Lesson 1: Meet countries where they are

PATH has worked on vaccines against Japanese encephalitis (JE) for nearly two decades, but the work came about unexpectedly. This work did not begin by responding to a donor request for proposals. It began by listening to the concerns of local public health officials in India, where PATH learned that JE was having a devastating impact, and deciding to do something about it.

As the project progressed, PATH encountered unique circumstances and challenges in each country considering JE vaccine introduction. In response to these challenges, PATH and its partners first asked what is best for each specific country, then, with the country and other stakeholders, set out to co-develop a remedy. Today, thanks to nearly two decades of using this approach, ten additional countries have added childhood vaccination programs and hundreds of millions of children who would not have been vaccinated are now protected against JE.

JE mainly strikes poor, rural communities throughout Asia and the Western Pacific, and it historically received little attention compared to other vaccine-preventable diseases. By the end of 2000, this began to change thanks to concerned public health officials in Andhra Pradesh, India, and a PATH team that heard their need and decided to help.

In 2000, PATH was working with the government of Andhra Pradesh to strengthen routine immunization services and introduce urgently needed hepatitis B vaccines. Conversations with district- and state-level public health officials revealed a deep concern about “brain fever,” the local term for JE. PATH staff observed the situation and listened to the local concern. While continuing to prioritize work to prevent hepatitis B, PATH also began simultaneous efforts to better understand JE, the scope of the problem, and how to control it. PATH quickly learned that the broader global health community knew little about JE.

First, PATH assessed the magnitude of the problem. JE is caused by a mosquito-borne virus, and, although fewer than 1% of people infected with the virus become ill, infection can progress to life-threatening encephalitis, causing paralysis, seizures, inability to speak, and coma. Nearly 30% of people who fall ill with JE die and nearly half of all survivors have severe, life-long neurological damage. There is no treatment for JE, so the only solution is prevention through immunization. More than 3 billion people live in areas at risk for JE, and as of 2011, an estimated 70,000 cases occurred each year. Although this 70,000 is likely an underestimate due to surveillance limitations, these 70,000 encephalitis cases translate to more than 7 million human JE viral infections per year. Because the risk factors for progression are unknown, vaccination programs would have to develop a strategy that includes all children living in risk areas in the 24 JE-endemic countries.

Second, because there is no treatment for JE, PATH realized that childhood vaccination was the most sensible and economically feasible way to control the disease. Because the illness primarily occurs in children, and survivors may live for another 50 to 60 years, JE results in many more disability-adjusted life-years (DALYs), or healthy years of life lost, per reported case compared to many other vaccine-preventable diseases. To assess the potential impact and feasibility of JE vaccination, PATH performed an early cost-effectiveness analysis of JE vaccination for 14 endemic countries.² The analysis found that not only would a one-dose, live attenuated JE vaccine given through the routine Expanded Programme on Immunization (EPI) schedule likely be cost-effective in all JE-endemic countries, if the full costs of long-term consequences were included, such an intervention could be cost-saving in many countries.

Third, PATH sought to help countries better understand their JE burden. Investigation of encephalitis outbreaks and improved disease surveillance and diagnostics suggested a previously unrecognized high incidence of JE, prompting the government of Andhra Pradesh to pursue JE vaccination. Andhra Pradesh’s success with JE vaccination was shared across India and prompted Indian government ministries, the World Health Organization (WHO), UNICEF, and PATH to establish a cross-sectoral India JE working group to coordinate technical support and information sharing. The working group developed a roadmap for planning JE vaccination programs. JE vaccines were eventually implemented in all of India’s JE-endemic states, and lessons from India informed efforts to tackle JE globally. PATH hoped to replicate this model in other JE-endemic countries.

Every country was different in terms of their awareness about JE and their efforts to control the disease. While India was increasingly aware of JE’s impact, other countries had little-to-no awareness of their JE burden and had no way to identify and track cases. Similarly, countries like Japan and Thailand had already evolved solutions for JE over decades. Creating situations to share the awareness and the approaches to JE control in India, Japan, and Thailand would be an important step to improve JE control throughout the region.

Listening does not end after the initial contact meeting or with vaccine introduction. After introduction, decision-makers often faced additional, unexpected challenges that required a continuous and iterative method to identify these challenges and develop country-specific and innovative solutions to address them. For example:

• In Laos, vaccine uptake declined rapidly following the initial introduction. Country decision-makers met with PATH staff to figure out why. Upon investigation, the team found two major problems: parents had little knowledge about JE, and the government had difficulty procuring and distributing the vaccine within the country. To address these concerns, PATH worked with partners to develop short, animated cartoons delivered to parents’ phones via social media messaging apps as well as an interactive online training for JE vaccine procurement. This work is ongoing as Laos prepares for nationwide expansion of JE vaccination.
• In Vietnam, the initial JE immunization program was limited to areas thought to have higher incidences of JE cases. In 2007, PATH-supported enhanced hospital-based surveillance that showed many JE cases in areas not reached by the current JE immunization program, prompting officials to plan national expansion.

By incorporating countries’ input throughout the entire course of a project, teams could help ensure that programs met countries’ needs.

JE prevention and control efforts have been successful largely because of PATH’s desire to hear country concerns and partner with them to develop a tailored solution. A key factor in this success was a dedicated network of public health partners who jumped in and brought their own strengths and experiences to the problem-solving table. PATH worked with WHO, Centers for Disease Control and Prevention, UNICEF, country and local governments, civil society, and public-sector partners to communicate, collaborate, and solve commonly shared problems that could pose challenges to getting the vaccine to at-risk children. Sometimes that meant changing tactics to focus on an unanticipated need or investing in surveillance infrastructure. Other times, it meant finding a way to deliver vaccines to remote locations or focusing on public and healthcare worker education and communications.

The JE project would not have been successful in helping to protect so many children from JE without initially and continually collecting, seeking, and implementing feedback from countries and many partners over the nearly two decades of its work on JE. Listening and responding appropriately to the needs, priorities, and concerns of beneficiaries is a valuable way to ensure participation and sustainability. Meeting countries where they are is a lesson that can be applied not just to other vaccine programs, but to all public health and development initiatives.

In Indonesia, meeting countries where they are meant addressing the need to challenge some long-held assumptions. Surveillance data suggested a greater JE burden than previously appreciated. JE vaccine introduction in Bali led to questions about further introduction, and addressing community cultural concerns about the vaccine required social mobilization.

Many in Indonesia’s Ministry of Health (MOH) did not believe that JE was endemic in multiple provinces. Although sporadic human JE virus infections in Indonesia have been well documented on multiple islands since the 1970s, the actual JE burden remained unknown until a 2001 surveillance study conducted by the International Vaccine Institute (IVI) found a significant number of cases in the province of Bali. In 2005, the MOH expanded surveillance with PATH support and found that, although the greatest JE incidence was in Bali, endemic JE cases occurred in eight other provinces, establishing Indonesia as a JE-endemic country.³

After a decade of building political will and planning, subnational JE vaccine introduction in Bali became a reality. In March 2018 with Gavi and PATH support, the MOH vaccinated over 890,000 Balinese children against JE, and JE vaccination is now included in Bali’s routine immunization for children. But while Bali’s JE control is underway, the eight other JE-endemic provinces in Indonesia remain unprotected. Because the burden varies by province, ongoing cost-effectiveness analyses supported by PATH are informing decisions about which provinces to prioritize.

Another lesson from Bali’s experience has been in addressing vaccine hesitancy such as community cultural or religious concerns about the processes or ingredients used to make CD-JEV and other vaccines. To ensure demand for JE vaccine and reduce vaccine hesitancy, the MOH and other stakeholders worked together with Balinese religious and cultural leaders and conducted advocacy and social mobilization campaigns. As the MOH considers scaling up JE vaccination to the rest of Indonesia, these lessons from Bali may help guide the way.

² Suraratdecha C, Levin C, Jacobson J, La Force M. Demand-driven and affordable next generation vaccines for preventing Japanese encephalitis in Asia and meningococcal meningitis in Sub-Saharan Africa. Presented at: Sixth International Health Economics Association World Congress; Explorations in health economics, July 2007; Copenhagen, Denmark.

³ Maha MS, Moniaga VA, Hills SL, et al. Outcome and extent of disability following Japanese encephalitis in Indonesian children. International Journal of Infectious Disease. 2009;16(6):e389-393.

This is the first lesson in Approaching vaccination from end to end: Five lessons from more than 15 years of advancing Japanese encephalitis vaccination, a report developed by PATH's Center for Vaccine Innovation and Access.

Read Lesson 2: Prioritize public health and simple solutions

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