After experts called for “transformational change” to the “epidemic countermeasures ecosystem” in March 2023, our interest has been drawn to an initiative by Economist Impact: The Vaccine Ecosystem Initiative. This is described by the group as an attempt to “promote a sustainable vaccine ecosystem” by “examining and reimagining elements critical for vaccine development, deployment, and adoption”. From the context of a global pandemic to the concerning epidemiological climate, the initiative explores current practices to define the future of vaccines at every stage.
Why an ecosystem?
The use of the word ecosystem is particularly effective with connotations of complexity and interconnectivity. From concept to shot in arm, ‘ecosystem’ evokes a sense of delicate dependency at every stage. Indeed, recent experiences have emphasised these relationships more than ever.
“Building an environment conducive to innovation can reinvigorate a previously undervalued field of science.”
5 key pillars
In a report published by Economist Impact, 5 key pillars are identified. For greater detail on each pillar, we recommend accessing the report here. In this piece we explore the pillars and invite you to share your thoughts on this framework.
Research and Development (R&D)
The first pillar covers the research process from the “earliest stages of laboratory research through the Phase III (human) clinical trials” and the regulatory oversight that is “necessary for supporting vaccine development and innovations”. It also addresses the R&D needed to support the delivery of vaccine services, such as disease surveillance, policies, and partnerships.
Manufacturing
The second pillar is all things manufacturing, exploring the factors of “timely” processes, regulatory oversight, and “the use of good manufacturing practices at a scale necessary to meet demand”. It covers infrastructure, human resources and conditions, and strict quality control standards.
Procurement, pricing, and financing
The third pillar involves the policies, mechanisms, and partnerships behind vaccine purchasing and pricing. This includes the financing of R&D and implementation of immunisation programmes. Systems that “promote more equitable and faster access to vaccines” are of interest.
Distribution, logistics, and supply chain management
The fourth pillar covers the mechanisms that “enable safe distribution of vaccines”. This includes logistics, infrastructure, and systems. This pillar “recognises that consistently strong and resilient distribution networks, logistics capabilities, and global supply chain management” are needed for equitable and rapid protection of populations.
User acceptance and uptake
The fifth pillar explores the reasons that people choose to be vaccinated and the factors that enable them to access vaccination. This involves health literacy, education and awareness, and the ways that “public trust in vaccines” can be improved.
How well do you think these pillars represent the vaccine ecosystem, and what efforts do you think can be made in any or each of them to promote sustainable improvements?
The Immunisation Readiness Index
Building on this framework, the Vaccine Ecosystem Initiative will launch a new tool later this year, focused on “understanding the state of immunisation readiness”. The Immunisation Readiness Index assesses the “enabling environment for equitable and sustainable immunisation” for both routine and emergency vaccines. The Index identifies “opportunities for enhanced preparedness” by “qualitatively and quantitatively mapping” country-level immunisation policies.
“The Vaccine Ecosystem Initiative and the Immunisation Readiness Index provide evidence-based, actionable insights that stakeholders can implement to create a future that is more resilient to threats amenable to vaccination.”
Join us at the World Vaccine Congress in Washington next week to hear more from David Humphreys, Global Head of Policy at Economist Impact.
After a meeting in March 2023, WHO’s Strategic Advisory Group of Experts on Immunisation (SAGE) revised the roadmap for prioritising COVID-19 vaccines. This result is intended to “reflect the impact of Omicron and high population-level immunity” through infection and vaccination. WHO states that the roadmap “continues SAGE’s prioritisation of protecting populations at the greatest risk” from SARS-CoV-2 infection and its “focus on maintaining resilient health systems”.
Cost and context
The roadmap now considers “cost-effectiveness” of vaccination for lower-risk groups, such as healthy children and adolescents, in comparison with “other health interventions”. It also includes revised recommendations on boosters. SAGE Chair Dr Hanna Nohynek reflected that “much of the population” has either received vaccinations, been infected, or both. However, the roadmap “reemphasises the importance of vaccinating those still at-risk of severe disease”.
“Countries should consider their specific context in deciding whether to continue vaccinating low risk groups, like healthy children and adolescents, while not compromising the routine vaccines that are so crucial for the health and well-being of this age group.”
The roadmap presents a recommended prioritisation system for COVID-19 vaccination. The levels are high, medium, and low, and are “principally based on risk of severe disease and death”, consider “vaccine performance, cost-effectiveness, programmatic factors, and community acceptance”.
Priority groups
The high priority group includes older adults, younger adults with “significant comorbidities”, such as heart disease, people with immunocompromising conditions, such as people living with HIV or transplant recipients, children aged 6 months and older, pregnant people, and frontline health workers.
For this group, SAGE is recommending an “additional booster” of either 6 or 12 months after the last dose, with the timeframe “depending on factors such as age and immunocompromising conditions”. It emphasises this advice applies for the “current epidemiological scenario only” and should not be seen as for “continued annual” boosters.
“The aim is to serve countries planning for the near- to mid-term.”
The medium priority group covers healthy adults, usually younger than 50 or 60, without comorbidities, and children and adolescents with comorbidities. SAGE suggests that this group should be offered primary series and first booster doses but does not routinely recommend additional boosters “given the comparatively low public health returns”.
The low priority group includes health children and adolescents between the ages of 6 months and 17 years. Primary and booster doses are “safe and effective” in this group, but the consideration of the “low burden of disease” led SAGE to urge countries to “base their decisions on contextual factors”.
“The public health impact of vaccinating health children and adolescents is comparatively much lower than the established benefits of traditional essential vaccines for children – such as the rotavirus, measles, and pneumococcal conjugate vaccines”.
Other meeting considerations
During the meeting SAGE also considered other public health concerns, such as polio and measles. For polio, it evaluated the data on the novel oral polio vaccine type 2 and concluded that it should be the “preferred choice for response to circulating vaccine-derived poliovirus type 2” (cVDPV2) where possible. It also recommended that in “hard to reach or conflict-prone areas” the interval between vaccines could be reduced to 1 week, from the regular 4 weeks.
Regarding measles, SAGE described the “repercussions of the pandemic’s seismic impact on routine immunisation”. Measles cases have increased in all WHO regions in 2022, which prompts the need to review policies on vaccination, and accelerate the development and deployment of new technologies.
The meeting also covered TB concerns, identifying an urgent need for a more effective vaccine for adolescents and adults. SAGE recognised “substantial” efforts towards that end, with “several candidates” in trials.
Another concern during the meeting was the introduction of the RTS,S malaria vaccine, which has “resulted in a substantial reduction in severe malaria and all-cause mortality among age eligible children”. The high demand for the vaccine is at odds with the “highly constrained” supply, with SAGE recommending flexibility in the immunisation schedule.
Priority pathogens
WHO also stated that it is in the process of “defining regional priority targets” for new vaccine development for “non-epidemic pathogens”. Early research suggests that tuberculosis, HIV, and pathogens exhibiting “high levels on antimicrobial resistance” (AMR), are important across “all regions”.
Do you agree with SAGE’s recommendations, and do you think they will have an effect on vaccination efforts in your region? To participate in discussions about COVID-19 vaccination schedules and other pathogenic concerns, join us at the World Vaccine Congress in Washington next week.
A study published in Nature Medicine in March 2023 explores the factors associated with so-called “vaccine fatigue”, with a specific focus on the recent vaccination campaigns in response to the COVID-19 pandemic. The authors state that vaccines are “likely to remain one of the essential tools”. We have developed vaccines that are now “widely available in many countries” and progress in vaccine development has been made. However, the authors acknowledge that vaccines can only be effective if people get vaccinated.
“Unfortunately, several behavioural factors threaten to undercut the advances in vaccine supply and development.”
Previous studies have identified vaccine hesitancy as an “obstacle” to primary vaccinations and decreasing “enthusiasm” for boosters. The study suggests that “vaccine fatigue” has emerged as a “growing concern for public health officials”. In fact, it implies that this is a re-emergence rather than a unique phenomenon, already familiar from the “influenza context”, where “suboptimal uptake has repeatedly resulted in many unnecessary deaths”.
“It is very likely that the failure to address vaccination hesitancy and fatigue could have serious public health consequences in the long run and, in turn, increase pressure on healthcare systems.”
Understanding COVID-19 vaccine fatigue through the study
The study addresses two “practically and theoretically relevant research questions”.
Should vaccination campaigns adopt similar or different strategies for primary and booster vaccinations?
What are the most relevant contextual features and the most effective interventions that may affect vaccine acceptance in future scenarios?
The aim of the study was to gather evidence for the design of “effective” campaigns in the context of the “heterogeneous immunisation status in the population” and “possible contextual contingencies”.
The researchers designed two conjoint experiments, which allowed them to manipulate “multiple attributes of a hypothetical scenario” and “measure the responses of participants considering all attributes jointly”. A literature review demonstrated that the most important factors for COVID-19 vaccine uptake were the properties of vaccines, communication, costs/incentives, and legal rules.
Fatigue and hesitancy
The authors note that vaccine fatigue, in addition to the challenge presented by vaccine hesitancy, is a “growing concern” for public health due to “waning immunity” and the requirements for booster vaccinations considering new variants. They suggest that in “many countries” the uptake of boosters has remained “below expectations”.
Although the definitions of vaccine hesitancy and vaccine fatigue remain unclear across literature and media communication, the study refers to both in a “broad sense as an umbrella term”. This term describes a “low or intermediate propensity to get vaccinated either for the first time (hesitancy) or repeatedly (fatigue)”. The term covers those who are “in a state of indecision or uncertainty” but also those who “oppose and refuse vaccination”. However, the authors acknowledge that “more narrow conceptions coexist”.
The first question
The first question addressed the approach that should be taken for future vaccination campaigns; should they be a “one-size-fits-all” approach or should “group-specific characteristics” be taken into account?
The results suggest that distinguishing campaigns between primary and booster vaccinations is the best approach, in line with early pandemic research. However, the study builds on this previous research by showing “additional variation” between those who have not had a first booster and the “triple vaccinated”, suggesting that “further group differences may need to be considered”.
The results also indicate international differences. For example, the relevance of information on Long COVID mattered more in Austria than in Italy.
“These patterns underline our first piece of actionable advice that instruments of vaccination campaigns need to be tailored and tested before campaign rollout, taking into account characteristics of the national context and the different target groups based on their vaccination status.”
The second question
The second question explored how different groups “can and should” be addressed by campaigns. Although “from a medical perspective” the importance of closing the vaccination gap and focusing on the unvaccinated seems a priority, the authors state that this may be difficult. The unvaccinated score “low on trust in institutions” and are the “least likely to get vaccinated across all scenarios”. The study considers that the countries involved, Austria and Italy, had both considered some type of vaccine mandate during the pandemic, and therefore “most of those who can be reached by vaccination campaigns have already been vaccinated”.
“Only campaign messages conveying a sense of community and emphasising the need to hold together to overcome the crisis were effective in promoting behavioural change in the unvaccinated group.”
By contrast, legal rules such as mandates or vaccine passports were found to “undermine” trust in the vaccine. These results suggest that the “most socially agreeable way to encourage primary vaccinations” would be a focus on “promoting community spirit” over “stricter policy interventions”. Furthermore, it is “essential” to address the factors that contribute to vaccine hesitancy, such as mistrust and misinformation.
People who had been vaccinated once or twice were “strongly encouraged by positive incentives” such as monetary perks, and the availability of new vaccines. The latter was “only marginally statistically significant” but suggests the need to promote “better understand of heterologous vaccinations” and to obtain regulatory approval for new non-mRNA vaccines as boosters.
Triple vaccinated people
For those who were triple vaccinated, the authors considered the possibility that incentives and strategies may seem a “superfluous exercise”. It would be easy to act under the assumption that they will go and get the “necessary boosters” under “any circumstances”. However, the results suggest otherwise, with “seemingly trivial costs” presenting an obstacle to the triple vaccinated that might deter them from “translating their positive attitudes into actual behaviour”.
“We found a high degree of cost sensitivity among the triple vaccinated.”
This was reported as the “strongest effect” across the experiments and “most consistent” in both Austria and Italy.
“Cost-free and easy access to vaccines as well as creating awareness of when and how to get the vaccine, therefore, are likely to remain the mainstay for any vaccination campaign to succeed.”
Other factors that influence the triple vaccinated group are messages emphasising personal health benefits, the importance of “protecting vulnerable peers” and the healthcare system, as well as “community spirit and self-efficacy”. As this group represented the largest population in both countries, failure to “(re)activate and (re)mobilise” them is likely to result in poor booster rates.
What does the study show?
The authors conclude that the results present “several actionable points”:
Test the design and instruments of vaccination campaigns with target groups
Keep the cost-free provision of vaccines and easy access to vaccination sites in which even seemingly trivial costs could be strongly discouraging
Promote community spirit and set measures to strengthen social cohesion and institutional trust in the long term
Consider moving from communicative mobilisation to more institutionalised bonus programmes with positive incentives for booster vaccinations in the long term, if budgetary constraints allow
Carefully assess the risks and benefits of stricter policy instruments involving legal requirements, such as vaccine passports and vaccine mandates, which bear a risk of backlash
Facilitate consensus-building among medical professionals and scientists by supporting research and making relevant evidence readily available
How might these actions be implemented in your community, and do you think will be effective in encouraging vaccine uptake or overcoming vaccine fatigue? We look forward to considering these questions and more at the World Vaccine Congress in Washington next week.
In March 2023 the heads of the Quadripartite organisations working on One Health issued a call for greater global action for a safer world. WHO describes the call as “unprecedented”. The Quadripartite comprises four main agencies collaborating to achieve aims that cannot be achieved independently. The Food and Agriculture Organisation of the UN (FAO), the United Nations Environment Programme (UNEP), WHO, and the World Organisation for Animal Health (WOAH) are all participating in this union.
A statement from the Quadripartite acknowledges recent health emergencies such as the COVID-19 pandemic, mpox, Ebola outbreaks, and “continued threats of other zoonotic diseases” as well as AMR challenges, and the consequences of climate change. These elements “clearly demonstrate the need for resilient health systems and accelerate global action”.
A call to action
The statement from the Quadripartite emphasises the need for “enhanced collaboration and commitment” to “translate the One Health approach into policy action in all countries”. The leaders called for the promotion and undertaking of the following “priority actions”:
Prioritise One Health in the international political agenda, increase understanding, and advocate for the adoption and promotion of the enhanced intersectoral health governance.
Strengthen national One Health policies, strategies, and plans.
Accelerate the implementation of One Health plans.
Build intersectoral One Health workforces.
Strengthen and sustain prevention of pandemics and health threats at source.
Encourage and strengthen One Health scientific knowledge and evidence creation and exchange.
Increase investment and financing of One Health strategies and plans.
“To build one healthier planet we need urgent action to galvanise vital political commitments, greater investment, and multisectoral collaboration at every level.”
How do you think these actions can be implemented at international and national levels, and what support should the Quadripartite be offering to encourage this? We look forward to hearing more about the importance of One Health approaches and how vaccination features into these at the World Vaccine Congress in Washington next week.
A study released in March 2023 in iScience suggests that COVID-19 infection was a greater factor than COVID-19 vaccination in observed changes to a patient’s menstrual cycle. The researchers identified “substantial public concern” related to “disruption of menstrual cycles”. However, the possible causes, such as vaccination, infection, pandemic-related stress, or lifestyle changes, remain “understudied”. Therefore, it is imperative that further investigation is carried out to gain the relevant knowledge for “advising women about the relative risk of experiencing menstrual disturbance when getting vaccinated against COVID-19 versus infected”.
Vaccines and menstruation
The authors suggest that prior to the pandemic, research into the relationship between vaccination and menstrual cycle health was limited to prophylactic typhoid, HPV, and hepatitis B vaccines. Since the pandemic and associated vaccination drive, prospective studies have found changes in cycle length for participants. Beyond cycle length, other studies have identified “various changes in regularity, duration, and volume”.
“While there is accumulating evidence that COVID-19 vaccination-related menstrual symptoms are associated with small and temporary changes in cycle length, there has been no quantitative assessment of the risk factors for menstrual disturbances following COVID-19 vaccination prior to widespread media attention.”
The paper contrasts the “emerging picture” of a “small effect of COVID-19 vaccine on cycle length” with research into the associations between infection and menstrual cycle changes. This is described as “scarce and inconsistent”.
“A study better powered to evaluate the independent association of SARS-CoV-2 and abnormal cycle changes is better needed to inform vaccination decisions.”
What does the study find?
Based on data collected in the UK “prior to widespread media attention” the study identified that “perceived menstrual cycle changes” after vaccination are “very common” in the context of “international pharmacovigilance standards” (over 10%). Specifically, these perceived changes are “increased for participants reporting a history of COVID-19 disease”, but “decreased among those who use combined contraceptives”.
Furthermore, the authors conclude that “vaccination alone does not lead to abnormal cycle parameters”, but COVID-19 is associated with an “increased risk” of reporting frequent cycles, prolonged periods, heavier flows, and more inter-menstrual bleeding. They acknowledge that the experiences of cycle changes after vaccination are “diverse”.
Facts and figures of the study
The study involved almost 5,000 vaccinated pre-menopausal participants, and the University of Edinburgh describes a “vast majority” of 82% who reported “no menstrual changes”. 6.2% reported “more disruption”, 1.6% reported “less disruption”, and 10.2% reported “other changes”
It is notable that of the 18% who reported changes, the risk was higher among those who smoked, had previously had COVID-19, or who were not using oestradiol-containing contraceptives. The authors then considered a wider population of 12,000 participants, which included participants who had not been vaccinated against COVID-19 as well as vaccinated participants.
“Vaccination alone did not show increased abnormal menstrual cycle factors.”
Is this enough?
The authors recognise that their study is limited, particularly in its reliance on people recalling previous menstrual experiences. Dr Jackie Maybin from the University of Edinburgh identifies a potential for “bias” in those who chose to complete the study.
“Nevertheless, our results are reassuring that COVID-19 vaccination does not cause concerning menstrual changes, and helpful for identifying people who might be at higher risk of experiencing menstrual disturbance.”
Did you observe menstrual changes following COVID-19 vaccination, or has this research encouraged you in the context of widespread media concern? Join us at the World Vaccine Congress next month to discuss COVID-19 vaccination with experts across the community.
After we reported in March 2023 that possibly critical data concerning the Huanan Seafood Wholesale Market had been quietly released on GISAID, the story has developed with researchers and public health leaders challenging China for not sharing them sooner. With senior figures in WHO, including the Director General Dr Tedros Adhanom Ghebreyesus, suggesting that the data “could have – and should have” been shared earlier, questions are being raised about the apparent Chinese obfuscation of global pandemic origin research.
Dr van Kerkhove’s “hell”
In a “condensed” interview with Science Dr Maria van Kerkhove outlined her frustrations at being unable to access sufficient data to draw conclusions about the origins of the COVID-19 pandemic. She stated that WHO had been “calling for any and all data” to be shared, echoing previous emphasis on WHO’s reliance on Member States’ cooperation.
Dr van Kerkhove indicated that these new data do confirm “what has been suspected”: “there were animals at the market that were susceptible to SARS-CoV-2 infection, that the market of course played a really important role”. However, questions remain about where the animals came from and what research was carried out in the early stages of the pandemic.
“None of that information is available.”
Displaying diplomatic caution, Dr van Kerkhove also addressed the tension surrounding lab leak or zoonotic origin. She stated that just because “all hypotheses are on the table” it “doesn’t mean that all hypotheses have equal weight”. She emphasised that WHO is “pushing for more information through SAGO”, including immediate sharing of animal-specific information. She described the sudden glimpse of new information as a challenge to China’s “credibility”.
“It is beyond infuriating and frustrating to be in this position…And that is scary as hell.”
Cooperation from China
Experts have long been demanding greater communication from and with China, including Dr Mike Ryan’s reminder that WHO requires its Member States to direct research. Professor George Gao, who Science suggests “sat on” the data, has been contacted by SAGO but apparently not engaged in dialogue. However, for Dr van Kerkhove, the scenes that are unfolding “in social media and in media” are deeply concerning. She hopes to see a conversation “playing out with a robust debate with everything on the table”.
“We don’t have the cooperation from China.”
The “continued fighting” and “politicisation” represents an unnecessary “distraction” from the task at hand, and is “unconscionable”, says Dr van Kerkhove.
Why does it matter?
As we move into a fourth year of COVID-19, armed with evolving vaccine technology and surveillance, some might argue that it is time to abandon this seemingly fruitless pursuit. However, Dr van Kerkhove highlights the importance of “understanding the exact conditions in which this happened” in order to “get more refined” in our approach to prevention. In particular, she identifies a need to understand the specifics of the case in a country “that has excellent lab systems”, “fever surveillance” in place, and “capable scientists”.
Suggesting that “nobody knows” if we will ever know the origin of the pandemic, Dr van Kerkhove reckons that “anyone who speaks with absolute certainty really doesn’t know”. This “clue” is an important one, and one that she hopes to pursue further.
Who owns data?
Although WHO and public health officials have emphatically called for more transparency in data sharing, Science also considers the “appropriateness” of jumping on the data before it has been published in a paper by the Chinese researchers. Indeed, GISAID claimed in a statement on 21st March 2023 that the researchers who identified and analysed the data had been suspended for running “afoul” to the Access Agreement.
GISAID’s statement suggests that “select users” published a report in “direct contravention of the terms they agreed to” with specific emphasis on the “knowledge that the data generators are undergoing peer review assessment of their own publication”. Dr Michael Worobey of the University of Arizona represented the team of authors in a reply to GISAID. He presented email evidence of attempts at collaborations as well as reference to “multiple verbal entreaties” and Zoom messages to the Chinese team.
Consequently, GISAID has agreed to review the evidence, but the question of data ownership and permission continues to sound across media. Dr Jesse Bloom told Science that “all scientific data related to the early outbreak in Wuhan should be made available”.
“It’s frustrating that despite their now being two public analyses related to these data, the data are still not available.”
As we move further away from those first few months of the pandemic, how important do you think it is that we keep trying to understand its origins? What are your views on data sharing and international access?
Join us to discuss how lessons from COVID-19 shape preparations for future threats at the World Vaccine Congress in Washington 2023.
In a study published in Nature Communications in March 2023, researchers investigate the socioeconomic benefits of a set of “idealised” vaccine distribution scenarios in relation to COVID-19 vaccination programmes. Their results suggest that an equitable vaccine distribution could increase global economic benefits by $950 billion each year, compared to a scenario that ‘fully’ vaccinates vaccine-producing countries first. Lessons that should have been taken on from early pandemic vaccination strategies are emphasised in their evaluation of the multiple benefits of a more equitable approach.
COVID-19 vaccination
The authors note that the “recurrent waves” of SARS-CoV-2 variants have enabled the COVID-19 pandemic to threaten public and economic health across the globe for three years.
“Though vaccination has regionally mitigated the pandemic toll in certain areas, global inequities in vaccine distribution is an important issue which presently weakens the effectiveness of vaccines in lowering transmission globally.”
Despite efforts of many organisations to promote accessibility, such as the ACT Accelerator, the current levels of vaccination demonstrate that there are “still many disincentives for equitable vaccine distribution”.
“It is clear that nobody wins the race until everyone wins.”
Thus, the authors were motivated to consider the role of collaboration between countries that produce vaccines and other countries. To address the issues of disincentives and individual benefits, a “framework” to link epidemiological and socioeconomic modelling is required, to “probe the potential gains of global vaccine allocation strategies from the socioeconomic perspective”.
Benefits and consequences
The authors acknowledge that “local shortages of many commodities” across the world illustrate the importance of our “highly connected global supply chains”. This was demonstrated in the trickle down of negative economic effects from a country in lockdown to other countries along supply chains. The opposite is also true: “vaccination decisions in one country may be beneficial to the economic recovery of other countries, which is often referred to as one type of externality of vaccination”.
The study
In the study, the authors link epidemiological and socioeconomic modelling frameworks to “quantify the socioeconomic benefits of a set of idealised COVID-19 vaccine-distribution scenarios”. The evaluation considered three main outcomes:
The health gains
The lockdown-easing effect
The supply-chain rebuilding benefit
The researchers modelled three sets of scenarios into a tiered structure. “Tier Global” addresses the issue of the “cooperative attitude” of countries, while “Tier Domestic” address the issue of “how received vaccines are allocated within each destination country”. This approach provides “new information” to enable us to understand the “game” of vaccine distribution and facilitate global vaccine cooperation.
Equitable distribution brings benefits
The analysis conducted not only demonstrates the “potentially significant differences” in benefits achieved by each mode of distribution, but also reveals why equitable vaccine distribution, and the consequent global economic benefits, have “not been achieved”.
“The ‘equitable distribution’, in this study, is not a simple appeal, but a solution that makes economic sense.”
The authors emphasise that it is not a sacrificial approach, but a mutually beneficial mechanism. Despite this, they believe that a “bias” in the “player’s decision-making” is created by poorly quantified and considered benefits of economic recovery in comparison with health gains. The conclusion, however, is that a “multilateral benefit-sharing instrument should be developed” in time for “future pandemics”, in order to remove the disincentives for early and equitable vaccine distribution.
“Such an instrument would provide enormous global health and economic benefits in a sustainable manner.”
For more on the global vaccine distribution strategies at the World Vaccine Congress in Washington next month, get your tickets now.
A study published in PLOS Medicine in March 2023 suggests that the human and financial benefits of a Group B Streptococcus (GBS) vaccine would be significant but equitable access would depend on tiered pricing.
GBS
Streptococcus agalactiae is commonly known as Group B Streptococcus (GBS), and is described by the study authors as an “important bacterial pathogen” that causes morbidity and mortality in both pregnant and nonpregnant adults.
The disease is particularly threatening to neonates and young infants. The study states that in 2020, an “estimated 20 million pregnant women globally were colonised with GBS”. This resulted in 231,000 cases of early-onset GBS (EOGBS), which occurs in the first 6 days of life, and 162,000 late-onset GBS (LOGBS) cases.
“Together, these were estimated to have caused 58,000 to 91,000 infant deaths depending on the assumptions made about mortality in cases without access to healthcare.”
In addition to the tragic deaths that occur, survivors of iGBS are “at risk of long-term neurological sequelae”.
Prevention
Current prevention strategies are based on “intrapartum antibiotic prophylaxis (IAP)”. The authors note that many higher-income countries have reduced EOGBS incidence with IAP by identifying eligible patients through risk factor-based screening or routine testing. However, IAP has “several limitations”. It is not effective against LOGBS- or GBS-associated stillbirths. Furthermore, the need for “access to laboratory testing” and the “requirement to deliver antibiotics intravenously” creates a limit to the “prospect of attaining high IAP coverage in many low-resource settings”.
In addition to access issues, there are “concerns that routine administration of antibiotics” can contribute to AMR and have “unintended impacts on the gut microbiota of newborns”. Thus, there is a need to develop alternative approaches.
Maternal immunisation
The authors identify maternal immunisation as a potential strategy that would afford protection to “mother, unborn foetus, and newborn infant”. They refer to other immunisation strategies, such as the tetanus vaccination, and influenza and pertussis vaccinations, which have been successfully used in many areas.
The study
Although there have been “previous economic evaluations” of maternal GBS vaccination for specific locations, the authors suggest that none has estimated the value “in all world regions”. Thus, they perceived a need to produce a global economic evaluation of GBS vaccination to “drive investment”. It would also encourage adequate financing and pricing mechanisms for the vaccine. The study conducts such an evaluation across 183 countries, drawing on “recently updated global disease burden estimates for GBS”.
The study assumes the cost per dose as follows:
$50 in high-income countries
$15 in upper-middle-income countries
$3.50 in low- and lower-middle-income countries
The conclusions in the paper indicate that a “high-coverage” programme could avert “hundreds of thousands of GBS cases”. This would also prevent “tens of thousands of deaths, stillbirths, and cases of long-term disability”. The programme would have an estimated net cost of around $1.3 billion, with “most costs occurring in Europe and North America”.
“Our results suggest high coverage of a competitively priced maternal GBS vaccine has the potential to save tens of thousands of lives globally and is likely to be a cost-effective investment, particularly if the vaccine can reduce GBS-associated prematurity.”
Although the study is limited by lacking data, the authors believe that a 1-dose vaccination programme could save millions in healthcare costs. For more discussion on costs and benefits associated with vaccine development and deployment, join us at the World Vaccine Congress in Washington next month!
South Korean chemical company LG Chem announced in March 2023 that it will supply essential vaccines for infants and young children to “solve global public health issues”. It won a supply contract worth a total of $200 million in a UNICEF bid with vaccines for polio and a pentavalent vaccine. The ambition with this contract is to supply vaccines for “approximately 80 million infants and children worldwide”.
LG Chem and its vaccines
LG Chem is described as the largest Korean chemical company, and is based in Seoul, South Korea. In 2017 it was ranked the 10th largest chemical company in the world by sales. Since the approval of its hepatitis B vaccine Euvax in 1996, LG Chem has been delivering essential vaccines for infants and children. In 2022 it reported a vaccine business year-on-year growth rate of over 20%.
In 2016 and 2020 the company received WHO Prequalification for Eupenta and Eupolio respectively. Eupenta is a pentavalent vaccine against diphtheria, pertussis, tetanus, hepatitis B, and meningitis. Eupolio is a polio vaccine.
The contract
The contract covers $100 million worth of Eupolio for two years, starting in 2024, and $100 million worth of Eupenta for five years from 2023. LG Chem suggests that it “cemented its position as a major global supplier” by securing over 30% of the total procurement volume in the polio vaccine bid. It is actively investing in a facility to “boost the production of Eupolio” by over 60 million doses a year.
Park Heui-sul, Head of Speciality Care Business Unit at LG Chem, said they were able to win the order from UNICEF based on the agency’s “strong trust in LG Chem’s vaccine development and supply capabilities”.
“We will play a pivotal role in preventing infectious diseases in infants and young children around the globe by accelerating the development of both hexavalent vaccines and improved combination vaccines based on Eupolio.”
For more on global health concerns at the World Vaccine Congress in Washington this April, get your tickets here.
Writing in The Lancet in March 2023, public health experts called for “ambitious, transformational change” to the “epidemic countermeasures ecosystem”. The authors, including past interviewee Dr Jerome Kim of IVI, draw on years of collective experience to recommend “appropriate health countermeasures” to “rapidly” contain health threats.
“We are living in an era of unrivalled convergence of epidemic and other health threats, exacerbated by the climate and biodiversity crises.”
The paper acknowledges a contemporary “grave warning” from cases of avian influenza (H5N1) in mammals as an example of the hazards that we face. The authors call for a “fundamental change” in the deployment of health technologies, particularly relating to access to “knowledge and know-how”.
Current limitations and failures
As we witnessed during the COVID-19 pandemic, our current approach to R&D, manufacturing, and delivery of countermeasures is “deeply inequitable”. Disproportionately affecting people in LMICs and “vulnerable populations”, this approach needs transformation. Reference to the Access to COVID-19 Tools Accelerator (ACT-A) platform, describing a failure to provide “timely or equitable access”.
“A transformed epidemic countermeasures ecosystem is urgently needed that is rooted in equity at every step, regional resilience, and knowledge and technology sharing.”
As we heard in our interview with Dr Ike James recently, sharing technology and knowledge will be key to establishing more effective epidemic and pandemic preparation as well as responses. This new ecosystem must be based on a “common goods approach”, say the authors.
Moving forward from COVID-19 they are calling for a redefinition of collaboration in order to achieve the “collective goal of epidemic control”. They identify specific meetings and occasions during which key stakeholders should be included.
“We believe that LMIC representatives, civil society and community organisations, the scientific research and public health communities, and humanitarian groups must be meaningfully involved in all these discussions and processes.”
Core principles
The authors promote “core principles” for this transformed ecosystem. These will promote “equitable, effective, and sustainable” practises.
Human rights
Guaranteed equitable protection
National and regional resilience
A common goods approach
Inclusive governance and decision making
Equity
Access and freedom to operate
Sustainable financing designed for health impact
Accountability for investment and impact
Are there any principles that you would like to see added to this list? Which might be the most significant or challenging?
Urgent priorities
As well as the core principles mentioned above, the authors identify three priorities for change in the process of developing an equitable pandemic countermeasure ecosystem.
An end-to-end ecosystem that delivers equitable research, development, manufacturing, and access to epidemic countermeasures, grounded in a common goods approach that responds to local needs, with equity built in from research to access.
Inclusive and networked governance with decentralised decision making to address health needs optimally when and where they occur, shifting the centre of gravity to regions and countries.
A globally and regionally pre-negotiated financing system.
Can you identify further priorities, or specific methods of addressing them effectively?
“Now is the time for ambition and transformative change to protect people everywhere. If not now, when?”
The report continues with examples of some attempts to achieve a more equitable and sustainable ecosystem, and you can read it in full here. For more on preparedness and equitable access at the World Vaccine Congress in Washington next month, get your tickets here.
A study published in Current Biology in March 2023 suggests that getting sufficient sleep in the days surrounding vaccination is key to optimising antibody responses. Although this might seem an obvious assumption, the authors state that “simple behavioural interventions” associated with vaccine responses are “yet to be identified”. Thus, their meta-analyses summarised evidence that links amount of sleep with antibody response in healthy adults.
Vaccination during COVID-19
The authors indicate that in response to the pandemic, vaccination was “widely expected to be effective in controlling” the disease. However, “only 63% of adults worldwide” have been “fully vaccinated”, a term that is contested in the light of emerging variants and subsequent boosters.
“Thus, the vaccination effort needs to continue.”
Alongside COVID-19 vaccination efforts, “new” threats like mpox and evolving flu strains are “continuously identified”. This makes vaccination a “major tool for public health in an increasingly globalised society”.
Context to the study
The authors note that the protection provided by a given vaccine “depends on the magnitude of the individual immune response”. This can be identified by antibody response, a “clinically significant biomarker of protection”.
Other studies have identified a “wide variability” in antibody response to the same vaccine in healthy adults. Some of the relevant predictors of “lower antibody titers” include older age, history of smoking, and male sex. However, none of these factors can be targeted by “rapid behavioural interventions” to “optimise the humoral response”.
A previous study from 2022 demonstrated that immunoglobulin (IgG) antibody titers were affected by “sleep restriction” during an experimental study using an influenza vaccination. Further studies involving influenza and hepatitis vaccines have been carried out with “mixed” results.
The study
This study summarised existing evidence using a meta-analytical approach.
“Our objective is to better inform the scientific community and the public about a relatively easily modifiable behaviour that may optimise vaccine response in the context of the current COVID-19 pandemic.”
The results obtained indicate that “insufficient sleep duration substantially decreases the response to anti-viral vaccination”. Furthermore, they suggest that achieving “adequate” sleep during the days surrounding vaccination may “enhance and prolong the humoral response”. Although further studies are required, the authors believe that their work shows the importance of sleep to vaccine-induced responses, and they call for additional research into the “window of time around inoculation”, the causes of an observed “sex disparity”, and the amount of sleep required.
How much sleep do I need?
The question that many of us might be asking now, then, is how much sleep should I be getting in order to encourage effective vaccine responses in my body? The study describes “short sleep duration” as less than 6 hours a night in adults between 18 and 60, so presumably anything above 6 hours is a strong start!
However, the authors also acknowledge that “sex impacts the response” to vaccination. Thus, they calculated separate overall effect sizes (ESs) for men and women. When assessed “objectively”, the pooled ES was “large and highly significant for men”, whereas it was “smaller and not significant for women”. This is attributed to “wide variations in sex hormone levels”. This can be due to menstrual cycle, hormonal contraception, menopausal status, or hormonal replacement.
The authors recommend further investigation, as is so often the case, to determine the impact of sex hormones in the relationship between sleep and antibody response to vaccination in women. An “unprecedented opportunity” for this has been presented in the form of the vaccination programmes to combat COVID-19.
How much sleep do you get a night, and will this study encourage you to try and improve your sleeping schedule around vaccinations? We look forward to hearing more about the different factors that influence vaccination responses at the World Vaccine Congress in Washington this April.
With just two months until the World Vaccine Congress in Washington we are delighted that some of our wonderful speakers are keen to take part in exclusive interviews for the community. These interviews will be shared in preparation for the event as well as afterwards, and shine a light on the work that our speakers are doing and their sessions at the Congress.
In this zoom conversation we met Dr Mark Feinberg, President and CEO of IAVI: the International AIDS Vaccine Initiative. We discussed some of the key areas that he will be covering at the Congress in April, digging a little deeper into some of the key global health issues of today. If you would like to see the full transcript of the interview you can access it at the bottom of this page. We hope you enjoy it!
Tell us about your role at IAVI
For many in our community, Dr Feinberg will be a well-known and recognisable figure for both his academic and leadership roles. Still, we asked him for a little bit of an outline and he kindly obliged. He explained that IAVI is “now in its 26th year”. Founded with the “specific intent of accelerating HIV vaccine development”, it has more recently expanded to address “additional diseases” using the “capabilities and technologies” that were developed along the way.
IAVI has a particular focus on “global health threats that disproportionately impact people living in low-income countries”.
“It has a specific goal of really trying to make sure that the best, most powerful scientific innovations can be, you know, applied to addressing the needs of people who would otherwise be left behind”.
Furthermore, IAVI aims to keep the products it works on “available in an affordable and accessible manner to the people who need them”.
Why is accessibility so important to global health?
Accessibility is a word we hear a lot in the vaccine world, and it is a concept that is central to IAVI’s mission. We asked Dr Feinberg why it is so important to global health and what barriers prevent us from achieving it. He suggests that COVID-19 emphasised the importance of accessibility.
“If you don’t plan for equitable global access, there’s going to be really these tragic inequities”
“The health of every individual around the world is equally important”
That’s IAVI’s “commitment” and is shared by lots of people throughout the community. However, “access doesn’t happen by accident”. Dr Feinberg suggests that when developing a product, you must include “affordability and scalability” in the “profile or preferred product characteristics”. Without “appropriateness for diverse circumstances”, at the centre of your process, “you will not achieve those goals”.
What about sustainability?
Sustainability is another key aspect to IAVI’s work. Therefore, we asked Dr Feinberg about how this relates to accessibility. For him, they are “really connected”. He refers to IAVI’s work in Africa and India, where “many of the diseases” IAVI targets are “important problems”. In these places the organisation is working to facilitate “scientific research and product development capabilities”. He contrasts this with a “colonial view to global health” that was previously held by many, suggesting that IAVI has been working to address “for a long time”.
“If you want a product to be developed in a manner that’s appropriate for a population, you need to understand the needs and preferences of that population, and you also need to have a trusting and trusted relationship with those individuals.”
This kind of relationship is developed through “effective community engagement and understanding”. However, the best way to ensure that products are appropriate for a population, is to have “capable investigators who come from the countries where you are thinking that the products need to be used”.
Once more, COVID-19 exemplified this. Dr Feinberg identifies “many of the really important discoveries” of the pandemic as emerging from “studies done by African investigators in Africa”. He suggests that their “capabilities in the infrastructure” were “really catalysed by the response to the AIDS pandemic”.
“So in many ways we’re seeing the value of how investments in one area can have benefits in the future in other areas.”
COVID-19 and other diseases
One of Dr Feinberg’s sessions at the Congress will consider the issue of diseases that were “forgotten” during the pandemic. As he rightly points out, these diseases were never truly “forgotten” by people who experience them, nor their researchers, but perhaps neglected by the media in the shadow of COVID-19. However, he agrees that the “public health response to those other pressing global health problems has been compromised” by the pandemic.
From “distraction of resources” to “supply chain issues” it isn’t surprising that rates of various infections have increased. For HIV, TB, or malaria, the “public health response was compromised”.
“You know the nature of infectious diseases is when a problem is going in a bad direction, it has continued momentum to continue to go in the bad direction for a while, and so it’s not just that, simply restarting the earlier intensity of the control efforts is necessary. You need to think about augmenting that to really not only make progress, but get back on track”.
However, it’s not just COVID-19 that is to blame. TB was the leading cause of death to an infectious disease before COVID-19, yet there was “tremendous underinvestment” into public health control measures.
“Why that’s the case is to be honest with you, a mystery to me. I think it’s probably an issue where you know human nature is such that if you have a problem and it’s there for a long time, and it’s hard to deal with, you tend to try to ignore it and put it in the back of your mind.”
HIV vaccine trials
Another of Dr Feinberg’s sessions at the Congress will explore HIV progress from a vaccine perspective. We asked why, given progress in other areas of HIV management, vaccination is still a priority, and how much progress we can expect. Although we know of recent updates from Janssen there have been more positive updates in other areas that are neglected by the “headlines”. Despite the steps forward in pre-exposure prophylaxis and therapeutics, to end the problem we’re “going to need a vaccine”.
“The problem is that HIV is the most vexing pathogen that vaccinologists have ever really tried to take on”.
However, Dr Feinberg suggests that a lot of the “creativity” that the vaccine community now demonstrates is derived from the history of HIV vaccine research. We have “work to go” but the research is “viable” and Dr Feinberg remains “optimistic”.
Future threats
Our penultimate question is concerned with the two big challenges every vaccine developer faces at the moment. Not only is the health threat something to contend with, but once that is achieved we have to convince the public that it’s safe to accept. With disinformation and vaccine hesitancy becoming worse over recent years, this is a growing issue for the community.
Dr Feinberg recognises that COVID-19 vaccines were “a remarkable scientific accomplishment” but also an “accomplishment of collaboration across the scientific community and between private sector and public sector partners”. However, these efforts have been tragically undermined.
“What’s really tragic is the level of disinformation and the consequences of that disinformation have been really profound”.
Although “not an expert” in how to solve the problem of misinformation, Dr Feinberg suggests that scientists need to “consider what role they can play in making sure the public has a better understanding” of the “tremendous efforts” that go into vaccine production.
Why the World Vaccine Congress?
Our final question, as always, invites our speakers to share their reasons for joining us at the Congress. For Dr Feinberg, although COVID-19 had “many terrible consequences”, it also presented the “traditional vaccine development ecosystem” with a “shake up”.
“I think lessons from COVID are going to really help us do more and better in vaccine development broadly. And I think it will be very interesting to hear people’s ideas about how we can make that happen.”
We are so grateful to Dr Feinberg for his time and insightful responses to our questions. If you’d like to hear more from Dr Feinberg do join us at the Congress in Washington this April. For a full transcript see below!
Researchers at the University of Queensland are pursuing an experimental vaccine to tackle a venereal disease that “causes cattle infertility and costs the industry hundreds of millions of dollars”. Bovine trichomoniasis protozoa vaccines are available in other countries but not Australia.
A survey
The vaccine research was driven by results of a survey for the disease led by Professor Michael McGowan of the University of Queensland School of Veterinary Science. This revealed that bulls at abattoirs in all of the country’s major beef breeding regions, and “more than one in ten bulls in northern regions” were infected.
In North Australian beef herds, losses from confirmed pregnancy to weaning are believed to be between 5 and 15%, costing the industry up to $100 million a year. Although the disease is not the sole reason for these losses, it is “likely to be contributing to this reproductive inefficiency”.
Professor Ala Tabor from the Queensland Alliance for Agriculture and Food Innovation said that “bovine trichomoniasis is caused by a protozoa carried by bulls and is transmitted to females during mating”.
“This can make cows infertile or cause them to abort.”
International vaccines
Although vaccines are available in other countries, Professor Tabor thinks it is “more efficient and practical to manufacture the vaccine in Australia”.
“When you import a vaccine, it has to be quarantined and the animals treated with it aren’t allowed into the food chain”.
Thus, getting “local strains” to develop a vaccine is “effective, safer, and easier”. A candidate vaccine was tested successfully in a small group of bulls, with further trials anticipated through collaboration with Meat and Livestock Australia and commercial partners.
For more on developing effective vaccines to protect and support livestock management at the World Vaccine Congress in Washington this April, get your tickets here. You can read about bovine vaccine pursuits for the UK here.
A study in Midwifery in February 2023 examines the quality of maternal vaccination information available in pregnancy to patients in Aotearoa/New Zealand. The authors suggest that, although there is no fee to get vaccinated in the country, “less than half of all pregnant women are vaccinated”, leaving many women and infants at risk of disease. Furthermore, for pregnant Māori and Pacific women, lower vaccination coverage contributes to “severe morbidity and hospitalisation”.
It is apparent, from historic and more recent experience, that access to information and adequate communication is a factor in determining a person’s vaccination status. Thus, the authors investigated the quality of information provided to the pregnant Māori and Pacific population. The aim was to investigate how they found out about vaccination during pregnancy, to what extent this information “suited their needs”, and how its delivery could be improved.
The study
The study took place in Dunedin and Gisborne, enrolling 15 participants who were or had been pregnant up to a year ago. Semi-structured, face-to-face interviews were conducted between May and August 2021, with each interview lasting between 20 and 60 minutes. The researchers describe efforts to build whanaungatanga (close connections, relationships) with their study participants, observing appropriate cultural practices.
Results and observations
Of the 15 participants, only 2 were had been vaccinated against both influenza and pertussis during pregnancy. Most women had been “informed” about maternal vaccines by their midwife, but “some were unaware of recommendations”. The authors note that the issue of vaccination was sometimes discussed without written materials or presented in written materials without discussion.
“Insufficient information provision resulted in a lack of confidence in vaccination and an inability to make informed decisions.”
The participants who sought more information suggested that they preferred to receive it in “face-to-face discussions” or group workshops and presentations. Videos and written information were also raised. Due to the “busy and information-loaded” nature of appointments, the authors recognise that information can be forgotten overlooked. However, they also emphasise that it “should not be the woman’s responsibility to find out information”.
“At every health care contact there is the opportunity to make pregnant women aware of the recommendations for maternal vaccination and it should not only be the responsibility of a single healthcare professional.”
Presenting and explaining information
The study refers to previous research that indicates that recommending maternal vaccination “without discussion of benefits may be insufficient for women to prioritise vaccination”. Indeed, in this recent study, participants “appreciated” in-depth discussions and “felt confident” to get vaccinated after clear recommendations.
Other influences
Vaccine uptake is also influenced by discussions with whānau (extended family) or friends, and this study revealed that “more than half of participants were discouraged” by these discussions. Thus, “early” and “effective” communication with a “trusted healthcare provider” is essential to intercept misinformation or confusion. Furthermore, “addressing misunderstandings at the community level” as well as on an individual basis, will promote “more widespread knowledge and acceptance of maternal vaccination”. Once again, the study places the responsibility with the healthcare providers rather than the community.
“The lack of provision of basic information to pregnant women about vaccination is an unacceptable system failure and must be addressed.”
With this need in mind, the authors identify research that suggests some midwives feel insufficiently supported or trained to discuss vaccination or find time pressures overwhelming.
Conclusion
“Women who do not receive appropriate information cannot make informed decisions about their own and their infant’s health.”
The study highlights the link between unvaccinated women and lack of effective communication. The authors call for “system changes” to ensure that vaccine recommendations “reach every pregnant woman”.
Although the study had a small sample size, the authors believe that it gives an insight into possible shared experiences of pregnant patients. What more can be done to encourage maternal vaccination across all communities? If you have experienced pregnancy, were you able to access adequate information on maternal vaccination?
For more discussion on the importance of pregnant populations in vaccine development and deployment, join us at the World Vaccine Congress in Washington.
In February 2023, at a meeting of the African Union in Addis Ababa, African Heads of State agreed on the need to “revamp routine immunisation” across the continent. This comes after the disruptions caused largely by the COVID-19 pandemic, which have been observed globally but have had a particularly concerning effect in Africa.
The state of vaccination
WHO Africa states that compared to 18 million children across the world who were excluded from immunisation services in 2021, African had 8.4 million. “Poor or marginalised communities” and people “rendered vulnerable by conflicts” and “fragile settings” are more likely to find accessing vaccinations hard.
Across Africa, immunisation coverage for many of the vaccine-preventable diseases is “well below the 90-95% range” required to keep it free of these diseases. For example, in 2021 vaccination coverage for measles was 69%. Coverage for diphtheria-tetanus-pertussis was 82.5%, and the third dose of polio was 81.5%.
The statement from WHO Africa suggests that vaccine-preventable diseases are responsible for “93% of ongoing infectious disease outbreaks”, with outbreaks ongoing in 31 countries.
“Without renewed political will and immediate, intensified efforts, it is estimated that immunisation coverage will not return to 2019 levels until 2027.”
Building momentum
At the event in Addis Ababa, leaders endorsed a declaration called “building momentum for routine immunisation recovery in Africa”. This is intended to “revitalise the momentum for all populations to have universal access to immunisation to reduce mortality, morbidity, and disability”. Furthermore, it will enable Member States to achieve Sustainable Development Goals.
Dr Julius Maada Bio, President of Sierra Leone, believes it is “possible to achieve the national and global immunisation targets including eradication and elimination goals”.
“Progress in meeting immunisation targets, we believe, is a driver for equitable health outcomes”.
Dr Bio also expects the “returns on investment for immunisation” to be “very high”. This was supported by Dr Matshidiso Moeti, WHO Regional Director for Africa, who said that “immunisation saves lives and is one of the best health investments that money can buy”.
Ambassador Minata Samate Cessouma, AU Commissioner for Health, Humanitarian Affairs, and Social Development, hopes to “save many more lives” and end vaccine-preventable diseases”.
“This is core to achieving healthy, prosperous communities as premised in the AU Agenda 2063: The Africa We Want.”
Children are the key
Marie-Pierre Poirier, UNICEF Regional Director for West and Central Africa commented that “children who were missed by immunisation services are more likely to also experience limited or no access to health, nutrition, education, and other social services”.
“With strong political will and increased investment in essential services for children, including immunisation, we can accelerate progress towards the Immunisation Agenda 2030, the African Union’s Agenda 2063, and the global Sustainable Development Goals 2030 to ensure a healthier, safer, and more prosperous Africa for its children and for all”.
For more on global immunisation goals and Africa-specific immunisation targets, join us at the World Vaccine Congress in Washington this April.
In February 2023 WHO announced a collaboration with Montenegro’s Ministry of Health and Institute of Public Health (IPH) to launch a new initiative: the “Health Caravan”. This is an element of the American Rescue Plan COVID-19 Response Activity in Montenegro, financed by USAID. The aim of this “Health Caravan” is to “promote the benefits of immunisation as a life-saving intervention”.
Although the focus is largely on COVID-19 vaccination, the initiative also includes other vaccines such as those against HPV and MMR.
US Assistance
The US, through USAID, has provided $2.7 million in “urgent assistance” to help Montenegro “detect, manage, and treat” COVID-19. It also hopes to “strengthen and sustain response capacities to mitigate the pandemic’s public health and socioeconomic impacts”.
The Health Caravan
The Health Caravan comprises mobile vaccination sites in 4 municipalities: Budva, Nikšić, Bijelo Polje, and Ulcinj. Uptake of vaccines in these areas has been low. Thus, the Caravan will offer “on-the-spot access to vaccines and essential health information”.
The initiative will take place in February and March and has been promoted across television and radio programmes, in schools, and through “other means”.
Slobodan Mandić is the Director of the Directorate for the Quality of Health Care in the Ministry of Health, and hopes community members will be able to “get vaccinated”, learn more, and “receive routine health check-ups” from health workers and Red Cross volunteers.
“For health workers and health authorities, it’s a great chance to understand people’s health needs and the barriers they may experience in meeting them.”
Dr Mina Brajović, WHO Representative in Montenegro, states that “COVID-19 remains a threat”, particularly as “vaccine uptake is still low in Montenegro”. The Health Caravan will enable health workers to “reach as many people as possible” and make “essential vaccines more easily accessible”.
“To increase vaccination uptake, we need collective action, partnerships, strong local community engagement, and informed citizens.”
Dr Borko Bajic agrees that the initiative is “crucial” to “drive vaccine uptake” but also to “build people’s trust in vaccination”.
For more on encouraging vaccine uptake across the world join us at the World Vaccine Congress in Washington this April.
Dr Jean Kaseya was announced the new Director General of Africa CDC at the African Union summit in February 2023. He was approved by African heads of state during the meeting in Addis Ababa. Currently, Africa CDC is making the transition from a technical institute of the African Union to a public health agency. Devex reports that this will empower it with greater “authority, flexibility, and speed” for the future.
Who is Dr Kaseya?
Dr Jean Kaseya is a Congolese national with more than 20 years’ experience in public health both in the Democratic Republic of Congo and internationally. As well as his medical qualification he holds a Master’s in Public Health from Henri Poincaré University in France. His experience includes service of UNICEF, Gavi, and WHO.
Dr Kaseya’s application was supported by Professor Jean-Jacques Muyembe. He described his colleague as “strategic, with a great sense of leadership, proven technical expertise, and the political experience necessary” to execute the role.
The process of choosing a leader
Although many global health figures have congratulated Dr Kaseya across social media, The East African suggests that the announcement came as “the epilogue of a long secret diplomatic struggle”. Whatever this involved, we gather that around 180 candidates were considered for the post, shortlisting to three, including Kenya Dr Ahmed Ogwell Ouma, currently Acting Director.
The recruitment process took over a year, from a call for applications to interviews, recommendations, and ratification.
The role and plans for the future
Devex suggests that the position is a “four-year contract” based in Addis Ababa, with a “probationary period” of one year. The difference between Dr Kaseya’s role and the previous head of Africa CDC is allegedly “more power with the expectation of less internal AU bureaucracy to navigate”. This additional power is exemplified in his power to convene the heads of state on issues of public health.
Dr Kaseya will report to the AU chairperson with the task of guiding the agency towards greater health security in Africa. Dr Kaseya shared an insight into his intentions for the role with Devex, which reports that he will strive for a “new management culture” in the organisation through what he calls “The New Deal”. Furthermore, he will continue to implement Africa CDC’s New Public Heath Order, launched by predecessor Dr John Nkengasong.
In his application, Dr Kaseya identified the need for a “technically strong Africa CDC” that comprises “leading experts” and efficiently uses funds. Overcoming “cumbersome” processes and poor management will be crucial to his vision, as he noted that Africa CDC used only 39% of its operational budget from donors in 2020.
Dr Kaseya hopes to have conversations with advisors and publish a strategic plan within 100 days of assuming his new role, aiming to “initiate decisions to quickly correct deficiencies and restore the organisation’s credibility”.
Congratulations and messages of support
Dr Matshidiso Moeti, WHO Regional Director for Africa, tweeted that she looks forward to “strengthening our partnership”.
“His years of experience working in international development and health will support the continued growth of Africa CDC.”
Dr Tedros Adhanom Ghebreyesus, Director General of WHO, echoed the “congratulations”, stating “I and my colleagues at WHO look forward to continuing to partner with Africa CDC under your leadership”.
What do you hope to see from Dr Kaseya’s early days in the role, and what would you encourage him to consider as he settles into his position?
A paper published in Nature Communications Medicine in February 2023 examines the results of a study investigating how a person’s housing situation might factor into their vaccination status. With limited global data on this relationship, the authors concluded from the study in France that “taking housing into consideration plays a major role in vaccination campaigns”.
The paper establishes that “vulnerable populations”, including “people experiencing homelessness”, are less likely to have received a COVID-19 vaccine. The authors aimed to identify possible reasons for this through interviews with “homeless/precariously housed people in France”. Although many had been vaccinated, the vaccination rate was lower than the general population, with the least likely to be vaccinated living on the streets.
COVID-19 and vaccines in France
Evidence from early COVID-19 waves across the world suggests that groups such as “people experiencing homelessness (PEH) or precariously housed (PH)” are “disproportionately exposed to infection” and “severe forms of the disease”. Not only this, but the social and mental health consequences are believed to be worse. The risk of transmission is increased by factors such as:
Precarious living conditions
High population density
Need to access food distribution services
Poor access to sanitation and hygiene
Difficulties accessing care
Furthermore, preventative measures such as social distancing or self-isolation are “challenging to maintain”.
With the introduction of “highly efficacious” vaccines in 2021 we saw “strong protection against severe disease, hospitalisation, and death.” However, it was “already known” that PEH/PH “tend to uptake vaccination” for other diseases to a “lower degree than the general population”. Thus, attempts to prioritise “residents of migrant workers’ hostels and homeless people over 55” began in the first round of vaccinations in France. However, this was “nullified” by “lack of vaccines and of actors able to perform vaccination”.
Obstacles and barriers
As we explored in a previous post on reporting on vaccine hesitancy, there are many factors that influence or determine a person’s vaccination status. For PEH/PH these include “practical barriers and service limitations”, “suboptimal experiences with vaccines or health services”, and hesitancy or confusion about medicine or vaccines.
Other factors include “structural obstacles” such as “inadequate medical coverage and access to care” or “not considering disease prevention a priority”. For migrants and refugees in particular, “language barriers” or “lack of access to information” might be preventing vaccination in a host country.
“Moreover, migrants and refugees may also be reluctant to take up vaccination, for fear of deportation while waiting for the right to reside.”
PEH/PH population in France
The authors estimate that around 250,000 people in France comprised the PEH/PH population in 2021. In the specific regions of consideration, Ile-de-France and Marseille, the number is believed to have been around 150,000.
Some are housed in workers’ hostels, some in centres for asylum seekers or emergency shelters, and some in social hostels. An estimated 2,800 are understood to be “permanently living rough” in Paris, with 1,500 in Marseille. Despite these numbers, the authors found “no official French data” for COVID-19 vaccination coverage in “migrants, homeless, or roofless populations”. Additionally, data from other European countries with “similar migration and homelessness profiles” are neglected.
What does the study show?
The cross-sectional study took place from 15th November to 22nd December 2021 in the Ile-de-France region and the city of Marseille. Inclusion criteria were “to be aged >18 and in full capacity to give consent”. Inclusions were performed at the place where each participant last slept the night.
The study finds that “PEH/PH in France are less likely to receive COVID-19 vaccination than the general population (79.9% vs 91.1%)”. However, it also suggests that “vaccine uptake varied massively according to precariousness and social integration”. For example, those living in the streets, camps, or squats, were less likely to be vaccinated (42% with at least 1 dose) than “Accommodated (75%) and Precariously Housed participants (85%)”.
“Housing is thus the most important factor linked with vaccine uptake.”
The analysis reveals that “older people, undocumented migrants and refugees, people needing the vaccine certificate, people with medical coverage, and people followed by a GP and/or social workers” are more likely to be vaccinated. Vaccine uptake was “undoubtedly increased” by on-site vaccination by mobile teams.
Unfortunately, individual factors such as “negative influence by peers” or a “fear of the vaccine” were likely to dissuade a person from vaccination.
“Practical or physical obstacles to vaccine uptake were rare, as compared to personal motivations.”
The main factors associated with low coverage were “vaccine hesitancy or negative views on vaccination”. However, people who opposed vaccination “comprised a minority” in comparison with “hesitant people”, with 54% of non-vaccinate participants being “afraid of vaccine effects”.
Why is this so important?
As the study notes, the dangers to PEH/PH from COVID-19 are greater than faced by the wider population. Thus, it is important to encourage vaccine uptake to lower this threat. The data also demonstrate the importance of “awareness-raising and sensitisation by trusted third parties”.
As structural barriers reportedly play a “more minor role”, the authors identify “national policies” such as “free vaccination” and “increased access” as critical. To complement this, the “deployment of mobile teams” and “site-based vaccination activities” by various organisations may have helped overcome access issues.
Although “social and humanitarian actors” have played a role in reaching PEH/PH populations, “substantial effort is still needed to reach the most excluded, street-sleeping individuals”. What, then, do the authors recommend?
Outreach activities and onsite vaccination programmes should be extended and tailored
Sensitisation activities should take place early to address barriers like vaccine hesitancy or complacency
Policies ensuring free, universal access to vaccination and the support of field actors achieve high coverage
Although the study “cannot easily be extrapolated to other contexts”, the paper concludes with a call for further data on “vaccine uptake and its drivers”. Furthermore, the “lessons” it reveals “could be of use in countries with a similar migration and/or homelessness profile”.
What lessons do you think we can take from this study? How would you better approach vaccination across PEH/PH populations in a future global health crisis, or what efforts could be made to encourage more positive attitudes towards vaccinations and health interventions in general?
For more on COVID-19 vaccination policies and outreach efforts at the World Vaccine Congress in Washington this April, get your tickets here.
Next up in our series of interviews in preparation for the World Vaccine Congress in Washington this April are our speakers from US BIOLOGIC: Dr Jolieke van Oosterwijk and Chris Przybyszewski. We were delighted that they took the time to answer our questions and give us an insight into the work they are doing before we hear more at the Congress.
Tell us more about your work
US BIOLOGIC asks the question “what if we could protect ourselves without needles?”, developing oral vaccines for global disease prevention. We wanted to find out a little more about what this involves, and what applications they are working on. Says Dr van Oosterwijk:
“At US BIOLOGIC, we use our proprietary oral-delivery platform, OrisBio, to deliver vaccines and therapeutics to animals and humans, with a focus on zoonotic diseases.”
The platform has already been used to develop a vaccine for the mouse reservoir host of Lyme bacteria in the wild, which “interrupts the transmission cycle between mouse and ticks”. However, it doesn’t stop there. The platform is expanded to “multiple species”, with a “chewable influenza vaccine for humans” in development!
“With the OrisBio platform, we are building a product line that increases vaccine equity, negates the need for cold chain, increases shelf life, and allows for rapid response to new and emerging pathogens, anywhere in the world.”
Dr van Oosterwijk’s sessions
During the Congress, Dr van Oosterwijk will be exploring AMR and biodefence with One Health perspectives in mind. We asked what challenges these issues present, and how a One Health approach can be applied. Dr van Oosterwijk suggests that for both AMR and biodefence, the challenge is “the emergence of new pathogens and/or variants of existing pathogens”.
“Increased surveillance of pathogens circulating in human and animal populations is crucial for timely response.”
Furthermore, she emphasises the importance “developing rapid response measures that can be easily adapted” to suit new pathogens and strains, and “those can be produced large scale, have a minimal cost burden, and are easily distributed globally”.
“One paradigm to achieve these goals is One Health, which addresses diseases at the human and animal level.”
Pandemics at animal level
Mr Przybyszewski will be focusing on pandemics that start at an animal level at the Congress, so we asked about preparing for future threats. He told us that, apart from the human burden of animal-borne diseases, they “cost billions of dollars, directly, and trillions in global economic impact”.
“A key challenge is tracking the emergence and changes in diseases in wildlife and in the food industry, so we are always chasing the problem. We need an adaptive platform by which the predictive analytic toolsets help us build and apply responsive vaccines and other interventions.”
Oral vaccines
As US BIOLOGIC deals with oral vaccines, we wanted to understand more about the benefits they offer, and the challenges that might arise. Dr van Oosterwijk and Mr Przybyszewski suggest that they allow us to “reach a broader population than traditional syringe vaccines”. Why is this? Well, for US BIOLOGIC’s vaccines, they are “thermostable, cost efficient, and can be shipped anywhere at any time”.
Furthermore, they are “particularly useful in the animal world” because they can be “integrated in animal feed, animal water supplies, or applied to target species in wildlife”. However, each species “presents with a unique digestive system”. Thus, “vaccine formulations need to be adapted to reach those areas of the intestinal system that contain the lymphoid tissue to elicit an immune response”.
Why One Health?
We hear a lot about the importance of One Health in understanding and preventing threats, so we asked about its importance to the team at US BIOLOGIC and what it requires of them.
“One Health demands that we understand how people, animals, plants, and their respective environments interact with diseases and each other.”
Now, due to “encroachment into former wildlife habitat” and “geographic expansion of disease reservoirs and vectors due to climate change”, humans and animals interact “more than ever”. With this “increased contact” comes an “increased opportunity for pathogenic spillover”.
“One Health also demands close collaboration between the veterinary and human-health professionals identifying areas of need and implementing solutions, as well as active crosstalk between academic and research institutions, policy makers and industry.”
At US BIOLOGIC, this means working with experts to “respond to the needs of the target species, to understand pathogen transmission, and to develop an effective, targeted solution”.
How ready are we for future threats?
In our conversations with health and industry experts, we often ask for their opinion on our level of preparedness for future threats. For Mr Przybyszewski and Dr van Oosterwijk, “we are not as prepared for future threats as we could be”. They identify the need for an “infrastructure to lessen the threats existing or arising”.
“OrisBio is an important part of that infrastructure, combining artificial intelligence with active surveillance data to understand the identity, behaviour, and geographic movements of emerging threats, all to guide integrated solutions that can be implemented in 100 days.”
Why our Congress?
As always, we want to know what is bringing the team to the Congress in April, and what they hope to gain.
“At US BIOLOGIC, we say ‘Aspire. Innovate. Deliver.’ The Congress in an excellent place to convene with like-minded professionals who will build with us the future of pandemic prevention.”
We are grateful to Dr van Oosterwijk and Mr Przybyszewski for their thoughtful and valuable insights, and we can’t wait to hear more at the Congress. To join us there, get your tickets today.
In our discussions at the World Vaccine Congress and in published posts we continue to explore the meaning and applications of the concept of One Health. In an article for AgriPulse in February 2023, Ronald B Phillips presented how this can be realised from an agricultural perspective. He writes that “some of the biggest issues” the US is currently facing “intersect” at “animal health”.
“Keeping animals health contributes positively to the economy, public health, and sustainability goals, making it a bipartisan topic.”
His article encourages more “specific” action from the US Congress to promote sustainable and efficient practices.
Healthy animals contribute to a healthy economy
Phillips suggests that agricultural experts and stakeholders have “long understood” the “connection between animal health, human health, environmental health, and economic growth”. For example, the role of a “stronger and safer” food supply can be considered. Phillips identifies “nearly $199 billion” contributed by farmers and ranchers in 2020 thanks to their rearing of livestock.
High medical standards
Phillips emphasises the importance of supporting “healthy animals” with appropriate medication and diagnostic tools.
“Advanced medicines and diagnostic tools that identify, prevent, cure, and even eradicate disease in food animals help make the US food supply among the world’s safest”.
For the obvious reason that “healthy animals are simply more productive”, he encourages continued “innovations” to enable farmers “operate more sustainably and profitably”. Although there are “clear benefits” to this innovation, he suggests that “more work needs to be done”.
“One in five animals in the global food chain is lost to preventable disease.”
As Phillips suggests, this is “not just bad for the animals”, but a “waste of natural resources”. So, how can innovation be encouraged, not just in the US, but across the world? Certainly, funding is a consistent issue across diagnostics, vaccines, and therapeutics, but we also identify a need for better collaboration with agricultural experts to understand and meet their needs.
What would agricultural innovation look like for you and livestock practices in your country? What needs can you identify?
For more on One Health approaches to human and animal health, join us at the World Vaccine Congress in Washington this April.
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