The Critical Public Health Value of Vaccines Tackling Issues of Access and Hesitancy: Proceedings of a Workshop (2021) / Chapter Skim
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3 Improving Access and Closing the Global Immunization Gap
3 Improving Access and Closing the Global Immunization Gap
Pages 23-56
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From page 23... ...
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.
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, while Gavi-supported countries had relatively low vaccine coverage rates for Haemophilus influenzae type B (36 percent) , pneumococcus (1 percent)
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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.
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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.
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• 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.
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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.
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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)
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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.
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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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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.
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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.
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. 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-andflu-plans (accessed September 29, 2020)
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Routine immunization rates are recovering but still lagging behind pre-pandemic levels for children. Recovery for adult immunization lags behind that for children.
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. 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.
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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.
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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.
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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 21 More information about automated mobile messages increasing vaccine coverage is avail able at https://www.thenews.com.pk/print/524460-automated-text-voice-messages-increasevaccine-coverage-in-sindh-s-underserved-areas-by-26pc (accessed October 5, 2020)
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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_owner ship_2018.jpg (accessed October 5, 2020)
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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.
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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.
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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)
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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.
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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 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)
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. 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)
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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.
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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.
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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 pharmacybased vaccination.
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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.
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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.
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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.
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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. 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)
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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.
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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.
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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)
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