STATE OF CAMPAIGNS COVID-19

VOLUME 2 JULY 2021 INTRODUCTION This edition of State of Campaigns highlights the global effort to launch Covid-19 campaigns in virtually every country in the world.

The novelty of the pandemic has led to unique campaign implementation strategies. We’ll explore these in terms of delivery phases, target populations, and vaccine selection. THANK YOU Each country’s plans reflect its geography, trust in government, political relations, public health attitudes, health infrastructure, and more. These factors influence every The crosscutting campaign calendar improves transparency into campaign aspect of a campaign. We hope this overview of countries’ diverse approaches will planning across disease programs and geographies, helps improve data help our global partners learn from initial campaign-based delivery, empowering future collection and analysis across campaign platforms, and offers insight into Covid-19 efforts and supporting partners’ analyses of planning versus performance. The calendar would not be possible without the support of our implementation. The resulting insights may prove vital to prioritizing the best methods for partners who provide data, share insights, and have collaborated for years to reaching health goals. make campaign-based delivery more effective.

All updated calendar information can be found at campaigneffectiveness.org. In the second part of this report, we provide an update on other campaigns previously We are happy to provide the underlying data used for this report and you can delayed due to Covid-19 since the start of the pandemic in March 2020. As of June 30, contact us at: [email protected]. 2021, 106 of 305 campaigns have been reinstated across 96 countries. With just 35% reinstatement, countries are challenged with resourcing Covid-19 vaccination efforts With thanks, along with catching up on critical efforts to combat other diseases. Linksbridge SPC PROCESS OF Our team collects Covid-19 campaign data from major media sources: at the local level, COLLECTING the global level, and levels in between. Though we regularly check for updates, the INFORMATION reporting frequency varies among countries, no doubt due in part to the dynamic nature of these campaigns. We then review the data, validate it, and enter it in our Covid-19 ACKNOWLEDGMENTS Campaign database. We’re currently transitioning to a new data input process that will allow partners at any level to make direct edits to our database. We hope this will encourage more frequent updates and help us provide the most up-to-date information possible.

3 CURRENT COVID-19 The map below shows the start dates of Covid-19 vaccination campaigns, by country. The VACCINATION first campaigns were launched across 49 countries and territories in December 2020. By COVID-19 The following vaccines have been granted emergency use authorization by national regulatory bodies and have March 2021, 182 countries had started their campaigns. As of the end of June 2021, 201 CAMPAIGNS been confirmed as in-use by local media and health officials. Vaccines in orange have also been authorized for countries have active campaigns, with one country (Haiti) expected to start its campaign use by WHO-recognized stringent regulatory authorities (SRAs) and are confirmed to be in-use in country. later in the year. There are currently four countries with unknown campaign plans: Burundi, Eritrea, French Guiana, and Tanzania.

*Other includes vaccines authorized for use in just one country: Barakat - COVIran, CNBG42 Hayat Vax, Gamaleya Sputnik Light, Novavax NVX-CoV2373, RBD Dimer Zifivax, Soberana 1.

4 5 HOW ARE COUNTRIES Covid-19 campaigns resemble other health delivery campaigns in many SUCCESSFULLY ways, but several innovations stand out. ROLLING OUT THEIR As with other campaigns, leaders must consider their countries’ healthcare and campaign CAMPAIGNS? infrastructures. But Covid-19 vaccination campaigns tend to rely more heavily on digital tools, prioritization and planned phasing of target populations, and diversification of vaccine sources. Countries are also deploying public displays of vaccination among high-profile citizens and even financial incentives to overcome vaccine hesitancy. Examples of these trends are described below:

Campaign Infrastructure: Infrastructure includes key players, such as government officials and public health personnel, as well as advanced vaccine delivery, transportation, tracking, storage, and distribution systems. Although environmental and socioeconomic barriers limit access to resources in low- and middle-income countries (LMICs), previous successful campaigns (e.g., those against and Ebola) have equipped these countries with the knowledge and infrastructure to support urgent vaccine delivery.1 Lessons from HIV response in Africa also set the foundation for coronavirus vaccine storage and tracking systems and the engagement of community healthcare personnel.2

Supply: In addition to wealth, factors such as manufacturing capacity, vaccine diplomacy, and geography all play a role in a country’s vaccine supply. Mongolia, for example, has successfully leveraged diplomacy and geography to obtain AstraZeneca, Pfizer, Sinopharm, and Sputnik V doses from global partners in a timely manner.3 LMICs in Africa, Asia, the Caribbean, and Latin America often rely on donations (through sources like the COVAX Advance Market Commitment) to sustain their campaigns.4

Target Population Prioritization: The dynamic nature of Covid-19 vaccine supply and delivery has caused countries to inoculate population groups in phases, generally starting with the most vulnerable. Most countries are prioritizing frontline healthcare workers and personnel deemed essential, such as government workers, people in the uniformed services, members of the media, and teachers. Second phases often include older people, those with comorbidities, and environmentally and socially vulnerable populations (such as refugees and prison inmates).

Vaccination Willingness: Public trust in government plays a role in vaccination willingness, with a higher level of trust leading to increased vaccination rates, as seen in Bhutan.5 Campaigns are often launched with the heavily publicized vaccination of a government leader or respected frontline health professional. Many countries add financial incentives, while others take the opposite approach, threatening fines for those refusing to get shots.16

Digital Tools: Digital applications are being developed and used for vaccination registration in India6 and Togo,7 vaccine delivery and distribution in Estonia,8 and distribution and scheduling in sub-Saharan Africa.9 These resources have increased campaign efficiency in many countries; however, they’ve also created barriers for older, rural, and poorer populations when used as the sole method of registration.6

6 7 TARGET POPULATIONS Countries are using phased approaches to vaccinate their populations. Population Frontline Healthcare Workers groups are determined based on vulnerability and exposure to Covid-19, occupation, Most often the first population group targeted for vaccination. Includes doctors, nurses, and age. Each country is prioritizing target groups based on unique factors specific to its health assistant personnel, and all medical staff. Currently targeted by 175 countries and population. territories. Below is a summary of the number of countries targeting each high-level population group. The first campaigns began in December 2020, with countries rolling out vaccines to predominantly frontline healthcare workers and essential personnel. As of June 30, Older People 2021, seven population groups are being vaccinated across 201 countries and territories. Generally includes people age 60 and older, with and without comorbidities. Currently targeted by 129 countries and territories.

General Population

All other adult individuals (age 16 or 18 and older, depending on the country’s definition of adult) that do not fall within the previous target population groups. Currently targeted by 126 countries and territories.

Essential Personnel

Often includes government officials, government workers, teachers, religious leaders, journalists/media personnel, police officers, firefighters, uniformed services, transportation personnel, airport and border workers, factory workers, and critical infrastructure workers. Currently targeted by 122 countries and territories.

High-Risk Due to Health Conditions

Often includes those with pre-existing health conditions (such as HIV, cancer, diabetes, and other comorbidities) as well as pregnant women. Currently targeted by 118 countries and territories.

Environmentally and Socially Vulnerable Populations

Often includes nursing home residents, inmates, those who are homeless, members of indigenous and rural communities, immigrants, and refugees. Currently targeted by 59 countries and territories.

Children and Adolescents

The latest population group targeted for vaccination. Generally includes ages 12-15 and/or ages 16-17, with and without comorbidities. Currently targeted by 18 countries and territories. NUMBER OF COUNTRIES DELIVERING COVID-19 VACCINATIONS TO EACH TARGET POPULATION

8 9 CASE STUDY CASE STUDY

INDONESIA: A COVID-19 With a goal of achieving herd immunity10 by vaccinating 181.5 million people, or 70% of the IMPACT OF Covid-19 has caused a strain on the healthcare workforce and infrastructure CAMPAIGN PLAN population, the country is exploiting its strong campaign infrastructure, procuring a variety of COVID-19 ON globally, particularly impacting vaccination programs in LMICs.18 vaccines, judiciously targeting priority populations, mandating vaccinations, and deploying HEALTH At least 15 African countries have had to severely delay campaigns for yellow technology.

The fourth most populous country in INFRASTRUCTURE AND fever, polio, , and other diseases, with 90 countries doing so globally. the world, is rising to the Campaign Infrastructure: Indonesia has a solid public health infrastructure, due in part to CAMPAIGNS An estimated 24 million people who would have been protected through planned 11 challenge of vaccinating its population its anti-polio effort (which achieved the goal of eradication in 2014). Frontline healthcare and routine vaccination campaigns are now at risk. The pandemic has strained 11 over a unique geographical terrain. professionals involved in the polio success are applying their expertise to Covid-19, both the healthcare workforce and infrastructure, particularly for LMIC vaccination educating the public on vaccinations and coordinating vaccine delivery to rural areas.12 programs.18

Supply: Although Indonesia has not yet authorized a domestically developed Covid-19 LMICs are disproportionally affected due to lack of sufficient healthcare vaccine,10 the country is leveraging the infrastructure of state-run Bio Farma to locally resources and increased disease risk factors.18 Experts already predict long- produce Sinovac’s jab and is also deploying shots from AstraZeneca and Sinopharm. term consequences. For example, Kenya will likely see a long-lasting TB burden Indonesian leaders are proactively seeking out still more vaccines, expecting shipments of with 25,000 additional cases,19 and Zimbabwe’s healthcare structure has been Moderna, Novavax, and Pfizer doses in late 2021, while also negotiating for Sputnik .V 13 overburdened: in addition to crucial routine services becoming less available, the country’s focus is still on increasing access to proper PPE and screening services Target Population Prioritization: Uniquely, Indonesia is prioritizing the workforce along for Covid-19 at a time when other countries have vaccination campaigns well with frontline healthcare workers, in hopes that this method will speed up economic underway.20 Covid-19 vaccination campaigns are quickly exhausting the public recovery while also quickening herd immunity. The country targeted older people in phase health system, with vital health professionals experiencing fatigue and a doubled two (pending more research on the efficacy of Sinovac’s jab in this cohort),14 with those work burden.21 considered socially and environmentally vulnerable assigned to phase three, and the remainder of the population following.15 A new and energized focus on systems could lead to increased innovation in how campaigns are organized and delivered, thus improving emergency preparedness Vaccination Willingness: Indonesia kicked off its campaign by inoculating President Joko systems and opening the door for the possible integration of vaccine campaigns in Widodo and other high-profile officials on television.14 The government is imposing a fine the future.19 and threatening loss of social aid to those who refuse shots.16 Nonetheless, mass vaccine hesitancy is still hindering the campaign.

Digital Tools: Indonesia is using a digital health-tech platform to expedite registration and scheduling.17 One drive-through vaccination center saw vaccinations rise from 600 to several thousand a day, thanks to this app. Health-tech apps have also been essential in helping Indonesia’s Covid-19 task force distribute information to the public, but access barriers may continue to impede communication with rural populations.17

10 11 OTHER CAMPAIGNS CURRENT STATE OF The campaign calendar includes the latest status of all other (non-Covid-19) campaigns ALL OTHER 2021 globally. As of June 30, 2021, the database indicates there are 411 campaigns planned across 96 countries for the 2021 calendar year. The majority of these campaigns CAMPAIGNS come from the NTD program (30%) and the polio program (26%) and will take place in WHO’s Africa Region (63%). CURRENT STATE OF CAMPAIGNS DELAYED DUE TO COVID-19

Since May 2020, all disease programs have struggled to deliver necessary health products due to the ongoing impact of Covid-19. While the pandemic caused the cancellation or postponement of almost all health campaigns, some programs (specifically outbreak- prone vaccine-preventable diseases and malaria) are beginning to see signs of recovery and campaign reinstatement as of June 2021. Meanwhile, inequities between programs persist, with mass drug administrations for neglected tropical diseases and distribution of Vitamin A supplements continuing to face interruptions.

At publication, 35% of campaigns that were previously postponed due to Covid-19 have been reinstated (restarted or have since been completed) and 10% have plans for reinstatement. With a soft target of 80% reinstatement by the end of 2021, much progress can still be made towards a large-scale restoration of campaigns for most diseases.

REINSTATEMENT STATUS OF CAMPAIGNS DELAYED BY COVID-19 2021 CAMPAIGNS BY DISEASE AND REGION

12 13 LIST OF REFERENCED MATERIAL

1. “African countries have an advantage in rolling out Covid-19 vaccines,” last modified February 19, 2021, www.qz.com/africa/1974325/decades-of-vaccine-programs-will-help-africa-with-covid-19. LOOKING FORWARD 2. “Scaling Up Covid-19 Vaccination in Africa—Lessons from the HIV Pandemic,” last modified March 31, 2021, www.nejm.org/doi/full/10.1056/NEJMp2103313.

3. “How Mongolia Made the Most of Vaccine Diplomacy,” last modified May 6, 2021, thediplomat.com/2021/05/how-mongolia-made-the-most-of-vaccine-diplomacy.

4. “Can COVAX really vaccinate the world?” last modified June 8, 2021, ILLUSTRATION www.dw.com/en/can-covax-really-vaccinate-the-world/a-57816099.

5. “Bhutan’s experience with COVID-19 vaccination in 2021,” last modified April 23, 2021, gh.bmj.com/content/bmjgh/6/5/e005977.full.pdf.

6. “Explained: How digital divide impacts young India’s Covid-19 vaccination chances,” last modified June 7, 2021, www.indianexpress.com/article/explained/how-the-digital-divide-impacts-young-indias-vaccination-chances-7347012.

7. “In Togo, authorities vet on digital tools to fight Covid-19 and protect the most vulnerable,” last modified April 20, 2021, www.reliefweb.int/report/togo/togo-authorities-bet-digital-tools-fight-covid-19-and-protect-most-vulnerable.

8. “Estonia adopts a vaccine distribution app built by volunteers,” last modifiedApril 2021, FUTURE OF COVID-19 There are growing hints that co-administration of Covid-19 vaccines with other shots www.e-estonia.com/estonia-adopts-a-vaccine-distribution-app-built-by-volunteers. will become the norm once the acute phase of the pandemic ends. 9. “Digital Coordination: An industry partnership is working to ensure the distribution of COVID-19 vaccines across Africa,” last modified May 12, 2021, VACCINATIONS www.themedicinemaker.com/business-regulation/digital-coordination. In the United States, regulators lifted a rule against co-administration in spring 2021.22 Also, 10. “Indonesia’s Covid-19 vaccination program draws praise from WHO,” last modified June 9, 2021, en.antaranews.com/news/176138/indonesias-covid-19-vaccination-program-draws-praise-from-who. that spring, Pfizer started enrolling participants in a study of its 20-valent pneumococcal 11. “COVID-19 shows value of polio infrastructure to support resilient health systems,” last modified March 24, 2021, conjugate vaccine candidate co-administered with a booster dose of its Comirnaty coronavirus www.who.int/news-room/feature-stories/detail/covid-19-shows-value-of-polio-infrastructure-to-support-resilient-health-systems. 23 jab. Novavax later published data on the co-administration of its Covid-19 vaccine candidate 12. “Contributions of the Polio Network to COVID-19 Response,” last modified 2020, with an authorized seasonal flu shot: the study saw no early safety concerns and no negative apps.who.int/iris/bitstream/handle/10665/336261/9789240011533-eng.pdf?sequence=1&isAllowed=y. impact on the immunogenicity of the flu vaccine.24 13. “Indonesia is likely to approve Russian Sputnik V by late April,” last modified April 14, 2021 tass.com/world/1277923

Co-administration will likely facilitate Covid-19 booster programs, which may be indispensable 14. “Access to COVID-19 vaccines: Global approaches in a global crisis,” last modified March 18, 2021, www.oecd.org/coronavirus/policy-responses/access-to-covid-19-vaccines-global-approaches-in-a-global-crisis-c6a18370 to long-term control of SARS-CoV-2. Booster research efforts are increasingly widespread: 15. “Indonesia launches one of the world’s biggest Covid-19 vaccination drives,” last modified January 12, 2021, www.reuters.com/article/us-health-coronavirus-indonesia/indonesia-launches-one-of-worlds-biggest-covid-19-vaccination-drives-idUSKBN29I09U • Britain’s Cov-Boost trial is evaluating seven vaccines as potential boosters25 16. “Jakarta will fine people who refuse Covid vaccines. Will it work?” last modified February 23, 2021, news.trust.org/item/20210223133903-1yqor. • In South Africa, ImmunityBio is trialing its vaccine candidate as a booster in both fully 26 17. “Tech collaboration accelerates Indonesia’s COVID-19 vaccination programme,” last modified March 8, 2021, vaccinated people and those previously infected with SARS-CoV-2 www.opengovasia.com/government-accelerates-indonesias-covid-19-vaccination-programme.

18. “The Impact of the COVID-19 Pandemic on Immunization Campaigns and Programs: A Systematic Review,” last modified January 22, 2021, • The U.S. government is studying a single booster dose of Moderna’s vaccine in fully www.ncbi.nlm.nih.gov/pmc/articles/PMC7908591. vaccinated people27 19. “COVID-19’s impact on Africa, why it goes beyond healthcare,” last modified May 25, 2021, www.orfonline.org/expert-speak/covid19s-impact-on-africa-why-it-goes-beyond-healthcare. Whether through integrated campaigns or co-administered routine , Covid-19 20. “Rich or poor, in Zimbabwe crumbling healthcare is deadly for all,” last modified April 28, 2021, vaccines will likely remain embedded in the health delivery landscape and may help drive its www.aljazeera.com/features/2021/4/28/rich-or-poor-in-zimbabwe-crumbling-healthcare-is-deadly-for-all.

evolution. 21. “Risks and challenges in Africa’s COVID-19 vaccine rollout,” last modified May 14, 2021, www.afro.who.int/news/risks-and-challenges-africas-covid-19-vaccine-rollout.

22. “CDC says it’s OK to get a Covid-19 vaccine alongside other vaccines,” last modified www.cnn.com/2021/05/12/health/us-coronavirus-wednesday/index.html.

23. “Pfizer Initiates Study Exploring Coadministration of Its 20-Valent Pneumococcal Conjugate Vaccine Candidate Along with a Third Dose of the Pfizer-BioNTech Covid-19 Vaccine in Older Adults,” last modified May 24, 2021, www.pfizer.com/news/press-release/press-release-detail/pfizer-initiates-study-exploring-coadministration-its-20

24. “Novavax Announces Positive Results from First Study of Influenza Vaccine and COVID-19 Vaccine Candidate Administered Simultaneously,” last modified June 14, 2021, www.biospace.com/article/releases/novavax-announces-positive-results-from-first-study-of-influenza-vaccine-and-covid-19-vaccine-candidate-administered-simultaneously

25. “World-first COVID-19 vaccine booster study launches in UK,” last modified May 19, 2021, www.gov.uk/government/news/world-first-covid-19-vaccine-booster-study-launches-in-uk.

26. “ImmunityBio Expands Trials of T-Cell-Based COVID-19 Vaccine Candidate as a ‘Universal Boost’ in Vaccinated Subjects and Receives Approval to Test Intranasal Spray in South Africa,” last modified May 25, 2021, www.immunitybio.com/immunitybio-expands-trials-of-t-cell-based-covid-19-vaccine-candidate-as-a-universal-boost-in-vaccinated-subjects-and-receives approval-to-test- intranasal-spray-in-south-africa27.

27. “NIH clinical trial evaluating mixed Covid-19 vaccine schedule begins,” last modified June 1, 2021, www.nih.gov/news-events/news-releases/nih-clinical-trial-evaluating-mixed-covid-19-vaccine-schedules-begins 14 15