Engaging the Public in Decisions about Emergency Vaccine Deployment Strategies: Lessons from Scenario-based Discussions in Sierra Leone

"...the importance of engaging communities in the discussions around the design of emergency vaccine deployment strategies, rather than relegating public involvement solely to a question of building vaccine confidence."



Mistrust and misinformation pose a challenge to effective vaccination programmes in many situations. However, interventions to combat these dynamics have mostly drawn on top-to-bottom messaging designed to debunk rumours and misinformation, instead of consideration of how community perspectives and existing structures can shape deployment strategies - that is, how to deliver vaccines - in ways that address local concerns and realities. This study examines community preparedness in Sierra Leone's Kambia District, exploring diverse viewpoints on vaccine deployment strategies, emphasising Ebola and COVID-19 vaccinations. While the scenarios refer specifically to Ebola and COVID-19, the researchers argue that this approach offers broader insights for vaccination during health emergencies.



The paper begins by reviewing Sierra Leone's experience of recent health emergencies, including the Ebola outbreak in 2014-2016 and then, only 4 years later, the COVID-19 pandemic. With regard to vaccination during the latter emergency, the paper notes that, amongst those who reported being hesitant to take the COVID-19 vaccine, reasons included lack of trust, concerns about the safety and effectiveness of the vaccine, lack of information, lack of belief that COVID-19 is real, and low perceived risk of getting infected due to the invisibility of the disease in Sierra Leone at the time. Accessibility also proved to be a challenge for some. Several COVID-19 vaccination campaigns were organised nationwide. Many were accompanied by mass sensitisation efforts using print and electronic media and social mobilisation strategies at the community level to enhance access and uptake. However, by the end of May 2021, very few gains had been made in vaccination coverage.



Challenges associated with vaccine uptake in past emergencies in Sierra Leone are linked to the fact that this society upholds strong religious and cultural norms rooted in the belief that God gives and owns life. Some illnesses are understood to have underlying traditional meanings and causation, for example in relation to spirits or witchcraft, and therefore should be referred to traditional healers, herbalists, or Islamic "Karmokoh" (scholars). On the other hand, based on what they had seen on social media regarding the COVID-19 pandemic and the global death toll, many people conceived of COVID-19 as a western illness designed for white people that could only be combatted with western medicine. Although there was an appreciation on the part of many for the need to get vaccinated, deployment strategies could only succeed if they took into account the social and economic context in which potential recipients live.



The study uses ethnographic research from the Ebola vaccine trials (EBOVAC Salone) conducted in Kambia District from 2015 to 2021, including participant observation and tailored focus group discussions (FGDs), to investigate various deployment scenarios with community leaders and citizens. The FGDs were tailored to discuss general experiences with health care in their community and experience with previous epidemics and vaccination programmes. Then, participants were presented with two case studies - one of an Ebola-like illness and one of a COVID-19-like illness - and were asked to debate various vaccine deployment strategies that might be used in the context of each emergency, including:

• Scenario 1: Ring vaccination, in which public health staff identify an "index case" - the first person who tests positive without being in close contact with another person who is sick - and then vaccinate all of the contacts of the index case first. They then vaccinate the contacts of all of those contacts and then the contacts of those contacts. In communities that had significant exposure to Ebola, participants commented on the prolonged quarantine periods and the devastating effect they had on livelihood activities and social and religious practices, which gives a compelling reason for breaking the chain of transmission as early as possible through a ring vaccination approach.
• Scenario 2: Targeting key populations, which involves giving vaccines primarily to healthcare workers or other high-risk groups in the population, not to all community members, due to limited vaccine supplies. One strong suggestion was that chiefs and other stakeholders in the community should be consulted in deciding who should be included in the category of key populations for early vaccination in communities, since they know their communities best.
• Scenario 3: Pop-up vaccination, which entails stationing health workers in key parts of specific communities so that people can easily access vaccination. Almost all participants agreed that pop-up vaccination would be the best strategy as it not only accounts for social norms and livelihood activities but also maximises the potential for optimal uptake of vaccines and reinforces confidence in vaccines.
• Scenario 4: Single versus multiple doses, which is an issue in situations where two doses of vaccine are needed to give full protection against the infection, yet there is scarcity. Many participants believed that in the case of Ebola it would be best to provide a full course of vaccination to those living in Ebola epicentres and surrounding areas so as to provide them with full immunity and stop the chain of infection. However, in a COVID-19 outbreak, many participants believed that it is important to vaccinate as many people as possible within the shortest possible time that resources allow.

In conclusion: "The findings in this paper show not only the feasibility but also the significance of engaging citizens in discussions about strategies for effectively delivering vaccines before the moment at which vaccines arrive in their communities....This means not only speaking to communities about the strategies but also expanding policy-makers' understanding of what kinds of considerations are pertinent when making decisions about vaccine deployment. Such collaborative processes will include, for example, more contextual appreciation of how socio-economic realities affect the feasibility of different strategies in different communities as well as an appreciation of locally meaningful understandings of what is local and just. For the citizens involved in [this] project, such deliberations were rooted in local knowledge and experience, including vivid memories of recent outbreaks. Rather than considering questions of deployment and vaccine confidence as separate, this approach proposes utilising citizens' expertise and experience to arrive at strategies that are both epidemiologically and socially effective."