Mpox Vaccination: An opportunity to reconsider the role of the public in immunisation campaigns?

On the 5th of September, the first consignment of 99,100 doses of the Jyenneos vaccine against mpox arrived in the Democratic Republic of Congo (DRC). These vaccines arrived a few weeks after emergency declarations by both the Africa Centre for Disease Control (CDC) and the WHO, following a rise in cases, primarily in central and east Africa, and amongst rising concern of the spread of a new strain of the virus, clade 1b, which appears to particularly affect children. The number of vaccines arriving in DRC is far below those expected to be needed, and as affected neighbouring countries are still awaiting theirs, it seems unlikely that the 10 million doses requested by Africa CDC’s Director for the continent are on the horizon. Civil society organisations have called out prohibitive pricing by pharmaceutical companies and hoarding of vaccines by countries in the Global North as major obstacles to the mpox response in Africa. As in the days of the COVID-19 pandemic, global vaccine injustice is once again a glaring problem not only for countries immediately affected but for global efforts to stop transmission.

Who makes decisions about how vaccines are deployed?

Against this backdrop, efforts are being made to increase supply wherever possible, for example through Gavi’s activation of the new First Response Fund to mobilise 500,000 doses and plans to create a stockpile. As affected countries prepare to deliver vaccines, however scarce, important decisions face health officials about how to deploy scarce supplies. The National Immunisation Technical Advisory Group (NITAG) in DRC, for example, is planning to target both frontline healthcare workers and groups previously identified as being at risk, such as commercial sex workers. This decision has already raised questions, for example as to whether the “mechanical inclusion of groups without a clear history of recent exposure” makes sense or whether it might be better to focus on known contacts of contacts (as it was during ring vaccinations for Ebola in West Africa, for example), particularly with limited doses available. Normally, these decisions are made solely by governments and public health experts, rarely in consultation with communities affected by the disease or those belonging to groups targeted by vaccination plans. The public tends to be informed at the point at which vaccines arrive in their towns and villages, with limited time to engage communities in any meaningful way, if at all. There are however very good reasons why governments embarking on the design of an emergency vaccination campaign might want to consider consulting the public early, and important lessons can be learned from other experiences across the continent and beyond during other outbreaks and vaccination campaigns.

Lessons from the PULSE project

For the last year the UKHIH has been supporting a System Innovation Partnership to synthesise and develop evidence around how to best engage communities in vaccines delivery in crisis contexts.

The PULSE project, is a collaboration between the IFRC, Childcare and Wellness Clinics in Nigeria, Addis Ababa University in Ethiopia, the London School of Hygiene & Tropical Medicine and the Geneva Centre of Humanitarian Studies at University of Geneva, we have conducted qualitative research in Kano (Nigeria) and Dire Dawa (Ethiopia). It aims to establish an evidence base to support community-led vaccine deployment strategies in humanitarian contexts. This research highlights two key areas that those involved in the deployment of mpox vaccines may want to consider: the possibility of co-design of vaccination strategies and avenues to build trust amongst affected populations.

Co-Designing Vaccine Strategies

Despite increasing attention amongst humanitarian and public health practitioners to community engagement as a key component of epidemic response, in the context of vaccination, this remains seen primarily as an activity to be conducted at the point of delivery, to build confidence or address pockets of vaccine hesitancy. During emergencies in particular, these processes also tend to be hurried, responding as quickly as possible to vaccine availability or central decisions to vaccinate. In our research in Nigeria, for example, Red Cross volunteers were only given a couple of days to go house to house to alert the public that there would be a diphtheria vaccination campaign to respond to an outbreak in the North of the country. Even when there is a longer build up to develop a comprehensive engagement strategy, as was the case for example during the COVID-19 pandemic, community engagement specialists have to work around plans that have often already been made about how, when and where vaccination will take place. Consultations with the public prior to the design of a vaccination campaign however could improve the effectiveness of deployment and to build trust with the population. This is especially important in the current context of scarcity and humanitarian contexts, where mass campaigns are not always feasible and difficult decisions have to be made about targeting.

Questions around prioritisation could, for example, combine epidemiological considerations with local perceptions on the ethics of vaccine distribution as well as communities’ own insights on pathways of transmission as they are ongoing within their villages and towns, which are not always visible to public health officials. Similarly, the logistics of deployment, such as identifying times and locations for conducting vaccination that reflect people’s livelihoods and priorities can improve uptake. In Ethiopia, for example, Red Cross volunteers identified that the problem with a vaccination campaign they were involved in was “not the content of the vaccine per se, but it [was] mostly more a question of practical consideration in terms of accessing the site”, which then led to the creation of mobile vaccination points. With mpox, there are also additional sensitivities, for example around the stigmatisation of groups such as people who sell sex or men who have sex with men (MSM) that may be exacerbated by targeted vaccination campaigns. Another research project in Nigeria, for example, found that MSM wanted more information on how to protect themselves against mpox but were worried about being singled out or exposed.. Discreet conversations with these groups, ideally via trusted networks including CSOs, may provide new ideas not only about how to conduct sensitive community engagement but also on how to design deployment mechanisms that do not stigmatise or put people at risk. As a final example, particularly salient for areas such as Eastern DRC, which is affected by long-standing conflict, it is important to remember that local populations are experts in security dynamics that affect them and as such can advise on logistical considerations for delivering vaccines. This is especially crucial in a context where populations have long felt that their security is not prioritised and as the UN mission, MONUSCO, is drawing down despite continued conflict (see this brief for a detailed account of the socio-political dynamics and their implications for community engagement). In our PULSE case study in Nigeria we saw that commodities may need to be transported differently to avoid attention from armed groups, additional staff are needed, and that local information on how to reach vaccine users was essential if vaccination staff could not stay overnight in villages for the campaign.

Building Trust

In a context where supply is severely limited, a focus on vaccine confidence can be problematic. This is firstly because, as we found in our research in Nigeria and Ethiopia, engagement campaigns around measles vaccination that built momentum but then ran into a problem whereby people attending clinics were told there were no vaccines available, can be counter productive. Secondly, a focus on addressing potential ‘hesitancy’ risks displacing blame for low vaccination rates onto communities, when access is a primary problem. Rather than starting from a premise of ‘hesitancy’, then, we might rather consider pathways for building trust, including honest communication around supply challenges. Our research in Nigeria and Ethiopia found that much community engagement continues to focus on giving people information. In contrast to that, conversations with the public highlighted, as other research has also done, that concerns around vaccination is rarely about a lack of information, and more to do with whether people trust those delivering the vaccines and speaking to them about it, and that the mechanisms of trust are often rooted in longer-standing social, political and historical dynamics. Our project identified some practical lessons that may be more broadly significant. The first is that people trust the messenger more than the message. This requires developing a deep contextual understanding of public authority within communities, identifying who is trusted by whom, rather than assuming that communities are homogeneous. In Kano , for example, traditional birth attendants were identified as influential when discussing vaccination with pregnant women and mothers of young children. Power dynamics also change over time, for example, also in Kano, there was a perception that traditional leaders such as Emirs were becoming less influential than for example philanthropists or heads of large households in the neighbourhood. Prior experiences of vaccination, as well as interactions with the health system more broadly, also had a significant influence on willingness to vaccinate. For example, using a citizen ethnography approach, Red Cross volunteers found that in Ethiopia, caretakers grew fatigued after presenting multiple times at health centers with vaccines stock outs. In this context, there is often a paradox with RCCE interventions, a very limited supply of vaccines (as with mpox) means supply can be overwhelmed if demand increases. Whilst past negative experiences cannot be fixed, research in other countries has shown that facilitating dialogue between health workers and their patients can help mend broken relations. Conversely, coercive and punitive approaches, which we found in both study countries, can harm the establishment of long-term vaccine confidence.

Looking Ahead: Preparing for Vaccination

As cases of mpox continue to rise, the priority remains to ensure the availability of vaccines for affected countries and populations. When planning for the deployment of vaccines, once they arrive, public health agencies and other organisations involved in the rollout, should consider engaging the public early, seeking input into the design of immunisation campaigns, rather than only engaging citizens at the point of delivery. It is never too soon to work on building trust and transparent, consultative processes are an important first step. An exclusive focus on ‘hesitancy’ and providing more information, can similarly be counterproductive, especially in a situation of scarcity. Instead, identifying deeper, contextual roots of mistrust, working with trusted groups and individuals and developing sensitive and participatory approaches to avoid stigma, can help develop more effective campaigns.