Increasing Measles Vaccination Coverage to Improve Global Health Security

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This transcript is from a CSIS event hosted on January 23, 2024. Watch the full video here.

Katherine E. Bliss: Nearly a quarter century ago, global health leaders came together to launch what is now known as the Measles and Rubella Partnership. The goal of that partnership, originally called the Measles Initiative, was straightforward – to strengthen collaboration among diverse organizations and accelerate progress in order to prevent the transmission of a highly contagious and deadly virus, measles. Before the year 2000, there were millions of cases of measles and more than 750,000 deaths worldwide each year. The dissemination of measles vaccines, newly available in the 1960s, led to health improvements in the upper- and middle-income countries where they were marketed. But for a long time, they were too expensive or often difficult to procure for many lower income countries.

Thanks to national, regional and global collaborations, including the work of the partnership and Gavi, the Vaccine Alliance, in the early years of the 21st century measles vaccines were introduced and began to be scaled up in many lower-income settings as well. These efforts contributed to measles being eliminated in several countries and regions by 2014 and later. But just a few years later after that, in 2018, the number of cases began to rise, and in 2019 there were nearly 1 million cases of measles reported, with outbreaks in the United States, Europe, Latin America, and elsewhere. That same year, several countries lost their elimination status as they saw sustained measles transmission within their borders.

Now, while reported cases of measles decreased during the first few years, the COVID-19 pandemic, when people wore masks and practiced social distancing and often avoided health care settings, cases rose again in 2022. And in 2023, there were outbreaks in several countries including Yemen, India, Kazakhstan, and Ethiopia, particularly in regions or sub regions where immunization coverage gaps had widened during the pandemic. And just a few weeks into 2024, we’ve seen cases here in Washington, D.C., at least in the area airports, as well as Philadelphia and Atlanta, and in the United Kingdom where low coverage and a surge in cases prompted the government recently to declare a national health incident.

Now, preventing a measles through effective routine immunization is a lot simpler than detecting an outbreak and then launching a campaign to find children who missed getting vaccinated during routine health appointments. It’s a lot less expensive too. So if that’s the case, why is it that we’re seeing outbreaks now? And what can we do to change the situation? Hello, and welcome to today’s event on Increasing Measles Vaccination Coverage to Improve Global Health Security. My name is Katherine Bliss. I’m a Senior Fellow with the CSIS Global Health Policy Center, where I lead work on immunizations and health systems resilience under the Bipartisan Alliance for Global Health Security.

It’s my pleasure to welcome our three expert speakers today – Graça Matsinhe, who leads work on the MOMENTUM Routine Immunization Transformation and Equity Project in Mozambique, William Moss, Professor and Executive Director of the International Vaccine Access Center at the Johns Hopkins University Bloomberg School of Public Health, and Daniel Salas Peraza, Executive Manager of the Comprehensive Immunization Unit at the WHO’s regional office for the Americas, PAHO. So, Graça, Bill, Daniel, thank you very much for joining me today.

So, I want to start by really looking at the situation that we’re currently facing. You know, after several years of progress, really, in working to increase immunization coverage in key areas around the world, we saw these outbreaks in 2018 and 2019. Now, after a bit of a lull during the pandemic, we’re seeing another rise in cases. The WUENIC data of last year suggested that there’s been a bit of a bump up, an improvement, in coverage globally, but we know that that masks a number of challenges at the national level and at subregional levels as well.

So I want to ask you, kind of looking at the countries where you’re doing research or where you’re based, from your perspective what is driving these current trends? And what are your greatest concerns, you know, as you look at the areas that you focus on over the next couple of years? Bill, let me let me start with you. You’re with IVAC, which really kind of looks at these issues at a global level. You’ve been working on measles in Zambia and elsewhere for several decades. What are you seeing kind of globally that’s really kind of driving some of this?

William Moss: Yes, thank you, Katherine. And I think this is a really important seminar to talk about these issues. It takes two things to have a measles outbreak. You have to have a susceptible population and you have to have the virus introduced into that susceptible population. And, you know, the way I kind of look at this is really global measles vaccine coverage with the first dose has really stagnated at about 85 percent over the past 15 years. So we’ve really had this problem of reaching those 15 percent of children who have not received the first dose of measles vaccine.

So, yes, we’ve made enormous progress. And, yes, we saw a resurgence of measles in 2019, and particularly globally and here in the United States. This is actually, I think, a longer-standing challenge of reaching the hard-to-reach children, those 15 percent, with measles vaccines. As you said, the epidemiology during the course of the pandemic – the COVID-19 pandemic, very – really interesting. We had this big resurgence, global resurgence, of measles in 2019. Pandemic came. We had historically low reported numbers of cases in 2020. Increase in 2021, and then increasing since then.

There have been a number of hypotheses as to why the numbers were so low in 2020. I sometimes think that maybe that was the time to eradicate measles. But it was, you know, some of it – some speculate that perhaps there was just greater immunity because of the resurgence of measles in 2019. It could be in part a surveillance issue, because we know surveillance systems were impacted by the pandemic. But I think, as you – as you suggested that, you know, the restrictions that were put in place – the masking, the – all the efforts that we went into to reduce the transmission of SARS-CoV-2 had an impact on all respiratory viruses, and measles virus in particular.

And the COVID-19 pandemic impacted vaccination services on the supply side, on the demand side. And so we ended up with more unvaccinated children. And so what we’re seeing kind of coming out of this – coming out of the COVID-19 pandemic, more susceptible individuals, more susceptible children. And once the virus starts spreading globally and gets imported into those communities, then we get outbreaks.

Dr. Bliss: So thinking about what’s happened, you know, we saw this uptick in 2018. And then, you know, this global outbreak in 2019. You know, Daniel, you’re looking at the region of the Americas, kind of as a whole. And the Americas had kind of been declared eliminated, right? Or that measles had been eliminated in 2016, I think it was, right? But then you did see a number of cases in 2018 and 2019. Although I think – I think things have been a little bit calmer, you know, in the period since the pandemic. What do you see kind of shaping the current outlook in the region of the Americas? And what are you most concerned about, you know, as we kind of look ahead?

Daniel Salas Peraza: Well I think, as Bill mentioned, as long as we have susceptibles and – I mean, that’s going to be part of the scenario. It’s probably impossible to not susceptibles. But the problem is when you have that 15 percent that you are leaving behind, and that percentage accumulates, and then you have, like, you know, the perfect number to have large outbreaks. And in the Americas, as you mentioned, we’re getting close to the 10 years of not having – or having been declared free of the transmission of measles. First, unfortunately, in 2019 we had a large outbreak in Brazil and in Venezuela. And we had, like, in 2019, I think it was, like 87 deaths for measles in the continent.

And, of course, it required a lot of effort, you know, from those countries to really get the conditions to neutralize the transmission of measles. And in the last year, we have RVC, which is the commission – the regional commission that certifies or, you know, review the verification – or, reverification of the elimination of the transmission of measles in a country. And Venezuela got reverification, after losing that condition. And Brazil is pending. But Brazil has made important steps forward to reach that condition of reverification.

And, of course, we have importations – isolated cases that they – I mean, they find a block, a wall, that don’t allow them to really spread. Of course, the surveillance, to have a timely, you know, detection of those cases, an acute system that can really identify the cases, and then we proceed with all the epidemiology aid or support for those countries to neutralize the situation. That’s very important as well. And, of course, the laboratory, because we have a lot of horrible viruses here. And we know, for example, for the acute test that we have the IgM. That can be a false – a false positive, if – sometimes it can be, like, another disease – dengue or something different.

But that’s something that requires training, constant training. That’s something that requires a lot of, you know, support to – we have a framework of verification of the elimination of measles. And that framework has helped a lot. And we have counterparts for this regional commission in the countries, national commissions. And they work very intensively on trying to get the report. Every single year we have several meetings where the country’s expose their conditions, what is lacking, and what is leaving behind. And this regional commission, it’s very important to have that condition of reverification.

It is – and, of course, we have the regional TAC, the Technical Advisory Group, which is always encouraging countries to, you know, proceed with the strengthening of the programs – the regular programs. And we conduct here follow-up campaigns, which probably they are not like the ideal situation. But we – since 2021, we have been implemented a high-quality follow-up campaigns methodology to really try to identify which are the ones that are not vaccinated, and even to vaccinate those children during the vaccination campaigns and add those children to the regular coverage reports, so that we can really know what is happening. Because before that, they – the problem is you conduct a campaign, you conducted a campaign, and you vaccinated the ones that have been already vaccinated. And, of course, that’s not effective.

So we have been migrating to this high-quality methodology that is, of course, much better. And that’s what we have. I mean, it’s impossible to not conduct a campaign when you don’t see that you’re reaching 90 or 95 percent of coverage for both doses of MMR.

Dr. Bliss: So, Graça, I’ll look at you here. (Laughter.) Thank you for joining us from Mozambique. So both Bill and Daniel have really, you know, pointed to the importance of, you know, really reaching this this last, you know, 15 percent that that has been, you know, missed, at least at the global level, you know, in terms of access to measles vaccine. But also, just the real importance of micro planning and really understanding where the children who are missing out on these doses are. You’re with the M-RITE program in Mozambique. Really, you know, focusing on issues around equity in access to immunizations. So could you say, you know, a little bit about, you know, some of what you’re seeing in terms of reaching those zero-dose and under-immunized children with measles vaccine, and kind of where you see – where you see the trends at the current moment?

Graça Matsinhe: Thank you, Katherine. It’s a pleasure being here and discussing this very important topic.

Let me put you a bit in context on why this is happening in general in the African region. You all know that measles is one of the leading causes of infant mortality. And this is still real in our context. And, different from America where the – and other countries – where the elimination goal was met, we had a very ambitious 2020 goal for eliminating measles, which was not met. And we see a scenario in which the coverage of measles has been decreasing from 2017 to 2021. There’s a very big difference, not only in coverage – vaccination coverage, but also in surveillance. The indicators of surveillance have not been met by several countries in Africa. So definitely we have here a very fertile situation to have this outbreak arising in different countries.

And we have seen an unprecedented outbreak in South Africa, for example, which has been a country with very high coverages of immunization, and many, many other countries in Africa. So this is really, really challenging, especially when we look at the coverages that have been stagnating, as Bill mentioned also. We see this situation here. The coverages have been stagnating for many years, not only the MCV coverage but other vaccination antigens. But we also have one additional challenge, is that although many countries have been implementing supplemental vaccination activities, the implementation is suboptimal. So this obviously will create a lot of susceptibles. And we know that this is the perfect condition for us to have outbreaks.

In the African context, there are some particularities that are worthwhile to mention, because they – I believe this is very different in other regions. These particularities will affect directly the functioning of the immunization programs, the routine immunization programs, and also the campaigns. I’m talking here about inequality of access of health services, because the health facilities network is very poor in many, many settings. I’m talking about the low confidence of vaccines among the population. I’m also talking about the health system barriers, which had been affecting a lot the uptake of immunization services in different settings.

But also, we have other particularities, like the wars, conflicts in different parts of Africa. And we know that with conflicts, the health systems will have a rupture in service provision. So here we also have a big issue with achieving coverages and making sure that you are getting vaccinated. So those are some of the things that come to my mind when we’re talking about reaching children with measles vaccination. The context is very, very complex. And we need to work together in order to make sure that these situations are overcome.

Looking at how to better reach children in this context, obviously good micro planning is necessary, and all efforts – be it by governments and partners operating in immunization – towards improving the micro planning processes. Starting from the basis – I mean, the health facilities, and then the districts, and then the provinces. So having plans that develop bottom-up is crucial. And this is the efforts that we have been making. Associated with mapping and identifying children in the communities, we are now are bringing on innovative strategies like using the GPS to map and the identify those children, so that we can know exactly where those children are. And then it’s much easier to reach those children when they go to the community.

Dr. Bliss So several of you have mentioned the importance of, you know, really undertaking training for health workers, and improving surveillance and detection, as well as, you know, really – employing GPS and other kinds of technologies in order to really identify where children who are missing vaccines can be located. But, you know, one of the challenges, you know, certainly that we heard talked about a lot during the pandemic with respect to COVID-19 vaccines was, you know, that the health system was – in areas where the health system itself was fairly fragile, it was difficult to, you know, reach out to communities to really establish those connections and find – you know, find ways to build that dialogue and reach the families in need.

So, you know, Graça, maybe I would – I would, you know, go back and start with you, just to ask you to say a little bit more about, you know, the steps that you see needs to be taken to really, you know, ensure that the health system, you know, as a whole, is able to more effectively deliver vaccines. Is it – is it better training for, you know, health workers? Or is it – I mean you mentioned, you know, some of the issues around, you know, building confidence at the community level? You know, what steps can really be taken to prepare the health system to deliver vaccines through routine programs, you know, before we – before we even get to kind of needing to deliver through campaigns?

Dr. Matsinhe: Yes. Well, definitely the COVID pandemic unveiled health system fragilities in different contexts of the – of the world – be it in Africa, in Americas. Everywhere the health systems were severely affected by the pandemic. But this also gives us an opportunity to build more resilient health systems. And we need health systems that will effectively respond to the needs of the community, because we’re working for the community. Everything that we do is for the good of the community. Which is us, at the end of the day.

So in my view, to have very robust routine immunizations that are able to deliver not only measles vaccination, but all the routine immunization antigens, we need first to invest in human capital. Here, I mean allocating the human resources to the places where they’re needed the most. And I’m talking about the hard-to-reach areas, which usually tend to be the less served areas. So we need to make sure that we have that adequate cadre of human resources to provide good quality immunization services. But also, the ones that are already there, they need regular training, be it in the form of on-the-job training or mentorship programs. But we need to keep training the human resources to better provide immunization services.

The other thing that comes to my mind is the need of minimizing the health system barriers. Because when we talk about barriers, most of the times we look at the distance, but there are so many barriers – many barriers inside the health facilities which increases the missed opportunities of vaccination. And most of the opportunities, they are related to the health workers’ behaviors. So we need to minimize those barriers. We need to communicate better with the people who are seeking health services in a health facility, so that we can effectively provide good quality immunization services.

The other thing that that I think is fundamental is to ensure the availability not only of vaccines, but other consumables, including the cold chain. So those are the things that we need in order to have very strong routine immunization services and be able to deliver measles vaccination in good quality. Obviously, it’s not limited for those ones, but I think those are the most important issues that we need to work on.

Dr. Bliss: Thank you. Daniel, I know that in the Americas, PAHO has really, you know, placed an important priority on kind of rooting – well, building the capacity, you know, throughout the region to deliver primary health care and, you know, really, you know, rooting services in that kind of model. I wonder if you could say a little bit about, you know, some of the efforts throughout the region. I know you have experience in Costa Rica with the ministry as well, and with the primary health care model. But, you know, what is – you know, how can strengthening the health system in that context really facilitate delivery of vaccines?

Dr. Salas Peraza: Well, I think that it is very important to try to tighten up the relationship with the community and the primary health care because, I mean, that’s the essence of the primary health care, is to build, you know, like that social participation, that promotion of health. That you can go – wherever you go in a community, and you can breathe, you know, wellness, you can breathe the opportunities to improve your health. But that’s something that probably is not happening at the level that we would like it to be. So it is very important to work on that, really try to identify which are the social stakeholders, the partners, the nongovernmental organizations, or private sectors that can really build that network.

To, you know, facilitate vaccination, to facilitate – for example, if you have doubts about – to get a vaccine or not, and if you are waiting to get to the – you know, to the health facility – to the health care facility, probably sometimes that represents a barrier. I mean, it’s something that you have to defeat. But if you go to the local government office, or if you go to whatever – I mean, to pay a service or whatever, and you can find that information easily accessible in words that you can understand easily, that would be a game changer. But that’s something that we need to really continue working on.

Because something, for example, that we have found now is that families have migrated to a different composition. And now, for example, both parents work during the daytime. And they cannot take their children, you know, to the health care service if it is not after 4:00 p.m., when usually the service is closed. So we have now adapted the possibility for those parents to –or the single mother, or whatever – to really take their children to the – you know, to be vaccinated. For example, with COVID-19, what happened? We offered the vaccine in malls and shopping centers, you know, in cars. It was a really different modality of vaccination. So we really – I think that we need to – really need to stratify the analysis to find out what is happening with that 50 percent of population that is not receiving their vaccine.

Is it because they go to the – you know, to the health service and the vaccine is not available? I mean, because sometimes even the vaccination time of availability is just from 7:00 a.m. to 10:00 a.m. And then you get there at noon, and then the vaccine is not available anymore. Or simply you cannot go until, you know, evening or even later. In some countries, for example, in the Americas, they have been experimenting with offering at night or evening, like, visiting houses and checking, you know, the scales if they’re complete, and vaccinating the ones that they find that are not vaccinated.

But I really think that we need to adapt the offer of the primary health care and tighten up with older services as well, because it is not just to offer the vaccine alone. We need to really try to integrate this vaccine offering with other services, and have a course – you know, a life course approach, where you can really, you know, get the family to go to the – to the health service. Even on the weekends, because probably on the weekends we have just the emergency services, you know, working. And probably that’s the time where the families can really go, as a whole, you know, to have, like, this package of checking their health. So that’s something that we need to work on.

And I know that, of course, primary health care has been, like, a cornerstone of our services here in the region. But it is not enough. We really need to go to the next step, and to reach this next plateau of bigger integration, of bigger, you know, vision, of building the social participation of health in the community.

Dr. Bliss: So some of it, you know, really is adapting to the way people live and meeting people where they’re spending their time, and finding them at work or shopping or wherever they might be. Some of it also is relatively kind of traditional outreach, right? Going to people’s houses and talking, and really just engaging in the social environment. But, Bill, I want to turn to you. I mean, at the same time that it’s important to really undertake maybe some of these more traditional methods, there are kind of new innovations in terms of delivering vaccines that may also either make it easier to reach people or require different kinds of training. Could you talk about how some of these new innovations may change the measles vaccine landscape?

Dr. Moss: Yeah, certainly. And I – you know, the points that Graça and Daniel made about, you know, really trying to reach the communities is critical. And there’s – as you said, there’s not just a technological solution. But in the measles world and in the vaccine world, we’re very excited about the potential for what are called microarray patches. And what microarray patches are, they’re – the devices are kind of like the size of a Band-Aid. They have very tiny needles on them that are coated with the vaccine. It’s the same vaccine that we deliver by needle and syringe. But instead of kind of injecting it under the skin or into the muscle, they deliver the vaccine right into the dermis of the skin, where there are a lot of immune cells.

So this is a technology that’s been around for a long time, but is slowly kind of moving forward. And there have been some early studies that suggest that these are as immunogenic as a standard measles vaccine given by needles and syringe, meaning that they induce good antibody responses. But there are a number of advantages of this type of vaccine delivery platform. They obviously don’t require needle and syringe. Wo you don’t have the medical waste problems and the costs related to that.

They don’t require reconstitution, where measles vaccines are currently stored in a dried form – what we call a lyophilized form. They have to be immune – or, reconstituted with a diluent. There have been – rare, but sometimes – mistakes made with the reconstitution. They’re very thermostable, meaning that they can stand warmer temperatures. So you don’t need that kind of rigorous cold chain. They could be administered by people other than trained health care workers. Community health workers, for example, could administer them. They could even be self-administered. And they’re single use, so you don’t have the problem with multidose vials, where a health care worker may decide not to open a ten-dose vial for measles vaccine for a child.

So these are kind of moving through the normal process of evaluating vaccines. There have been – we’re now in phase two trials in humans. There was an early study from Ghana that was reported about the safety and immunogenicity. And also say the acceptability. Parents, caretakers much preferred that vaccine delivery platform. And so it’s going to take a while to kind of get this through the regulatory process, get manufacturing scaled up. It requires different manufacturing requirements. People are projecting maybe around 2030. I hope it’s earlier than that when these become available.

But many of us in the measles world feel that these could be – this technology could really be a gamechanger for measles control, elimination, and then hopefully eradication, because of the ease of administration. You can really take these out to those hard-to-reach children that we’ve been talking about.

Dr. Bliss: So these could potentially address some of the challenges that Graça raised, you know, around remoteness of the population, or not enough health care workers, or not enough trained workers. How expensive are they likely to be?

Dr. Moss: Yeah. (Laughs.) We don’t know yet. That’s a key question. There’s no doubt they’re going to be more expensive than the current measles vaccine, which is quite inexpensive. And, you know, this is one of the challenges for the vaccine manufacturers, is ensuring that there’s actually a market for this. You could think of this – you know, wouldn’t this be great for kind of, I’ll call it, the niche market, for those 15 percent children, you know, who are very hard to reach. But that may not be enough financial incentive for the vaccine manufacturers. So there’s a lot of discussion about how to have, for example, an advanced market commitment to help support, you know, finance these.

There are – these micro – this technology can be used for other vaccines, and have been developed for other vaccines – influenza, rabies, polio. So you could imagine kind of a vaccine manufacturer, you know, using their manufacturing facilities to make multiple vaccines. But that is one of the challenges that this field faces, is that there’s – no doubt it’s going to be more expensive than the current vaccine. And how much are willing – are governments, bilateral organizations, willing to pay for the advantages of that vaccine delivery platform?

Dr. Bliss: So cost and really financing immunization programs is kind of a perennial question, right? We talked a little bit earlier about the importance of really integrating measles into – I mean, it is integrated into routine immunization programs, but making sure those vaccines are delivered in the routine programs. Because if not, then you – if there’s an outbreak, you have to undertake a campaign, which all of you have said, you know, it’s much more expensive, involves different levels of planning, and workforce, and the like.

I wanted to just, you know, ask each of you to reflect a little bit on, you know, the importance of increasing financing for immunization programs, and kind of what the needs are in the current context. You know, we’ve come out of the pandemic where clearly lots of money was generated for immunizations. We saw COVAX. And, you know, now there are, you know, plans for new manufacturing facilities in different parts of the world and, you know, real efforts to kind of drive – kind of shape the market, as you were saying.

This is – you know, for countries that are eligible for Gavi, this is an important year. The replenishment and the start of a new strategic period will be starting in the next – in, I guess, Gavi 6.0 will be starting in the next couple of years. Obviously, for countries that – or regions that – you know, where countries are not eligible for Gavi, there are other concerns. A lot of the middle-income countries still face considerable challenges when it comes to ensuring equitable access to vaccines, but are not eligible for those kinds of support.

So, Daniel, maybe, you know, let me start with you. I mean, most of the countries in the PAHO region are not eligible for Gavi support. Obviously, there are donor countries, you know, to Gavi that are – that are in the Americas. A few eligible countries. But you also have the revolving fund that has really shaped a lot of the market. Could you just say a bit about the importance of kind of ensuring financing for immunizations in the next phase?

Dr. Salas Peraza: Well, I think that the most important thing about this is to position the importance of vaccination on the policymakers, you know, the leaders, the president. Because we need to look into co-responsibility. We should not, like, rely totally on external donor. And countries should be responsible. I mean, we’re talking about the cost – a high-cost, effective intervention, vaccination. And you’re getting a return. For each dollar that you are investing, you’re getting several dollars per that investment. But the thing is that usually those dollars goes to other – you know, go to other programs, not to the immunization program.

But the first thing that I think that we need to work on is to have this co-responsibility. We shouldn’t let the countries to be totally dependable on external support. But of course, we’re going to need support. I mean, the countries – and we’re talking about, in the Americas, mostly middle-income countries. They do not have the budget, the funding, to really, you know, cope with all the challenges in health. And we know that, you know, communicable diseases, you know, the burden of disease has been really getting, you know, higher in the last decades. And of course, we need to prioritize.

But what we have – for example, for the follow-up campaigns, the governments take responsibility about the majority of the – you know, the funding for those follow-up campaigns. So it’s not something that, oh, if, for example, an external donor is not going to help, that follow-up campaign is not going to take place. No. It’s not that way. But, for example, we are always trying to, you know, catalyze, to channel, all those funding that we can get to really give that extra, you know, support for countries. Because they need – I mean, we’re talking about middle-income countries – they need that support.

But of course, we’re not – I mean, we’re expecting what is going to happen with the mixed strategy and Gavi 6.0. We’re really hoping to get more support from Gavi. We don’t know what is going to happen. But –

Dr. Bliss: Sorry to interrupt, but when you say the mixed strategy, that’s the middle-income country strategy, where there’s been some technical assistance, but it’s an ongoing discussion? Is that –

Dr. Salas Peraza: Yeah. The criteria that they have, you know, chosen for this strategy is very, like, strict. So many of the countries that – for example, they – we have a lot of polarization. We have – we are the most unequal region in the world, you know. And so it doesn’t mean that because you have, like, a threshold of being above a percentage of income, of general GDP, or whatever, it means that that country is totally sustainable and can really face all the challenges in vaccination, or whatever topic. So that’s something that – I think that there should be, like, a more comprehensive approach on defining which are the criteria for the country to be eligible to have extra funding.

But, of course, we’re always looking with other partners. We have a longstanding partner, for example, the CDC, the GID, the Global Immunization Division. And they have helped a lot our countries. And we’re always, for example, for measles, Red Cross has been a great ally in the past. And we’re always looking – for example, for polio, we have the Rotary Foundation. But we’re always looking to get, of course, extra aid. Because countries are not self-sustainable. But one message important here is that we should not, like, make them believe that if they do not get the funding, I mean, nothing is going to happen to strengthen the EPI, the Expanded Program on Immunization. Because countries should take responsibility and should take that accountability of what is happening in their countries.

But, of course, I mean – and that’s something that we really need to continue working on. We’re now working on a methodology to develop – a methodology to estimate the impact of the overall vaccination program. Because sometimes we really do proceed with these just for the introduction of new vaccines, but not for the – I mean, for the regular program, what has happened with education, what has happened with, you know, tourism, what has happened with production, what has happened to the workforce, because we have been having strong programs on immunization.

So we’re working on these to really get, you know, to the ears of the president, of the ministry of finance, of the ministry of education. Because they need to hear what does it mean to have strong immunization programs for them, not – we always are counting deaths and disease, and the people that got sick. But not are talking in their terms, you know? We need to apply some kind of social marketing tools to really convince them, to get them engaged. And they see the need to the Congress, to everybody that could take a decision, we really need to get those people with, you know, very clear messages about why it is important to have immunized – strong immunization programs.

Dr. Bliss: So, it sounds like it’s really needed to have that – just a frank dialogue around policy and the importance of investments for the overall economy, not just – not just kind of the health – the specific health aspects of it.

Graça, let me – let me turn to you. I mean, what are you hearing in your conversations in Mozambique around the, you know, thinking in terms of co-financing and the – you know, some of what is likely to come forward in the next round of, you know, the Gavi discussions and the formulation of the next series. Is the discussion around financing something that that M-RITE is involved in? Or is this – you know, are these, you know, bringing together the – you know, the discussion around the investments and the importance to the – to the larger – to the larger economy? You know, where do you see that conversation taking shape?

Dr. Matsinhe: Well, Katherine, one of the of the gains we had from the COVID pandemic, it was that the very first time we had different presidents or heads of states talking about vaccines and vaccination. So COVID was not – definitely was not a good situation. But from that, we could have this understanding from the political leaders on the importance of vaccines, which we had been battling for, for years and decades, to make them understand that vaccination is really key for the prevention of diseases. So at that level, I think we – now it’s much easier to be heard when speaking about vaccines, the importance of having children vaccinated, and the importance of having investments to make sure that the vaccines are there.

Well, one thing is what they know, but the other thing is what happens in reality. So definitely, like Daniel said, we need to continue working in terms of doing advocacy with the political leaders so that they can raise the domestic funding for immunization. Of course, they will say that there are a lot of priorities. But, yes, immunization is a priority. If you vaccinate children, we show that we have a human capital that is healthy in our society. So I think this is very important. And this is what we have been doing. We have been addressing – as a group of partners, we’ve been addressing the parliament so that they can understand the importance of channeling more resources to the immunization program. So this is an ongoing work that we’ll continue doing as a group to make sure that the financing is increasing.

But also, I want to bring here the idea of exploring nontraditional partnerships. We have a very good experience from COVID vaccination where we had – we worked with the private sector to mobilize resources to buy vaccines, and also supporting us in the implementation of vaccination in the remote area. So I think those are things that we really need to explore. And most of the time when we’re thinking about financing, we only – I mean, when we think about support, we think about only the financial support. But there’s non-financial support that we can benefit from, especially with the economic agents in the rural communities. So those are things we have been discussing in the immunization working groups in order to find alternatives for financing the immunization program.

When we’re talking about the co-financing, in my context, in my country, the government has been consistent in in complying with the co-financing requirements. But as the vaccines increase in the calendar, obviously the obligation also becomes larger. So it’s about time for the government to set priorities and make sure that more resources are channeled for the immunization program.

Talking about the Gavi replenishment, yes, the funds are there, but we cannot only rely on Gavi funds, because they’re not limitless. One day you can wake up, and no funds to support the country. So I think I want to stress this importance of governments working together to raise funds to support the implementation of immunization programs, especially in low- and middle-income countries, where they really need those resources. However, the replenishment is also an opportunity for countries to narrow down their priorities, because we want money for everything and it’s not possible to cover everything at once. So I see the replenishment as an opportunity for us to look at exactly what we want to do that will have a very good impact in the immunization services.

I look – I see here the importance of scaling up the RED strategy, which is crucial for reaching the children with measles vaccines and other vaccines. So as I think we should look at that. I see here also opportunity to look at innovation, such as the electronic register, which is not happening in many African countries. And we know that it’s crucial to make sure that we track these students throughout the system, and not lose these children. But also, I see the opportunity to improve the cold chain and the availability of vaccines through the resources that Gavi will be providing in the next cycle.

Dr. Bliss: So all of you have really emphasized the importance of multisectoral partnerships in not only financing but, you know, really thinking about some of the different technical challenges that are currently faced, and even some of the political challenges that you’ve talked about as well. I want to turn to the issue of vaccine confidence that so several of you have also raised. And, of course, the issue of partnerships there, both, you know, in terms of thinking about communication around vaccines, but also just some of the different media that that are used for communicating about them as well.

Bill, I want to start with you, because, you know, before we came in here we were talking a little bit about your work in Zambia, where you started out working with a hospital that had a ward that had, what, 30 or 40 beds filled on any given day with children with complications from measles, right? But then over some period of time, that ward was – once vaccines had been introduced – was really not in service as much anymore. And, you know, so over several decades, you know, certainly we’ve seen this here in the United States and elsewhere, people have kind of forgotten what the challenge really is, maybe not in areas where the rates are lower.

But could you say a little bit about – you know, reflect on that experience, but also the work that IVAC has done, you know, around vaccine confidence, and what some of the current challenges, with respect to measles vaccinations in particular, are that you’re seeing?

Dr. Moss: Yes. Katherine, it was quite remarkable to see in in Zambia, you know, a hospital ward filled with children with measles. And then after Zambia conducted their first mass measles vaccination campaign, to really see that ward go away. Measles hasn’t gone away in Zambia, but that measles ward was eventually shut down.

I think of, you know, just some higher-level reflections. You know, when I think about vaccine hesitancy and vaccine competence, first of all, it’s really – it’s a spectrum. It’s not a – it’s not a binary. And people and beliefs can move along that spectrum. And the other kind of assumption I go into discussions about vaccine confidence is that I think every caretaker, every parent, every mother, every father wants what’s best for their children. But they – and so they’re weighing risks and benefits. And for some, that calculus is different than for others. And I think what we, as public health officials, need to do is make sure that people are making that calculus, that risk-benefit calculus for their own child or for themselves, with accurate information.

And there is a tremendous amount of disinformation and misinformation on vaccines. Measles virus in particular, historically, but certainly extending to other vaccines. And what can be, I’ll say, disconcerting for those of us in public health can be the fact that this is a – this is a long-term war. (Laughs.) A long-term battle. This is not something we can kind of flip, you know, or, you know, in one activity, you know, turn it around.

And just to come back to points that Graça and Daniel made before about the community, I think, you know, it’s really identifying the trusted messengers within the community that’s so essential. And, you know, some of the work out of IVAC – I’ll refer to the work by Lois Privor-Dumm, our colleague, around COVID-19 vaccines in the Baltimore – in the Baltimore community, around where Johns Hopkins is. And really engaging with the faith leaders, the faith-based leaders, and the religious leaders, and the community leaders, and have them be the ones, you know, delivering the accurate information and delivering the messages to really try to best inform people as they weigh the risks and benefits of vaccination.

And I think public health officials need to be very honest about what – that there are risks associated with some vaccines. And so, we need – but we – but there’s – again, we’re up against kind of a tidal wave of disinformation and misinformation. And so this is a – this is something we need to continue to do for the long term, to be able to move people along that spectrum, and best understand the benefits and risks of vaccination and that calculus.

Dr. Bliss: Thank you. Daniel, you know, thinking about the region of the Americas, I think you mentioned – maybe it was earlier today or in an earlier conversation – just that health workers in the region had been exposed to so many different messages on social media. And, you know, we’re at different times, you know, feeling bombarded by all of these different messages. What are some of the approaches that you’ve seen that have been most effective in kind of helping provide that community in particular with the confidence they need to continue providing vaccines?

Dr. Salas Peraza: The most important thing is actually to train them to be advocates for vaccination. Because usually you train them to know how to manage the vaccine, how to handle, you know, the cold chain operations. And probably you have trained them, of course, to know about the possible adverse effects, the technique of application. But usually, you did not empower them to be a strong defendant of the importance of vaccination. So that’s something that you first have to work with them.

What I have mentioned before is the during COVID-19 vaccination – and I think the COVID-19 vaccination was a chapter – really a specific chapter in our history. Especially in the Caribbean, we found that even 32 percent of the nurses were against the vaccination of COVID-19. But we have not detected that this has spilled over to other vaccines in the regular program. And probably we are facing here two problems. And one of those is the lack of risk perception, because we don’t have these large outbreaks of measles, or polio, or diphtheria. I mean, just in the specific countries, but it is not the case anymore. So I think that that’s something that we need to work on, and increase the why do we need to protect against measles? What are the consequences if you don’t protect your child against measles, or rubella, or.

But, and of course, the other topic is how to deal with misinformation, with disinformation. And the social media, you know, phenomenon has been really hard to challenge and to really, you know, tackle, the problem of having just the easiness of tapping, you know, a button in WhatsApp, or whatever social media you’re using, and spread the misinformation. And even I have received from professionals in health care some of the messages trying to – or asking me, is that true? And it is something that is completely fundamental. I mean, it’s – but that – we need to work on how to timely tackle those fake news, for example, to identify the leaders at the community level. It is very important.

But also, in the social media, how to identify the positive examples of, you know, leaders that can really help us in the social media platform, to, you know, rapidly tell the truth about the fake news, or whatever, that is spreading out. So that’s something that we really need to continue working on, the social listening. We now have social listening tools, but, OK, what to do with those? Are you detecting on a timely manner if a fake news is really spreading out and causing, you know, like these kinds of doubts, or whatever?

What do we have found out, during the follow-up campaigns is that, for example, for MMR vaccine, that people are still very positive about receiving that vaccine. Even when we had some kind of problems – there was a combination of using the COVID-19 vaccine at the same moment or applying that vaccine when the measles vaccine was applied. But, of course, there were a lot of misinformation about the COVID-19 vaccine. But I think we need to really continue training our healthcare workers to be very defendant, very – you know, like, leaders to give all the elements to people why it is important to vaccinate against X or Y vaccine.

That is, in time try to identify those leaders at the community level, the religious ones, the ones that, you know, can really know where are the houses of the children that are not vaccinated? And why do they think the way that – I mean, it is more – and at the social media, you know, level, to identify the leaders, the influencers, that can really help us to – you know, to just minify any kind of fake news.

Dr. Bliss: That’s interesting, that you said people are trained to deliver the vaccine but not the communication about why it might be positive to take it. Graça, let me just ask you. You know, are you – have you seen it kind of an impact from the tensions or, you know, hesitancies around the COVID 19 vaccines? You know, did you see that spill into kind of some of the feeling about measles as well?

Dr. Matsinhe: Yes, definitely COVID-19 vaccine has its own challenges. And I won’t repeat what Daniel just mentioned because the scenario was pretty the same, health workers not wanting to vaccinate, communities not wanting to vaccinate, and we needed a very strong communication strategy to make sure that they do accept vaccination. And we saw that when the cases started to increase, that’s when people really started to seek for the vaccines.

However, for under-five immunization, we don’t experience the same challenges. I have a perception that these vaccines are much more accepted, and communities tend to accept more easily. Which is not happening, for instance, when there is cholera outbreaks, which we not vaccinating only children but we’re also vaccinating adults. There are lots of myths and misinformation around cholera vaccines. But we also see challenges and some hesitancy in HPV vaccines, where people believe that the vaccines will cause infertility in the girl.

So those are some of the issues that the vaccines bring, especially when it’s a new vaccine and not targeted to the under-five. So community engagement. Involvement of the community structures, the leaders – be it religious community leaders, politically leaders at the –at the more peripheral level. This has been very crucial to make sure that people will accept the vaccines, and also the myths and misinformation are dissolved.

Dr. Bliss: Well, thank you. So we’ve covered a lot of ground in the last hour or so. I want to – you know, we kind of started out looking back at, you know, the year 2000, and even back to the 1960s, with the introduction of the vaccines. Let me ask you each just to maybe offer just one or two very brief, you know, kind of predictions, or looking ahead. But let me ask each of you to, you know, just say, you know, as you think about the effort to eliminate measles and protect global health security, kind of looking ahead to 2030 or so, or beyond, what is – what are one or two kind of developments on the horizon that you’re most optimistic about, or most excited about., as you look ahead?

Graça, let’s start with you.

Dr. Matsinhe: Well, Katherine, what comes to my mind is that we have come a long way with the immunization programs we established around 45 years ago in Africa, especially. However, the threat of measles continues to be real. And we need to take collective measures in order to halt this threat. We need to strengthen community surveillance. We need to improve the visibility and funding of routine immunization and the health systems, as broad. But we also need to make sure that the measles efforts are very well aligned with routine immunization. The micro planning of the campaigns, the integration of intervention, and the resource – the resource sharing, I think those are the key issues to make sure that we, as a global community, will be the defeating this enemy, which is measles, and other vaccine-preventable diseases.

Dr. Bliss: Thank you. And that’s right, this is the 50th anniversary of the expanded program on immunization, right? So coming up big celebrations, I think, in April, or so.


Dr. Salas Peraza: Well, we have this global framework to work on immunization, which is an immunization agenda 2030. And there is a lot of partners supporting that agenda. But I’m enthusiastic to see that, you know, that level of coordination on the global level can really translate into a synergistic approach at the country level. Because I think that there is a lot of ground to move forward in terms of really integrating, you know, our efforts, our possibilities, our capacities, and different, you know, partnerships that we have with different partners to really see the country and see how can we help that country in a very comprehensive way. That’s something that it’s very positive, but I think that that immunization agenda, the immunization agenda of 2030, was somehow interrupted or disrupted by the pandemic. But now we are trying to recover, you know, the effort. And really we need that, to really have a coherent coordination at the global level, at the regional level, but at the country level as well. So I think that that’s very positive.

And at the same time, of course, these new kinds of technologies, as Bill mentioned, the microarray patches. We have conducted a workshop in Guyana here to see how they see this technology, how can we have some kind of feedback to improve that technology. And now we’re going to conduct in March in Brazil another workshop about that. So that’s something that could really be a gamechanger, as Bill mentioned. So that’s something that is very positive, and really have me excited about the future that we could have with these new possibilities of – you know, you don’t need a nurse to apply this vaccine. This could be really a gamechanger at all. So that’s something very positive.

Dr. Bliss: Bill.

Dr. Moss: Yeah, so, very briefly, I’ll just say, you know, what I hope to see in – the in the next decade is a real pathway toward measles eradication. We’ve talked about a number of different strategies – the tools, the technologies. I think we know how to do this. I think we can do it. But we need a clear path to achieving measles eradication. So that’s my big hope.

Dr. Bliss: (Laughs.) So we have technical possibilities, opportunities for greater collaboration in terms of financing and, you know, economic outlooks, governance, new frameworks, and positive options with respect to the challenge of social media, but also positive options in terms of using new social media and other communications – maybe more traditional – for reaching people. And, of course, the challenge of political will. In many ways, we know what to do it’s just a matter of getting it done.

I want to thank each of today’s speakers for taking the time to share your expertise during this conversation. We had Graça Matsinhe from JSI in Mozambique representing the M-RITE Project, Bill Moss from the International Vaccine Access Center at Johns Hopkins University Bloomberg School of Public Health, and Daniel Salas Peraza at the Pan-American Health Organization. I also want to thank you, the audience, for joining today’s discussion as well. Thank you.