Opinion: Global immunization efforts need a new BRAVE and BOLD approach

Early last year, journalist Yukfu Sylvie Bantar summed up the sluggish COVID-19 vaccine rollout in cosmopolitan Kumbo, a conflict-ridden town in northwest Cameroon, with one sentence: “Global problem, global solutions, but local resistance.” Other media reports in low- and middle-income countries have echoed that view, highlighting astounding variations in the acceptance of and demand for vaccines — not only between countries but also within countries.

The message is loud and clear: A globally prescribed, one-size-fits-all approach to vaccination is obsolete. Global institutions must listen to local voices, respect their expertise and wisdom, and co-craft solutions if we are to deliver on the transformational power of vaccines for society.

Global health institutions have rightly sounded the alarm over the largest sustained decline in routine immunization in 30 years. However, it would be overly simplistic and dangerous for public health leaders to conclude that the problem is temporary and that immunization coverage declines will automatically be reversed with status quo programming as COVID-19 pandemic restrictions are lowered.

Even before the pandemic, vaccination rates were plateauing after decades of steady increases. Expanded programs on immunization have largely served the families and households that are easiest to reach. Meanwhile, families living in extreme poverty, under the shadow of active conflict, or those who had been displaced are frequently deprived of immunization and other essential services such as nutrition, education, and sanitation. As a result, millions of children remain “zero-dose,” having not received even the most basic lifesaving vaccinations.

The truth is that progress on global targets set under Immunization Agenda 2030, the Sustainable Development Goals, and the Gavi 5.0 Strategy is moving in the wrong direction. Maintaining the status quo on immunization is not an option — it is time for a BRAVE and BOLD approach that puts the people with the most impact on vaccination decisions at the center of efforts to reach and vaccinate those who are perennially left behind.

At Sabin, we have set a new BRAVE vision to boost immunization, reduce the number of zero-dose children, and accelerate vaccine introductions. All while valuing communities’ and women’s change-making role in immunization decisions, and enhancing the integration of vaccination programs within primary health care systems.

This cannot be achieved without a BOLD approach to bridge the gap between global and local levels by organizing two-way exchanges, listening to communities, and developing solutions collaboratively and proactively, and dynamically distill and disseminate what works.

Focusing on zero-dose children to spur immunization progress

Prior to COVID-19, 1 in 8 children were zero-dose, and they accounted for nearly half of all vaccine-preventable deaths. The pandemic exacerbated an already dire situation, adding another five million zero-dose children in 2021 and raising the total to 18 million — a staggering 37% increase in children defenseless against many deadly diseases.

The deaths of zero-dose children — often living in extreme poverty — reflect a moral and humanitarian failure. But it is also a major ongoing threat to global health security. Polio, measles, and other diseases are returning with a vengeance, even in countries that had long eliminated them through decades of tireless effort and massive public investment.

Catching up missed children through nationwide, indiscriminate, disease-focused campaigns isn’t enough to deliver the full potential of vaccines. We will only be able to reach these zero-dose children through highly targeted approaches that defer to community-level sentiments.

Recalibrating life-course vaccination programs

Inequities in immunization are not limited to unvaccinated or under-vaccinated children. Lessons from the COVID-19 vaccine rollout have underscored a long-simmering dichotomy: Vaccination programs have largely been designed around reaching infants and young children. But getting vaccines to halt and mitigate deadly pandemics requires targeting high-risk populations across all ages. Case in point: As of July 2022, only 28% of older people and 37% of health workers in low-income countries had received their primary course of COVID-19 vaccines, and most had not received any booster doses.

The challenges of strengthening life-course vaccination go beyond the development of safe and effective vaccines. Consider the case of vaccines for the human papillomavirus, which can reduce the incidence of cervical cancer by nearly 90% for a disease that is a leading cause of death among women in low- and middle-income countries. Yet, immunization coverage for HPV is a paltry 12% despite its proven ability to prevent most of the 342,000 deaths it causes each year. The toll of cervical cancer now exceeds maternal deaths globally.

It is not easy or simple to focus and sustain efforts to reach the populations who can most benefit from vaccines as well as diligently work in a holistic cycle — including everything from evidence to advocacy to decision-making, implementation, and course correction. But when we have seen this approach applied in practice, it has helped end epidemics such as Ebola in the Democratic Republic of Congo and polio in India, a country that accounted for more than half of all global polio cases until 2009.

Vaccines are one of the most transformational innovations in human history — preventing an astonishing 50 million deaths across LMICs over the last 20 years; saving nearly 20 million lives from the devastation of COVID-19 in the first year of the largest vaccine rollout in history; and yielding a return of up to $52 for every $1 spent on vaccinations in the last decade.

However, as we have learned from the stories, expertise, and voices of those closest to the solution — including local journalists and immunization professionals, researchers, and health workers associated with Sabin’s global immunization program — a flexible approach that listens and adapts to communities is crucial for the full promise of vaccines to be realized.