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The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop (2021)

Chapter: 3 Improving Access and Closing the Global Immunization Gap

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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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3

Improving Access and Closing the Global Immunization Gap

The first session of the workshop focused on improving access and closing the global immunization gap. The session’s objectives were to assess the current state of vaccine-preventable diseases globally, to delineate key barriers to dissemination and uptake of vaccines, and to examine evidence-based strategies to improve access to vaccines and increase immunization coverage both locally and globally. Anuradha Gupta, deputy chief executive officer at Gavi, the Vaccine Alliance, discussed how an equity lens can be used to close the global immunization gap by using the “zero-dose” conceptual framework to reach unvaccinated children. Litjen (L. J.) Tan, chief strategy officer at Immunization Action Coalition, explored strategies to reduce barriers to vaccination and increase vaccination uptake among adults. Momin Abdul Kazi, assistant professor at the Aga Khan University, Pakistan, examined opportunities and challenges in using mobile health (mHealth) interventions to improve vaccination coverage. Jeff Goad, chair of the Department of Pharmacy Practice at the Chapman University School of Pharmacy, presented on the role of community-based pharmacy interventions in improving access to vaccines and the potential for pharmacy-based immunization as a response to pandemics. The session was moderated by Noni MacDonald, professor in the Department of Pediatrics at Dalhousie University, Nova Scotia, Canada.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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APPLYING AN EQUITY LENS TO IMMUNIZATION TO CLOSE THE GLOBAL IMMUNIZATION GAP

Presented by Anuradha Gupta, Gavi

Gupta described how viewing immunization through an equity lens can help to close the global immunization gap. She noted that the coronavirus disease 2019 (COVID-19) pandemic has exacerbated and compounded many long-standing inequities in global immunization as well as the vulnerabilities that underlie those inequities. To highlight the value of vaccination for ensuring equity, she invoked the words of Nelson Mandela: “Life or death for a young child too often depends on whether he is born in a country where vaccines are available or not.”

Progress in Closing the Vaccine Gap

Gupta distinguished between equity among and equity within countries, pointing out that the landscape of global vaccine equity has improved since Gavi was established in 2000. In the years since, the efforts of Gavi and others to scale up new vaccines has achieved substantial progress in improving children’s health outcomes worldwide and in closing the vaccine gap between low- and high-income countries. Gupta asserted that between 2000 and 2017, the scale-up of new vaccines contributed to a 44 percent decline in under-age-5 mortality in Gavi-supported countries1 and a 71 percent decline in deaths from vaccine-preventable diseases. To illustrate the divergent trends in vaccine coverage for Gavi-supported versus non-Gavi-supported countries, she compared the coverage rates for Haemophilus influenzae type B, pneumococcus, and rotavirus vaccines. In 2010, the coverage rates for all three were higher in non-Gavi-supported countries than in Gavi-supported countries. However, according to Gupta, by 2019 this had reversed, with coverage rates in Gavi-supported countries exceeding those in non-Gavi-supported countries.2 Although vaccination coverage has improved writ large, Gavi-supported countries have realized a faster expansion of coverage and a larger proportion of coverage than non-Gavi-supported countries. In

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1 For a list of Gavi-supported countries and eligibility criteria, visit https://www.gavi.org/types-support/sustainability/eligibility (accessed May 20, 2021).

2 In 2010, non-Gavi-supported countries had relatively high vaccine coverage rates for Haemophilus influenzae type B (45 percent), pneumococcus (24 percent), and rotavirus (18 percent), while Gavi-supported countries had relatively low vaccine coverage rates for Haemophilus influenzae type B (36 percent), pneumococcus (1 percent), and rotavirus (0 percent). In 2019, Gavi-supported countries had relatively higher vaccine coverage rates for Haemophilus influenzae type B (58 percent), pneumococcus (47 percent), and rotavirus (28 percent), while vaccine coverage rates in non-Gavi-supported countries in the same year were 81 percent (H. influenzae type B), 49 percent (pneumococcus), and 46 percent (rotavirus).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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this case, upper- and middle-income non-Gavi-supported countries have struggled to introduce new vaccines. This is a peculiar case of inequity, Gupta said.

According to internal Gavi data, Gupta said more children are being reached with more vaccines. Between 2000 and 2019, the vaccination coverage rates increased for numerous vaccines throughout Gavi-supported countries, as shown in Table 3-1. In these countries, vaccination rates started at zero, but much progress has been made.

Progress Needed to Reach Underimmunized and Zero-Dose Children

Despite the great strides made in increasing vaccination coverage in Gavi-supported countries over the past two decades (see Figure 3-1), many children worldwide remain unimmunized or underimmunized, said Gupta. Only 11 percent of children in Gavi-supported countries receive the last recommended dose for each of the 11 antigens currently recommended by the World Health Organization (WHO).3 Gupta explained that the term zero dose is a new distinction being used in strategies developed by Gavi, WHO, and other partners to refer to individuals who have not received a single dose of diphtheria, tetanus, and pertussis vaccine (DTP). Historically, vaccination coverage for DTP dose 3 has been used as a proxy indicator of access to immunization. However, children who have not received a single dose of DTP are those most likely to be living in communities with compounded

TABLE 3-1 Vaccine Coverage in Gavi-Supported Countries (2000, 2019)

Vaccine Vaccine Coverage (2000, %) Vaccine Coverage (2019, %)
HIB3 0 81
PCV3 0 49
Rotavirus 0 46
MCV2 0 59
RCV1 0 57
IPV1 0 76
YFV 0 43

NOTE: HIB3 = Haemophilus influenzae type B dose 3; IPV1 = inactivated polio vaccine dose

1; MCV2 = measles containing vaccine dose 2; PCV3 = pneumococcal conjugate vaccines dose

3; RCV1 = rubella-containing vaccine dose 1; YFV = yellow fever vaccine.

SOURCE: Gupta presentation, August 17, 2020.

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3 More information about Gavi and Gavi-supported countries is available at https://www.gavi.org/sites/default/files/document/2020/Gavi-Facts-and-figures-June.pdf (accessed November 3, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×
Image
FIGURE 3-1 Zero-dose, underimmunized, and immunized children in Gavi-supported countries (2000–2019).
NOTE: DTP = diphtheria, tetanus, and pertussis vaccine; DTP3 = diphtheria, tetanus, and pertussis vaccine dose 3; m = million.
SOURCE: Gupta presentation, August 17, 2020.

vulnerabilities and deprivations that contribute to the lack of not only vaccine coverage, but also virtually all essential services, she added.

Gupta presented data showing the relationship between immunization status and the number of surviving infants in Gavi-supported countries between 2000 and 2019 (see Figure 3-1). During this time, the number of surviving infants who received DTP dose 3 increased, and the number of underimmunized and zero-dose surviving infants decreased. This trend reflects use of DTP dose 3 vaccination as a proxy indicator of access to vaccination. Gupta noted that the rate of decrease in underimmunized and zero-dose cohorts has plateaued since 2010.

Two-thirds of zero-dose children live in households surviving on less than $1.90 per day. Gupta noted that this fact designates the zero-dose child as a bellwether of acute inequity and poverty in a community. In this sense, targeting zero-dose children can be used to identify communities where there are opportunities for multiagency, multi-sectoral action. For example, communities with zero-dose children also tend to have girls who are not in school; women with limited agency; high rates of violence against women; and lack of contraceptive, reproductive, maternal, neonatal, and pediatric health services. These communities are often the epicenters of disease outbreaks (e.g., yellow fever, measles, meningitis, cholera, Ebola virus disease) and can thus be valuable targets for prevention efforts. Traditionally, the risk of outbreaks in these communities has been addressed by maintaining

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

stockpiles and providing support for outbreak response.4 However, Gupta noted that reaching zero-dose children in these “missed” communities and ensuring that they receive on-time vaccinations can help mitigate the growth of an unvaccinated population and thus reduce said communities’ outbreak susceptibility.

Sustainable Framework for Reaching Zero-Dose Children and Underserved Communities

While zero-dose children present a valuable opportunity for retargeting vaccination efforts (and health service interventions more generally) to likely outbreak epicenters, there are huge challenges associated with identifying, reaching, and monitoring such children. Gavi has developed a new framework to sustainably target zero-dose children and underserved communities by leveraging new mindsets, approaches, and partnerships, said Gupta. The aim of this new framework is to leave no one behind in terms of immunization, and Gavi is advocating for dedicated funds to implement this framework to reach zero-dose children and underserved communities. The framework is a cyclical model that includes the following steps:

  • Identify target populations (e.g., “who, where, why, how many?”).
  • Reach populations through flexible approaches that address both supply- and demand-side barriers.
  • Monitor progress and correct course as needed.
  • Measure outcomes.
  • Advocate for immunization using evidence from measured outcomes.

Gupta explained how allocating resources simply towards finding zero-dose children and their communities reveals not only their identities and locations but also the barriers they face and how they have arrived in their current situation. In contrast to the traditional emphasis on global approaches to vaccination—that is, a one-size-fits-all approach—Gavi has rapidly shifted toward flexible approaches for reaching zero-dose children and underserved communities, recognizing the need to use tailored strategies that account for supply-side and demand-side barriers. Global or regional strategies may still be applied, but they should be tailored to be ultra-local, community-based, community driven, and community owned, she added.

Gupta emphasized the value of good monitoring in order to allow for course correction and the evaluation of outcomes, noting that challenges often arise in the monitoring and measurement processes. According to

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4 Since 2006, more than 140 million people have been protected with more than 170 million doses from Gavi-funded stockpiles and outbreak response.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

Gupta, in the field of immunization, monitoring and measurement are currently conducted using annual estimates generated by a methodology reliant on occasional surveys. These estimates offer a sense of immunization trends, but they do not allow for real-time progress assessment. To ameliorate this, Gavi’s framework calls for the establishment of “learning hubs” to help evaluate the impact of investments and approaches being used to increase vaccination coverage. These hubs can then produce data that can be used as evidence for advocacy efforts to bring the issue of zero-dose children into political discourse. Gupta claimed that an important reason why zero-dose children are neglected is because they are not seen and have no voice or political influence. She further emphasized that Gavi’s framework calls for the continuous use of immunization data to advocate for investment in zero-dose children. This aspect of the framework is linked to efforts to create financial incentives that help trigger national conversations about prioritizing zero-dose children.

Recognizing That National Averages Mask Inequities

Because national averages and other macro-level data can mask inequities, Gavi has begun disaggregating data in the past 4 years to focus on subnational areas, Gupta said. For instance, Gavi has used subnational data to identify disadvantaged populations in Pakistan and Kenya. In Pakistan, various data sources were used to reveal exactly where zero-dose children live and to identify provinces, districts, and even city blocks with high zero-dose populations. In Kenya, geospatial mapping was used to identify disadvantaged populations in terms of DTP dose 1 coverage versus composite education and contraceptive use in areas of poor accessibility. Once clusters of disadvantaged children are identified, it is easier to support countries in addressing the needs of these children, she added.

Using Differentiated Strategies to Reach Zero-Dose and Underimmunized Children

Gupta explained how in recent years, Gavi has encouraged countries to adopt highly differentiated approaches, and are continuing to build on this strategy to strengthen efforts to reach underimmunized and zero-dose children. For example, the lived experiences of the population of Myanmar (Burma) can vary dramatically depending on social or geographic context. Gupta categorized certain regions based on the challenges in access: geographic hard-to-reach (H2R), due to dense forest and inaccessible mountain ranges; social H2R because of poor infrastructure or ongoing sectarian and state-sponsored violence; and active conflict zones. The country’s poor urban cores and certain remote impoverished ethnic communities are home

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

to increasing populations of zero-dose children. Gupta claimed that overall population growth spurs the growth of poor urban populations, creating disease hotspots that go unreached by vaccination and other services. Additionally, Gupta said, other geographic and social H2R communities exist in inaccessible rural areas and thus lack access to services. Gavi encourages diverse countries like Myanmar to adopt a differentiated approach (e.g., by prioritizing districts based on service delivery and access challenges). Interventions can also be tailored for specific settings to (1) increase demand for immunization services; (2) expand cold chain access to underserved populations; (3) improve health infrastructure, workforces, transportation, and communication facilities; and (4) strengthen leadership and program management.

Broadening Partnerships to Enhance Services

Building well-designed partnerships to enhance immunization services is another area of focus for Gavi, WHO, and the United Nations Children’s Fund (UNICEF), said Gupta. Several years ago, Gavi established a new country-centric partner engagement framework that aimed to shift technical support and investment from the global and regional level to national and subnational levels. This shift has resulted in a breadth of new partnerships. For instance, in Afghanistan, Gavi has partnered with the International Federation of Red Cross and Red Crescent Societies (IFRC), Acasus, and UNICEF. Gavi is working with IFRC to provide integrated primary health care, including basic health interventions and COVID-19 prevention, mitigation, and case management, especially in fragile and conflict-affected areas. Gavi has successfully partnered with Acasus in Pakistan, Afghanistan, and the Democratic Republic of the Congo (DRC). Acasus supports countries by strengthening programmatic leadership, management, and coordination; Acasus and Gavi also help countries develop dashboards to monitor program performance with a particular focus on inequity. UNICEF is working in Afghanistan to ensure that vaccines are properly delivered and co-administered with a range of other services, such as combining multi-antigen campaigns with nutritional support in targeted low-coverage districts. The overall aim of these partnerships is to provide a range of services in which immunization is included, she added.

Strategic Political Engagement

Gupta noted that Gavi has maintained constant dialogue with political leadership in six pivotal Gavi-supported countries that are home to 65 percent of zero-dose children: Nigeria (20 percent), India (18 percent), Pakistan (9 percent), the DRC (6 percent), Indonesia (6 percent), and Ethiopia (5

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

percent).5 Gavi segments countries into tiers based on their immunization rates, she added. The first tier consists of 10 large countries that are home to more than 75 percent of underimmunized and zero-dose children. Tier two consists of 10 countries that are fragile and have immunization-related challenges that are complicated by issues such as political instability or conflict. This group includes countries like the Central African Republic, Haiti, and Somalia, which require focused technical assistance from partners.6 These two tiers are referred to as pivotal countries, Gupta explained. Gavi has worked to elevate immunization dialogue to the highest levels of government in these pivotal Gavi-supported countries, and it has invested in political will to ensure that immunization is a top priority among these nations’ prime ministers, financial ministers, and health ministers. This approach has been fruitful, she said, as immunization outcomes in these tier one countries have begun to improve.

Addressing Gender Barriers

Gender-related barriers have become an increasing area of focus for Gavi owing to the inextricable link between inequity and gender, said Gupta. In aggregate terms at the global level, boys and girls have equal access to immunization, but caregivers themselves face gender-related barriers to accessing vaccines. However, there are interventions aimed at alleviating these gender-related barriers that have been shown to improve immunization coverage. For instance, Senegal made adjustments to its immunization services (such as extending clinic hours or even simply relocating vaccination sites) to address the needs of caregivers, most of whom are women in Gavi-supported countries. These adjustments included weekend and late-night immunization sessions, vaccination at key transport hubs, and advocacy from key leaders, administrative personnel, religious leaders, and community leaders. These adjustments contributed to an increase in national DTP dose 3 coverage from 86 percent in 2018 to 93 percent in 2019.

Using Multiple Methods to Improve Coverage and Equity

Gavi strives to use all of its methods to improve vaccine coverage and equity, said Gupta. For example, in the DRC, a subnational approach was used, focusing on nine provinces. Political will was rallied through Gavi’s sustained engagement with policy makers. The supply chain was improved

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5 These data are likely internal and unpublished. The speaker cited no sources, and these figures could not be verified by the rapporteurs.

6 For more information on Gavi’s Partners’ Engagement Framework, see https://www.gavi.org/news/media-room/engaging-partners-success (accessed March 2, 2021).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

through cold chain expansion in partnership with UNICEF. To improve data systems, District Health Information Software 2 (DHIS2) was rolled out and the health management information system was strengthened in partnership with the University of Oslo, WHO, and The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund).7 Community organizations were engaged to implement social mobilization programs in 20,000 villages in partnership with Sanru. Gavi spurred innovation by partnering with VillageReach to explore vaccine delivery by drones. Performance-based financing was secured through collaboration with the Global Fund, the World Bank, and the Global Finance Facility. Through this approach 15,000 children were reached in Mongala province, 5,000 in Tshuapa province, and 55,000 in Kinshasa province. Gupta explained that this strategy has yielded good results, and innovative approaches to real-time data collection have allowed Gavi to track how many children were vaccinated as a result of these efforts.

Halting the COVID-19 Pandemic Requires Equitable Access to Vaccines

Gupta emphasized that ensuring equitable access to vaccines through a global, coordinated approach will help to halt the COVID-19 pandemic. To that end, WHO, the Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi are co-leading the COVAX facility, a global pooled procurement mechanism designed to help countries obtain vaccines by guaranteeing predictable demand to vaccine manufacturers. Its goal is to accelerate equitable access to appropriate, safe, and efficacious COVID-19 vaccines, and all countries are invited to participate in order to secure affordable access to COVID-19 vaccines—including the 92 low- and middle-income countries (LMICs) supported by Gavi. COVAX is a risk management tool that will assist certain countries that may not be able to secure vaccines otherwise. It incentivizes manufacturers to develop products and scale up their manufacturing capacities by assuring future vaccine procurement. It also offers an actively managed portfolio of vaccines. Through this effort, Gupta explained, Gavi aims to ensure that doses secured between 2020 and 2022 will be equitably distributed worldwide and that high-risk populations will be covered in all countries. If doses are sold to the highest bidder, she said, the wealthiest countries are likely to secure the bulk of forthcoming vaccine doses in a time of scarcity.

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7 More information about DHIS2 is available at https://www.dhis2.org (accessed September 25, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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REDUCING BARRIERS AND INCREASING VACCINE UPTAKE AMONG ADULTS

Presented by Litjen (L.J.) Tan, Immunization Action Coalition

Tan explored strategies to reduce barriers to vaccination and increase vaccination among adults. He discussed the effects of COVID-19 on adult immunization, other factors associated with low vaccination coverage among adults, and strategies for improving adult immunization rates.

Burden of Vaccine-Preventable Disease Among Adults in the United States

Tan began with an overview of the vaccine-preventable disease burden among U.S. adults. Because the United States has well-developed pediatric and adolescent immunization programs, the burden of vaccine-preventable disease is primarily among adults. He noted that cases of invasive pneumococcal disease, influenza, pertussis, hepatitis B, zoster, and measles make up much of this burden:

  • 2015: A multistate outbreak of measles linked to California, with 55 percent of infections occurring in adults aged 20 years or older (Clemmons et al., 2015)
  • 2016: 21,600 new hepatitis B infections8
  • 2018: 31,400 cases of invasive pneumococcal disease that caused 3,480 deaths, 91 percent of which occurred in individuals aged 50 years or older9,10
  • 2018: 3,322 acute cases of hepatitis B
  • 2019: 15,662 pertussis cases with 3,736 cases among adults aged 20 years or older11
  • October 1, 2019, through April 4, 2020: 24,000 to 62,000 recorded influenza deaths with approximately 90 percent of cases occurring among adults aged 65 years or older12
  • Reported herpes zoster cases reach approximately 1 million each year (Harpaz et al., 2008)

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8 More information about hepatitis surveillance is available at https://www.cdc.gov/hepatitis/statistics/2018surveillance/HepB.htm (accessed September 28, 2020).

9 Each year, 649 per 100,000 patients are hospitalized with community-acquired pneumonia, and the mortality rate among these cases is 6.5 percent (Ramirez et al., 2017).

10 For more information on Streptococcus pneumoniae surveillance, see https://www.cdc.gov/abcs/reports-findings/surv-reports.html (accessed May 20, 2021).

11 More information about pertussis surveillance is available at https://www.cdc.gov/pertussis/downloads/pertuss-surv-report-2019-508.pdf (accessed September 28, 2020).

12 More information about the 2019–2020 U.S. flu season estimates is available at https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm (accessed September 28, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

Tan said that vaccine-preventable disease in adults is not highly prioritized. For instance, a 2015 measles outbreak that began in Disneyland was the focus of much media attention, yet little attention was paid to the fact that 55 percent of infections from that outbreak occurred in adults aged 20 years or older. This indicates the need to build awareness of the burden of vaccine-preventable disease in adults and of evidence-based guidance on these diseases from WHO and the U.S. Advisory Committee on Immunization Practices (ACIP). Tan presented the estimated costs and number of cases of four vaccine-preventable diseases in 2013, which totaled more than $15 billion in estimated medical and indirect costs (see Table 3-2). He added that the cost of vaccine-preventable diseases in persons aged 50–64 would add an additional $11.2 billion to this estimate.

Adult Immunization Coverage Rates in the United States

Adult populations in the United States remain undervaccinated despite the known consequences of undervaccination in terms of cost, mortality, and morbidity, said Tan. He presented adult immunization coverage rates from U.S. Centers for Disease Control and Prevention (CDC) National Health Interview Surveys conducted between 2014 and 2017, comparing reported immunization coverage with Healthy People 2020 immunization targets.13 During this period, immunization coverage for pneumococcus for individuals aged 65 years or older increased from approximately 60 percent to nearly 70 percent, falling short of the targeted 90 percent coverage. Similarly, pneumococcal immunization coverage for high-risk individuals (those with an

TABLE 3-2 Cost Burden of Four Adult Vaccine-Preventable Diseases in Persons Older Than 65 (United States, 2013)

Vaccine-Preventable Disease Estimated Number of Cases Estimated Costs, Medical and Indirect (millions, $)
Influenza 4,019,759 8,312.8
Pneumococcal 440,187 3,787.1
Zostera 555,989 3,017.4
Pertussis 207,241 212.5
Total $15,329.8

a Herpes zoster is commonly known as shingles; see https://www.cdc.gov/vaccines/vpd/shingles/index.html (accessed December 18, 2020).

SOURCES: Tan presentation, August 17, 2020; McLaughlin et al., 2015.

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13 More information about vaccination coverage among adults is available at https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2017.html (accessed September 29, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

increased likelihood of severe consequences from infection) aged 19–64 years fluctuated between 20–25 percent, falling short of the 60 percent target. However, immunization coverage for zoster increased from approximately 27 percent to 33 percent during this period, exceeding the coverage target of 30 percent for 2015–2017. Tan also presented data on seasonal influenza vaccination coverage from the 2015–2019 influenza seasons (see Table 3-3). Influenza vaccination is fairly low among adults in the United States—even among high-risk groups—despite recommendations that any individual aged 6 months or older receive the vaccination annually.14

Effect of the COVID-19 Pandemic on Adult Immunization

Tan noted that the immunization rates in the United States have declined during the COVID-19 pandemic for all vaccines and across all risk and age groups, not just pediatric vaccines. For instance, herpes zoster vaccination declined by 67 percent and use of the 13-valent pneumococcal conjugate vaccine at U.S. Department of Veterans Affairs facilities decreased by 88 percent.15 Regional variability in the number of COVID-19 cases has affected vaccine-seeking behavior disparately, with regional declines in

TABLE 3-3 Influenza Vaccination Coverage Among Adults (United States, 2015–2019)

Group 2015–2016 (%) 2016–2017 (%) 2017–2018 (%) 2018–2019 (%)
Persons aged ≥ 18 years 41.7* 43.3* 37.1* 45.3*
Persons aged 18–49 years, all 32.7 33.7 26.9* 34.9*
Persons aged 18–49 years, high risk 39.5 39.3 31.3* 40.4
Persons aged 50–64 years 43.6* 45.4* 39.7* 47.3*
Persons aged ≥ 65 years 63.4* 65.3* 59.6* 68.1*

* = Statistically significant declines/increases from the previous season (p < 0.05).

SOURCES: Tan presentation, August 17, 2020; https://www.cdc.gov/flu/fluvaxview/index.html (accessed May 20, 2021).

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14 More information about influenza vaccination coverage is available at https://www.cdc.gov/flu/fluvaxview/index.htm (accessed September 29, 2020).

15 More information about the effect of COVID-19 on adult immunization coverage rates is available at https://www.izsummitpartners.org/2020-naiis/covid-impact-on-adult-imm-and-flu-plans (accessed September 29, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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vaccination coverage being linked to regional increases in infections. Tan suggested that localized planning may help to address these unique situations and variations in timing. Routine immunization rates are recovering but still lagging behind pre-pandemic levels for children. Recovery for adult immunization lags behind that for children. Moreover, at the time of this workshop, there have been no catch-up immunization efforts for either pediatric or adult populations and many individuals remain underimmunized because of the impacts of the pandemic. The pandemic also caused a significant decline in wellness visits for adults of all ages that have not yet recovered to pre-pandemic levels. Ambulatory care visits plummeted during the COVID-19 pandemic, and they remain 33 percent below pre-pandemic levels. Tan suggested that dispelling fears about exposure to COVID-19 in health care facilities could help encourage the public to return to their health care providers and mitigate the declines in vaccination among both adults and children. He added that telehealth—which has been implemented increasingly in the United States throughout the COVID-19 pandemic—could provide a platform that reassures the public they can safely use other health services.

Factors Associated with Low Vaccination Coverage Among Adults

Tan described three categories of factors that contribute to low vaccination among adults: patient factors, provider factors, and system factors. Unlike pediatric patients, many adult patients do not have a regular health care provider or only see medical specialists, but it is regular health care providers who routinely remind and advise adult patients about immunization. Patients also may not have convenient access to vaccination services and can often face competing social and economic demands. In the United States, many patients aged 18–64 years are underinsured and may not have the means to cover the costs of vaccines. While pediatric providers have well-established visit schedules that serve as a platform for routine immunization, adults tend not to use preventive health services. This is related to provider factors that contribute to low vaccination coverage. Because health care providers most frequently see adult patients when they are seeking care for acute health issues, reactive care often competes with preventive services, such as recommending and reminding patients about immunizations. System factors that contribute to low vaccination rates among adults include employment, qualifications required for administering vaccines, and government regulations about vaccine delivery. Tan opined that changing these system factors may be the easiest way to realize quick improvements in vaccination coverage. Finally, he pointed out that the complex adult vaccination schedule makes it difficult for some patients and providers to understand which vaccines are needed or when to recommend certain vaccines.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Confidence Barriers May Limit Demand for COVID-19 Vaccines

Vaccine hesitancy is not typically considered to be a contributing factor to low vaccination coverage among adults, said Tan. However, the trend of increasing vaccine hesitancy in the United States may limit the demand for vaccines in the future, particularly for forthcoming COVID-19 vaccines. Polling data from 2020 indicated that only half of all Americans would be willing to receive a COVID-19 vaccine if it became available (Schoch-Spana et al., 2020). Other polls have found that vaccine hesitancy and vaccine mistrust is greater among African American respondents than among Hispanic and white respondents.16 Overall, 49 percent of adult respondents said they plan to get a vaccine against COVID-19 when it becomes available. The affirmative response was more common among adults aged 60 years or older (67 percent) than younger adults (40 percent) and more common among white adults (56 percent) than Hispanic adults (37 percent) or African American adults (25 percent) (Neergaard and Fingerhut, 2020).

The most common rationale for accepting the vaccine was that individuals wanted to protect themselves or their families; other rationales included reductions of various hardships (e.g., illness, morbidity, death, isolation of physical distancing, disruption of economic activities). The primary reason cited for vaccine refusal was concern about vaccine side effects. Other concerns included institutional mistrust (e.g., mistrust of vaccine manufacturers, regulating agencies, public health authorities), concerns about contracting COVID-19 through the vaccine, lack of concern about the seriousness of the disease, and access issues, including concerns about affordability, ease of access, and safety of access. These concerns demonstrate the value of communication to reassure the public that the rapid development of vaccines is not being pursued at the expense of safety or efficacy, said Tan. Furthermore, these findings may indicate increasing rates of vaccine hesitancy among adults toward vaccines in general, because the concerns about COVID-19 vaccines cited by college-age respondents overlap with commonly cited myths and concerns about influenza vaccines (Ryan et al., 2019).

Strategies for Improving Adult Immunization Rates

Tan discussed a variety of strategies that are known to improve adult immunization rates, including enhancing access to vaccines, increasing community demand for vaccines, leveraging health care providers, and engaging health care systems. Enhancing access to vaccines is known to

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16 More information about COVID-19 vaccine polling is available at https://apnorc.org/projects/expectations-for-a-covid-19-vaccine (accessed October 1, 2020) and https://www.newsweek.com/will-black-americans-fear-vaccine-more-covid-19-opinion-1516087 (accessed October 1, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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improve immunization rates, and it can be accomplished by introducing innovative access points and eliminating vaccine costs for patients.17 Community demand for vaccines can be increased by calling patients directly to remind them about vaccinations and using family incentives to encourage vaccination. For instance, some insurance plans offer coupons or health club memberships as rewards for families that get vaccinated. Tan emphasized the value of leveraging health care providers, explaining that concise, consistent, confident, and presumptive recommendations from health care providers are often effective for increasing vaccine acceptance. Finally, system-based changes can be implemented to increase vaccine coverage, including provider reminders, provider assessment and feedback, standing orders, and worksite interventions with onsite, reduced cost, and actively promoted influenza vaccinations for health care personnel. For example, provider reminders might be generated through the linking of electronic patient records to immunization registries.

Tan presented evidence from a meta-analysis of interventions to increase adult immunization uptake and cancer screening services (Stone et al., 2002). The analysis found the following interventions improved the odds ratio (OR) for use of immunization and cancer screening services among adults:

  • Patient education (OR = 1.3)18
  • Patient reminders (OR = 2.5)
  • Patient financial incentives (OR = 3.4)
  • Provider education (OR = 3.2)
  • Provider reminders (OR = 3.8)
  • Organizational changes, such as standing orders and separate clinics devoted to prevention (OR = 16.0)

Tan pointed out that each intervention improved adult vaccination; however, the OR for organizational changes was greater than the ORs of the other interventions (Stone et al., 2002), meaning that strategies like standing orders and vaccine-devoted clinics had the strongest positive effect on adult vaccine uptake.

Adult Vaccination During the COVID-19 Pandemic and Beyond

The COVID-19 pandemic has provided an opportunity to establish or improve existing infrastructure for vaccinating adults, said Tan. If done well,

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17 More information about vaccination programs is available at https://www.thecommunityguide.org/topic/vaccination (accessed October 1, 2020).

18 Odds ratio in comparison to usual care or control group, adjusted for all remaining interventions.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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such infrastructure improvements could result in durable progress in adult uptake of routine vaccinations. For instance, providers and health systems could send unified and coordinated messages about vaccination, engaging multiple stakeholders and leveraging the trusted voices and recommendations of health care providers. Such communication strategies may improve seasonal influenza vaccination and other routine adult vaccinations. Providers continue to be a trusted voice, he said, and they can play a valuable role in overcoming immunization barriers related to awareness, vaccine hesitancy, and simple logistics.

Tan advocated for innovative approaches to increasing vaccine access. Examples might include new delivery tactics, such as drive-through clinics, which have been successfully implemented for diagnostic testing during the COVID-19 pandemic. Many valuable lessons have been learned about health care delivery during COVID-19, and best practices from these experiences can be derived, shared, and expanded in order to better address the challenges of the pandemic, combat health care inequalities, and improve vaccine accessibility. Tan suggested that providers’ compensation ought to be commensurate with efforts to mitigate the COVID-19 pandemic and the costs of innovation.

With the Northern Hemisphere’s 2020 influenza season in mind, Tan highlighted the importance of the use of hashtags such as #takefluoffthetable and #avoidthetwindemic on social media. These movements will set the stage and prepare needed infrastructure for vaccination efforts in response to the COVID-19 pandemic.19 He proposed that influenza vaccination efforts remain in full force throughout 2020 and into 2021—until every dose is administered—thus extending the influenza vaccination season from August into January with appropriate clinical judgment.

National Vaccine Advisory Committee Standards for Adult Immunization Practice

The United States has a standard of care for adult immunization practice established by the National Vaccine Advisory Committee (NVAC).20 Tan emphasized that this standard calls for more than merely advising patients to get needed vaccines—providers should follow up with patients about vac-

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19 The speed and progress of vaccine development for COVID-19 have exceeded general expectations from the time of the workshop in August 2020. FDA issued the first emergency use authorization for a vaccine against COVID-19 on December 11, 2020. See more at https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19 (accessed May 20, 2021).

20 More information about the National Vaccine Advisory Committee’s Standards for Adult Immunization is available at https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html (accessed October 5, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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cines at every clinical encounter. To advance a paradigm shift in adult immunization, the NVAC standard calls for all health care providers (including non-vaccinating providers) to take four steps when they see an adult patient:

  1. Assess immunization status of the patient at every clinical encounter.
  2. Strongly recommend vaccines that the patient needs.
  3. Administer vaccines at the same visit or refer the patient to a vaccine provider.
  4. Document vaccines received by the patient.

Tan emphasized that this four-step standard of care is based on existing knowledge of the barriers to vaccination and established best practices for combating them. The problem is not a failure of understanding the problem; it is a failure of properly implementing proven solutions in the health care system.

USING MOBILE HEALTH INTERVENTIONS TO IMPROVE VACCINATION COVERAGE

Presented by Momin Kazi, Aga Khan University

Kazi described how mobile health (mHealth) interventions can help to improve vaccination coverage by addressing barriers to immunization and using geospatial mapping to follow disease outbreaks. He also explored challenges related to the use of mHealth interventions. He remarked that the implementation of policies intended to slow the COVID-19 pandemic have collaterally halted preexisting mass immunization efforts, regardless of a country’s income (Hoffman and Maclean, 2020). Lack of adherence to childhood vaccination schedules also negatively affects vaccination coverage, he added (Lighter, 2019). Text messages are sometimes considered “the magic pill” for addressing these types of challenges. However, although automated mobile messages have shown effectiveness at improving vaccination coverage, as demonstrated in Pakistan’s Sindh province,21 there are drawbacks to the use of such interventions.

Using Mobile Phones for mHealth Interventions

Kazi suggested that mHealth interventions aimed at increasing vaccine coverage may be most effective if they are compatible with non-smartphones

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21 More information about automated mobile messages increasing vaccine coverage is available at https://www.thenews.com.pk/print/524460-automated-text-voice-messages-increase-vaccine-coverage-in-sindh-s-underserved-areas-by-26pc (accessed October 5, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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to increase accessibility (Kazi et al., 2018). Even though mobile phone coverage has rapidly expanded in recent years,22 smartphone access has not expanded as rapidly in low- and middle-income regions of Asia when compared to wealthier regions, Europe, or the United States. Non-smartphones still outnumber smartphones in some Asian nations (e.g., India, Indonesia, the Philippines, and Thailand),23 with less than one-third of the population using smartphones.

Because mobile usage across the world is variable, Kazi suggested considering people’s preferred methods for text communication when determining an intervention. Kazi cited 2018 data from Textrequest Reports, claiming that there are 7.7 billion mobile phone service subscriptions globally.24 In 2018, 8.5 billion person-to-person messages were sent via short message service (SMS) each day, and each mobile phone exchanged an average 32 SMS messages per day. He added that volumes on messaging apps are even larger. If planning to implement a digital health–based intervention, such as mHealth, Kazi suggested first considering the program’s basic requirements, such as:

  • Mobile network accessibility
    • Internet access
    • Mobile phone coverage
  • Population access to mobile networks
    • Mobile network usage
    • Literacy
    • Technological savvy
  • Availability of electricity for timely charging of mobile phones
  • Device security
    • Risk of theft

In addition to technological requirements, Kazi pointed out some important considerations regarding infrastructure and the use of applications. Implementers will likely need to adhere to various regulations and maintain access to some gateway or portal through which they can view and monitor intervention data.

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22 More information about global mobile phone coverage is available at https://www.brookings.edu/wp-content/uploads/2019/04/20190410_futuredevelopment_Mobile_ownership_2018.jpg (accessed October 5, 2020).

23 More information about smartphone penetration is available at https://www.nielsen.com/bd/en/insights/article/2013/the-asian-mobile-consumer-decoded (accessed October 5, 2020).

24 More information about mobile phone subscriptions worldwide is available at https://www.statista.com/statistics/262950/global-mobile-subscriptions-since-1993 (accessed April 2, 2021).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Using Automated Messages to Address Barriers to Immunization

Kazi described the use of automated messages in addressing barriers to immunization. These messages can be sent via messaging apps, SMS, and as automated calls; the content is typically a reminder, educational message, or interactive message. Reminder messages may inform the recipient that their child is due for vaccination on a particular scheduled date. Educational messages may inform the recipient that their child’s scheduled immunization will protect them against certain diseases (e.g., polio, whooping cough, diphtheria, measles, pneumonia, tuberculosis). Interactive messages may remind the recipient of a scheduled vaccine or checkup and prompt the recipient to send a response from a set of programmed options.

Kazi emphasized that these automated messages can be tailored to address specific barriers to immunization such as vaccine hesitancy, lack of knowledge, forgotten appointments, lack of trust, adverse effects, and religious or social barriers (Kazi et al., 2018). One systematic review of 12 studies—9 of which were conducted in the United States and 3 in LMICs—found modest evidence that messages sent via digital push technologies could improve vaccine uptake and series completion (Kazi et al., 2019). In this review, reminders and educational messages were used to promote the uptake of a wide range of vaccines, including all childhood vaccines; measles, mumps, and rubella (MMR); human papillomavirus (HPV); influenza; measles containing vaccine dose 4 (MCV4) or DTP; and pneumococcal.

According to Kazi, another review evaluated 21 studies, including 14 studies conducted in the United States and 7 studies conducted in LMICs. The studies evaluated the use of both one-way and two-way SMS reminders to promote coverage for a variety of vaccines, including all childhood vaccinations, HPV, MMR, influenza, MCV, DTP, and varicella. Researchers found that all the messages sent via SMS and automated calls increased vaccine uptake compared to the control arm—especially messages involving adolescent vaccines—demonstrating the potential for mobile phone–based interventions to improve immunization coverage for children and adolescents, said Kazi.

A 2020 systematic review examined 25 unique mobile applications designed to improve vaccine coverage. The review evaluated the applications for cost-effectiveness, usability, acceptability, participant perception, and vaccination outcomes (de Cock et al., 2020). The review comprised 28 studies, including pre–post studies, cross-sectional surveys, longitudinal studies, randomized controlled trials, qualitative studies, economic studies, and interrupted time series studies. Out of nine studies that evaluated vaccination uptake, four found significant improvement in vaccination coverage. Out of 10 studies that evaluated the effect of vaccination apps on knowledge and learning, 4 showed statistically significant improvements. He pointed out that

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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the quality of the 28 studies was moderate to poor, with many aspects of the studies’ methodologies being unclear to the reviewers. Thus, further work is needed to develop new methods of evaluating these technologies, he added.

Kazi described additional studies that investigated the use of SMS interventions as a monitoring strategy in vaccination campaigns. In one pilot study, Kazi and his colleagues used automated SMS messages to monitor polio supplementary immunization (Kazi et al., 2014). To look at the role of SMS two-way messages for monitoring and supplementing immunization activity for house-to-house polio immunizations, they collected demographic and surveillance data and conducted a baseline survey in three towns in Karachi, Pakistan. Interactive messages in Urdu were sent to the households asking whether the vaccine had reached the household and whether the child had been vaccinated. The coverage data collected from responses to these messages were compared to coverage data generated from phone calls and National Quality Assurance Standards, which is WHO’s preferred technique for household monitoring in the field. Kazi reported the coverage data from all sources were found to be comparable. Furthermore, the monitoring method used in the pilot study allowed for additional data collection, including geographic coordinates that could be used to generate vaccination density maps. Although this technique for remotely monitoring vaccination coverage via SMS messaging is valuable, Kazi cautioned that reminders sent via SMS messages may not be sufficient to guarantee improved immunization coverage. For instance, the technique used in this study did not allow researchers to collect vaccination data for all children in the household.

In another study, Kazi and colleagues conducted a randomized controlled trial on the effect of mobile phone text message reminders on routine immunization uptake in Pakistan (Kazi et al., 2018). They sent one-way reminder messages to participants on the expected week of vaccinations at weeks 6, 10, and 14. Results showed a 5 percent increase in immunization coverage for those receiving SMS messages when compared to the control arm. Both the intention-to-treat and per-protocol analyses showed higher coverage for each visit, but only the routine immunization coverage scheduled at 6 weeks was statistically significant. Furthermore, they found that 94 percent of participants had a mobile phone in their household and 99 percent of participants were comfortable using text messages. This study concluded that simple, automated, one-way SMS reminders in local languages may be feasible for improving routine vaccination coverage. However, it was not clear whether SMS reminders alone are sufficient to alter parental attitudes and behavior. Studies designed with higher statistical power are needed to compare the effectiveness of various types of messaging with various forms of content, Kazi noted. He added that further investigation is needed into the perceptions and barriers associated with immunization in local settings that can affect the implementation of SMS-based interventions.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Based on experiences from the previous studies, Kazi and his colleagues conducted another study investigating the use of SMS messages in improving vaccine coverage among children in urban and rural districts of Pakistan. The mixed-method study began with qualitative interviews and enrollment of children aged 0–2 weeks. The intervention comprised a sequence of weekly immunization messages.25 The study had four intervention arms: one-way SMS messages, two-way SMS messages, one-way automated phone calls, and two-way automated phone calls (i.e., interactive voice recordings). Each week, messages were sent to participants in their chosen language.26 These messages were rigorously designed to address the barriers to immunization identified during qualitative interviews, and were also adapted based on families’ reported perceptions of vaccination and daily life challenges. Barriers revealed through qualitative interviews included forgotten due dates, lack of awareness, lack of socioreligious buy-in, distrust, and concerns about adverse effects. Kazi reported on the demographic findings of the study: 79.1 percent of participants had access to a simple function phone; 54.5 percent of fathers and 13.8 percent of mothers owned a mobile phone; 99 percent of participants were comfortable using SMS; and 50 percent of mothers and 38.4 percent of fathers had no formal education. The intervention used in this study showed a significant improvement in vaccination coverage, said Kazi. The greatest improvement was achieved by the interactive voice recording arm of the study, which showed a 26 percent improvement in vaccination coverage compared to the control arm. One technical challenge identified by the researchers was that a concerning number of families did not receive the intervention messages. Still, Kazi suggested that this intervention be scaled up using interactive voice recordings that are tailored according to identified barriers to immunization.

Using Geospatial Mapping to Follow Outbreaks

Kazi discussed the role of geospatial maps in improving vaccination coverage. Such a technique was used to investigate an outbreak of ceftriaxone-resistant Salmonella enterica serotype typhi in Hyderabad, Pakistan (Qamar et al., 2018). In this case, geospatial mapping data helped research-

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25 The intervention messages included general immunization education, education about adverse effects of immunization, education about religious immunization concerns, immunization reminders when participants’ children reached ages 6 weeks, 10 weeks, and 14 weeks, and combination messages.

26 Participants’ language of choice was assessed during qualitative interviews, and these interviews were also used to select appropriate background music and dialogue for automated calls. Languages used in the study included English, Roman Urdu, Urdu, Roman Sindhi, and Sindhi. Forms of Urdu were often preferred at urban sites, while forms of Sindhi were often preferred at rural sites.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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ers understand the burden of extensively drug-resistant typhoid in various areas throughout Pakistan, including Karachi. These maps have also been used to identify opportunities for catch-up vaccination and to strategize about DTP vaccination efforts.

Challenges in the Use of mHealth Interventions to Increase Vaccination Uptake

Kazi discussed several challenges related to the use of mHealth interventions for increasing vaccination uptake. Phone access and ownership is central to the success of these interventions, particularly in LMICs. Importantly, phone access and ownership vary between females and males, within family structures (i.e., fathers’ access versus mothers’ access to phones), and within communities and villages. Literacy is another important concern, as low literacy rates can reduce the effectiveness of mHealth interventions reliant on text messages. Thus, care should be taken in intervention design to identify and use the appropriate method of best understanding in each setting. Using participants’ preferred language, or pictorial aids, can help address issues of literacy and language comprehension. Kazi reiterated the importance of tailoring messages to address specifically identified barriers as well as carefully selecting the types of messages used in mHealth interventions. Availability of appropriate infrastructure and lack of technological savvy may also pose challenges to mHealth interventions, he added. Local infrastructure needs to be able to sustain the communication infrastructure demands of these interventions so participants can send and receive the requisite messages to fully partake in interventions. These interventions also require that participants have sufficient ability to operate their mobile phones and smartphones. Lastly, he pointed out that in settings where mobile services, vaccination services, and other health care providers are unavailable, mHealth interventions cannot be effectively implemented. He characterized these situations as missed opportunities.

Given the need for well-planned, personalized, community-based, knowledge-translation interventions, Kazi suggested that mHealth should be scaled up at the program level. He proposed that these programs be barrier based and connected with digital immunization registries to engage directly with caregivers throughout routine immunization programs. These interventions may also be adapted to artificial intelligence and machine learning models. He acknowledged that scale up is complex and requires extensive stakeholder engagement, adding that considering the “human factors” is invaluable during the scale-up process. Lastly, Kazi highlighted the importance of both implementation and evaluation for the success of digital health interventions. Evaluation of efficacy is valuable, he said, but evaluation of the “why and how” is of the utmost importance.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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THE ROLE OF COMMUNITY-BASED PHARMACY INTERVENTIONS IN INCREASING VACCINE ACCESS

Presented by Jeff Goad, Chapman University School of Pharmacy

Goad discussed an approach to pharmacy-based vaccination that could potentially be implemented in various settings throughout the world. This approach requires only access, expertise, and operational efficiency to facilitate the delivery of vaccines in a community. He began with an overview of pharmacists’ involvement in vaccination efforts in the United States. Increased pharmacy involvement in vaccination began in 1993, when the U.S. Department of Health and Human Services asked the American Pharmacists Association (APhA) to define the role of pharmacists in administering vaccines to adults.27 Before 1996, fewer than 14 states had approved pharmacists to administer influenza vaccinations, and few pharmacists were trained to administer vaccines. In 1996, APhA created the Pharmacy-Based Immunization Training Program and by 2009 all states allowed pharmacists to administer influenza vaccines to adults. Goad explained that the 2009 influenza pandemic was the breaking point that spurred all states to partner with pharmacists to assist with vaccine administration. By 2020, pharmacists in 52 U.S. states and territories had been permitted to administer vaccines that cover influenza, meningococcus, tetanus/diphtheria/pertussis (Tdap), zoster, and pneumococcus, and currently 47 states allow pharmacists to administer any vaccine. Between 2007 and 2017, the number of U.S. pharmacists trained to administer vaccines increased from 40,000 to 320,000. Pharmacists are trained to administer vaccines through a national immunization training program recognized by CDC.

Goad invoked the concept of a “neighborhood of other providers,” adding that providers ought to “walk the walk and talk the talk” in terms of vaccination. He presented data on vaccination coverage among health care providers to underscore this point. Influenza vaccination rates among pharmacists has been documented since the 2012–2013 influenza season, and coverage among pharmacists has remained between approximately 85 percent and 91 percent since 2012.28 Similarly, during the 2018–2019 influenza season, at least 90 percent of physicians, nurses, and nurse practitioners/physician assistants were vaccinated against influenza. Goad explained that the

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27 More information about the number of states authorizing pharmacists to administer influenza vaccine and the number of pharmacists trained to administer vaccines is available at https://www.pharmacist.com/sites/default/files/files/States_Authorizing_Pharmacists_vs_training_December_2017.pdf (accessed October 7, 2020).

28 More information about influenza vaccination coverage among health care personnel is available at https://www.cdc.gov/flu/fluvaxview/hcp-coverage_1819estimates.htm (accessed October 7, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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pharmacy has become one of the primary places of influenza vaccination for adults, second only to the traditional vaccine distribution setting of doctor’s offices.29 Between 1998 and 2019, the percentage of adult influenza vaccine administered at pharmacies increased from 5 percent to 32.2 percent. Importantly, this increase in vaccination at pharmacies reflects improved access to vaccines and an expanded pool of vaccinated adults, rather than merely a shift in location of vaccine administration (Papastergiou et al., 2014).

Challenges in Pharmacy-Based Vaccination

While the expansion of pharmacy-based influenza vaccination has been successful overall, there have been some shortcomings, said Goad. For instance, in 2017 only 10.3 percent of recently pregnant women who received influenza vaccines had their vaccine administered at a pharmacy, drug store, supermarket, grocery store, or superstore.30 Similarly, in 2017 only 7.4 percent of women who received Tdap vaccines had their vaccine administered at a pharmacy, drug store, supermarket, grocery store, or superstore.31 Goad pointed out that pharmacists are allowed to administer Tdap vaccinations in all U.S. states, but there is an apparent drop-off in pharmacy-based vaccination among pregnant women. This drop-off is likely related to perceptions and knowledge about the role and training of pharmacists, he said. Patients may be unaware that pharmacists are authorized and trained to administer vaccines other than influenza vaccines and that they are able to administer vaccines to pregnant women. Education efforts may help to address these challenges, he said.

In a study that investigated the role of pharmacy-based vaccination and extended hours of vaccination, Goad and colleagues conducted a retrospective database analysis (Goad et al., 2013). They looked at the number and proportion of vaccines administered by a large chain pharmacy during traditional clinic hours (i.e., weekdays between 9 a.m. and 6 p.m.) and off-clinic hours (i.e., early mornings, evenings, weekends, and federal holidays). The chain administered 6.2 million doses of vaccine between 2011 and 2012. Of those vaccinated, 69.5 received the vaccination during traditional clinic hours and 30.5 percent received the vaccination during off-clinic hours, with

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29 More information about general population vaccination coverage is available at https://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2018.htm (accessed October 7, 2020).

30 More information about influenza vaccination among pregnant women in the United States is available at https://www.cdc.gov/vaccines/pregnancy/hcp-toolkit/pregnant-coverageestimates.html (accessed October 7, 2020).

31 More information about pregnant women and Tdap vaccination in 2017 is available at https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/tdapreport-2017.html (accessed October 7, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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10 percent in evenings.32 Of the vaccines administered by the pharmacy chain, 85 percent were influenza vaccines and 15 percent were routine vaccines, travel vaccines, or other vaccines. Goad commented on the surprising number of people choosing to vaccinate on federal holidays (around 182,000 people).

Goad discussed unexpected findings regarding age groups and after-hours vaccination rates. Of those vaccinated at the pharmacy chain, 46 percent were aged 65 years or older and 3.3 percent were aged 18 years or younger. During non-clinic hours however, 22 percent of those vaccinated were aged 65 or older while 51 percent were aged 18 years or younger. Goad suggested that this pharmacy may have met the needs of parents who wished to have their children vaccinated after work. Even though the group for children aged 18 years or younger comprised only 3.3 percent of all vaccinated individuals in the study, Goad interpreted their overrepresentation in the evening vaccination cohort as a possible opportunity to expand vaccine access during off-hours.

One way that pharmacy-based immunization has been promoted is through the creation of state-authorized providers, said Goad. In 18 states, pharmacists who have this designation are authorized to provide influenza vaccines without a prescription or any other protocol involving a physician.33 Even with this designation, however, there are some variations based on age. State-authorized providers are only allowed to administer vaccinations to children above a certain age, which varies by state.34 In these states, pharmacists’ authority to administer vaccines comes from a statute, a state board of pharmacists, or public health regulations.

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32 Goad reported that 10.19 percent of those vaccinated received their vaccination during the evening; 17.39 percent of those vaccinated received their vaccination during a weekend, and 2.92 percent of those vaccinated received their vaccination on a federal holiday.

33 More information regarding state regulations about pharmacist-administered vaccines is available at https://www.pharmacist.com/sites/default/files/files/practice/07-2020/pharmacistadministered-vaccines-june-2020.pdf (accessed October 7, 2020).

34 Goad explained that the age breaks in each state are set based on state-specific considerations. For instance, the age break in California is based on the CDC anatomic age break for vaccination for children. According to CDC, children aged ≥ 3 years may be vaccinated via the deltoid (versus the vastus lateralis). Accordingly, California authorizes pharmacists to vaccinate individuals aged ≥ 3 years. In Arkansas, New Hampshire, and New Mexico, pharmacists are authorized to vaccinate individuals of any age. In Virginia, pharmacists are authorized to vaccinate individuals aged ≥ 6 months. In Arizona and California, pharmacists are authorized to vaccinate individuals aged ≥ 3 years. In Idaho and Wisconsin, pharmacists are authorized to vaccinate individuals aged ≥ 6 years. In Louisiana, Maine, Oregon, Texas, and Wyoming, pharmacists are authorized to vaccinate individuals aged ≥ 7 years. In Maryland, pharmacists are authorized to vaccinate individuals aged ≥ 9 years. In Montana and South Carolina, pharmacists are authorized to vaccinate individuals aged ≥ 12 years. In South Dakota and West Virginia, pharmacists are authorized to vaccinate individuals aged ≥ 18 years.

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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The Case for Pharmacy-Based Immunization

Goad made a case for pharmacy-based immunization based on three factors: geographic distribution of pharmacies and pharmacists, the access to vaccines through pharmacies, and the training systems in place for pharmacist-administered vaccination.

First, pharmacies and pharmacists are common and accessible throughout large portions of the country. There are 88,181 pharmacies across the United States, around half of which are independent and half are corporate chains (Qato et al., 2017). Goad claimed that the country has more than 300,000 licensed pharmacists, making it one of the largest health care professions in the country after physicians and nurses; about half of all pharmacists work in community pharmacies.35 Around 86 percent of the U.S. population lives within 5 miles of a pharmacy (NACDS, 2018). Some regions have fewer pharmacies per 10,000 population, especially on the West Coast where the majority of the population is concentrated in high-density metropolitan areas.

Second, pharmacy-based vaccines are more accessible. In support of his case, Goad added that all 50 U.S. states allow pharmacists to administer vaccines, and because pharmacies are typically open during off-clinic hours, they extend the hours available for vaccination.

Third, pharmacists are trained and qualified to administer vaccines. Schools of pharmacy are required to teach immunization as part of their curricula, ensuring that pharmacists have the requisite expertise to administer vaccines. Pharmacists can receive additional training about vaccination through a national, CDC-recognized training program, he added.

Potential for Pharmacy-Based Immunization in Response to Pandemics

Goad presented findings from a Monte Carlo simulation of an influenza pandemic to demonstrate the potential of pharmacy-based immunization as part of multimode vaccine delivery response (Bartsch et al., 2018). The simulation revealed that having multiple providers administering vaccinations reduces stress on any given system. In the simulation, when only clinics and physician offices were administering pandemic vaccines, the overall vaccination coverage was lower than when vaccines were administered through a combination of delivery modes, including large retail pharmacies, independent pharmacies, urgent care centers, clinics and physician offices, and hospitals. In a scenario in which only clinics and physician offices could provide vaccinations against a pandemic influenza, Goad suggested that the

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35 For more information on community pharmacies, see https://www.bls.gov/ooh/healthcare/pharmacists.htm (accessed December 17, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

quality of routine care would also be reduced owing to the additional vaccination burden. The simulation confirmed the value of starting vaccination early in a pandemic and maximizing the immunization rate to maximize the benefits of immunization during a pandemic. In the simulation, using pharmacies to administer vaccines increased vaccine coverage by 33.7 percent, avoided up to 23.7 million symptomatic influenza cases, and realized a cost savings of up to $2.8 billion to third-party payers and $99 billion to society.

Goad discussed the 2009 H1N1 pandemic as an example of pharmacy-based vaccination. During the 2009 H1N1 pandemic, pharmacy-based vaccination was implemented relatively late. Still, between December 2009 and February 2010, CDC distributed 5 million doses of 2009 H1N1 vaccine to pharmacy chains. Ten percent of people in the United States who were vaccinated against that pandemic virus received their dose in a pharmacy (Koonin et al., 2011). Had pharmacy-based vaccination been implemented immediately, pharmacists would have likely administered an even greater proportion of vaccine doses during that pandemic, said Goad. He emphasized that this valuable lesson may inform pandemic responses in the future to ensure that all partners are used to deliver efficient, effective, and safe vaccines.

DISCUSSION

Applying the Zero-Dose Children Concept to Other Populations

MacDonald acknowledged the value and impact of the zero-dose concept in low-income countries and asked whether this model could work in middle- and high-income countries. Gupta pointed out that the zero-dose concept is still nascent, but it has value as a measure of vaccination coverage in LMICs such as Brazil, the Philippines, and South Africa where the number of under or unimmunized children is increasing. In high-income countries, it may also be worthwhile to measure zero-dose children because of the emerging trends of vaccine hesitancy and anti-vaccine sentiment. Thus, although the drivers of zero-dose children rates may vary, the measure itself could have value in any setting. She added that the zero-dose concept also demonstrates the need to proactively address stigmatization and compounded vulnerabilities. MacDonald asked whether the zero-dose concept can be applied to adult populations who have never received DTP/Tdap, pneumococcal vaccine, varicella vaccine, or influenza vaccine. She also proposed that these would-be zero-dose adults could be identified via geospatial mapping, similar to the techniques discussed by Kazi.

Tan commented that measuring zero-dose children in the United States could be problematic; for instance, selective dose skipping of pediatric immunizations may complicate the measurement process. However, it may be more feasible to use geospatial technology, zip code tracing, and geographic

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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information systems to identify adults who have not received immunizations. These technologies may help to reveal not only the location of underimmunized adults, but also possible underlying causes that should be addressed (e.g., socioeconomic barriers to vaccination). He pointed out the difficulties associated with addressing social determinants of health in the United States and hypothesized that applying the zero-dose concept to American adults could help to identify geographic areas with limited access to vaccines and preventive health—so-called vaccine deserts or preventive health deserts. He suggested that issues of vaccine trust may also be connected to the broader considerations related to the social determinants of health.

MacDonald remarked that Gavi has focused its efforts on childhood vaccines and HPV for school-aged children, but WHO has not focused on adult immunization in a commensurate way. She asked whether the zero-dose concept could be repurposed for adult immunization. Ann Lindstrand, Expanded Programme on Immunization coordinator at the Department of Immunization and Biologics at WHO, said that the concept could kick-start efforts to increase vaccine reach and access. It could also improve approaches to vaccination of adults as well as at-risk groups (e.g., older adults) that have complex challenges related to identification and monitoring. She added that the zero-dose concept is also appropriate for children in high-income countries, where there are many socioeconomically deprived children, children of undocumented migrants, and other children in marginalized populations who may not have received a single dose of any vaccine. She noted that whether targeting zero-dose children or adults, the same steps apply: map, find, listen, adapt, tailor, and respond with services. MacDonald suggested that those steps should be instilled in all health care professionals.

Role of Pharmacies in Immunization Delivery and Education

MacDonald pointed out that in the United States and other high-income countries, pharmacies are fairly accessible, and most individuals visit a pharmacy much more frequently than they visit a family physician. She asked how pharmacies could be used as vaccination delivery sites for forthcoming COVID-19 vaccines once they become widely accessible to adult populations. Goad noted that there are efforts already under way to address this question. With funding from a CDC grant, the California Department of Public Health is working on adapting the current model used for influenza vaccination. However, because of the novel protocols associated with the COVID-19 pandemic—such as the need for personal protective equipment (PPE) and other safety precautions—it is yet unclear whether pharmacies can transition to administering COVID-19 vaccinations while maintaining the same operational efficiencies and high throughputs they have been able to achieve with the seasonal influenza vaccine. Pharmacies are typically

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

located in retail locations near parking lots, in grocery stores, and in other spacious settings, so innovative approaches to vaccination and pharmacist deployment could be beneficial in the pandemic context. Furthermore, the increase in mail-order medication distribution has afforded pharmacists more time that can be spent on patient care programs. Goad maintained that pharmacists could play a major role in distributing forthcoming vaccines in 2021 by serving as the access point of convenience for both receiving and distributing vaccines.

McDonald asked about the potential role of pharmacies in providing immunization education as well as serving as vaccine delivery sites, given the frequency with which people tend to visit pharmacies. Goad noted that the role of pharmacists as educators has been explored not just for immunization education, but for other preventable diseases as well. A wide range of tools are available to pharmacists, including informative posters and targeted campaigns informed by databases. He pointed out that each time a person visits a pharmacy, it is a unique opportunity for the pharmacist to provide education. He suggested using data to target interventions, as well as using patients’ frequent visits to afford pharmacists the opportunity to come out from behind the counters and interact with their patients.

Tan suggested using other health care delivery settings in addition to pharmacies. For instance, immunization efforts could use the ongoing shift in the United States and abroad toward larger, comprehensive health care systems. In addition to using business models as a driver, the case for investment in immunization could be made stronger by invoking the benefits of immunization in connection with chronic disease management and patient experience. Tan suggested implementing known strategies for expanding immunization coverage and other preventive and educational services. For instance, health systems could begin to recommend that patients visit their pharmacist, who can have systems in place to provide innovative access to immunizations and education. These systems will be especially relevant in addressing the ongoing COVID-19 pandemic, but they should also be sustained indefinitely. These systems can also reduce costs and introduce new pathways for care. For instance, in the future, patients may be able to begin their care with a telehealth visit, then be referred directly to an expanded access location such as a pharmacy.

Literacy and Vaccine Uptake in Low-Income Countries

MacDonald asked whether literacy is an issue connected to poor vaccine uptake in low-income countries. Lindstrand said that literacy plays a role in vaccination uptake, adding that oral communication between health care providers and parents must be conducted in an appropriate and respectful way. She added that if immunization strategies transition toward digital tools

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

and SMS messages, then literacy will certainly be a barrier. Strategies for sharing and discussing the value of vaccines should be tailored to a specific population based on the kind of information that needs to be conveyed. Gupta cited evidence on the connection between immunization uptake and literacy and compelling data to support the claim that maternal health literacy is independently associated with child vaccination (Johri et al., 2015). Gupta added that the connection between female literacy and immunization uptake in low-income settings is related to the fact that mothers are disproportionately bearing the burden of child care. One aspect of strategies for addressing gender-related barriers is to bring men into the conversation. Additional gender-related issues also need to be considered, such as the gender gap in access to mobile phones.36 She cautioned that when targeting zero-dose children among the poorest of the poor, digital interventions may actually exacerbate underlying inequities.

Kazi said that literacy has been a hurdle in the studies he has conducted, particularly with regard to the use of text messages. In a study evaluating personalized text messages and automated calls for improving vaccine coverage among children in Pakistan, around 50 percent of fathers and 38.4 percent of mothers had received no formal education and the majority of illiterate participants lived in rural areas (Kazi et al., 2018). Pictorial messages or other messages personalized and tailored for such families may help to alleviate this barrier. For instance, when a message is sent to a husband or mother-in-law who then passes on the message to the participant—typically the mother of the child—that message can help bring about a change in vaccination choices.

This same notion applies to the issues of gender disparities, he noted. Fathers are often the only household member with access to a mobile phone. If health care workers counsel families appropriately and send messages to the household that address the issues raised by the household decision maker, then mobile phone–based interventions can change behavior despite gender disparities in access to mobile phones. Kazi suggested that the mobile phone–based techniques used to promote child vaccination in low-income countries could be used to promote vaccination among adults in high-income countries, especially for forthcoming COVID-19 vaccines. Because mobile phones are ubiquitous in high-income settings, messages can be personalized both in terms of identified barriers and in terms of the technologies used to deliver messages. MacDonald asked whether mobile phone–based interventions should send messages at a particular time of day. Kazi said that in his group’s studies, participants were asked at which time they would like to

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36 More information about the mobile gender gap is available at https://www.gsma.com/mobilefordevelopment/wp-content/uploads/2020/05/GSMA-The-Mobile-Gender-Gap-Report-2020.pdf (accessed October 8, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

receive messages during the baseline interview process. Although preferred times varied between rural and urban participants, around 70 percent of participants said that any time was acceptable. Some participants, especially in rural settings, preferred to receive messages during the evening. He speculated that the evening preference may reflect that the mobile phone is with the male member of the family during the day. If so, it may be the case that evening messages would be more effective because it would increase the likelihood that female family members might also see the messages.

Building Trust and Overcoming Racial and Ethnic Disparities in Immunization

Regarding the COVID-19 vaccination survey, MacDonald reiterated the finding that African American and Hispanic populations in the United States were found to be less willing to receive the vaccine. She asked Tan to elaborate on the survey participants (e.g., whether it was possible to determine geospatial location and identify first-generation immigrants—and their access to vaccination services). Tan replied that the survey did not capture whether participants were first-generation immigrants.37 He said:

The Minority Quality Forum has conducted research about adult immunizations among African American communities which found that a majority of African Americans living in urban areas reside in one of 32 U.S. zipcodes that could potentially be used to geographically map racial disparities and target those populations with messaging that encourages them to visit a pharmacist and get vaccinated.38,39

Cultural sensitivity is needed in considering the use of access points, such as community centers and places of worship, where trusted community voices can deliver messages about vaccinations. He suggested that mistrust of health care systems (especially government entities) among some demographic groups, specifically among the African American population, may be a barrier that could be addressed by community leadership engagement and culturally sensitive consideration of alternative access points.

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37 More information about COVID-19 vaccine polling is available at https://apnorc.org/projects/expectations-for-a-covid-19-vaccine (accessed October 1, 2020) and https://www.newsweek.com/will-black-americans-fear-vaccine-more-covid-19-opinion-1516087 (accessed October 1, 2020).

38 For more information on zip codes as tools for geographically targeting areas of poor vaccine coverage, see https://link.springer.com/article/10.1007/s12325-020-01324-y (accessed December 4, 2020).

39 For more information on the National Minority Quality Forum’s indices, see https://www.nmqf.org (accessed May 20, 2021).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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MacDonald said that in low-income countries, buy-in from religious leaders and community leaders significantly improves uptake of vaccines and other health services. She highlighted the value of imbuing a sense of ownership in health care providers at the community level to mobilize them to address health issues in their own communities. To that end, she asked how pharmacies could play a role in promoting community-level ownership. Goad suggested two methods. Pharmacists are consistently ranked among the most trusted professions in terms of honesty and ethics;40 however, much progress remains to be made to ensure that pharmacists better reflect the communities they serve. For example, pharmacies can hire technicians and clerks who live in the communities where pharmacies or clinics are located. This will bring patients and pharmacists closer together, and improve opportunities for basic education about vaccinations. He added that community pharmacies have made more progress than retail pharmacies in this respect.

Tan pointed out that policy regarding racial and ethnic disparities is set at the national level, but implementation happens at the local level. Geographic data can be used to identify those local health care providers who are falling short in implementing such national policies—not to highlight their failures, but to address gaps in implementation and give these providers the appropriate tools for outreach and communication. Tan suggested using political advocacy to help gain funding for local-level efforts. For example, immunization advocates could inform members of the U.S. House of Representatives of the low rates of vaccination among their African American or Hispanic constituents to galvanize both fiscal and policy support.

MacDonald noted that in 2004, UNICEF and WHO published guidance on working with religious leaders to build trust in immunizations (UNICEF, 2004). She asked whether any guidance efforts were under way to support engagement with trusted community members, specifically in communities in high-income countries with low immunization uptake. Lindstrand said that such guidance is not yet under development, but there are efforts under way to address misinformation related to the COVID-19 pandemic that may include leveraging trusted community voices. MacDonald said that religious leaders play an important role in promoting vaccines in communities around the world. Therefore, engaging with these trusted individuals could be an effective step for changing perceptions in vaccine-hesitant communities.

Gupta explained Gavi’s philosophy that immunization programs must be locally developed and adapted. Furthermore, developing language and idioms that resonate with communities is critical. For instance, in Laos, the use of the languages of certain ethnic minorities is prohibited under national

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40 More information about Gallop’s ranking of honesty and ethics in professions is available at https://news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx (accessed October 8, 2020).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
×

law. This creates a “problem of idiom” and gives rise to communication barriers that may need to be addressed through methods of visual communication. She noted that religious leaders have played important roles in Gavi’s strategies, such as efforts to fight polio in India and their work with an Uluma organization to address challenges related to halal restrictions in Indonesia. Religious leaders play an important role in most contexts, but the strategy used to engage religious leaders will vary according to the context, she added.

MacDonald remarked that Canada uses state immunization documents in 12 languages to account for the large population of new immigrants and refugees that arrives each year. Despite this attempt at bridging language gaps, it is likely these documents were translated without accounting for idiom and community mindsets. Tan replied that the Immunization Action Coalition translates documents as well; they currently offer documents in 27 languages, but they have not yet made an effort to ensure culturally competent communication. Culturally competent communication goes beyond merely the correct language, but includes a cultural understanding founded on knowledge of societal doctrines. For instance, in a collectivist society, collectivist language should be used. Alternatively, cultures that value individual independence, such as the Russian immigrant communities in the United States, may be more receptive to different styles of wording. He said that broadly, the vaccine advocacy community has not yet captured and applied this kind of knowledge to better engage with racial and ethnic minorities.

Reflections on Session 1

Heidi Larson, professor of anthropology and risk and decision science at the London School of Hygiene & Tropical Medicine and director of the Vaccine Confidence Project, provided her reflections on the first day of the workshop. She noted the importance of simultaneously considering issues related to both demand and access. COVID-19 has globally disrupted vaccines and public health, and has broadly impacted immunization rates and practices. While strong infrastructure, appropriate messaging, and education are needed to improve vaccine uptake, the often neglected role of personal values in immunization attitudes cannot afford to be ignored. The moral foundations of decision making and engagement with health care are often poorly integrated into public health and immunization efforts, where context-specific values such as care, fairness, loyalty, authority, purity, liberty, and a sense of self-agency should be considered. Larson said that diversity is another major issue that demands differentiated, context-specific strategies to unmask inequities (e.g., the COVID-19 pandemic’s disproportionate impact on marginalized groups).

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Geospatial mapping has promise for enhancing the capacity to think locally, while advocacy, strategic political engagement, and new public–private partnerships could help to link local and national efforts. The COVID-19 pandemic has most severely impacted those adult populations in which vaccination rates were already low, which has revealed the inadequacy of efforts to address vaccine hesitancy among adults. She noted that the Sage Vaccine Hesitancy Working Group has identified several determinants of vaccine acceptance—including demand factors such as confidence, convenience, and complacency—and pointed out some complacency around the COVID-19 pandemic, with some groups believing that COVID-19 is not a serious concern.

Larson noted that mHealth interventions can play a valuable role in addressing certain barriers to vaccination, but the success of those interventions may hinge on underlying determinants such as infrastructure factors (e.g., access to the Internet, electricity, and mobile phones), gender barriers, intra-family power dynamics, timing of messaging, and synchronicity of interventions within other health system components. Moreover, mHealth interventions cannot be effectively deployed in settings where the corresponding health services are unavailable. Not only would such interventions be ineffective, they may be counterproductive and reduce public confidence.

Community engagement is foundational to promoting immunization and reducing vaccine hesitancy, said Larson. Pharmacists and religious leaders can be leveraged to improve education and vaccine acceptance in communities, but community engagement should be conducted with an appropriate awareness of context and societal doctrines. The response of religious leaders in the face of the COVID-19 pandemic has shown that religious leaders are receptive and willing to engage with public health; however, they should be consulted on the design of messaging to their communities, not merely asked to disseminate information. She suggested using the resourcefulness demonstrated by religious groups that have transitioned to online gatherings and other creative solutions to stay engaged and connected with their congregations. Additionally, COVID-19 vaccinations could be presented as an opportunity to resume in-person gatherings for worship, just as it is being presented as an opportunity to resume in-person work activities. In closing, Larson emphasized in an anecdote the need to collaborate with religious leaders as partners in planning for vaccination efforts, instead of just using them as a communication conduit. She quoted a Nigerian archbishop that she met during her immunization work with UNICEF, who pointed out how organizations like UNICEF “come to us for our megaphones; come to us for our pulpits. But what they don’t come to us for, as religious leaders, is our insights and understandings.”

Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Suggested Citation:"3 Improving Access and Closing the Global Immunization Gap." National Academies of Sciences, Engineering, and Medicine. 2021. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26134.
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Immunization against disease is among the most successful global health efforts of the modern era, and substantial gains in vaccination coverage rates have been achieved worldwide. However, that progress has stagnated in recent years, leaving an estimated 20 million children worldwide either undervaccinated or completely unvaccinated. The determinants of vaccination uptake are complex, mutable, and context specific. A primary driver is vaccine hesitancy - defined as a "delay in acceptance or refusal of vaccines despite availability of vaccination services". The majority of vaccine-hesitant people fall somewhere on a spectrum from vaccine acceptance to vaccine denial. Vaccine uptake is also hampered by socioeconomic or structural barriers to access.

On August 17-20, 2020, the Forum on Microbial Threats at the National Academies of Sciences, Engineering, and Medicine held a 4-day virtual workshop titled The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy. The workshop focused on two main areas (vaccine access and vaccine confidence) and gave particular consideration to health systems, research opportunities, communication strategies, and policies that could be considered to address access, perception, attitudes, and behaviors toward vaccination. This publication summarizes the presentations and discussion of the workshop.

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