Report Stakeholder Meeting for Vaccine Safety Communication

12–13 September 2017 UNICEF Headquarters, New York, United States

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Contents

Executive summary 2

Introduction 4

Background and rationale

Objectives

Expected outputs

Day One: Stakeholder highlights and summary points 7

Global trends in vaccine safety concerns, confidence and trust 7

Investing in vaccine safety communication: Global perspectives and agency updates

WHO presentation and outcome

CDC presentation and outcome

UNICEF presentation and outcome

What counts as evidence in vaccine safety communication and why does it matter? Update on latest evidence on vaccine safety communication, direction, approaches and messaging to reinforce confidence in vaccines

9

Thematic group breakout sessions, discussions and suggestions 9

Group 1: Current communication strategies, approaches and tools at the global, regional and country levels

Group 2: Web analytics and social networking

Group 3: Community engagement and capacity building of front line health workers

Group 4: Partner coordination

Day Two: Stakeholder strategic planning to promote effective vaccine safety communication: Key discussion highlights and action points

12

Regional perspectives on vaccine safety communication challenges and solutions in light of recent AEFIs responses and lessons

13

Vaccine safety: The challenge of communicating ‘known knowns’, ‘known unknowns’, ‘unknown knowns’, and ‘unknown unknowns’

14

Concluding highlights 15

Next steps 15

On a vaccine safety communication framework

On health worker capacity building for community engagement

On web analytics and social networking

On partner coordination

On ensuring quality standards for vaccine safety communication

On the messaging framework

On the overall strategic direction

On operationalization and follow up

Annex 1: Feedback and reflections 17

Annex 2: List of participants 19

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Executive summary

The ‘Stakeholder Meeting for Vaccine Safety Communication’, co-hosted by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) at UNICEF Headquarters in New York from 12–13 September 2017, aimed to hold a consultation on vaccine safety communication in order to further characterize barriers to public confidence and trust in vaccine safety, take stock of new opportunities and review strategies and approaches to overcoming those barriers. Fifty global and regional meeting participants, who attended both remotely and in person, deliberated on the global trends of public trust in vaccines; heard updates on the latest evidence in the field of vaccine safety communication; shared valuable perspectives from regional settings; reviewed new initiatives and shared experiences in communicating digitally, highlighting both challenges and actions for the future. Participants had the opportunity to provide inputs and suggestions on the meeting outcomes under the following five themes: 1) a safety communication framework to identify safety communication scenarios and propose common principles to address specific situations; 2) common messaging on vaccine safety issues for global partners; 3) pooling and sharing existing communication resource materials through an e-library; 4) developing quality standards for planning and implementing vaccine safety communication; and 5) facilitating partner collaboration and coordination that would allow opportunities for actionable contributions. Taken together, the discussions and outputs of the two-day deliberation pointed to the need for partners to coordinate efforts around vaccine safety communication. One of the strategies discussed was strengthening/developing an immunization quality and safety brand or platform. Participants reviewed the possibility of using existing networks and repositories. The brand/ platform could also serve to build in-country capacities for more effective vaccine safety communication. Another important suggestion that emerged over the course of the meeting was that a vaccine safety communication framework could be agreed upon so that all partners have a set of common principles when communicating on vaccine safety. In the thematic group discussion on community engagement and capacity building of front-line health workers, participants stressed the importance of building on existing tools, best practices and lessons learned to ensure comprehensive and tailored approaches to building communication capacity in immunization programmes. Potential areas of support ranged from improving the interpersonal communication (IPC) skills of specific health cadres to ensuring that managers create enabling environments that encourage staff to listen and interact with service users and their families in ways that build trust. To use communication to build support for vaccination, participants suggested improving approaches for how to communicate in addition to what to communicate. Specific suggestions included engaging individuals and communities based on mutual respect and receptivity to facilitate more constructive and effective conversations that will better establish the trust and confidence necessary to overcome vaccine hesitancy. During a lunchtime session, a framework for identifying challenges and opportunities was explored that comprised four quadrants: 1) ‘known knowns’; 2) ‘unknown unknowns’; 3) ‘known unknowns’; and 4) ‘unknown knowns’. Other broad and strategic suggestions included the following: 1) align communication objectives with goals and objectives that originate from the global and regional vaccine action plans and adapt broad strategies to local settings; 2) scale up horizontal engagement across communication programmes in the health sector that are beyond immunization; 3) navigate the continuum from vaccine refusal to acceptance to demand; 4) learn from polio lessons by emphasizing demand-

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side communication; 5) reconsider use of the word “routine” in the context of ongoing immunization programmes; 6) develop evidence-informed communications messaging, balancing the benefits and potential risks; 7) advocate for immunization programmes to be prioritized and budgeted in national health and development planning processes, to contribute to reaching universal health coverage targets.

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Introduction

Background and rationale UNICEF and WHO have been working closely with Gavi, the Vaccine Alliance, the United States Centers for Disease Control and Prevention (CDC) and other partners on building and maintaining public trust in vaccine safety. Although current resources and tools provide guidance on how to communicate effectively about vaccine safety, these warrant further scale up. Without adequate communication strategies and processes, any vaccine safety concern or event may affect public trust and confidence in vaccination. Various communication resources and tools about vaccine safety and benefits are under development, and studies to collect new evidence are being implemented. Still, recent attempts to question the safety and effectiveness of vaccines and their benefits have raised concerns among WHO, UNICEF and partners. Given these challenges and the current climate, a proactive vaccine safety communication strategy that makes use of modern communication channels is required. Towards this end, UNICEF and WHO, in collaboration with partners, hosted the ‘Stakeholder Meeting for Vaccine Safety Communication’ at UNICEF Headquarters in New York from 12–13 September 2017.

Objectives

1. Consult stakeholders on crafting strategies and resources to guide efforts aimed at reinforcing confidence in vaccines.

2. Update stakeholders on the vaccine safety communication tools and trainings that have been developed and agree on the next resources to be developed.

Expected outputs

1. Vaccine confidence barriers are further characterized. 2. Approaches, resources and intervention gaps facing partners in their management of

vaccine safety communication are assessed. 3. Strategies are formulated, leading to action planning and the development of communications

tools. 4. Dissemination strategies and partner coordination mechanism are agreed upon.

On Day 1, Stefan Peterson, UNICEF Chief of Health, Robin Nandy, UNICEF Chief of Immunization and Patrick Zuber on behalf of WHO welcomed participants and shared opening remarks in relation to strategic communication and messaging on vaccine safety. Heidi Larson, Director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, shed light on the global trust environment, setting the stage for subsequent sessions, including: 1) global perspectives and agency updates on vaccine safety communication by WHO, UNICEF and the CDC; 2) understanding and leveraging the latest evidence on engaging vaccination skeptics and critics, moderated by Daniel Salmon, Professor, Johns Hopkins Bloomberg School of Public Health, with speaker John Parrish-Sprowl, Director, Global Health Communication Center, Indiana University-Purdue University, who gave an overview of what counts as evidence in vaccine safety communication and why this matters. He emphasised that how we communicate is often more important than the content of the messages and introduced the notion of communications as a bioactive process that enables mutual reactivity or receptivity; and 3) challenges and opportunities for digital dialogue, moderated by Galit Gun, UNICEF Social Media Specialist, with speakers, Rafael Obregon, UNICEF Chief of Communication for Development, Alberto Tozzi, Chief Innovation Officer at Ospedale Pediatrico Bambino Gesù in

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Rome, Italy, Hugh Reilly, UNICEF Social Media Specialist, and Kimberly Chriscaden, WHO Communication Officer. Informed by the day’s presentations, participants then went into breakout sessions and presented outputs under four thematic areas: communication approaches and strategies at global, regional and country levels; web analytics and social networks; community engagement and capacity building of front-line workers; and partner coordination. Day 2 featured discussions, experience sharing and feedback sessions on regional perspectives in vaccine safety communication, and challenges and solutions in the context of recent adverse events following immunization (AEFIs). Detailed discussion focused on next steps and all participants had an opportunity to provide input on the final meeting outcomes under the following five themes: 1) a vaccine safety communication framework; 2) sharing resources in common; 3) a vaccine safety messaging framework; 4) quality standards for vaccine safety communication; and 5) partner coordination. The meeting ended with concluding remarks by Robin Nandy, UNICEF Chief of Immunization.

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D

Day One Stakeholder highlights and summary points

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Global trends in vaccine safety concerns, confidence and trust The global trust environment is broader than vaccine safety issues

In her presentation, Heidi Larson, Director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, shared recent evidence affirming that public distrust is not limited to and/or associated with vaccine safety concerns alone; distrust and concerns vary by person, group, belief, setting and vaccine. She also highlighted the difference between the safety of vaccines versus the safety of vaccination. Whether safety concerns are a perception or a reality, adverse events associated with these concerns can drive people’s behaviours towards vaccines. Furthermore, refusal is not always due to safety concerns. It can also be caused by alternative belief systems such as religion. She also stated that as access and awareness issues decrease, acceptance issues are rising. These considerations should be factored into communication strategies that leverage online media aimed at building public trust in vaccines.

Monitoring for signals of risk escalation into a crisis can be helpful

Based on the complex and changing trust environment, Dr Larson suggested that monitoring the media, including social media, can provide valuable signals of emerging vaccine confidence issues. She also recommended thinking broadly about signals given that no single report or event with a risk signal is the sole cause of a breakdown in public confidence. A breakdown usually requires multiple concerns and the ‘fertile’ ground where the concerns germinate. The same negative events or concerns can have very different outcomes in different settings and the impact of waning trust might take time to manifest in the form of vaccine refusals and disease outbreaks.

Investing in vaccine safety communication: Global perspectives and agency updates Yields from investing in vaccine safety communication: Global perspective and WHO update

Perspective

Isabelle Sahinovic, Technical Officer, WHO, Geneva, explored WHO’s perspective on investing in vaccine safety communication. She explained that WHO prioritizes leveraging expert advice and scientific analyses/evidence and supporting national agencies and authorities. She also presented the spectrum of activities (international collaborations, global campaigns, research projects) and tools, guidelines and training packages developed to support WHO Member States that specifically address vaccine safety communication. She concluded by stating that vaccine safety concerns are a driver of vaccine hesitancy and vary over time, place and vaccine. Addressing these concerns requires communication approaches that are tailored to each context. WHO finds that addressing safety-related vaccine hesitancy requires targeted and evidence-informed strategies that respond to specific barriers and enablers.

Investment

Ms. Sahinovic also outlined WHO’s investment in the Global Vaccine Safety Initiative, which is the operational arm of the WHO Global Vaccine Safety Blueprint.

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Yields from investing in vaccine safety communication: Global perspective and CDC update

Perspective

Jane Gidudu, Vaccine Safety Officer presented the CDC’s perspective on investing in vaccine safety communication. She explained that the organization’s approach has been to focus on scaling up successful joint communication activities, integrating monitoring and evaluation systems in communication interventions, engaging and working with communities beyond health care providers, working with the media, and establishing and managing a collaborative platform for crisis situations.

Investment The CDC has a long-standing domestic vaccine safety programme that closely and constantly monitors the safety of vaccines. The CDC Global Immunization Division recently added a vaccine safety and risk communication goal to its 2016–2020 strategic plan. The CDC is expanding efforts to integrate IPC into its risk/crisis communication work. The Center is also working with WHO regions to draft a guidance tool for use when clusters of AEFIs occur, including deaths that follow the administration of hepatitis B birth dose vaccine.

Yields from investing in vaccine safety communication and UNICEF work perspective

Suleman Malik shared the UNICEF perspective and update on investing in vaccine safety communication. He outlined important elements of the UNICEF approach and prospective framework for partner collaboration on vaccine safety communication, which is underpinned by: 1) global and regional coordination needs; 2) joint resource polling; and 3) coordinated implementation and reviews, including coordinated in-country capacity building and capacity enhancing support. Investment UNICEF recently invested in the development of the Basic AEFI Communication eLearning Course, which has generated lessons on partnership and collaboration. UNICEF has drafted an advanced course concept note, which includes plans for the roll out of in-depth and hands-on learning about media handling, community engagement, digital listening and dialogue, the formation of a peer review team, and the possibility of a face-to-face component and institutional building. UNICEF is also in the process of developing the following innovative communication tools for reinforcing vaccine safety communication: The Speaking Book initiative, a four-hour IPC for AEFI course for health workers, and a mapping/gap assessment of AEFI communication materials across nine communication areas. Lessons/suggestions UNICEF’s lessons learned and suggestions from these investments include the need to: 1) further invest in developing and utilizing joint resources (expertise, evidence and tools) to broaden collaboration and enhance national capacity and linkages; 2) develop a joint global vaccine safety communication framework and action plan; 3) provide greater clarity on roles/accountabilities for risk, outbreak and crisis communication; 4) regularize learning between partners and countries; and 5) set up coordinated systems to measure and track vaccine trust and confidence.

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What counts as evidence in vaccine safety communication and why does it matter? Update on the latest evidence on vaccine safety communication, direction, approaches and messaging to reinforce confidence in vaccines Daniel Salmon, Professor at the Johns Hopkins Bloomberg School of Public Health, moderated the session and John Parrish-Sprowl, Director, Global Health Communication Center, Indiana University-Purdue University was the main speaker. Mr. Parrish-Sprowl explained conceptualization challenges in applying evidence to engage skeptics, deniers and critics of vaccines and vaccinations. He explained that what counts as evidence depends on for the source of data, the models and theories used to interpret data, and the degree to which one trusts the data source. For example, providing scientific evidence to counter experiential evidence (e.g. “I know someone who became sick after taking vaccines”) will only fuel an argument. Evidence can be a relative concept—vaccine skeptics speak from an evidence perspective that is different from vaccine advocates. For communication to effectively win skeptics over, Mr. Parrish-Sprowl recommended engaging with individuals and communities in the context of mutual receptivity and respect, and using dialogue to establish the trust necessary to overcome hesitancy in a constructive and effective manner.

Challenges and opportunities for digital dialogue Moderator Galit Gun, UNICEF Social Media Specialist, opened the session by introducing the three discussion segments: 1) ‘Digital listening’, which featured speaker Rafael Obregon, UNICEF Chief of Communication for Development; 2) ‘The Vaccine Safety Net Web Analytics Project’, which featured speaker Alberto Tozzi, Chief Innovation Officer at Ospedale Pediatrico Bambino Gesù in Rome, Italy; and 3) ‘Digital trends in campaigning and communicating’, which featured speakers/presenters Hugh Reilly, UNICEF Social Media Specialist, Kimberly Chriscaden, WHO Communication Officer, and Hayatee Hasan, WHO Communication Officer. Following presentations and discussions across the three segments, participants stressed the need for social and digital media strategists who handle vaccine safety communication in partner organizations to adopt a proactive approach to risk communication through: 1) reshaping communication activities to avoid debunking, which increases polarization of opinion, and supporting dialogue and discussion between those with different opinions; 2) shifting from debunking to pre-bunking vaccine critics and those who oppose vaccination and setting the communication agenda instead of just responding to false claims; 3) conducting pre-emptive social media monitoring that searches for early signals or looming crises in vaccination campaigns and mitigates these in a timely manner; 4) listening to multiple signals and integrating these across platforms and information channels; and 5) applying an audience engagement approach where engaging relevant communication counterparts, including the general public and the private sector, is deemed useful. One novel initiative was presented (the Vaccine Safety Net Web Analytics Project) on how, by pooling analytics from a worldwide network of vaccine safety-focused websites, users’ needs are identified, data-driven vaccine safety digital information and communication strategies are implemented using the network, and their impact is measured.

Thematic group breakout sessions, discussions and suggestions Following the Day 1 presentations and discussions, participants went into breakout sessions, dividing themselves among the following four thematic groups: 1) communication approaches and strategies at the global, regional and country levels; 2) web analytics and social media networks; 3) community engagement and capacity building of front-line health workers; and 4) partner

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coordination involving global and regional working groups. Each group reviewed the opportunities, challenges, gaps and means of addressing the gaps.

Group 1: Current communication strategies, approaches and tools at the global, regional and country levels

Gaps: Group participants discussed how to move vaccine safety communications from reactive to proactive at global, regional and country levels. One gap identified was the lack of or diminishing brand and importance around immunization. Often too much time is spent by partner organizations reacting to negative immunizations messages rather than proactively developing and implementing overall communications campaigns around the importance of immunization. There was an overall feeling that partners cannot continue to ride on the fact the in many places of the world coverage rates are high. Communication campaigns are need to not only keep coverage high, but also to pull countries and regional levels up. Suggested solutions: The group suggested the following solutions to the gaps identified: 1) develop and launch an unified communization’s campaign to raise the profile of immunization and diminish anti-vaxx messages; 2) use the campaign to also potentially raise money or encourage countries to fund or increase funding for immunizations; 3) develop a communization’s toolkit or leverage existing partner materials to house general immunization messages and templates for countries and regions to adapt for their context, 4) tie vaccine safety communications to communications around the Global Vaccine Action Plan, as well as national or regional immunization strategies .

Group 2: Web analytics and social networking

Gaps: Group participants shared experiences and identified the following gaps: 1) weak tactics for audience targeting and tracking when deciding on social media content, platforms and tools; 2) inadequate innovation in listening across digital platforms, especially platforms that channel rumours and are difficult to monitor, such as messaging platforms; and 3) lack of proactive approaches, including pre-empting scenarios, positioning communication strategies and acting in anticipation of risks rather than in reaction in times of crisis. Suggested solutions: Based on the gaps identified, the group suggested exploring multiple sources for pre-bunking by identifying pre-bunking champions, proactive pre-bunking content, the best approaches to delivering content, accurate audience targeting, etc. The group suggested investing in better understanding the value of information and its analysis from social media and the web in ways that may be relevant to immunization strategies. Additional suggestions were to involve multi-disciplinary competences in the process and integrate multiple data sources. Group 3: Community engagement and capacity building of front-line health workers Gaps: Group participants shared experiences and recognized that a varied set of resources and tools have been developed, or are under development by a range of stakeholders. These resources and tools need to be tailored to different audiences. The following gaps and issues were highlighted: 1) the mapping of relevant existing communication resources, such as UNICEF’s AEFI and HPV communication materials and WHO’s community engagement framework for quality, people-centred and resilient health services; and 2) stronger linkages and collaboration should be established in regard to current community engagement approaches and tools to build the IPC capacities of health workers.

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Suggestions to address gaps: 1) adequate investment in identifying relevant interventions that address scale up from the outset and the use of existing joint resources to foster collaboration and enhance country capacity and linkages (vertical and horizontal); 2) the provision of adequate clarity on roles and accountabilities for risk, outbreaks and crisis communication at different levels; and 3) the establishment of a coordinated system for measuring and tracking vaccine trust and confidence.

Group 4: Partner coordination The group acknowledged that coordination mechanisms for vaccine safety communication are insufficient. The possibility of convening a working group was not retained as an immediate priority due to concerns that the actual expected deliverables have not yet been sufficiently explicated.

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reak out session on strategic plan on reinforcing confidence in vaccines

Day Two Stakeholder strategic planning to promote effective vaccine safety

communication: Key discussion highlights and action points

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Regional perspectives on vaccine safety communication challenges and solutions in light of recent AEFI responses and lessons Moderator Lisa Menning, Technical Officer, WHO, Geneva, introduced the speakers, Deepa Pokharel, Communication for Development Specialist, UNICEF Eastern and Southern Africa Regional Office; Jonathan David Shadid, Communication for Development Specialist, UNICEF West and Central Africa Regional Office; Houda Langer, Regional Adviser, Vaccines Regulations and Production, WHO Regional Office for the Eastern Mediterranean Region; and Katrine Bach Habersaat, Technical Officer, WHO Europe Region. The session featured discussions on vaccine safety communication practices from the African, Eastern Mediterranean and European regional perspectives. African regional perspective Deepa Pokharel and Jonathan Shadid led the African region presentation and discussions by outlining the African experience and challenges related to ensuring vaccine safety and building public trust in vaccines. For example, in Kenya, in 2016, some Catholic Church groups questioned the safety of vaccines before and during a measles and rubella and tetanus toxoid campaign. The national and social media picked up the story and its exposure impacted public trust in vaccination. The Kenyan Ministry of Health and its partners responded by: 1) establishing close coordination among partners to respond to the trust issue; 2) developing a risk communication plan; 3) asserting the strong and active leadership of the Ministry of Health and its partners; 4) conducting intensive social mobilization and proactive outreach to inform families and communities on risk perceptions and the importance of vaccination; 5) mobilizing immunization ambassadors and 47 county immunization champions across Kenya; and 6) engaging champion religious leaders. The following mitigation measures were considered: 1) media orientations with key facts and figures on the importance of vaccination, followed by continuous collaboration with the media; 2) engagement with professional groups (i.e. paediatric associations, nursing associations, etc.); 3) engagement with other line ministries (e.g. education, local government, etc.); 4) senior Ministry of Health personnel appearances on talk shows and in mass media; and 5) regular media monitoring. The outcome was that the measles and rubella and tetanus toxoid campaign was conducted with over 95 per cent coverage, with support from the press before and during the campaign, which ultimately overshadowed vaccine skepticism. Eastern Mediterranean regional perspective Houda Langer outlined a number of country experiences in dealing with vaccine safety issues in the Eastern Mediterranean region. In 2014, the United Arab Emirates Ministry of Health requested that WHO provide information about its measles campaign in the northern Syrian Arab Republic following news reports of 15 deaths and 50 cases of acute flaccid paralysis. In 2015, due to vaccine hesitancy expressed by the population, some parents requested WHO support for advocacy and the provision of technical information to address the issue. Based on this and similar challenges in Egypt and Tunisia, WHO found that AEFI surveillance and case management was problematic and that most AEFIs were due to programmatic errors and inadequate injection practices. AEFI reporting, investigation and causality assessment were not properly performed and there was no vaccine safety crisis plan in place. Based on this situation, WHO suggested the need to review: 1) training programmes for health care providers, especially vaccinators; 2) injection safety practices; 3) vaccine safety measures, particularly how to manage and report AEFIs; and 4) communication about risk and the benefits of vaccines. WHO also stressed the need to advocate for the inclusion of vaccine safety training in academic curricula for medical, nursing and other health care professional students. These suggestions led to remarkable improvements in clinical safety precautions and proactive communication.

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European regional perspective Katrine Bach Habersaat outlined the following common features of managing vaccine safety perception and behaviour in the WHO European Region: 1) lack of preparedness even among strong programmes; 2) lack of confidence in (health) authorities and resilience against vaccine safety scares; 3) slow and untimely response; 4) challenges with coordination across institutions; 5) challenges with coordination between communication and investigation experts; and 6) lack of communication capacity, especially for middle-income countries, and lack of good media relations. Due to the challenges, earlier this year, WHO launched a new resource, including a theoretical background document developed based on experience from countries and available evidence on human risk perception, vaccine decision-making and determinants of trust in vaccination, as well as a range of supporting documents with stepwise guidance on long-term confidence building and crisis preparedness and response (www.euro.who.int/vaccinetrust). The Regional Office also took several actions, including training workshops (19 countries trained), working in countries responding to events, and continuously refining and adjusting guidance and tools. The resource package, among many other documents, also included diagnostic tools to understand the necessary level of communications needed at each stage of a vaccine safety-related event, as well as guidance on stakeholder management, presentation of data, a checklist to assess crisis preparedness in the national immunization programme, guidance on monitoring of public perceptions on vaccination, and a template terms of reference for a suggested communication/feedback group.

Vaccine safety: The challenge of communicating ‘known knowns’, ‘known unknowns’, ‘unknown knowns’ and ‘unknown unknowns’ During the panel discussion, David Curry, Executive Director, Center for Vaccine Ethics and Policy at the University of Pennsylvania, presented four possible scenarios for full knowledge, no knowledge and partial knowledge of a risk/crisis in the making and how to forestall or mitigate it. The scenarios are: 1) ‘known knowns’; 2) ‘known unknowns’; 3) ‘unknown knowns’; and 4) ‘unknown unknowns’. Fully grasping these scenarios can help risk strategists pinpoint the circumstances under which there is: 1) a high challenge to mitigate a vaccine safety and trust crisis through proactive communication and other actions; 2) a moderate challenge to mitigate or prevent a vaccine safety crisis through communication; or 3) a low challenge to mitigate a vaccine safety crisis. In the concluding session, each participant reflected on the two-day deliberations and provided input on coloured stickers on the following five thematic areas: 1) a vaccine safety communication framework; 2) sharing resources in common; 3) a vaccine safety messaging framework; 4) quality standards for vaccine safety communication; and 5) partner coordination. This input is described in the section on next steps.

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Concluding highlights

The two-day deliberation successfully identified vaccine confidence barriers and the critical issues that underpin vaccine safety concerns. The meeting also provided partners with an opportunity to discuss and share experiences, including approaches, intervention gaps and the resources already available and needed for effective management of vaccine safety communication. Useful suggestions and recommendations were provided that can guide the development of vaccine safety communication frameworks for strategy formulation, including tools, strategies and mechanisms for communication and partner coordination. Participants noted the following constraints: 1) the inadequate provision of funding and incentives to scale up and mainstream IPC skills and tools in health worker immunization activities, especially to scale up community engagement activities; 2) lack of coordinated efforts in regard to listening to and engaging in digital dialogue; and 3) the absence of a mechanism for the global communication coordination of programmes that build and maintain public confidence in vaccines.

Next steps

On a vaccine safety communication framework The meeting recommended the following key interventions for advancing strategic thinking and planning: the provision of a joint global vaccine safety communication framework and action plan to guide the communication approaches, interventions at all levels, establishment of coordination mechanisms and progress sharing; clear roles and accountabilities for risk, outbreak and crisis communication; institution of a regular learning exercise between partners and countries; establishment of a coordinated system for measuring and tracking vaccine trust and confidence; and in-country capacity building.

On health worker capacity building for community engagement Participants suggested: 1) creating a resource pool on IPC and other related interventions that address provider communication and service user experience in immunization programmes and 2) supporting the engagement needs and communication functions of immunization programmes to build broad skills for identifying and responding to various types of vaccine-related events.

On web analytics and social networking Participants suggested focusing on: 1) using data from social media and the web to capture signals that may require communication interventions and to better understand the information needs of the public; 2) engaging in digital dialogue and mediating between different positions; 3) pre-bunking by identifying pre-bunking champions, developing proactive pre-bunking content and devising effective approaches to delivering content with accurate audience targeting; and 4) providing adequate sharing of robust monitoring and analysis of content at a global level across the broad spectrum of media and social networks.

On partner coordination Participants suggested the need for: 1) adequate investment in the development and use of joint efforts to foster collaboration and coordination (vertical and horizontal); and 2) branding general benefits of vaccines while also promoting public trust in vaccine safety/effectiveness, which can serve as the basis for fostering partner collaboration and coordination.

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On ensuring quality standards for vaccine safety communication It was suggested that greater documentation that captures learning and experiences on a regular basis is needed to help mobilize effective planning and interventions in this area. Participants also recommended consulting and agreeing on criteria for establishing and abiding by vaccine safety communication quality standards. This will facilitate the development of quality evidence as well as advocacy, planning, implementation, clarity and transparency/openness, which will in turn support the process of crafting, defending and adhering to standards, and making standards relevant to specific contexts and situations.

On the messaging framework The compilation of case studies was suggested as an important initial step towards learning how messaging evolved and messages were adapted for different contexts and events. Participants also proposed drafting a framework to guide message and content development that links scenarios to audiences, content, messages and materials.

On the overall strategic direction Recommendations included: 1) solidly ground/integrate communication strategies/plans into substantive immunization and vaccine safety programmes; 2) link/align communication for vaccine safety to higher level outcomes through strategic direction and coordination; 3) scale up horizontal engagement across health sector programmes beyond immunization; 4) navigate the behaviour spectrum from vaccine refusal to demand; 5) learn from polio lessons by emphasizing demand side vaccine communication; 6) pitch messages well by not letting safety concerns drown messages about vaccine benefits; 7) act proactively in anticipation of risks rather than in reaction in times of crisis; 8) advocate for the prioritization of immunization programmes in health agendas; 9) raise the game in digital listening and response by using innovative ways of listening across digital platforms, especially those that channel rumours and are difficult to monitor, such as messaging platforms, using an approach that moves away from debunking and towards pre-bunking critics.

On operationalization and follow up The meeting concluded with the proposal to establish a vaccine safety communication framework and collaboration, as a basis for partner coordination, collation of existing evidence, and broader dissemination of guidance. Specifics and next steps are still to be determined.

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Annex 1: Feedback and reflections

The meeting attracted 50 global, regional and country participants from WHO, UNICEF, the CDC, the Gavi Alliance, PATH, The Vaccine Confidence Project, Sabin Institute, Clinton Health Access Initiative, Johns Hopkins University, governments, and vaccine research and academic institutions.

Participants Figure 1 provides the distribution of participants across sectors. United Nations participants constituted the majority, followed by academic and research institutions, non-profit and advocacy organizations, health care providers and government/federal institutions.

Meeting organization (level of participation, facilities and services)

As illustrated in Figure 2, most participants agreed that: 1) the meeting facilities were adequate for achieving its goals; 2) they were given adequate opportunity to get answers to their questions; 3) plenary and group discussions were interactive; 4) they clearly understood and followed the meeting deliberations; and 5) the meeting agenda fully met their expectations.

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Figure 2: Participants assessment of meeting organization

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Figure 1: Participant distribution across sector of work

UN Agencies Academic Institutions Nonprofit/Advocacy Healthcare Provider Government/Federal Agency Others

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Meeting content As illustrated in Figure 3, most participants agreed that: 1) they networked with other vaccine safety stakeholders; 2) they felt a strong vaccine safety communication coordination mechanism is needed to provide guidance and oversight; 3) they were adequately updated about current vaccine safety communication needs; 4) they were adequately updated about current evidence and communication to raise awareness and confidence about vaccine safety; and 5) they contributed to the drafting of strategies and tools that reinforce confidence in vaccines.

Suggestions for improvement

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Figure 3: Participant assessment of meeting content

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Figure 4: Participants views on top three things to change about meeting

Include more country/regional experience in deliberations

Include more in-depth discussions on strategies/next steps

Include in-depth discussions about digital media engagement

Allocate more time to working groups/breakout sessions

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Annex 2: List of participants

# Participants

1

Patrick ZUBER

Group Lead for Vaccine Safety HIS/EMP/RHT - Safety and Vigilance (SAV) World Health Organization, Switzerland tel: +41 22 791 1521 e-mail: zuberp@who.int

2

Isabelle SAHINOVIC

Technical Officer HIS/EMP/RHT - Safety and Vigilance (SAV) World Health Organization, Switzerland tel: +41 22 791 15033 e-mail: sahinovici@who.int

3

Kimberly CHRISCADEN

Communication Officer HQ/DGO/DGD/DCO/SCO World Health Organization, Switzerland e-mail: chriscadenk@who.int

4

Hayatee Binti HASAN

Communication Officer WHO HQ IVB World Health Organization, Switzerland tel: +41 22 791 2103, e-mail: hasanh@who.int

5

Madhav Ram BALAKRISHNAN

Medical Officer HIS/EMP/RHT - Safety and Vigilance (SAV) World Health Organization Switzerland tel: +41 22 791 3786, e-mail: balakrishnanm@who.int

6

Christine MAURE

Technical Officer HIS/EMP/RHT - Safety and Vigilance (SAV) World Health Organization Switzerland tel: +41 22 791 1532, e-mail: maurec@who.int

7

Lisa MENNING

Technical Officer HQ/FWC/IVB/EPI World Health Organization, Switzerland tel: +41 22 791 1493, e-mail: menningl@who.int

8

Asiya ODUGLEH-KOLEV

Technical Officer HQ/HIS/SDS/QSR

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World Health Organization, Switzerland tel: +41 22 791 2458, e-mail: oduglehkoleva@who.int

9

Houda LANGAR

Regional Adviser, Vaccines Regulations and Production (VRP) EMRO - Immunization and Vaccines (IMV) WHO Regional Office for the Eastern, Mediterranean, Egypt tel: + 20222765690, e-mail: langarh@who.int

10

Katrine HABERSAAT

Technical officer Vaccine-preventable Diseases and Immunization (VPI) Programme EURO – EU/RGO/DCH/VPI WHO Regional Office for Europe, Denmark tel: +45 45336977, e-mail: habersaatk@who.int

11

Catharina REYNEN-DE KAT

Communications, Web and Information Officer EURO - EU/RGO/DCH/VPI WHO Regional Office for Europe, Denmark tel : +45 45336907, e-mail: reynendekatc@who.int

12

Alma SOKOLOVIC-RASMUSSEN

Vaccine Safety Net Communication consultant, Denmark e-mail: alma071@gmail.com

13

Smaragda LAMPRIANOU

Vaccine Safety Net Scientific consultant, Switzerland e-mail: lamprianous@who.int

14

Robin NANDY

Principal Advisor & Chief, Immunization UNICEF NYHQ e-mail: rnandy@unicef.org

15

Robert KEZAALA

Senior Health Adviser (Measles & Rubella) UNICEF NYHQ e-mail:

16

Yodit SAHLEMARIAM

Health Specialist (Measles & Rubella) UNICEF NYHQ e-mail: ysahlemariam@unicef.org

17

Godwin MINDRA

Immunization Specialist

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UNICEF NYHQ e-mail: gmindra@unicef.org

18

Rafael OBREGON

Chief, C4D UNICEF NYHQ e-mail: robregon@unicef.org

19

Ketan CHITNIS

C4D Specialist UNICEF NYHQ e-mail: kchitnis@unicef.org

20

Benjamin HICKLER

C4D Specialist (Immunization) UNICEF NYHQ e-mail: bhickler@unicef.org

21

Suleman MALIK

C4D Specialist (Immunization) UNICEF NYHQ e-mail: smalik@unicef.org

22

Marianna ZAICHYKOVA

C4D Specialist (Polio) UNICEF NYHQ e-mail: mzaichykova@unicef.org

23

Tommi LAULAJAINEN

C4D Specialist (Polio) UNICEF NYHQ e-mail: tlaulajainen@unicef.org

24

Rustam HAYDAROV

C4D Specialist (Polio) UNICEF NYHQ e-mail: rhaydarov@unicef.org

25

Hugh REILLY

Digital Communication Specialist UNICEF NYHQ e-mail: hreilly@unicef.org

26

Galit GUN

Social Media Specialist UNICEF NYHQ e-mail: ggun@unicef.org

27

Guy TAYLOR

Communication Specialist (Health) UNICEF NYHQ e-mail: gutaylor@unicef.org

Page 22 of 26

28

Erica GUTIERREZ

Programme Specialist (Polio) UNICEF NYHQ e-mail: egutierrez@unicef.org

29

Mohamed Sidie SHERIFF

C4D Consultant UNICEF NYHQ e-mail: mssheriff@unicef.org

30

Celina HANSON

Immunization Consultant UNICEF NYHQ e-mail: chanson@unicef.org

31

Deepa Risal POKHAREL

C4D Specialist UNICEF ESARO Nairobi, Kenya e-mail: drpokharel@unicef.org

32

Jonathan David SHADID

C4D Specialist UNICEF WCARO Dakar, Senegal e-mail: jdshadid@unicef.org

33

Jane GIDUDU

Vaccine Safety Officer, Access Utilization Team /Immunization Systems Branch, Global Immunization Division Centers for Disease Control and Prevention USA e-mail: bwv5@cdc.gov

34

Brent WOLFF

DPC Team Lead Centers for Disease Control and Prevention USA e-mail: irv3@cdc.gov

35

Elisabeth WILHELM

Health Communications Specialist Centers for Disease Control and Prevention USA e-mail: nla5@cdc.gov

36

Wenzhou YU

Guest Researcher Centers for Disease Control and Prevention USA/China e-mail: nyp8@cdc.gov

Page 23 of 26

37

Yulia YUROVA

Prog. Officer Public Policy Engagement GAVI, Geneva, Switzerland e-mail: yyurova@gavi.org

38

Susan BROWN

Director, Public Policy Engagement GAVI, Geneva, Switzerland e-mail: sbrown@gavi.org

39

Alberto TOZZI

Telemedicine Unit Ospedale Pediatrico Bambino Gesù (OPBG) Italy e-mail: alberto.tozzi@gmail.com

40

Nicola ZAMPERINI

Via Laura Mantegazza, 30 00152 Rome Italy Tel: +39 3358116897 e-mail: nzamperini@gmail.com

41

Heidi LARSON

Director Vaccine Confidence Project The London School of Hygiene & Tropical Medicine (LSHTM) UK Tel: + 44 79 47204226/ +44 207 927 2858 e-mail: heidi.larson@lshtm.ac.uk

42

Scott LAMONTAGNE

Director HIV Vaccines, Center for Vaccine Innovation and Access Programme for Appropriate Technology in Health (PATH) USA Tel: +1 206-285-3500 e-mail: slamontagne@path.org

43

David CURRY

Executive Director Center for Vaccine Ethics and Policy University of Pennsylvania Philadelphia, PA 191014 USA Tel: +1 267-251-2305 e-mail: david.r.curry@centerforvaccineethicsandpolicy.org

44

Daniel SALMON

Johns Hopkins Vaccine Initiative Johns Hopkins Bloomberg School of Public Health

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USA Tel: + 1 317 278 3145 e-mail: dsalmon1@jhu.edu

45

Bill GLASS

Director, Strategic Communication Programs Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland 21202 USA Email: wglass@jhu.edu

46

Bruce GELLIN

President Global Immunization Sabin Vaccine Institute 2175 K Street, NW, Suite 400 Washington, DC 20037 USA Tel: + 1 202 842 8403 e-mail: Bruce.Gellin@sabin.org

47

Robert PLESS

Office of Public Health Practice Public Health Agency of Canada 120 Colonnad Road, PL 6702A Ottawa, Ontario, K1A 0K9 Canada Tel: + 1 613 948 86 15 e-mail: robert_pless@phac-aspc.gc.ca

48

Lora SHIMP

Senior Technical Officer John Snow International 44 Farnsworth Street Boston, MA 02210 USA e-mail: lora_shimp@jsi.com

49

Sarah LOVING

Vaccine Knowledge Project Manager Oxford Vaccine Group CCVTM Churchill Hospital University of Oxford UK Tel: +44 (0) 1865 857420 e-mail: sarah.loving@mpls.ox.ac.uk

50

John PARRISH-SPROWL

Director, Global Health Communication Center Professor, Communication Studies Adjunct Professor, Women’s Studies Faculty member, Russian & Eastern European Institute Indiana University Purdue University Indianapolis

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Indianapolis, IN 46202 USA Tel: +1 317 278 3145 Email: johparri@iupui.edu