Lesson 3: Work together

What does it take to identify, evaluate, introduce, scale, and sustain a safe, effective, and low-cost vaccine to millions of children? In the case of the Japanese encephalitis (JE) vaccine, a diverse set of partners—governments, civil society, local immunization champions, multilateral organizations, and the private sector—working toward a common goal were essential.

At the start of the project, JE and its burden were not well understood at global and national levels. To gain and maintain the necessary support from global, regional, and local partners to tackle JE, PATH used advocacy to raise awareness and build consensus for JE control throughout the project.

The first priority was partnering with the World Health Organization (WHO) to raise awareness of JE and gain consensus on regional priorities through the bi-regional meetings on JE control. These regional meetings brought together partners and country officials from countries in South Asia, Southeast Asia, and the Western Pacific and became a strategic venue for JE advocacy and communications. PATH also worked to ensure that national convenings in endemic countries, such as annual pediatric association meetings, included JE.

Another priority for advocacy and awareness raising was the collection of new and existing data and information on the burden and control of JE from a variety of resources, which were reconfigured and disseminated to various audiences. These included a series of training presentations, messaging, fact sheets, newsletters, case studies, peer-reviewed publications, a vaccine introduction decision-making guide, social media resources, and media outreach. Early in the project, the team and its partners also developed three films for use by stakeholders and health officials in advocacy efforts—two of which aired on BBC World and were broadcast in more than 200 countries.

Advocacy and communication efforts to highlight JE’s burden and the impact of vaccination helped prioritize JE immunization, build consensus, foster collaboration, and inform strategy decisions from WHO, Gavi, and country governments. Working together requires starting on the same page, and advocacy and communications about the issue is a critical way to ensure consensus.

Bringing together partners makes progress possible. Several key partners played crucial roles throughout the course of the JE project, including:

• Country stakeholders: Country decision-makers, advisors, implementers, health workers, and immunization champions—from Cambodia, India, Laos, Nepal, Sri Lanka, and other JE-endemic countries—were the crucial change-makers to protect their countries’ children from JE. Country advocates and experts were a key part of helping to determine the burden of disease, conducting and supporting clinical trials to build the evidence base, raising local and global awareness around JE, convincing country governments to introduce JE vaccine into routine immunization, and increasing country demand. Countries also learned from each other’s experiences and expertise and took a leadership role in driving momentum in global discussions.
• World Health Organization (WHO): WHO is a critical partner for setting global JE standards and recommendations for countries. WHO regional offices played a key role in seeing and responding to countries’ needs, hosting the bi-regionalmeetings on JE, and communicating with regional and national immunization technical advisory groups and in-country stakeholders. PATH also worked with the global WHO office in several ways, including helping develop global surveillance standards for JE and forming a JE laboratory network. PATH helped inform the WHO Prequalification team in order to achieve prequalification for CD-JEV in 2013 and worked with the WHO Strategic Advisory Group of Experts on Immunization (SAGE) JE working group, which led to a new JE vaccine position paper recommending vaccination in 2015.
• Bill & Melinda Gates Foundation (BMGF) and other funders: Without funding and prioritizing protection against JE through vaccination, none of these efforts would have been possible. Funders like BMGF played a crucial role in supporting, guiding, and advising the JE project from the start. The long-term commitment of BMGF and their willingness to look comprehensively at the problem in order to develop effective, country-specific solutions proved critical to long-term success.
• Chengdu Institute of Biological Products (CDIBP): As the CD-JEV manufacturer, CDIBP played a key role through their commitment to achieving and maintaining international quality standards and scaling up production capacity to meet demand. CDIBP’s willingness to negotiate an affordable private-sector price was also integral to other countries’ ability to access the vaccine. The strong partnership with CDIBP revealed the important role that emerging country vaccine manufacturers can play in helping to meet the needs for regionally targeted vaccines that large, global manufacturers may not be willing to address.
• Gavi, the Vaccine Alliance: From the beginning, Gavi was a pivotal and willing partner to help collate and disseminate information on JE disease and vaccines. Gavi’s decision to open a funding envelope for CD-JEV immediately after the vaccine was prequalified greatly expanded and expedited country introductions of JE vaccine. Gavi also provided crucial insights into vaccine procurement and funding as well as technical assistance, awareness raising, and monitoring for countries.
• United Nations Children’s Fund (UNICEF): UNICEF was crucial in helping to ensure that the supply and procurement of CD-JEV was a smooth process for countries both with and without Gavi support. UNICEF also played a key role in developing information, education, and communication (IEC) materials for social mobilization in countries introducing the vaccine.
• US Centers for Disease Control and Prevention (CDC): The CDC’s global programs made it possible to set up data and surveillance systems to track JE cases and outbreaks, informing countries of their burden of disease, contributing to cost-effectiveness analyses, and verifying the impact of the vaccine post-introduction.
• US Armed Forces Research Institute of Medical Sciences (AFRIMS): AFRIMS played a key role with helping to strengthen early diagnostic capacity for JE through assay evaluations and support to countries.
• International Vaccine Institute (IVI): IVI’s leadership in surveillance and partnership in developing cost-effectiveness models for global use of JE vaccine were pivotal for informing countries’ decisions to introduce.
• Microsoft: An innovative partnership between Microsoft employees and PATH provided flexible funding to support ad-hoc, country-identified needs for JE vaccination efforts in Cambodia, Laos, and Vietnam.
• Clinical trial sites: Highly skilled clinicians and researchers at diverse institutions, such as the International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b) and the Research Institute for Tropical Medicine, conducted trials in JE-endemic countries. The trial results were pivotal to global and regional decision-making for JE vaccines.
• Academic institutions: Academic institutions were instrumental in the development of standards and guidelines to advance the field of JE prevention, control, and monitoring throughout the project. The University of Liverpool, for example, developed a tool for healthcare providers to assess children’s level of disability after becoming ill with JE and a guide for JE disability management in low-income countries.

The partners listed above are only a subset of all the individuals, organizations, corporations, and countries that played a part in achieving success. With this large number of important partners, PATH had to define and emphasize its role as the global coordinator of this partners network. Regular communication and meetings within this network ensured that all the partners were aligned in their direction and able to communicate challenges, remedies, and best practices. The partners’ continuous input, which required a plan to regularly collect and address, was vital to the flexibility and success of the project.

Because of the importance of partners, building and maintaining relationships became critical. PATH had to establish communication mechanisms, build partner capacity and buy-in, and conduct regular outreach. Large-scale projects in immunization—as in all global health and development efforts—need leadership and dedicated time to reach across national, cultural, and sectoral boundaries; forge new partnerships; and encourage participation through active, sustained engagement.

By acknowledging and building in objectives around advocacy, coordination, outreach, and/or coalition building, projects can help ensure that all the right partners are at the table. Working together means that all the right voices can not only be heard, but also acted upon.

With an estimated 12.5 million people at high risk for JE and a significant historical JE burden, Nepal’s efforts to control and prevent JE through surveillance and vaccination are an excellent example of how a low-income country can overcome barriers such as the lack of disease surveillance data, inadequate financial resources, competing vaccination priorities, and the need for technical assistance.

Nepal’s decision-makers knew that, in order to overcome these barriers, they needed to work with many partners. To improve surveillance, Nepal worked with WHO to expand JE laboratory testing. To justify investment in a vaccination program, Nepal collaborated on a cost-effectiveness analysis with the University of Liverpool. For financial assistance, Nepal applied for a loan from the World Bank and then, years later, funding from Gavi. Nepal worked with PATH’s JE program team for assistance with planning, advocacy, communications, and training materials. Nepal worked with CDC to demonstrate the impact of vaccination on the disease burden in order to justify ongoing support for JE vaccination. The government also collaborated extensively with local community, religious, and media stakeholders to increase JE awareness and build demand for the vaccine.

No matter the barrier, Nepal prioritized collaboration and partnership in order to protect its children from JE. With the success of its JE immunization program, Nepal then became a resource and partner for other countries, sharing best practices through peer-to-peer learning opportunities at conferences and meetings.

This is the third 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 4: Decide with data