From Endgame to Long Game: A Multi-Method Analysis of Immunization, Integration, and Equity During Outbreak Response and Recovery in Low- and Middle-Income Countries
Embargo until
Date
2022-04-20
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
Johns Hopkins University
Abstract
Background: Achieving and sustaining high levels of equitable immunization coverage during and after outbreaks remains a major public health challenge for many health systems in low- and middle-income countries (LMICs).
Objectives: The objectives of this dissertation are to (1) describe vaccine delivery challenges that emerge during the last mile of outbreak response; (2) explore how routine immunization programs recover from epidemics; and (3) characterize the relationship between integrated vaccine delivery and equitable vaccination coverage. The ultimate goal of this investigation is to inform how decision-makers in LMICs might strengthen or reform vaccination systems to increase equitable immunization coverage.
Methods: Paper 1 presents a conceptual framework of last mile challenges in vaccine delivery during outbreaks, based on a scoping literature review and key informant interviews. Paper 2 presents a comparative case study analysis of post-epidemic routine immunization challenges in Haiti and Liberia. Paper 3 applies group-based trajectory modeling to describe longitudinal trends in vaccination equity in 78 LMICs and examine associations between integrated vaccine delivery and equity.
Results: In Paper 1, we find that last mile challenges in vaccine delivery may be conceptualized in terms of geography, epidemiology, target populations, and health system considerations, and span the domains of governance and leadership, surveillance, health workforces, program implementation, vaccine uptake, and population immunity. In Paper 2, we find that embedding in-country expertise within outbreak response structures, respecting governmental autonomy and self-determination, aligning post-epidemic recovery plans and policies, and integrating response assets into systems for routine care resulted in more equitable levels of immunization coverage. In Paper 3, we report positive associations between integrated vaccine delivery and both geographic and socioeconomic vaccination equity in select settings reporting high baseline levels of vaccination inequity.
Conclusions: The health system challenges associated with achieving and sustaining high levels of equitable immunization coverage differ between pre-, post-, and inter-outbreak periods. Strengthening linkages within and between relevant health system components can help address these challenges in LMICs. Further research is needed to characterize the barriers and facilitators of equitable vaccine delivery in these settings.
Description
Keywords
Vaccines, integration, health systems, equity, outbreaks