Introduction of the Pneumococcal Conjugate Vaccine in Humanitarian and Fragile Contexts: Perspectives from Stakeholders in Four African Countries

"We can benefit from the experience of countries that have already gone through this process to learn from the lessons already learned by others, so that we can move forward quickly and well." - interview participant from Guinea

Childhood pneumonia causes a significant burden of preventable child morbidity and mortality in Chad, Guinea, Somalia/Somaliland, and South Sudan. Leaders from these countries have committed to introducing the pneumococcal conjugate vaccine (PCV) into their immunisation programmes in 2024. To support long-term sustainability for expected PCV introductions in settings afflicted by prolonged humanitarian crises, this research explores national stakeholders' perspectives on contextual factors that may influence optimal vaccine implementation.

Traditionally, vaccine access research has focused its gaze "downstream" by studying populations to assess their perceptions of vaccines, misinformation about vaccination services, and questions of vaccine acceptance and access. To gain a more well-rounded perspective, the present research "studies up" proximal factors to better understand the power structures that facilitate and create the conditions that elicit population-level perceptions. To that end, the qualitative study used purposive sampling and semi-structured interviews of 16 key informants from government, partner organisations, and international health agencies who are involved in the decision-making and rollout of PCV.

Findings from the interviews fit within the following four overarching themes:

1. There are population-level vulnerabilities to pneumonia, exacerbated by climatic risks and low levels of maternal education - e.g., stakeholders from Chad, Guinea, and Somalia said many caregivers were uninformed about pneumonia danger signs, delayed care-seeking, and exhibited vaccine hesitancy.
2. Participants highlighted that there are currently gaps in country-level disease surveillance systems, which are needed to document the impact of PCV introduction.
3. Participants highlighted that, in spite of potential barriers impacting vaccine decision-making procsses, there is strong commitment to leverage existing support to facilitate the sustainable implementation of PCV.
4. Participants discussed priorities, including communication, infrastructure, cold chain, and training, to support the rapid introduction and sustainability of PCV. Most participants discussed varied and successful communication approaches that had been used to increase demand and counter hesitancy, particularly in the context of COVID-19 vaccines, and which could be leveraged to support PCV rollout. For example, participants from Chad and Guinea said local "sensitisers" or town criers - a traditional one-person messenger who moves through small villages announcing important news with a megaphone - have an important role in explaining the benefits of vaccines at the local level. Participants also shared that national and international partners played a significant role in the rollout of vaccines, particularly in countries experiencing major humanitarian emergencies.

In drawing practical implications from the findings, the researchers recommend, in part:

• Efforts to increase caregivers' awareness about pneumonia danger signs and associated health worker training and availability are needed alongside vaccine implementation. Communication campaigns around new vaccines are a means for increasing demand, while refresher training for health workers associated with a new vaccine introduction should support improved service delivery.
• New vaccine rollouts can build on existing community demand generation strategies, create locally tailored communication campaigns, and rely on locally embedded, trusted messengers, such as religious leaders and town criers, to drive uptake and acceptance in communities. Leaders can establish early warning systems to identify and respond to both misinformation and lower-than-expected uptake.
• Competing priorities result in countries attempting to simultaneously address urgent infrastructure and community needs. However, technical committees have been supporting countries with identifying ways to simultaneously address barriers to vaccine uptake.
• Country governments can use their immunisation advisory groups to work with technical committees and professional societies to increase public awareness and advocacy using evidence-based approaches. It is critical for the passion and urgency that participants expressed for PCV introduction to be translated into vocal, high-level political support during implementation.
• It is essential to nurture and maintain effective relationships between country leaders and global partners through participatory planning and implementation stages. Identifying context-specific determinants of implementation success will be valuable to building tailored introduction strategies for each country.

In conclusion, "in order to ensure the best outcomes in these countries, effective multi-sectoral collaborations are needed to support activities that address specific factors contributing to pneumonia susceptibility, strengthen country-level surveillance systems, and build on momentum to strengthen decision-making processes to bolster new vaccine implementation and sustainability."