Introducing New Vaccines in Developing Countries

Sonali Kochhar; Barbara Rath; Lea D Seeber; Gabriella Rundblad; Ali Khamesipour; Mohammad Ali


Expert Rev Vaccines. 2013;12(12):1465-1478. 

In This Article

Macro & Micro Planning

National authorities should be fully involved in introducing a vaccine in their country. In this regard, political commitment is essential. All key stakeholders involved in this program should be in agreement and a memorandum of understanding describing their tasks and responsibilities should be in place and signed by the different parties involved. The coordinating committee needs to engage all relevant individuals and departments at the level of the Ministry of Health, other Ministries and implementing stakeholders and partners. A subcommittee is also needed for planning and supervision of the activities, developing toolkits for information, communication and social mobilization, assessment of the logistics requirement and preparing the budget and finance for the activities related to introduction of the new vaccine. It is also important to ensure that the vaccine is registered by the national regulatory authorities. The vaccination program should establish an intersectorial coordinating committee and thematic subcommittees and analyze epidemiological data to determine the target areas and population. Again, scientists, religious/spiritual leaders, community organizers and patient advocacy groups should be involved. Individuals' responsibilities, task sharing and the schedule of activities are to be clearly defined for the program. Accordingly, a budget is to be made to procure the vaccine, store and maintain the cold chain. Social mobilization, vaccination outposts and staff and logistic requirement need to be finalized for the program. It is also important to develop strategy and operational guidelines, review the acute disease surveillance data base, conduct capacity building workshops, prepare tools for data management, strengthen and develop guidelines for AEFI collection, for monitoring, supervision, communication strategies, media management and field-test guidelines, field-test social mobilization and advocacy materials.

The success of a mass vaccination campaign depends on having an adequate number of vaccination teams.[107] A team usually comprises of vaccinators and volunteers, preferably chosen from the population to be vaccinated. Qualified health care workers should be drawn carefully from hospitals and/or health facilities to ensure the least possible disruption of essential services including routine EPI activities. Depending on the setting, an additional person may be needed to control the crowd. The composition of vaccination teams may also vary depending on the registration system. For a mass vaccination campaign linked to research studies, the number of team members should be increased.

Supervision is necessary to ensure the quality of planning and implementation of the program activities. The success of a campaign largely depends on the work of motivated supervisors who assist in preparation, support training and are able to identify and solve problems before referring issues to the next management level.[107] Supervisors at central level should visit all places before the start of the campaign and revisit the problematic places (in terms of logistics and social mobilization, etc.). Several households should be visited to verify whether the population is aware of the campaign, dates, target population and location of the nearest vaccination center. If the supervisory visit indicates that social mobilization is inadequate or ineffective, efforts should be intensified and effective messaging to the population reinforced. During immunization campaigns, the supervisors should verify that the teams follow set procedures, collect tally sheets and fill in daily summary reports. They should also take the responsibility of quality control.

There should be a provision for revising the budget in a new vaccine introduction plan, so that any incidental or unforeseen expenses can be included. Field guidelines at each point of immunization, receipt of cold-chain and immunization supplies and review of the storage and logistic situation should be included in the micro plans. Just keeping the vaccines cool is tough in a tropical country where average daytime temperatures are 35–40°C, and rural electricity supplies are not reliable.[108] There is a need to develop supervisory checklists, tally sheets and summary forms. The authorities should prepare training materials on running an immunization session and develop radio and television announcements and press articles. They should also make social mobilization toolkits, advocacy materials and develop evaluation plans. The distribution of vaccines and other materials should take place at the planned time, from central to district level, from district to subdistrict level and finally to vaccination posts. The distribution plan should account for the distance that has to be covered to distribute vaccines and materials, the mode of transport and the costs, staff (drivers, technicians for cold-chain final checks and maintenance) and the time required for distribution.

Social Mobilization

Prior to conduct a vaccination program, social mobilization should be done through culturally adaptive method.[109] The information regarding vaccination campaign such as target population, target areas, vaccination outposts and the scheduled dates of campaign should be disseminated. Key messages for prevention of the disease should also be disseminated in the communities. Local medias such as the radio, television, newspapers, mobile teams equipped with loudspeakers, posters, leaflets, etc. may be used in disseminating the information related to the new vaccine. Local health care providers should also be informed about the vaccination program and their cooperation sought during the campaign.

Enrolling prominent figures from the community such schoolteachers, religious leaders, sportsmen and women, singers and actors can help disseminate the message. In addition, social mobilization may also be conducted in places where people tend to congregate (e.g., railway and bus stations) and are available to listen to specific messages. The success of social mobilization strategies depends largely on local and cultural specificities and how well they are understood and integrated into strategy and message development.[107] Special care should be taken to avoid cultural misunderstandings that might jeopardize the success of the vaccination campaign. Campaign organizers should also be attentive to negative messages spread by opponents to the campaign. Specific strategies should be developed and attempts to enter into dialog with potential opponents should be undertaken. It is important that the population understand that the immunization campaign is a preventive measure. Special attention should also be paid to local customs, sociocultural determinants, literacy rates and languages. Social mobilization should start at least 2 weeks before the beginning of the vaccination session. The campaign itself should be launched with an opening ceremony in which high-ranking officials should participate.

Introduction of a new vaccine requires a long-term trustworthy and respectful relationship between the vaccine implementers and the community members. There could be a gap in understanding between implementers and the participants due to inequalities in social, structural and physical environment.[62] Sometimes, there could be rumor regarding the vaccine (e.g., the vaccines to be used are of low quality, will be used post their expiry dates or are intended to cause sterility). To combat these rumors, the program implementers have to work with the community prior to introducing the vaccine. Lack of adequate political will among the community leaders may affect smooth conduct of vaccination campaign.[63] The implementers should be cautious to make sure that personal political views did not affect the participation of the individuals during the campaign. Holding discussions with the community leaders, informing them about the benefit of the vaccine and seeking their cooperation are necessary. Many people in developing countries do not have the necessary minimum literacy to understand the mechanism of action of the vaccine, and the risk and benefits while participating in a vaccination campaign. Thus, community and youth engagement strategies are essential for the introduction of a new vaccine.[64,65] Such community engagement should involve bringing together people affected with the target disease, community stakeholders, school officials, educators and health providers to develop partnerships, address service gaps and difficulties and support families and individuals to increase awareness about the prevention of the disease.