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Countries around the world are eager to accelerate efforts to deliver covid-19 vaccines.

Lessons from countries currently delivering mass covid-19 vaccination programmes can shed light on the complexity of this unprecedented effort.

They also offer valuable insights on how vaccination campaigns have been adapted to suit local contexts, writes Dr Patrick Osewe, Chief of the Health Sector Group, Asian Development Bank.

In partnership with the Asian Development Bank

The UK and India are among the countries leading the way in the total number of vaccine doses administered. The practical considerations involved in operationalising a successful vaccination programme ⎯ including the strategies adopted and adapted to deliver vaccinations within specific populations and settings ⎯ were shared during a webinar hosted by BMJ and the Asian Development Bank on 19 March, 2021.

Adopting context-informed prioritisation strategies

In the UK, the decision on who should get vaccinated first was made by the Joint Committee on Vaccination and Immunisation. The Committee set out ten priority groups, stratified by age. Dr Liz Avital, Operation Lead for a vaccination centre in London, explained that there was significant debate in the UK on this issue, as the country hadn’t prioritised emergency service personnel (e.g., police and fire crews) thus diverging from the path set by other countries.

She emphasised that no one system or strategy is perfect. However, acceptance rates of vaccination in the UK have been high and the country has recently expanded access to individuals in group 9 – people 50 years and older. And it is now also administering second doses to some groups. In India, the country prioritised three main groups ⎯ healthcare workers; people 50 years and older; and people below 50 years with underlying conditions ⎯ with a gradual progression to other groups. As countries consider who gets vaccinations first, they will have to grapple with how to protect as many people as quickly as possible, while also taking into consideration issues of vaccine equity.

Recruiting a fit-for-purpose and flexible vaccination workforce

The importance of sufficient workforce capacity to administer covid-19 vaccines was also emphasised. Establishing the right mix and diversity of workforce at London-based vaccination sites was crucially important, said Dr. Liz Avital. She shared that at the start of their programme, which was general practice-led, the majority of the vaccinators were nurses and GPs. However, as general practices became busier, this model was no longer sustainable.

The solution was to use a more diverse mix of trained vaccinators. These included retired doctors and nurses as well as dentists, pharmacists, and medical students. In addition, non-medics have been recruited and trained to be vaccinators. Volunteers to guide clients to vaccination points and security staff have also been vital in operationalising the centre. In India, close to one million vaccinators across public and private facilities have been trained – these include doctors, nurses, and midwives. The country has the capacity to mobilise cadres at the community level as well.

In most settings around the globe, defeating the pandemic will require sufficient human resources and likely an extensive corps of both medical and non-medical professionals and volunteers. At the same time, flexible and sustainable approaches are necessary to ensure the appropriate mix and level of staffing ⎯ depending on the site, the volume of clients served, and workforce capacity.

Prioritising scientific investments and cooperation

Both India and the UK leveraged previous investments in vaccine development and delivery. India has a long history of vaccine production. Building on this expertise, the country made the decision early on to produce and distribute a cost-effective covid-19 vaccine for its own population and the world.

Dr Vinod Paul, the head of India’s covid-19 task force, explained that a vaccine task force was established in March 2020 followed by a national group for vaccine administration to explore the practicalities of delivering vaccines. In the UK, Oxford University worked with AstraZeneca to develop a cost-effective and easy-to-administer covid-19 vaccine.

India manufactures this vaccine locally through the Serum Institute of India and had also developed a second vaccine, Covaxin, with a number of other vaccines in development. The current pandemic has underscored the need to strengthen scientific capabilities and cooperation in low- and mid-income countries in order to rapidly expand worldwide access to vaccines. 

Leveraging robust data infrastructure and IT systems

Robust data infrastructure and IT systems are crucially important not only for vaccine distribution (e.g., allocation, ordering, distributing, managing. and tracking) but also for vaccine administration (e.g., scheduling appointments and reminders, documentation, and reporting adverse reactions). The UK’s vaccine appointment system is linked to GP records and is automatically updated once someone receives a dose of vaccine.

Dr Paul noted that India’s robust digital vaccine management system, CoWIN, forms the backbone of the country’s vaccine administration, and importantly it allows people to make appointments at a place of their choice. Countries should ensure that data and IT capabilities are made ready as any gaps may stall efforts to distribute and administer vaccines quickly.

Developing nuanced vaccine messaging

Vaccine hesitancy has a long history in many communities and remains a key barrier to vaccine uptake. Combatting misinformation around the efficacy and safety of covid-19 vaccines and increasing vaccine confidence has required targeted efforts to engage communities, along with nuanced messaging that speaks directly to identified concerns. In order to address the needs of diverse populations and low vaccine uptake, the London vaccination site ensured that information leaflets were available in different languages and engaged local leaders and religious councils in myth-busting and community-based outreach efforts. In India, early efforts to reduce hesitancy among healthcare workers was science-driven, emphasising safety from trusted vaccine messengers such as nurses.

The use of the media and appeals by prominent politicians and others in the public eye have also contributed to increased vaccine confidence. Engaging communities who remain at highest risk of infection with appropriate messaging and ensuring they have equitable access to the vaccine is critical to the effort of suppressing transmission and preventing new variants from gaining a foothold.

Moving beyond traditional partnerships

The complexity of the pandemic coupled with the rollout of mass covid-19 vaccination campaigns requires an extraordinary degree of coordinated action across multiple sectors and areas of expertise. In both the UK and India contexts, forging new and sometimes non-traditional partnerships has been integral to meeting the challenge of this moment. In India, the private and public sectors have worked together to administer the vaccine to as many people as possible through a network of 50,000 facilities ⎯ 39,000 of which are currently in operation.

Dr Paul further shared that India’s approach has been a whole-of-government, whole-of-society response, with partnerships at all levels.  At the London-based vaccination site, medical professionals have worked alongside volunteers to run the site safely and efficiently. Outside of the vaccination site, doctors and nurses have worked with religious and community leaders in order to combat vaccine hesitancy and increase vaccine confidence.

The current effort to vaccinate entire countries is unprecedented and the world is learning as it goes. One thing that has been made clear through lessons in the UK and India is that it is only through a wide array of efforts and actors that vaccinations will reach all the people that need them. Both countries have also demonstrated how operational considerations for vaccine delivery efforts must reflect local realities.

Countries at the early stages of vaccine rollout, and even those developing solutions to existing challenges mid-implementation, have an opportunity to learn from one another ⎯ shoring up the systems, capacities, and infrastructure required to tackle the largest global vaccination effort in history.

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Mitali Wroczynski
Director of Global Health