxic, he said. *
Hepatitis D: protection can largely be found in the HBV vaccine unless the patient already has HBV. A recent paper by Dr Glenn suggested that the HBV vaccinations played a significant role in reducing HDV infection in certain areas, alongside factors like “socioeconomic improvements”.
Hepatitis E: there is a vaccine, but it is only licensed in China.
Going forward, the WHO has set the following targets to achieve hepatitis elimination by 2030:
Reduce new infections of hepatitis B and C by 90%
Reduce hepatitis related deaths from liver cirrhosis and cancer by 65%
Ensure that at least 90% of hepatitis B and C positive patients are diagnosed
Enable 80% of those eligible to receive appropriate treatment
How can the vaccines industry contribute to these targets, and is it likely that they can be achieved in time?
*To see Dr Jeffrey Glenn and other industry experts at the World Antiviral Congress in November head here to get your tickets.
In our previous article on vaccine hesitancy, we identified the ‘5Cs’ associated with a reluctance or refusal to accept vaccination. Vaccine inequity and vaccine hesitancy come together as “part of a complex matrix of social norms, economic concerns, historical factors, discrimination, issues with service delivery, and personal experiences”. We require cross-sector collaboration to overcome this. When we look back at the ‘5Cs’ we must acknowledge each cause and respond with a creative and compassionate approach.
The RSPH report Moving the Needle called for several actions in engaging and encouraging people to receive their vaccine. Some suggested efforts include improved vaccine education. It also included logistical concerns, such as offering vaccines in a more diverse range of locations. Although 95% of respondents to the survey suggested that the GP surgery was the most convenient place to receive a vaccination, more than half agreed that a hospital, community centre, or local pop-up facility is convenient.
What poses a greater threat to vaccine confidence? Are people hesitant because of inaccessibility or misinformation? The latter is arguably harder to tackle. Getting the public to trust their leaders when asked to take a vaccination requires confidence in the reliability and authenticity of the demand, particularly among those with lower levels of scientific literacy.
We cannot overemphasise the need for a stronger union between science and society. Communication between the developers, producers, and distributors of these vaccines, and the people expected to take them is confined to political paraphrasing. We need to allow the public greater insight into the reasons for vaccines, the processes of creating and testing them, and their benefits.
Dr Peter Hotez is a great example of this outreach. He is prolific on Twitter with measured and rational responses to challenges, questions, and insults. He speaks of a “political monster” that exploits and exacerbates vaccine hesitancy. This monster rages against reason with emotive and fantastical arguments, but what can be done to undermine its authority? Is the answer to make more noise?
Vaccine hesitancy is described by SAGE as a “delay in acceptance or refusal of vaccines despite availability of vaccination services”. It might also be considered a “state of indecision and uncertainty that precedes a decision to become (or not become) vaccinated”. In 2019 the WHO included vaccine hesitancy as one of the ten threats to global health. A variety of factors influence this hesitancy, categorised into ‘the 5C model’.
Confidence – trust in…
The effectiveness and safety of vaccines
The system that delivers them
The motivations of policymakers who decide on the need of vaccines
Perceived risks are low, and vaccination is not deemed a necessary preventative action
Constraints (an alternative to convenience)
Affordability and willingness to pay
Ability to understand – language and health literacy
Appeal of immunisation service
Individuals’ engagement in extensive information searching
The more information a person seeks the more vaccine-critical sources will be obtained
Willingness to protect others through herd immunity
Vaccine hesitancy is by no means a recent phenomenon, growing in line with increasing access to information through social platforms and the expansion of vaccine portfolios. Numerous studies on the role of the internet in influencing vaccine sensibilities have concluded that it represents a threat to informed decisions about vaccination. This encyclopaedic store of information includes swathes of misinformation, intentional or not.
The term ‘infodemic’ is pertinent to this problem; understood to mean a surplus of information that includes misinformation, we can suggest that an ‘infodemic’ exacerbates vaccine hesitancy by challenging acceptance of scientific fact. This poses a huge risk to general public health, particularly in times of pandemic. Tackling vaccine hesitancy is a feat that requires an understanding of the causes as well as an answer to each of them.
Addressing colleagues at the World Vaccine Congress in 2022 Dr Nicole Lurie, suggested that they were “still not really understanding” the “human behaviour” of vaccine hesitancy.* Perhaps, to people so comfortable and familiar with the intricacies of vaccine safety and efficacy, some of the reasons above are incomprehensible. So how can we better understand and address this “behaviour” in order to make progress out of the pandemic? We explore this in our article on overcoming vaccine hesitancy.
*To see Dr Nicole Lurie in action at the World Vaccine Congress in Washington, April 2023, click here.