Vaccine Preventable Diseases in the tropics: Why are we still struggling?

This week is World Immunization Week, which aims to promote the use of vaccines to protect people of all ages against disease. Dr Sadia Shakoor, Editor of Tropical Diseases, Travel Medicine and Vaccines, discusses the challenges faced by immunization programs and the problems, such as education and delivery, which still need to be overcome.

A wakeup call

In 2015, CNN ran a story about 500 parents arrested in Pakistan for polio vaccine refusal. To most of us practicing in this environment, the episode was a wakeup call on the ramifications of omitting to educate, and convince, every parent to vaccinate their children on each patient contact. If physicians failed to engage every household in making this decision, will they then be arrested?

We often assume that the benefits of vaccinating are inherent knowledge. Even highly literate populations have a certain percentage of vaccine refusals, albeit due to different concerns. This is ample proof that vaccination benefits need to be indoctrinated among the public. Lacking these efforts, any moves to blame the public for being unaware (especially where literacy rates are low) are simply unfair. Despite education, some people still may not choose to vaccinate. This is because knowledge does not equal belief. However, we cannot strive to change beliefs if there is no knowledge.

Even highly literate populations have a certain percentage of vaccine refusals, albeit due to different concerns. This is ample proof that vaccination benefits need to be indoctrinated among the public.

There is a large body of work by Heidi Larson on vaccine refusal, or vaccine hesitancy, and the issue has been highlighted here, here, and here. There are also valuable suggestions on how to promote vaccine acceptance among the public.

Eventually all of those arrested in Pakistan received bail on pledging to vaccinate their children. One would assume, however, that drastic measures such as these would be necessary only as a last resort and after every stone has been turned to educate the public on the pros of vaccination. Not so. Sadly, this is one area where vaccination programs in resource-limited tropical and sub-tropical countries falter.

Why are we still struggling?

Most governments would wager that their immunization plans run as perfectly orchestrated programs. That may be true of the logistics, but is not the case with vaccine awareness. Most programs do not set aside budgets for education and awareness. As most mobilized funding comes from international agencies like GAVI, and very little local funds are generated – despite which many funding gaps remain – advocacy is frequently side-lined in favor of operational budgets. The immediate priority for many immunization programs is to invest in delivery mechanisms, but not the final step: actually making sure children receive the vaccines.

Again, one would assume that countries should be able to educate without huge advocacy budgets set aside, right?! It seems as though what gets funded, gets done. If there isn’t money set aside in international agendas to get things done, they don’t happen.

Even when money is set aside, there must be political will to see immunization and awareness campaigns through. Many resource-limited countries continue to be in a vicious cycle of poor economic growth due to misuse of funds and resources. Political commitment to a goal is the only way to override this and ensure appropriate use of funds.

Even when money is set aside, there must be political will to see immunization and awareness campaigns through.

Another generally held view among public health officials is that vaccinators should be able to educate and convince parents to vaccinate. This again is an imbalanced view, as vaccinators who are supposed to cover 15 households everyday cannot be relied upon to deliver all components of a vaccination program. Many programs already have limited resources and inadequate workforce. Vaccinator mobility and security are also significant hurdles to delivery of vaccines to willing parents.

A harmonized approach

Many vaccination programs focus predominantly on delivery infrastructure, and while this is an important aspect of vaccines, including supply chains, and door-to-door delivery, we have been told that you can lead a horse to water, but cannot make him drink. Or can you? There are proven techniques to increase acceptance of vaccines among the community. One way is by conditional cash transfers (CCTs), but many more have been advocated and tried in different situations. But there is always another mountain to climb…in areas where CCTs have been successfully used, vaccine stocks have often run out!
What is needed therefore is a harmonized approach to education and delivery and the recognition by programs that one cannot survive without the other.

Vaccines are the most potent weapons we have against infections. While we strive to develop more and better vaccines, we also need to ensure that communities are engaged and invested in making vaccination programs successful. If we want to go far, we have to travel together.

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