Introducing New Vaccines in Developing Countries

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

Disclosures

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

In This Article

Building a Knowledge Base

There is a need to collect information from various vaccine introduction projects in the developing countries. Information on the introduction of a new vaccine is important, because the vaccine may need to be applied to many different situations. The information may be used to design appropriate strategies for the countries, who wish to introduce the vaccine in their disease control program. The experience from one area can then provide guidance for building a knowledge base on the use of the vaccines in another setting. Importantly, building the knowledge base will need to be a dynamic process. The knowledge base acquired from various vaccine introduction projects will need to include specific information that will help make decisions. For example, different projects may use different strategies, but they may not necessarily document or even appreciate these differences. Building a knowledge base will require an understanding of the differences and documenting these differences so they can be evaluated, and future introduction programs can learn which approach will be best suited for a given situation. Additionally, many programs will choose to evaluate the effectiveness of the vaccination program, but unless similar methods are used, the results may not be comparable. Thus, the methodological issues for evaluation of the effectiveness of the vaccination program need to be properly documented, and the results of the evaluation interpreted with care.

Local opinion leaders and expert groups, who are knowledgeable about the need of vaccine introduction, should be actively engaged early in the process.[25] Health care providers, who are up to date on their own immunization, are usually better at motivating others to follow their example.[26] Focus group and qualitative sociocultural research on perceptions of the new vaccine among health care workers, parents, technical experts and political leaders should be conducted prior to implementation of the immunization program.[27–29] To this end, social media networks, expert panels and academic institutions, including medical students should all get informed to be on board with the planned program.[30] Interdisciplinary and multinational advisory and monitoring boards could be assembled to facilitate the accumulation of expertise from different viewpoints. Advisory boards could consist of representatives of the ministry of health, ministry of higher education, public health experts, private public partnerships with experiences in vaccination, clinical researchers, safety pharmacovigilance experts, WHO and other global partners (UNICEF, GAVI, Gates), possibly funders and religious leaders. National expert committees have successfully been engaged in the safety monitoring during the MenAfriVac introduction campaign across 33 sites in Niger.[31] Strategies need to be formulated on how opinion leaders can be identified and engaged, bringing them together with people who already have gathered experience with the new vaccine in other settings.

Background materials including protocols, reports, communications materials, etc. should be made available to the vaccine introduction program, so that health officials do not need to 'reinvent the wheel'. Availability of such materials will facilitate smooth introduction of a new vaccine. An important aspect for this documentation will be reports from staff to the sites to understand the type of programs and strategies that work well and the constraints of those, which did not. A standardized reporting and evaluation form may be used for this purpose. This document will then be able to describe the different vaccination programs in order to compare their costs, their logistical evaluations, their program effectiveness and potentially their cost–effectiveness – the knowledge base that will help making a successful vaccination introduction program.

Documenting crucial experiences and lessons learned from prior and existing vaccination programs are important. The documents can be used by the project implementers when they plan for a new vaccine introduction in order that they can benefit from past introductions. They, in turn, can contribute their lessons to this section for the next set of implementers.

Lessons learnt from existing immunization programs include the need to have rapid response emergency programs and panels in place that can respond to sudden outbreaks of vaccine-preventable diseases, such as the current measles outbreak in Wales, UK, as well as safety signals, real or perceived.[32,33]

For instance, in a cholera vaccine introduction program in Batil, South Sudan, the vaccine recipients experienced some reactions (vomiting and nausea) on the first day of vaccination.[34] It turned out to be a psychological effect, as several women would collectively run away from the site and vomit or spit out immediately post vaccination. The vaccinators managed to stop them from running away and advised them to breathe deeply to prevent the nausea and vomiting. This worked effectively.[34] The tradition in many communities in the area is that a man cannot drink in front of his mother-in-law. The vaccinators had to assure the male vaccine recipients that they would not be seen by their mother-in-law while taking the vaccine. Another tradition is that newly married couples cannot eat or drink outside the house, thus they were given the (oral) vaccine inside their house.[34]

Religious and cultural implications of immunization programs may need to be considered early on. In Muslim communities, for example, immunization programs – regardless of the route of administration – should not be planned for the month of Ramadan (fasting month). In some regions, it is wise to plan for male vaccinators to administer vaccines to males and use female vaccinators for the administration to female vaccine recipients.

In an area of Odisha, India, the vaccine introducers observed that participants did not like the 'taste and smell' of the cholera vaccine during a pilot introduction project. The communities described the taste as 'fishy' or 'rotten egg' in nature. Since many people in the area are vegetarians on a specific day of the week, the taste of the vaccine resulted in lower participation in the campaign [Binod Sah, IVI, Pers. Comm.]. Understanding community concerns and traditions and adequately addressing them are important when a new vaccine is planned to be introduced in a specific society.

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