How can COVID-19 prevention programmes support the roll-out of COVID-19 vaccines?

The successful development, approval, and roll-out of COVID-19 vaccines is being seen by many as a welcome ‘light at the end of the tunnel’, heralding a meaningful breakthrough toward curbing COVID-19. However, it is also clear that vaccines will not be a rapid solution and that their success is contingent not just on timely development and equitable distribution, but also on behaviour change at the individual and societal levels and combating vaccine hesitancy. This resource is designed for Water, Sanitation, and Hygiene (WASH) actors, and other COVID-19 response actors, who have to date been working on prevention programmes and are now adapting their work to be sensitive to the vaccine roll-out.

Organisations involved in COVID-19 prevention programmes should broadly consider the following actions in relation to the vaccine roll-out:

  1. Increase awareness and understanding among staff about vaccines (development, approval, supply and roll-out) so that they can adequately respond to community concerns.

  2. Adapt prevention programmes so that they are able to counter misconceptions and misinformation, and support evidence-based information to increase vaccine confidence and prompt individuals towards uptake.

  3. Help people to understand why COVID-19 prevention behaviors (such as hand hygiene, appropriate mask-wearing, physical distancing, and covering coughs and sneezes) remain essential to interrupt transmission, even after getting vaccinated.

  4. Identify opportunities for integrating activities which promote COVID-19 prevention behaviours within vaccine roll-out programmes.

This resource is structured according to these four actions.

Section 1: What information should COVID-19 response actors know about the COVID-19 vaccines?

The first section synthesises resources on vaccines in general. Whilst this section is not a comprehensive list of materials, it is designed to provide response actors with sufficient background information so that they can answer questions arising from communities if necessary. The section covers what vaccines are, how vaccines generally work, the role of vaccines alongside other prevention measures, explanations of herd immunity and vaccine efficacy, and the impact of COVID-19 mutations or variants.

Section 2: How can COVID-19 response actors challenge vaccine hesitancy, and support vaccine confidence and uptake?

WASH actors and others involved in COVID-19 response programmes have been frontline workers throughout the pandemic to date, and many have developed trusted modes of communication with communities. Response actors are therefore in a unique position to listen and learn about community concerns and build community confidence in vaccines. This second section highlights some specific actions that can be taken to mitigate misconceptions and misinformation about vaccines and encourage populations to come forward for vaccination.

Section 3: Why is it critical to continue to promote existing COVID-19 prevention methods?

The third section recognises that vaccines will not be a quick solution and discusses reasons why we need to work with communities to continue to promote covering coughs and sneezes, mask-wearing, physical distancing, and hand hygiene.

Section 4: How can initiatives promoting COVID-19 prevention behaviours be integrated into vaccine roll-out?

The fourth section summarises prior examples of where hygiene and other preventative behaviours have been incorporated into vaccination programmes and identifies potential opportunities for this synergy during the COVID-19 pandemic.

Section 1: What information should COVID-19 response actors know about the COVID-19 vaccines?

Response actors need to be able to explain vaccines and related terms in clear, concise, and actionable language through trusted sources. This communication may be easier with the aid of videos or illustrative articles. The video below from the Vaccine Knowledge Project is useful because it visualises the immune system and how vaccines harness the natural activity of our immune system in a way that’s easy to understand and explains key technical terms. WHO’s “Vaccine Explained” and “Science in 5” series also provides a structured set of illustrated articles on how vaccines work, how they are developed and the different types of vaccines available. Furthermore, the Johns Hopkins COVID-19 Training Initiative has developed three training modules on vaccines for health care workers, including how to communicate about them (“Building trust in vaccination through communication”).

What are vaccines and why should we promote them?

Vaccines are preventative - they are used to prevent infection, serious illness, and death. Vaccines are designed to teach the body’s immune system to recognise, and therefore be able to stop, the cause of a specific disease before it can make someone ill.

How do vaccines work?

The immune system is the part of the body that fights infection and disease. The active ingredient in different types of vaccines is made from deactivated or non-infectious organisms or a part of the organism (e.g. a protein) that you are trying to train your body’s immune system to stop. The part of the organism is called an antigen and can’t cause disease. When your immune system is introduced to these harmless antigens in very small amounts through vaccination, it learns what the cause of an illness (e.g. a specific virus or bacteria) ‘looks like’ so that your immune system builds specially targeted antibodies ready to fight off any future infection with this type of organism. This means that if you are fully vaccinated and get infected with the actual organism months, or for some vaccines years later, your immune system will recognise it and destroy the invading organisms before it causes disease.

Key takeaways:

  • Vaccines teach your body’s immune system to prevent specific diseases.

  • Vaccines do not stop a person who has been fully vaccinated from getting infected with the pathogen that causes disease (such as the SARS-CoV-2 which causes COVID-19). But if someone is fully vaccinated and they get infected with SARS-CoV-2, they are unlikely to develop serious illness, and vaccination makes it harder for an infection to spread.

How have vaccines been used to combat public health problems throughout history?

Millions of people are alive today due to vaccination. Vaccines have helped reduce the global burden of tetanus, diphtheria, and measles and can now combat epidemics such as Ebola and cholera. The first vaccines were introduced in the 18th Century. Today, most countries have routine vaccinations, often known as ‘routine immunisation’ programmes, which are given to people at different stages of their life, usually starting in childhood. Research estimates that routine vaccination against 10 common diseases (such as Hep B, rotavirus, measles, and rubella) has prevented 37 million deaths between 2000 and 2019.

Key takeaways:

  • Vaccines have been used to reduce the burden of diseases for more than 200 years, saving millions of lives.

How were the COVID-19 vaccines made?

The COVID-19 vaccines have been developed and approved through a rapid, yet safe, process due to emergency funding and unprecedented levels of global coordination and collaboration. This has been possible for a number of reasons. In part it is because COVID-19 is not the first coronavirus to threaten health in recent years. From the Severe Acute Respiratory Syndrome (SARS) coronavirus in 2003 and Middle East Respiratory Syndrome (MERS-CoV) coronavirus in 2012, scientists have had a head start in understanding the properties of coronavirus SARS-CoV-2. The unique structure of these viruses has enabled the development of a vaccine in record time through leveraging knowledge and technology platforms. There has also been unprecedented investment and research into vaccine development due to the COVID-19 pandemic.

There are various methods and approaches that are used to assess the effectiveness of vaccines. All of the globally authorised vaccines that are most advanced in their research, trials, and production use four different approaches, and here Wellcome Trust explains their differences. Whilst, this Johns Hopkins University resource explains the clinical trial process for vaccines.

All COVID-19 vaccines approved by the World Health Organization (WHO) undergo the same review and regulatory process, with safety and efficacy review boards composed of independent scientists not involved in vaccine development.

Key takeaways:

  • All vaccines approved by WHO have undergone the same levels of scrutiny and regulation.

  • The pace of vaccine development has benefitted from an existing knowledge about coronaviruses, as well as unprecedented emergency funding and global collaboration.

What is the meaning of key vaccine-related terms such as herd immunity, susceptibility, vaccine efficacy, and viral mutations?

There are many words and phrases used to explain COVID-19 and vaccines. It’s important that key terms are explained so that people understand them.

Immunity - Immunity to a specific infection means that if someone gets that infection, their body’s immune system can recognise the infection and stop it before it causes disease. For example, if someone is fully vaccinated against COVID-19, it means that if they get the coronavirus SARS-CoV-2, their immune system will recognise it and destroy it, so it cannot cause severe COVID-19. Some level of immunity can also be gained from having the disease. This is often called natural immunity.

Susceptible/Unsusceptible individuals - Viruses, such as SARS-CoV-2, exist to reproduce and replicate. However, viruses need a susceptible host, someone who is not immune, in order to replicate. If a vaccinated, uninfected person is exposed to an infected person, the uninfected person is not a susceptible host. As a result, the virus will have a reduced ability to spread. If you have enough people within a community that are vaccinated and less susceptible, the virus dies out.

Herd Immunity - Herd immunity is the community protection that is created when a high percentage of the community is vaccinated, which provides a protective barrier to those who have not been vaccinated, or unable to be vaccinated (e.g., immune-compromised). Currently, the world has not reached herd immunity against COVID-19. This video – How does herd immunity work? – provides a practical explanation. For COVID-19, the coverage necessary to reach herd immunity remains unknown. However, data suggest the coverage level is between 70% and 85% of the population being fully vaccinated. As we have not yet reached this level, we cannot rely on herd immunity now. This makes it critical to promote vaccine uptake and continue to encourage preventive behaviours such as hand hygiene, appropriate mask-wearing, physical distancing, and covering coughs and sneezes. It is also essential that countries are equipped with the diagnostics to detect and test, track and trace contacts, facilitate the quarantining of cases and provision of medical care to those who are seriously ill.

Vaccine Efficacy - Vaccine efficacy is how effective a vaccine is at preventing infection and disease-related morbidity and mortality. Many different endpoints (comparison between vaccine candidates and within differing populations) are used in vaccine research to describe vaccine efficacy. In the case of SARS-CoV-2, an efficacious vaccine might prevent infection, disease, hospitalisation, intensive care unit admission, death, or transmission as per the figure below.

Source: Lancet - What defines an efficacious vaccine?

No vaccine is 100% effective at preventing infection. Current COVID-19 vaccines reduce the probability of infection by 90% (Pfizer & Moderna vaccines) in people who were fully vaccinated and 82% (Johnson & Johnson vaccine) to 100% protection (AstraZeneca vaccine) is provided against severe disease. Experts are still learning how effective COVID-19 vaccines are at stopping transmission of SARS-CoV-2. Recent research suggests that those given a single vaccine dose can reduce household transmission of the virus by up to half (vaccinated people are between 38% and 49% are less likely to pass on than unvaccinated people). Efficacy is also dependent on how many doses of a vaccine are needed. For a single-dose vaccine, our immune system will take a few weeks after vaccination to mount an antibody response to the vaccine. For a two-dose vaccine, both doses are needed to provide the best level of protection possible. The duration of protection from vaccines is currently unknown and we are less clear about how long natural immunity lasts. It is possible that in the future we may be offered ‘booster doses’ of COVID-19 vaccines which are designed to sustain protection for a longer period. But initial COVID-19 vaccine data suggests high levels of protection (+90%) of up to six months. For all vaccines, this is an important outcome and will continue to be monitored in the period following vaccination.

Variants & Mutations - Like all viruses, SARS-CoV-2, is mutating (changing in small ways over time). This is a normal evolutionary process and true of all viruses and other living things. Even with these mutations, it is still the same SARS-CoV-2 virus. The mutations that have arisen so far have meant that the virus can pass more easily between people, cause more or less severe illness, or slightly different symptoms. Globally, several variants have emerged, and these variants differ in their related morbidity and mortality. WHO, in joint collaboration with their global partners have assessed the evolution of SARS-CoV-2 and have characterised specific Variants of Interest (VOIs) and Variants of Concern (VOCs) in order to systematically prioritise the global monitoring and research, which is critical to the pandemic response. The simple, easy-to-say labels for the VOI and VOC can be found here. Proactive efforts are already in place in real-time to revise the vaccine to tackle vaccine variants and mutations. One advantage of the current vaccines is that they can be reconfigured quickly, and therefore will play an important role in responding to the variants.

Key takeaways:

  • It is not unexpected for new variants to emerge. All viruses mutate as they make copies of themselves to spread and thrive.

  • Evidence suggests that COVID-19 vaccines prevent severe infection and disease caused by all the current variants.

  • There is technology and knowledge to sequence and subsequently develop more targeted vaccines if necessary.

Section 2: How can COVID-19 response actors challenge vaccine hesitancy, and support vaccine confidence and uptake?

What is vaccine hesitancy and what factors influence it?

Vaccine hesitancy is the delay in acceptance, or refusal, of vaccines despite the availability of vaccine services. It is complex, context-specific, and varies across time, location, disease burden and vaccines available. Attitudes towards vaccines fall on a continuum - as shown in the diagram below. It is therefore critical to acknowledge and respond with communities to challenge misperceptions and misinformation, and promote vaccine confidence and uptake.

Source: Johns Hopkins University of Medicine - Coronavirus Resource Center

The Vaccine Confidence Project has developed a Vaccine Confidence Index (VCI), which defines four domains influencing vaccine confidence including importance, safety, effectiveness, and compatibility with beliefs. Globally, this tool has been used in India, Pakistan, Nigeria, Georgie, and the UK to map vaccine confidence for routine, new and underutilised vaccines.

The Vaccine Hesitancy working group within the WHO Strategic Advisory Group of Experts (SAGE) outline reasons for vaccine hesitancy across three domains.

  1. Individual and group influences – This includes people who are against vaccines in general, feel that vaccines are at odds with alternative or traditional medicines, perceive the risk of getting COVID-19 to be low, deem personal vaccination unnecessary if everyone else in their vicinity is vaccinated, and that certain social groups have different levels of immunity.

  2. Contextual influences – This includes people who are vaccine hesitant due to issues of health equity, distrust in national institutions, fears of ethnic persecution, experiences with past vaccinations (HPV, MMR), and those who feel vaccines are incompatible with their religious, political, cultural, social, economic and or philosophical views. Past negative experiences related to vaccines or other aspects of health service delivery may colour people’s decision making about COVID-19 vaccines, even if those experiences related to events many decades before.

  3. Vaccine and vaccination – This includes people who may resist vaccines due to concerns about safety, the side effects, the pace of the vaccine development, perceived lack of efficacy, vaccine roll-out schedules and accessibility, and the emerging mutations and variants.

Misinformation, rumours and misunderstanding about COVID-19 vaccines contribute to vaccine hesitancy within each of these three domains. The working Group also highlights that it is critical to use local insight, knowledge and data in every context. This is because the willingness to accept vaccines is not static - it is highly dependent on real-time information, the status of the pandemic, the perceived risk of contracting the infection and subsequent disease, and previous experience with vaccination campaigns and roll-out, vaccines and rumours about vaccines. This necessitates a dynamic, compelling and productive two-way conversation to challenge vaccine misinformation and misunderstandings, and enable vaccine uptake.

What can response actors do to promote vaccine confidence and uptake?

Below are some general principles to consider in order to build vaccine confidence:

  • Meaningful community engagement is key - Response actors should seek to strengthen community engagement components of their programmes and develop their skills in active listening, tolerance and empathy in order to build vaccine confidence. This may involve setting up structured and informal mechanisms to gather and document questions, concerns and opinions on vaccines. Where possible, data should be collected on a rolling basis to capture changes in perceptions. Response organizations should also facilitate regular opportunities for staff to come together to discuss community perceptions and decide on potential courses of action to address these within programming.

  • Identify diverse ways of promoting vaccine confidence - For each individual there will be a different combination of factors that will influence their attitudes towards vaccines. For example, it is important to recognise that your programmes are not the only source of vaccine information that people are exposed to. Each individual will have their own combination of people within their social circles that influence their behaviour and beliefs, and they will be exposed to a range of information (including mis-information) and stories about vaccines. Therefore there also needs to be a range of programmatic responses to promote vaccine uptake.

  • Facts alone may not shift opinions - The sharing of correct information about vaccines is critical in promoting vaccine confidence, but may not always be sufficient to overcome vaccine hesitancy. This is because vaccine hesitancy is often related to deeper underlying values that an individual may hold. Facts and figures will only be accepted after people feel they have been listened to and that their concerns and values have been acknowledged. For others, they may be more persuaded by seeing and hearing the vaccination experiences of people who are similar to them or by hearing ‘thought leaders’ within their communities endorse the use of vaccines.

  • Utilise behaviour change thinking - Behavioural science plays a leading role in understanding and addressing a range of opportunities and constraints to vaccine uptake. The Little Jab Book presents common barriers, such as structural (cost, access, infrastructure), behavioural (inertia, prevailing social norms, misperception, social motives etc), and informational barriers (misinformation, lack of and complexity of information). Additionally, the following existing Hygiene Hub briefs might be useful when trying to understand and define effective behaviour change interventions:

  1. Lessons from previous outbreaks that can inform the COVID-19 response

  2. Common behavioural responses to outbreaks

  3. A summary of what works to change handwashing & hygiene behaviours

  4. Process for designing effective behaviour change projects for COVID-19 prevention

  • Build trust - Mistrust is often the most common reason for vaccine hesitancy. Trust can be broken down into three levels - trust in the vaccine (the product), trust in the vaccinator (the provider), and trust in those who make the decisions about vaccine provision (the policymaker/institution responsible for development and delivery). It is important to realise that mistrust normally exists for a reason, such as inadequate health care services or decision making that lacks transparency or is not always in the best interests of populations. Building trust may require response actors to look at strengthening broader aspects of health care systems and re-evaluating the conduct of health care staff and policy makers.

  • Be honest about what is not known - Response actions must be transparent and honest about both their own expertise and the state of evidence around COVID-19 vaccines. It’s perfectly ok to respond to community questions by saying “I don’t know but I will find out”, and then follow up with this individual when you have more information. The amount of new evidence about COVID-19 is so overwhelming that no one has all the answers, and pretending that you have all the answers is setting organisations up for failure. Build realistic expectations from the community and enable community-led solutions.

Below we list a range of response interventions and tools, which could be replicated and or adapted across a range of settings:

Practical approaches for understanding and learning from communities:

  1. Conduct formative research (and or make use of existing findings) about the factors that influence vaccine perceptions in your context. This should aim to explore patterns of social influence and sharing patterns, historical, cultural and religious beliefs related to vaccines, common vaccines concerns, local disease coping strategies and community level innovations or mechanisms that could support the vaccine roll-out and continuation of preventive behaviours. Think carefully about how you ask about vaccines. Rather than just asking “Would you accept the vaccine?”, frame and convey the right questions so that they are more action-oriented questions, i.e., “What information would you like, what do you need, from who and how?”.

  2. Map and understand where conversations about vaccines are happening within the community as different countries and social groups will use different platforms.

  3. Make use of existing ways that vaccine perceptions are being tracked and try to align your work to these. Some examples include, but are not limited to COVID-19 Misinfo.org, Oxfam’s Community Perception Tracker, Rumour has it by CDAC Network, UNICEF’s Talkwalker National Country Dashboards, Rooted in Trust - Global Rumour Bulletin, Internews Rumour Tracking Methodology, First Draft and WHO’s infodemic management toolkit. Utilisation of these resources may help you preempt the emergence of similar perceptions in your local community and can allow you to connect with people in other regions of the world to understand what is working to encourage vaccine acceptance.

    Useful resources to guide the development of your strategy for promoting vaccine confidence

  4. Develop a strategy to engage and communicate with a range of audiences via a range of delivery channels. The following resources incorporate useful guidance and tips to inform this process. The Vaccine Misinformation Management Field Guide provides a phased approach (preparation, listen, understand and engage), with tips to make your content resonate more than misinformation, examples of inoculating messages, and interventions to build immunity to misinformation. Other tools related to effective Risk Communication and Community Engagement (RCCE) include 10 steps, RCCE tools, behavioural indicators and the Global COVID-19 RCCE strategy.

    Possible activities and approaches for promoting vaccine uptake

  5. Develop a list of frequently asked questions that are emerging from communities and recommend ways that staff can address these if they arise in the course of their work. Keep this list updated and ensure information is in line with current evidence and national vaccine roll out plans. Having this document to refer to will boost the confidence of staff when discussing vaccines, given that this topic is unfamiliar to many frontline workers.

  6. Share personal experiences of getting vaccinated as this can be a powerful motivator for others. Ethan Lindenberger, who initiated a wave of pro-vaccine advocacy in 2018 conveyed that “people resonate with people, not data” and emphasised, “it’s important to start with empathy as a way of opening up the conversation”. Sharing experiences can be as simple as encouraging people to take vaccine selfies and share their vaccine status on social media or it could involve developing short videos of well known individuals getting their vaccine and talking about the factors that influenced their decision making.

  7. Engage religious leaders, social groups, health workers, teachers and other influential individuals and encourage them to discuss vaccine uptake with people in their community.

  8. Use presumptive communication by framing vaccination as the default or normative behaviour.

  9. Help communities to understand vaccine concepts like herd immunity and focus on the fact that vaccination is something that you can do to protect everyone in society, not just yourself.

  10. Build public resilience to misinformation, including by building digital and media literacy. This helps individuals understand what to look out for in fake news or false information and when they should or shouldn’t share content with their network of friends and family. For example, GoViral is a 5-minute game that helps protect you against COVID-19 misinformation. Studies have also shown that encouraging critical reflection can make people less likely to share misinformation. The use of different audio-visual communication formats can help people to stop and think before they share information or content on social media without fact-checking it first.

  11. Focus on making vaccine-related communication clear, simple and actionable. This could include developing clear ‘calls to action’ to drive behaviours and ensuring information is contextualised and tailored to specific sub-groups of the communities and certain types of beliefs. Using terms like ‘you’ and ’we’ is more likely to drive motivation and action and prioritising and grouping key messages can prevent people being overwhelmed with information. For example the ‘rule of three’ can be a helpful approach to enable people to remember key behaviours (eg. hand hygiene, mask use, physical distancing).

  12. Mass media such as television and radio are a trusted source of information for many. Response actors can work with the media as a partner to create opportunities for two-way communications which address factors contributing to vaccine hesitancy. Some examples include:

  • COVID and Me which are short film-based dramas which share conversations about vaccine research and the importance of being vaccinated. Each story is based on real patient experiences and conversations are conveyed in multiple languages.

  • BBC Media Action’s updated handbook on communication about COVID-19 includes ideas and tips for effective communication to support prevention behaviours, vaccine confidence, and counter misinformation. It is designed for media but is useful for anyone communicating about the pandemic and response.

  • Team Halo, an active global network which uses a network of scientists and health professionals who communicate Q&A videos of COVID-19 vaccine research and immunisation programmes to demystify their work and address the issues around vaccine fears. Their bite-sized videos are posted to TikTok, Twitter, and Instagram.

Key takeaways:

  • Willingness to accept a vaccine is not static, therefore it is critical to understand historical, contextual and social factors that may affect attitudes towards vaccines.

  • Learn about COVID-19 vaccine concerns and create opportunities for ongoing dialogue.

  • Identify community skills, strengths, advocates and trusted individuals that could facilitate uptake.

Section 3: Why is it critical to continue to promote existing COVID-19 prevention methods along with vaccination?

There are still many ‘unknowns’ around vaccines, including how long they confer protection, and the risks of vaccinated individuals passing on SARS-CoV-2 to others. While vaccines for COVID-19 have been developed rapidly and efficiently, there are still substantial challenges for global vaccination programmes in terms of vaccine access and delivery at an unprecedented scale. Given this, we need to create reasonable expectations about how the pandemic will evolve, what it will take for COVID-19 to no longer be a public health threat, and to encourage people to continue to practice COVID-19 preventative behaviours. Vaccines are only one of the tools we need to control the COVID-19 pandemic and therefore we need to avoid presenting the vaccine as ‘the solution’ but rather that it is ‘part of the solution’. The response must keep sight of the history of other diseases. This BBC article provides a visual explanation of how other pandemics have evolved and makes the point that many of the diseases which rampaged through societies in the past, are still around but are no longer major public health threats. Ultimately, the choice is not vaccines OR other key preventative measures, but rather we need to adopt programming which allows vaccines and prevention measures to be promoted jointly to protect individuals, families and communities. For more information on the effectiveness of other COVID-19 prevention behaviours search the Hygiene Hub resources.

Key takeaways:

  • For the foreseeable future, COVID-19 response actors should promote in equal measure – vaccination, hand hygiene, covering coughs and sneezes, mask-wearing, physical distancing and tackle misinformation on a rolling basis.

Section 4: How can initiatives promoting COVID-19 prevention behaviours be integrated into vaccine roll-out?

Response actors can be resourceful, relevant and supportive during the vaccine roll-out by integrating activities across vaccine roll-out initiatives, health care services and prevention programmes .

Invest in health systems strengthening and the protection of healthcare workers

  • Support healthcare workers and health facilities with access to and use of WASH infrastructure, hygiene consumables and Personal Protective Equipment (PPE).

  • Provide training on vaccine communications and building vaccine confidence, Infection Protection & Control (IPC) training and PPE for all healthcare workers – cleaners, guards, traditional healers, and other stakeholders where relevant.

  • Provide hygiene consumables both at the workplace and at home to protect staff, patients and family members.

  • Health care workers and vaccine programme staff should support community outreach to solicit trust, confidence and uptake in the vaccine roll-out.

Continue with disease surveillance

  • Coordinate and integrate disease surveillance efforts for COVID-19 and other diseases between health and WASH stakeholders. Keep sight of other health issues and impacts, alongside the COVID-19 vaccine roll-out and routine immunisation.

Aligning communication approaches and programming.

  • Build communication networks across different types of response actors and leverage those that have already been established. For example, Risk Communication and Community Engagement networks often combine government and non-governmental actors from a variety of sectors and expertise. These groups meet regularly and can be a good starting point for finding out who is doing what in a country or region. Encouraging partners to share information about community perceptions, communication and programmes that are being delivered or that are being planned can avoid duplication or confusion in communication. Ongoing sharing on what is working well, as well as common challenges, can help improve programme quality. Where possible work together to develop a strategy for risk communication and community engagement that covers prevention behaviours and vaccine promotion.

  • Trusted and established communication systems which have already been utilised to share information about COVID-19 prevention behaviours are well-placed to support the vaccine roll-out as well.

  • Many countries’ populations are facing other crises, such as conflict, drought, other disease burdens, food insecurity and livelihood constraints. These broader concerns are likely to affect vaccine-related perceptions. By collaborating with other sectors you may be able to develop programming that is more holistic, which acknowledges these competing concerns and which is ultimately more relevant to communities.

Use vaccine delivery sites as opportunities to continue promoting prevention behaviours

  • Conduct capacity strengthening activities to support the work of health workers and frontline response so that they have sufficient information about vaccines and prevention behaviours and so that they are able to effectively listen to populations. This may include skills to understand the secondary impacts of the pandemic or other health and livelihood concerns and to communicate about vaccine side effects.

  • Consider using vaccine centres as locations for the promotion of COVID-19 prevention behaviours and the promotion of other health behaviours and services. This could include distributing COVID-19 prevention or hygiene kits, informing people about other health services (e.g. routine vaccinations) or promoting the uptake of other health behaviours (e.g. use of mosquito nets)

Key takeaways:

  • Create an enabling environment with products, information, services and infrastructure.

  • The pandemic necessitates response actors to be empathetic, have robust listening and analytical skills.

  • Utilise vaccination centres as opportunities to promote preventative behaviours.

  • One size does not fit all – we need adaptive programming for each and every context.

Is there experience in integrating preventative hygiene programmes into vaccine roll-out?

There is unfortunately limited information on the effectiveness of integrating hygiene programming into vaccine programmes. A few examples include:

  • A cluster randomised control trial in Bangladesh demonstrates the impact of adding handwashing and water disinfection promotion in conjunction with oral cholera vaccination on diarrhoea-associated hospitalisation in Dhaka, Bangladesh. They trialled targeted interventions to provide handwashing hardware and hygiene promotion at both the household and compound level in conjunction with cholera vaccination programmes. Two years after the interventions, 45% of households receiving hygiene promotion sessions had a functioning handwashing station compared to 22% of households receiving the vaccination alone.

  • In Nepal, WaterAid and the Government of Nepal’s Ministry of Health decided to maximise having a ‘captive audience’ of thousands of caregivers who visited immunisation clinics at least five times in the first nine months of their child’s life. Outcomes from formative research created a hygiene intervention package (with the theme of ‘Clean family, Happy family’) which was later delivered through hygiene awareness sessions at vaccination centres. Rotavirus immunisation brought hygiene and public health sectors together and helped avoid miscommunication about the rotavirus vaccine being a ‘diarrhoea vaccine’ and highlighted the need for a comprehensive strategy rather than an individual approach to control diarrhoeal diseases. The programme continues to be delivered at scale.

Despite limited data, there are compelling arguments that support efforts to integrate hygiene promotion into vaccination programmes. Immunisation programmes reach many people and serve as a critical entry point to integrate WASH, with a particular emphasis on hygiene behaviour change interventions. Strategically, such collaborations provide an opportunity for efficient utilisation of resources and to communicate that there are multiple routes contributing to disease and therefore multiple prevention strategies needed at an individual or household level.

Editor Notes:

Written by: Jenny Lamb

Reviewed by: Lizzie McKee, Tom Heath, Victoria Maskell, Genevieve Hutchinson, Sarah Malycha, Rupali J. Limaye, Sian White, Daniel Korbel

Last update: 30.06.2021

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