Research

Abstract

Background: Persistent inequities in access to vaccinations pose challenges for immunization programs worldwide. Innovations facilitating vaccine delivery, such as leveraging vaccine thermostability through a Controlled Temperature Chain (CTC), have emerged as a potential solution to increase coverage in low- and middle-income countries (LMICs) countries such as Côte d’Ivoire, reducing dependence on the cold chain and improving vaccine delivery efficiency. However, the added value of thermostable vaccines and their integration into national immunization programs is under-recognized by stakeholders. This consultation aimed to convene key immunization stakeholders in Côte d’Ivoire in order to examine their perceptions regarding the value of vaccine thermostability to address barriers to outreach and equity in immunization programs. 

Methods: A novel workshop model involving structured group discussions was used to document the viewpoints of national stakeholders representing different areas of the immunization program. They prioritized barriers undermining coverage and equity in their country and explored the potential impact of CTC on the immunization program in the context of thermostable vaccines. The vaccines discussed were for Hepatitis B, Human Papillomavirus, and Meningitis. 

Results: The workshop outcomes highlighted the context and vaccine-specific variation of the importance of certain barriers, emphasizing the need for tailored strategies. The barriers considered most likely to be alleviated by vaccine thermostability were under the categories of human resource management, vaccine supply and logistics, and services delivery. The least relevant category of barriers concerned demand generation. 

Conclusions: The consultation provided valuable insights into stakeholder perspectives, priorities, and conditions for the effective integration of thermostable vaccines, informing future product development and policy decisions to optimize vaccine delivery and address immunization challenges in LMICs.

Highlights

• Effective HPV delivery can be constrained by having to maintain a proper cold chain.

• Reducing last mile cold chain requirements could potentially improve HPV coverage rates.

• More evidence is needed on the impact of leveraging HPV vaccine thermostability through a CTC.

Abstract

Background: Microarray patches (MAPs) are innovative, needle-free vaccine delivery systems, suitable for administration by minimally trained health care workers or trained community health workers. Their introduction may transform immunization programmes, particularly for vaccines where high coverage is required for population immunity, such as measles, and where vaccine delivery is challenging, such as in low- and middle-income countries. Recognizing the need to understand how best to tailor these products to reflect country priorities, workshops on measles and rubella MAPs (MR-MAPs) were conducted in multiple regions to collect insights on needs and preferences from relevant stakeholders at country level. Methods: The CAPACITI Innovation Framework was used to structure stakeholder discussions in nine countries in the period from August 2022 to July 2023. The discussions, building on the findings from a situation analysis on the barriers related to measles and rubella vaccine delivery, followed the four-step process outlined in the framework. Results: Key barriers hindering delivery of measles and rubella vaccines across the countries were in the categories of human resource management, service delivery, and demand generation. MR-MAP attributes that stakeholders believed would reduce or eliminate these barriers included ease of preparation and administration, improved thermostability, fewer (ancillary) components, and single-dose presentation. Some attributes such as the site of administration, wear time, and storage volume could exacerbate certain barriers. Based on an understanding of key barriers, product attributes, and underserved populations, stakeholders identified several potential use cases for MR-MAPs: (i) delivery at a fixed health post, (ii) delivery through outreach sessions conducted by health workers, and (iii) administration by community health workers. To enable robust national decision making about the introduction of MR-MAPs and successful implementation, global and national evidence on feasibility and acceptability of MR-MAPs should be generated. To prepare for the potential introduction of MR-MAPs, immunization programmes should evaluate their immunization policies based on their preferred use cases and modify them if needed, for example, to enable community health workers to administer vaccines, along with making programmatic adjustments to waste management and training. Conclusions: MR-MAPs have the potential to reduce key barriers to MR delivery. Yet, their future impact depends on the ability of global stakeholders to steer the development of MR-MAPs to be responsive to country needs and preferences. The generation of evidence to enable robust decision making, timely modification of vaccine policies, and addressing programmatic considerations will be key to successful uptake.

Abstract

Primary Health Care (PHC) is the most equitable and cost‐effective way to enhance the health of populations and improve health security and is a requirement for achieving universal health coverage (UHC). Vital to advancing the PHC agenda is effective global health partnerships, particularly with Global Health Initiatives (GHIs) which provide financial support for improving population health. Despite progress, GHI support at times remained parallel to rather than embedded in national health strategies. To improve the impact of GHI support, World Health Organization (WHO) member states requested specific guidance to better align GHI support to national health strategies and PHC principles. We present the PHC‐GHI Toolbox as a comprehensive set of resources for use by countries to apply the PHC approach to development of plans for securing and optimally utilizing funding received from GHIs, such as Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM); and the Global Financing Facility (GFF) as well as other donors. The PHC‐GHI Toolbox includes a PHC resource database, GHI‐specific overviews, a database of health system strengthening (HSS) investments, COVID‐19 funding rapid assessment tool, and a focal point database for identifying expert technical assistance. This paper describes the process undertaken for Toolbox development and outlines its potential applications.

Abstract

To ensure that limited domestic resources are invested in the most effective interventions, immunization programs in low- and middle-income countries (LMICs) must prioritize a growing number of new vaccines while considering opportunities to optimize the vaccine portfolio, as well as other components of the health system. There is a strong impetus for immunization decision-making to engage and coordinate various stakeholders across the health system in prioritization. To address this, national immunization program decision-makers in LMICs collaborated with WHO to structure deliberation among stakeholders and document an evidence-based, context-specific, and transparent process for prioritization or selection among multiple vaccination products, services, or strategies. The output of this effort is the Country-led Assessment for Prioritization on Immunization (CAPACITI) decision-support tool, which supports using multiple criteria and stakeholder perspectives to evaluate trade-offs affecting health interventions, taking into account variable data quality. Here, we describe the user feedback from Indonesia and Ethiopia, two initial countries that piloted the CAPACITI decision-support tool, highlighting enabling and constraining factors. Potential immunization program benefits and lessons learned are also summarized for consideration in other settings.

Abstract

Articulating the wide range of health, social and economic benefits that vaccines offer may help to overcome obstacles in the vaccine development pipeline. A framework to guide the assessment and communication of the value of a vaccine—the Full Value of Vaccine Assessment (FVVA)—has been developed by the WHO. The FVVA framework offers a holistic assessment of the value of vaccines, providing a synthesis of evidence to inform the public health need of a vaccine, describing the supply and demand aspects, its market and its impact from a health, financial and economic perspective. This paper provides a practical guide to how FVVAs are developed and used to support investment in vaccines, ultimately leading to sustained implementation in countries. The FVVA includes a range of elements that can be broadly categorised as synthesis, vaccine development narrative and defining vaccine impact and value. Depending on the features of the disease/vaccine in question, different elements may be emphasised; however, a standardised set of elements is recommended for each FVVA. The FVVA should be developed by an expert group who represent a range of stakeholders, perspectives and geographies and ensure a fair, coherent and evidence-based assessment of vaccine value.

Abstract

Background: The break-up of Yugoslavia led to political turmoil, accompanied by socio-economic changes, wars and civil unrest. Health as a social phenomenon is directly and indirectly affected by such changes.

Objective: To give an overview of the changes in life expectancy, as a measure of population health, during times of crisis and large societal changes. The dynamics of change of life expectancy in the different Balkan countries are analysed by calculating the contributions of age and cause specific mortality to the observed changes of life expectancy.

Methods: An original dataset of life-tables is used to calculate life expectancy, created based on mortality data from national civil registers from the 6 ex-Yugoslav republics, assessed for accuracy and completeness. Arriaga’s method is used to decompose the contributions of age groups and causes of death to the observed changes in life expectancy during three time periods: Socialist Federation (1975-1985), Transition (1988-2000), Independence (2007-2017).

Results: Large improvements in life expectancy at birth are noted in all countries, although there is heterogeneity in the dynamics of change. During the Socialist Federation period, life expectancy increased consistently across countries mainly due to reductions in infant and child mortality, as well as reduction in infectious diseases mortality. During the Transition there was a divergence of trends and some countries noted continuous increase in life expectancy, contrasting the decrease in life expectancy in Serbia and Montenegro. In all countries life expectancy increased during the Independence period, due to a reduction in mortality from non-communicable diseases among the older population. 

Conclusion: The findings of this study are important not only because they create an understanding of changes in population health during a period of crisis, but also because they provide accurate estimates of life-expectancy and dynamics of mortality change, allowing for further analysis on the social determinants of health. 

Abstract

Objective: To evaluate the evidence describing how the controlled temperature chain approach for vaccination could lead to improved equitable immunization coverage in low- and middle-income countries. 

Methods: We created a theory of change construct from the Controlled temperature chain: strategic roadmap for priority vaccines 2017–2020, containing four domains: (i) uptake and demand for the approach; (ii) compliance and safe use of the approach; (iii) programmatic efficiency gains from the approach; and (iv) improved equitable immunization coverage. To verify and improve the theory of change, we applied a realist review method to analyse published descriptions of controlled temperature chain or closely related experiences. 

Findings: We evaluated 34 articles, describing 22 unique controlled temperature chain or closely related experiences across four World Health Organization regions. We identified a strong demand for this approach among service delivery providers; however, generating an equal level of demand among policy-makers requires greater evidence on economic benefits and on vaccination coverage gains, and use case definitions. Consistent evidence supported safety of the approach when integrated into special vaccination programmes. Feasible training and supervision supported providers in complying with protocols. Time-savings were the main evidence for efficiency gains, while cost-saving data were minimal. Improved equitable coverage was reported where vaccine storage beyond the cold chain enabled access to hard-to-reach populations. No evidence indicated an inferior vaccine effectiveness nor increased adverse event rates for vaccines delivered under the approach. 

Conclusion: Synthesized evidence broadly supported the initial theory of change. Addressing evidence gaps on economic benefits and coverage gains may increase future uptake.