Approaching Vaccination from End to End: Five Lessons from More than 15 Years of Advancing Japanese Encephalitis Vaccination

"By acknowledging and building in objectives around advocacy, coordination, outreach, and/or coalition building, projects can help ensure that all the right partners are at the table. Working together means that all the right voices can not only be heard, but also acted upon."

Developed by PATH's Center for Vaccine Innovation and Access, this report explores the strategies that shaped PATH's efforts to address a previously neglected tropical disease - Japanese encephalitis (JE). PATH highlights in the report the partnerships forged over 20 years to introduce JE vaccination in the Asian and Western Pacific regions, which PATH says resulted in more than 300 million children being protected from JE and strengthened health systems across multiple countries. The purpose is to explore how the JE project experience can inform current and future vaccination projects, to ensure impact and sustainability.

PATH explains that, from the outset, the JE project team developed one comprehensive plan with several paths, all leading to the common goal: decreased death and disability due to JE. These included but were not limited to:

• Elevating global, regional, and national awareness of JE and disseminating evidence through advocacy and communications;
• Supporting countries' JE surveillance and diagnostics efforts;
• Ensuring safety and quality of a suitable vaccine through clinical trials and chemistry, manufacturing, and controls (CMC) activities;
• Supporting stable and predictable vaccine supply and demand through demand forecasting;
• Informing country decision-making with evidence from clinical trials and health economics;
• Supporting countries' data-based decision-making, planning, and logistics for vaccine introduction; and
• Coordinating global efforts by convening a global resource centre for JE.

The title of the approach refers to the "end-to-end approach to vaccine introduction" that characterised the JE project, "with cycles of feedback, learning, and recalibrating from multiple points of view along the way."

Following an introduction, the report is organised according to 5 main lessons; selected communication-centred elements are highlighted below:

1. Meet countries where they are - PATH and its partners first asked what is best for each specific country; then, with the country and other stakeholders, they set out to co-develop a remedy. PATH worked with the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), country and local governments, civil society, and public-sector partners to communicate, collaborate, and solve commonly shared problems that could pose challenges to getting the vaccine to at-risk children. A few examples:
   • In Laos, vaccine uptake declined rapidly following the initial introduction. Upon investigation, country decision-makers and PATH found two problems: parents had little knowledge about JE, and the government had difficulty procuring and distributing the vaccine within the country. To address these concerns, PATH worked with partners to develop short, animated cartoons delivered to parents' phones via social media messaging apps, as well as an interactive online training for JE vaccine procurement.
   • In Bali, Indonesia, there were community cultural or religious concerns about the processes or ingredients used to make JE vaccines. To ensure demand for JE vaccine and reduce vaccine hesitancy, the Ministry of Health (MOH) and other stakeholders worked together with Balinese religious and cultural leaders and conducted advocacy and social mobilisation campaigns.
2. Prioritise public health and simple solutions - The team identified that one JE-endemic country, China, had developed an effective live attenuated vaccine that met many of the public health requirements. The report describes the process of leveraging buy-in from JE-endemic countries and increasing product confidence in China's first WHO-prequalified vaccine.
3. Work together - At the start of the project, JE and its burden were not well understood at global and national levels. To gain and maintain the necessary support from global, regional, and local partners to tackle JE, PATH used advocacy to raise awareness and build consensus for JE control. For example, the team collected new and existing data and information on the burden and control of JE, which it reconfigured and disseminated to various audiences. These included a series of training presentations, messaging, fact sheets, newsletters, case studies, peer-reviewed publications, a vaccine introduction decision-making guide, social media resources, media outreach, and 3 films for use by stakeholders and health officials in advocacy efforts (2 of which aired on BBC World and were broadcast in more than 200 countries). UNICEF played a key role in developing information, education, and communication (IEC) materials for social mobilisation, like the one above (from Nepal), in countries introducing the vaccine. Among the roles various partners played in the effort were those of country advocates and experts, who helped determine the burden of disease, conducted and supported clinical trials, raised local and global awareness around JE, convinced country governments to introduce JE vaccine into routine immunisation, and increased country demand. Countries also learned from each other's experiences and expertise and took a leadership role in driving momentum in global discussions.
4. Decide with data - Building in-country surveillance capacity allowed governments to generate data to determine whether their country would benefit from introducing a JE vaccine. The JE project also showed the potential and value of regularly sharing high-quality data between neighbours in order to make decisions on new vaccine uptake. Advocacy and communication efforts around data included: translating results from surveillance studies, clinical trials, and cost-effectiveness analyses into clear and simple messages for various audiences; including messages in published materials and media resources; providing conference and workshop presentations, and policy briefs; and working with clinical trial teams to provide guidance and support on communicating trial results to the media. One key lesson from dissemination efforts was realising the importance of highlighting JE's regional and country-specific impact.
5. Plan for the future - For example, PATH stresses that plans for safety monitoring and how to respond to any safety signals (crisis communication) should be in place before vaccine introduction.

A concluding thought, looking ahead: "In order to ensure the sustainability of not just one specific vaccine, but of all vaccination programs, planning for surveillance, monitoring, demand forecasting, and vaccine procurement must be prioritized.