Opinion: Invest in the people and the systems delivering vaccine confidence

As Pakistan responds to the catastrophic flooding in their country, we are once again reminded of the fragility of communities everywhere — but also of the resilience of leaders who rescue, revive, and restore their communities every day. Investing time and money in these community leaders is central to saving millions of lives by increasing COVID-19 vaccine uptake and reversing the largest sustained global backslide in routine childhood immunization in 30 years.

Every day, we see the importance of health workers being able to reach their communities. Earlier this year, when disastrous flooding hit the Phalombe District in southern Malawi, maternal and child health coordinator and nurse Rashid Mang’anda’s resilience came to the forefront. He quickly recognized the potential devastating impacts if health workers could not get routine childhood and COVID-19 vaccines out to the 15,000 households displaced by flooding in the district. Fueling the biggest of his concerns were the first new cases of polio in more than five years in Malawi and an emerging cholera outbreak.

Mang’anda and his fellow health workers’ adaptive leadership and tailored approaches were central to improving population health in a way that served each community’s unique needs. Some, for example, wanted sexual and reproductive health services to be included within COVID-19 vaccine efforts, while others did not want COVID-19 vaccines and routine immunizations delivered at the same time. So, health leaders shifted their outreach strategies — including more door-to-door outreach — and adapted services based on community feedback.

The hard work of millions of health workers like Mang’anda in transforming vaccines into vaccinations is the central reason immunization has been among the most transformational interventions in the history of public health — drastically reducing deaths and disability from many infectious diseases such as measles and smallpox.

Vaccines to prevent 10 diseases administered in just the past two decades will help save an astonishing 52 million lives in low- and middle-income countries by 2030. And in their first year alone, COVID-19 vaccinations saved 19.8 million lives worldwide as a result of the largest single vaccine rollout in history.

Reversing alarming declines in immunization

Yet, as we at Sabin Vaccine Institute prepare to join leaders for discussions at the United Nations General Assembly this month — we and others are sounding the alarm that immunization trends are heading in the wrong direction.

In July, the World Health Organization and UNICEF reported alarming declines in routine immunizations on top of the starkly inequitable COVID-19 vaccine rollout, a 400% increase in vaccine-preventable measles in Africa early this year, and the first new cases of polio in years — sometimes decades — from Malawi to Mozambique to the United States.

The only way we’re going to reverse these trends is if global health policy and financing begins to center around the people and the systems needed to make immunization programs work.

Policymakers must enable investment to better understand and respond to how decision-making and access to vaccines has changed as a result of the pandemic.

Sabin’s Vaccination Acceptance Research Network and related grants program have surfaced an array of evidence countering a one-size-fits-all approach to building vaccine acceptance and demand. Whether it’s addressing the needs of people living with disabilities when designing immunization programs or the engagement of faith-based leaders in addressing vaccine misinformation, the future power of vaccines rests in listening and adapting to the priority needs of each community and the people who care for them.

As I stated at the Second Global COVID-19 Summit in May, we all applauded health workers during the pandemic; however, given the high numbers of infections and deaths among health workers from COVID-19 and other diseases — as well as increased stress and mental health issues, decreased productivity and retention, and increasing numbers ready to resign — sustaining high vaccine uptake can only occur with comprehensive and long-term investment in the people developing, deploying, and delivering vaccines and trust in immunization.

Such recommendations often receive head nods from global health policymakers and influencers. However, when it comes to the hard work needed to deliver community investments, the web of policies and funding needed across several different sectors often ends up leading to collective inaction. Right now, we must advocate for:

• Specific inclusion of investments to support health workers in increasing vaccine acceptance and demand in the new Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, managed by the World Bank;

• A costed and financed plan to recover the lost ground of routine vaccination and plans for how to achieve vaccination targets set forth in the Immunization Agenda 2030, as well as COVID-19 vaccine targets set forth by COVAX. These efforts should include innovative research and actionable solutions to understand and adapt to the social and behavioral drivers impacting decision-making on vaccine uptake in communities; and

• Sustained, focused commitments to new development assistance for the health workforce through global mechanisms such as Working for Health Multi-Partner Trust Fund and regional initiatives such as the Africa Frontline First initiative of the African Union. The Group of Seven leading industrial nations must follow through on the recommendations of their own task force, which calls for $2-3 billion in new development assistance to build and sustain a robust and resilient global health workforce.

We are entering a danger zone of the panic-neglect cycle, and as a result, vaccines’ potential to save millions of lives and prevent severe disease for millions more is threatened for the first time in decades. Policymakers and influencers must show the same commitment as those closest to communities if we want to right this ship.