"One measure we used to know whether the communication was working was to see the tone of the messages in the media, and we saw mostly positive or neutral messages, which was a good indication that things were going well." - Lauren Vulanovic, Communication Specialist, Family, Gender and Life (FGL)/PAHO
This report examines the introduction of the inactivated polio vaccine (IPV) and synchronised switch from the trivalent oral polio vaccine (tOPV) to the bivalent oral polio vaccine (bOPV) ("the Switch") in the Pan American Health Organization (PAHO) / World Health Organization (WHO) Region of the Americas. All countries/territories in the Region slated for IPV introduction and the Switch in 2015-2016 carried out the required decision-making, planning and preparation, implementation, and communication tasks, through their national immunisation programmes (NIPs), within the established timeframe. To learn more about the facilitators and barriers for this achievement, PAHO's Regional Immunizations team conducted two country surveys (one on IPV introduction, and the other on the Switch). The purpose of this report is to document and analyse the information collected from the survey respondents about their experience, including the lessons learned, as well as the processes that led to this experience in IPV introduction and the Switch. The present summary focuses on the communication elements of the experience - as detailed in the report.
In order to explain the Switch and why it happened, PAHO here outlines the objectives of the Global Polio Eradication Initiative (GPEI)'s Polio Eradication and Endgame Strategic Plan 2013-2018 ("Endgame Plan"). As part of that plan, in 2014, the Regional (PAHO) Technical Advisory Group on Vaccine-preventable Diseases (TAG) endorsed IPV introduction and the switch from tOPV to bOPV in the Americas. In October 2015, WHO's Strategic Advisory Group of Experts on Immunization (SAGE) confirmed a 2-week window (April 17 to May 1 2016) for the global Switch and called for the withdrawal of tOPV from the world market. Once global eradication of polio is certified, use of bOPV will also cease. (The International Commission for the Certification of Poliomyelitis Eradication for the Americas (ICCPE) certified the Region of the Americas as polio-free in 1994.)
The paper next explores in detail the process of IPV introduction and the Switch in the Americas. After the Polio Working Group was convened in January and March 2014 to adapt the Endgame Plan to the Regional situation, TAG held a virtual meeting in April 2014. Based on TAG's recommendation, PAHO's Regional Immunizations team developed a comprehensive technical cooperation strategy. The strategy included organising and conducting several virtual and face-to-face meetings, as well as developing and adapting different types of support materials (technical documents, training materials, and communications materials). These materials are described within the paper; to cite one example: Various communication materials and tools were developed for use by NIP managers and communication specialists, including the Issues Management Guide and the Media Resource Kit. The latter contains practical guidance on: 1) developing key messages for IPV introduction, including spokesperson question and answers; 2) avoiding common errors in communication activities; 3) writing press releases, and 4) organising a press conference. PAHO allowed the countries to adapt the materials as needed, which is described here as crucial. In 2015, all support materials were made available in English, French, and Spanish through the PAHO website and direct email communications to in-country PAHO immunisation focal points. In addition, "walk-throughs" of the materials were performed via virtual training sessions and during face-to-face Regional meetings. PAHO's in-country communication focal points and their immunisation counterparts were involved in the development of the communication materials to allow for a more integrated approach to the use of the materials in each local setting.
Among the elements described as contributors to the success of the process: the support of international and regional partners such as the United Nations Children's Fund (UNICEF). The UNICEF Regional Office for Latin America and the Caribbean played a role in advocacy, social mobilisation, and preparation and validation for the Switch.
To analyse the implementation process, in March 2016, PAHO sent out a survey on IPV introduction via email to the 32 countries in the Region that had completed it in 2015 or 2016 as part of the Endgame Plan. The main survey findings from the 31 countries that completed the survey are provided in the paper by category (decision-making, planning and preparation, IPV introduction, and communications). With regard to the latter category, communications messaging to parents and caregivers about IPV introduction was mostly in the form of printed materials (10 of 31 countries) and face-to-face talks (6 countries); one country also used radio. Health care workers only received printed materials (10 countries) and face-to-face communications (5 countries). The general public received communication messages about the IPV introduction mostly by radio (16 countries) and printed communication (13 countries), along with TV programming (7 countries). A large number of countries (24 of 31) said they did not perceive any challenges in communications about the introduction of IPV. Of the 7 countries that did mention challenges, 4 of them said they were related to the vaccine changing from a drop to a shot. In about two-thirds of the countries (22 of 31), the public had a positive reaction to the IPV introduction. Representatives of 9 of the countries said the public had initial concerns, but after the communication efforts, they embraced the change.
Several themes emerged from the survey responses about facilitators (see Figure 5 on page 30) and barriers (see Figure 6 on page 31) in the IPV introduction process. When asked what they would have done differently in the IPV introduction process, 21 of 31 said they would make changes, such as increasing communication about the vaccine introduction to doctors in the private sector and to other stakeholders (6 of 31 countries). Country representatives noted that the PAHO training materials were not as useful as they could have been because some of them arrived after introduction and communication plans were already finalised. They felt that the multiple technical documents could have been replaced by one or two documents, such as the practical guide and guidelines for social communication. They also suggested that a feedback questionnaire to distribute to health workers and parents post-vaccination would have been helpful.
In addition, in July 2016, PAHO administered a survey about the Switch (see Annex B) to representatives of the 36 countries that implemented the Switch. A total of 29 of the 36 countries said they had specifically sought to reach different audiences with specific communication activities. Almost all countries targeted health care workers; some countries also targeted parents and caregivers, the media, and the general public. Almost all countries (34 of 36) conducted briefings with key stakeholders such as paediatricians, medical associations, and non-governmental organisations (NGOs), before the Switch. Half of the countries (17 of 36) said they had organised or produced media or public communication activities or materials, such as press releases. In addition, half of the countries (17 of 36) said they had a risk communication or crisis communication plan in place. The most common communication materials reported by the countries were posters or brochures (mentioned by 18 of 36 countries), press releases (mentioned by 11 of 36 countries), and radio spots (mentioned by 10 of 36 countries).
Table 3 and Figures 7 and 8 (pages 40-42) show positive and negative factors (facilitators and barriers) affecting the Switch, from the countries' perspectives.
The next portion of the report explores lessons learned by various groups within the WHO and PAHO that took part in the Switch in the Region. For example, "There was very good communication between the IMG [the GPEI Immunization Systems Management Group] and the regions to ensure that the message was fully aligned, and understood, by all stakeholders." PAHO reportedly "maintained permanent and close contact with the countries, with absolute availability for communications and country missions as requested." The overall political challenge was to have all countries on board.
"All in all, what seemed impossible became possible thanks to countries in the Americas taking ownership of the Endgame Plan's polio eradication goals, enhanced by the Regional support of immunization as a means of improving public health." PAHO asserts that the analysis of lessons learned presented in this report - from the perspective of the countries in the Region, and PAHO/WHO and their partners - could help guide the introduction of other vaccines or the withdrawal of current ones (e.g., bOPV, once polio eradication has been achieved) by policymakers and health specialists in the Americas and other regions of the world.
PAHO/WHO Institutional Repository for Information Sharing and PAHO website, both accessed on January 2 2018. Image credit: Luis Fermín Tenorio / PAHO