Let's talk: Vaccines in an emergency

Kate Elder: 
Hi welcome everybody. Thanks so much for joining us this afternoon for our first episode of the spring webinar series Let's Talk Vaccines. My name is Kate Elder, I am the Senior Vaccines Policy Adviser for the Médecins Sans Frontières, MSF as we will refer to it today, Access Campaign. I’m based here in New York City. 

Today we’re going to be talking about vaccinating during emergencies. While everybody is pretty wrapped up right now with COVID-19 and access to COVID-19 vaccines, understandably as it saturates the news cycle, there are many other essential vaccines that MSF is working day in and day out to deliver to our patients and people around the world. For nearly 50 years MSF has been delivering vaccinations in some of the world's toughest conditions. We’re supporting emergency vaccination campaigns in response to various epidemics and ensuring that routine immunization services continue to operate despite very difficult situations like war or civil unrest. Whether we’re vaccinating against more common or older diseases, like measles or pneumonia, or trying to fight newer threats like Ebola or COVID-19, we know that vaccination is a key component of the medical package and truly one of the most effective public health interventions. So that’s what we’re going to be discussing today. 

Just to start off, a little bit of housekeeping. We will be speaking for about 45 minutes. Wherever you are joining from today, please feel free to pop some questions in the chat. We will be taking those later in the discussion. If you are watching via livestream, YouTube live, Facebook live, or Twitch you can just pop your questions over there and my colleagues working behind the scenes are going to digest those questions and send them over to me. We’ll prioritize the questions that relate directly to what we’re discussing today. There are also live captions if you would like to opt for that. You can view them on a separate URL, or you can watch on YouTube where you click on the CC button to activate that closed captioning. So, without further ado, let's get to your experts and panel who are here with us today. 

We have Dorothy Esonwune. She is MSF’s project coordinator in Old Fangak in South Sudan. Welcome Dorothy. 

Dorothy Esonwune:
Hi everyone.

Kate Elder:
We have Mirjam Molenaar, MSF’s medical team leader on Samos island in Greece. 

Mirjam Molenaar:
Good evening.

Kate Elder:
And we have John Johnson, MSF’s vaccination and epidemic response referent based in Paris, France. Hey John.

John Johnson:
Hello.

Kate Elder:
We’re going to start with you, John. Since you’re working at one of our global headquarters there in Paris and you really have an overview of MSF’s vaccination projects across the world, can you tell us John from your perspective, why is it so important to make sure we vaccinate people who otherwise have very limited access to medical care.

John Johnson:
I think I would start by saying it is not just people that have limited access to health care that need to be vaccinated. Obviously, vaccination is a good idea for people who have good access to health care as well. Sort of the basic things, vaccines are used to prevent disease. So, clearly if you can prevent someone from getting sick it’s a very cost effective and rather quick and easy method of avoiding someone from being hospitalized or having a bad outcome like long-term morbidity or death. So, a simple vaccine like measles vaccines or rotavirus vaccine or pneumococcal vaccine can keep a child from coming down with an illness, being hospitalized. In the case of measles, you have not just the disease of measles but also the sequela the follow-up diseases that come with measles, such as post measles malnutrition and other things like that. There is the obviously the prevention of getting sick, which is fairly obvious. It makes sense to avoid sending someone to the hospital when they can just get a vaccine to prevent that. There is also the prevention of outbreaks. So, when we vaccinate people in refugee camps or IDP camps, internally displaced persons camps, you can avoid having a massive outbreak of contagious diseases like meningitis or measles. 

There is the other factor of helping to bring about the end of an epidemic. COVID is a great example. Everybody is looking at how we can stop this epidemic by using vaccines among the other epidemic control measures. So, often MSF will use vaccines like meningitis, yellow fever, measles, cholera to respond to bring about the end of an epidemic more quickly than just classic control measures would be able to do.

Kate Elder:
Thanks John. You’ve given a really good overview of the importance of vaccination. Not only for people who have limited access to health care but just in general as a global public tool. Dorothy you are joining us from one of MSF’s projects in South Sudan, Old Fangak. Can you describe to us a bit your settings, where you are sitting right now and what the context is like and what MSF vaccination activities are like in Old Fangak please?

Dorothy Esonwune:
Old Fangak is in Jonglei states in the new states of South Sudan, and it is the biggest freshwater wetland in the whole world. It has a very beautiful swamp. In Old Fangak, MSF has been there since 2014 during the war there was influx of patients and Old Fangak requested MSF to be there. MSF came, and since that time MSF has been in Old Fangak. It is like a limited place, just like you said. We are there we do routine immunizations that cover children from 0 to 11 months, and we also take children from 12 months and above when they catch them. During the flooding and in Old Fangak they are very limited. There is no vehicle, you only have boats. And in some of the places people can trek up to 72 hours before they get access to the hospital. During the flooding it was very drastic, and people couldn’t walk onto the swamp because the level of the flood is getting to their chests. So, they couldn’t walk. We, to catch people because we had a lot of dropouts in our daily immunizations in the hospital. So, we had a fixed stations like health stations, where we go every month to catch up children that are supposed to be vaccinated. We took extra measures during the flooding. We had health promotion. So, all the places we had displaced people. So, we did our team go and give them health promotion messages, explain to them the purpose of immunization and direct them, the ones that are close to the hospital, direct them to access Old Fangak hospital for their daily routine immunization. But for the ones that couldn’t access, we go to them. What we do is, we have one week planned for the outpatient. Before one week we write letters to inform the community leaders that they will be coming on a particular day. We start from Monday to Friday. So, if your turn is on Friday, we tell you we are coming on Friday. And we use also that opportunity to do health promotion. Then, on the very day of the vaccination, we have a team of the vaccinators and we also have the health promotor that continues throughout the vaccination to give health promotion messages.

It is very interesting. We are so happy for the testimony we got. That is what is motivating us. I can remember once we went for outreach because during this flooding MSF was going every day to assess the flooding and the people are so happy that we are coming to visit them. During one of my visits one of the mothers said, “do you know my husband is not around and the water is getting at my neck level. I have a child that is under 11 months. I couldn't move because I don't have canoe to paddle. But when I saw you come in, I feel so happy.” So, when MSF team came for vaccination, the child was able to be vaccinated. So, she felt very happy, and the testimony was giving us joy. It was also one day when we went for assessment, she was really very sick. She said “oh, I already planned that I'm dying. But I have five children. My husband is not around. So, I was like, who will I leave these children for.” Luckily for her, we just came in for assessment to see how they are faring. We got the information that she is sick. We took her to our boats and referred her to the hospital. So, the testimony is giving us joy. We also have some of them because the health messages we give, and we protect their health card with zip lock. So, one of the women told us that she puts the health card in the zip lock in the roof of her tukul. When the flooding came displaced her house, it was only that that was saved. So, she didn't want to lose it because she had understood the importance of immunization. 

Kate Elder:
Wow. Thank you, Dorothy. That's such an incredibly powerful story and I imagine probably that many other people who work for MSF also see the value of that health care card that parents and caretakers place truly treasuring and making sure that they keep protected the document that shows how their children have been vaccinated. Thanks for sharing with us Dorothy of what your experience has been in Old Fangak and how difficult it is sometimes, despite all circumstances, to get vaccines out to people, taking them to people despite the flooding. Or making sure people understand they need to come for their next appointment to keep on schedule, as you say. Mirjam, tell us, speaking of what Dorothy said. Sometimes they have to use boats in Old Fangak to take health services to people themselves. Many of the people where you are working, Mirjam, have arrived on the island of Samos after some pretty treacherous journeys. Taking boats, as well, and arriving there in this camp setting where you are working. Can you tell us what you hearing from people that are in the camp on Samos island and what sort of vaccination activities MSF is offering there? 

Mirjam Molenaar:
Thank you for having this event. Here on Samos, first of all, we have people coming from many, many different countries, which is very different from any other setting that I have been. We have a lot of people coming from different countries in Africa, but we also have people from Syria, Iraq, Kurdistan. So, there are many different people all together in this camp on the hill. And they all have different experiences with vaccinations. Some people have never in their life been vaccinated. For instance, many people coming from the Congo, and other people coming from Syria that have fled the war might have been vaccinated in the past but have not had any vaccinations for at least ten years since the war started. They have had children, they brought young children with them or they have had children while they were on the way or have had children while they have been living in the camp. As we are here on Samos to fill the gap in absence of health care from the ministry of health. We actually focused initially on mental health here for people as well as sexual and reproductive health care. On our project, we started with vaccinations for pregnant women for tetanus and Hepatitis B. Then we realized that many children in the camp were not vaccinated by the authorities because also COVID had arrived on the island in the beginning of this year and there was the threat of it worsening, so all of these activities were stopped. Our team decided we could not leave the children unvaccinated and so we started a vaccination campaign initially for children under five to catch them up on their immunizations. That was done once a week on a soccer field in front of this camp with all the measures in place for COVID. So, distance, wearing masks, people were screened before they could enter the line and so on. Hand sanitizing and hand washing. Information at the end of the vaccinations, all of these things were put in place. Then since our, the camp here for the migrants is - the conditions are pretty abhorrent. We also received many people after rat bites. 

We as MSF on Samos do not provide primary care to people because there was another organization that does this well. So, we work together with them and whenever somebody was bitten by a rat previously, they got sent to MSF for their tetanus vaccination as well as immunoglobin which is given as an injection when you have sustained a bad wound. Then we realized to protect people against tetanus, we needed to do a campaign for the entire camp. We started this when we actually were full on in the COVID period because we are afraid with the new policies for migrants in Europe, people might be going to a closed camp, where we may not have this kind of access. We decided to put some action into it and in December we did the first round and were able to vaccinate many, many people. I believe we vaccinated some 90 percent of the people in the camp, with the help of our health promotors, with community volunteers with the agreement from the authorities from the official camp here in Greece and also the police. They knew we would have everything in place for COVID measures. So, we did that. 

By now we have given the second dose of tetanus to people which is one month after the initial dose. At the same time new children are being born in this camp and are not being vaccinated in hospitals. So, we also continue to vaccinate these children with the same yellow booklets as Dorothy. They all get a zip lock bags. Although we are in Greece, it is wintertime. So, lots of rain and storms. And so, like you said Dorothy, people guard that yellow booklet and bring it back to us when they come for follow-up. We continue to vaccinate the newborns. Also, some children that might have missed a round of vaccinations. In the meantime, here many people are transferred off the island to the mainland, which is something we actually are really working towards. Because that way people are closer to the necessary facilities for their health care, which are lacking here. And so, we try our best to vaccinate the children completely before they leave the island. So, it's always wonderful, I think vaccination is one of the most gratifying things that we do in MSF. We know what it prevents, and I've been in many different situations where we did emergency vaccination as John explained for measles where you are running to save children from death. It's with one vaccine, it saves many.  

Kate Elder:
Thanks, Mirjam. It is so interesting to hear about the variety of contexts that people have come from when they arrive in Samos at that camp. And just how variable their immunization history is and how MSF is trying to respond to all of those specific needs. You have given us such a clear illustration of the challenges, but also the opportunities as you say. Because vaccination goes so far. John, we had this question from Michelle W when she registered for this event. Mirjam has already listed off a number of different types of vaccines. Could you please just quickly talk us through what vaccines MSF administers in our projects, and then also, if there is an emergency, John, for example an outbreak of measles like in the Democratic Republic of Congo we see right now, what is the thinking with you as the vaccination referent when you work with our medical operations to really assess the community’s needs. What are those steps and how do you work set that action plan? The real mechanics of getting started and kicking off a vaccination activity. 

John Johnson: 
To answer the first question, we do a lot different vaccination activities. All sorts of different activities depending on the project. Some of vaccines we use, I may not name all of them, but measles, meningitis, DTP, polio, tetanus, hepatitis B, pneumococcal rotavirus, BCG at birth, yellow fever, did I cholera, did I say Ebola. Depending on the context and the project, we do all those things. We do projects that are surgical where we do tetanus vaccination, and we do sexual violence projects where we do post exposure prophylaxis with tetanus and hepatitis B vaccinations. So, we do most of them. 

And then to answer your question about how we set up a project. So, classic example would be Congo and the measles epidemic. Typically, what we do is, MSF has sustained presence in the Congo for the last 25 years in all five sections. We all work in different areas of the country; we would send a team to do what we call an explo. They go and visit the area where the outbreak is happening. They meet with the local health officials and typically they will visit the hospital and some of the outpatient clinics and look at some of the data to see how many cases we have been seeing. Then determine if it's an area where they would be interested in our support. We will typically make a proposal for a few months of sort of boosted support where we can come in and help them with case management for severe cases. Typically, we also work on transfers. Some of the biggest issues were patients in these areas where there is limited access to health care is transferring them from where they live, where they may have access to a clinic. Getting them from the clinic to the hospital if it’s a severe case and they need hospitalization. And we’ll set up a reference system usually with motorcycle taxis, things like that, to be able to move patients. We work with small clinics to make sure they have treatment. We give them a kit with certain medicines. And then discuss with them how we would do references. So, they can start treating for simple cases. If there is a severe case, they refer them to the hospital. We will typically set up an isolation unit because measles is obviously a contagious disease. You have to separate these children from the rest of the children in the hospital. And so, we’ll identify an area in the hospital that can be isolated for treating these patients apart from the other children. Or, in some cases, we’ll set up a tent outside and treat the children there. We will bring in extra human resources and obviously medicines and materials to be able to help them ramp up their response. And then if warranted we will look at vaccination activities. It's typically a pretty good activity to get involved in and it usually makes a lot of sense unless you arrive really late in the epidemic. Typically, we’ll discuss how we can help them carry out a vaccination activity. 

Most of these countries where we work, they know quite well how to carry out vaccination activities. They just don’t have the means to do it. MSF will come in and usually work with them on a planning process of, okay, how many sites would you like to have? How many teams would we like to have? And how many children can we reach with this number? And then, how many children are there? So, are we getting the right number of children vaccinated for the area? We’ll usually help them mostly with logistics and human resource support. So, management of the vaccination teams, making sure they’re paid for their work. The logistic side is making sure the vaccines get to the vaccination sites. That is usually one of the trickiest parts in some of these resource poor settings because there is a lot of difficulty in moving things around because in a lot of places there’s not good road access. We have to think of how we can get it from the central warehouse out to these vaccination sites. Vaccinations need to be kept cold and that's one of the biggest challenges, from the time they leave the warehouse until the time they get to the site where they are injected into the patients, the vaccines stay at a certain temperature. To do that you have to use all sorts of different refrigerators but when they leave the central warehouse you need to have what’s called a passive cold chain. That is basically just a cooler where the vaccines are kept cold. You need to make sure that they can stay cold for enough time to get to these sites, and you need to have a good transportation plan, to make sure they are not wasted. That is typically how we go about it. I don't know if that is too long of an answer but that is more or less A to Z for a vaccination response. 

Kate Elder: 
Thanks, John. That’s great to hear the nuts and bolts and to have an appreciation for how many steps there are before we actually get to vaccinating children and other people. A couple of things you said DTP, diphtheria, tetanus, and pertussis vaccine. That is a laundry list of vaccines we offer. I thought it was interesting to highlight to that for every child the World Health Organization has a standard list of vaccines that every kid around the world should get, but you also mentioned other vaccines for particular populations. For example, MSF programs for people who have experienced sexual violence as well. The vaccination protocols for people that have been in certain circumstances too. And of course, in terms of those logistics, not to be under mentioned, the extreme logistics around the cold chains. If there are no roads transportation is hard, and if there aren’t roads electricity might be scarce as well. So, making sure those vaccines stay cold so they can remain efficacious. We know that prevention is better than the cure. We are vaccinating people to try and avoid that disease, so we don’t have to treat that disease. If we focus on routine vaccinations, the effects on a community can be far less severe than if there are deadly outbreaks. We have seen around this around the world where MSF works. We will watch a video about MSF’s recent measles vaccine campaign in Mali. Please join us. 

Thanks for joining us for that video and seeing what some MSF activities are like in the places where we work. I’m going to go to Mirjam. I think you had some reactions to what John just said, we’ve also had a question from our colleagues online. We have a question from Leslie on the livestream directed at Mirjam, has MSF seen any disruption of routine immunization services because of the COVID-19 pandemic? 

Mirjam Molenaar:
Okay, let me first react to John. When he explains what MSF does, I am sitting here very happy. I was in the Congo for one of those reactive measles campaigns where, initially, there was an outbreak of measles. Actually, we had malnutrition before measles broke out because very often it is malnutrition and then people, particularly children, are more likely to get measles. And also, the other way around. We lost many children in that area. The year after that I was in Sudan, not in South Sudan where Dorothy is right now, but in East Darfur and we did preventive measles campaign in a complete different setting with healthy children coming from all over. On carts through the desert, ten kids on a cart drawn by mule, or running through the sandstorm. We vaccinated almost 20,000 children in one week going around in this area with five teams. It was great. In one day with the team that I was with, we would do 1,200 to 1,400 children, all in a line. It was loud, it was happy, I mean parents were happy and even children would go away waving. In that setting we didn't lose any children to measles in my time there, so it was spectacular. 

Here, no, the good thing is when we realized the gap, to answer the question regarding COVID, this is exactly why we picked up doing these vaccinations. Yes, there is a gap for the ministry of health. The hospital on Samos, I am not really sure. But these things are not happening. We realize that so we are filling that gap. And in keeping all these measures that we need to keep to prevent the spread of COVID with a proper set up with logistics and medicals working very closely together. And the proper cold chain we call it the happy temperatures between two and 8 degrees Celsius here. Then you can prevent the lack of vaccinations. Now it is difficult here because these transfers are not always happening with us being aware of them. So, this is very difficult. That's why our HPs run through the camp every day to check on people, to see who is ready to leave the island or who is still there, so that we catch as many as we can. And so, we try as much as possible to prevent these gaps. I strongly believe, as we have shown with tetanus campaign, that we can continue proper vaccinations in times of COVID. It just needs to be set up properly with everybody working together.

Kate Elder:
Thanks, Mirjam. If you are just tuning in now, I want to welcome you to our discussion on vaccination in emergencies, the first session of our spring Webinar series, and invite you to pop any questions you may have into the chat. We will get to some of those questions soon. I want to take a look at some of the results of the social media quiz we did later this week. I will read some of the questions we posted to the audience. Feel free to type your answer in the chat. We will go over what the group responded. How many lives are saved each year thanks to vaccinations? Is it a) up to one hundred thousand lives, b) up to five hundred thousand lives, or c) up to three million lives saved? You can see 83 percent of you got it right. Bravo. Three million lives are saved each year. When you think of prioritizations, making sure it is well resourced. Can you imagine how many more lives we can save if we make sure every person has access to vaccination. Next question. Routine immunizations should be halted when a new disease outbreak strikes. This is false, 82% got that right. You have just heard about the importance of continuing vaccinations services despite what we are hit with. If we can do it safely it is critically important to continue offering people immunization services that target these diseases to make sure people’s immunity remains high. Finally, what is the most critical element of an outbreak response. Is it a) infection prevention and control measures, b) widespread vaccination, c) community engagement, or d) all are important components. The correct answer is D, and 84% of you got that right. Thanks very much for your responses. 

Let's talk about these for a minute actually. That second question perhaps seemed a bit obvious. Of course, we don't want to shift resources away from our existing vaccination work when there is a new outbreak. Especially in some of the contexts where MSF is working and where it seems like there can be many repetitive crises, something like Ebola or, if you will, COVID-19. But it’s not always that simple. John I will throw a question to you. How do we make sure we don't neglect our standard prevention practices for some of the older diseases we have while tackling the new threats? Maybe you can talk about your experience responding to the Ebola outbreak. 

John Johnson:
That is a huge risk whenever you have a big emerging disease like COVID or Ebola. Everything else getting pushed aside. If you look at global vaccination numbers in 2020, they went way down because of COVID. It is not an easy question to say you have to do X and it will solve everything. I think at least for MSF we need to make sure we keep our focus on things that are sometimes boring or tiring to talk about like measles. If you look back in 2019 and 2020 there was the world's largest measles outbreak in the DRC and in Chad and in the Central African Republic, but it got very little attention because of COVID. I think we need to prioritize our activities and make sure we are focusing on things that will save the most lives and that are the most important activities to be involved in. But at the same time, if you look at COVID and Ebola, these diseases are helping us learn how better to work in vaccination and how to adapt our vaccination activities in an outbreak. If you look at COVID and all of the scientific research that’s happened in developing new vaccines, some of these things will help us get better vaccines for other more classic vaccine preventable diseases. We can use technology like mRNA. And that’s super.

Another thing we need to think about how we can combine some of these activities. Just because we are vaccinating for COVID doesn't mean we can't use this opportunity to check vaccination status for measles or other vaccine preventable diseases and train our teams to come back and do the same activities later, how to use some of the same resources later. We will have extra cold chain material available after COVID-19 vaccine rolls through that we can use for activities in the future. It is not an easy question to answer. We need to keep our focus and think of how we can use some of these distractions to our advantage. 

Kate Elder:
Thanks John. And although some may be boring as you say day in and day out, some of the fundamentals, it is not any less important getting it right. Many of us haven't seen measles but it is still a severe problem in many parts of the world. Dorothy I will come to you next. I am sitting here in Brooklyn, New York and there are some people here that don't want to vaccinate their kids. It boggles my mind. My child is vaccinated and will stay on schedule. But the rise of vaccine hesitancy in some places is really alarming. I’m curious, in Old Fangak, in your project how do people respond to the vaccines? Are they eager to get vaccines where you’re working?

Dorothy Esonwune:
In Old Fangak we have some people that -- some people that awareness is the most challenging aspects of it. Some people, that got the awareness, they respond positively to vaccination. But we have other challenges that hinder people from getting vaccinations. One of them is accessibility. Just like we said, some people trek like three days to access the health center. And during this flooding, it was really very disturbing to them. They couldn't trek. So, it's made us to have dropouts of immunization. Not that people are not willing to be vaccinated, but the challenge of accessing the health facilities. Most of them only access when they are sick, and they come for treatment of their child or themselves. They use that opportunity to take the vaccine. In Old Fangak the experience we are having with the flooding. We have experience with movement of people, especially now in Old Fangak where we have food insecurity. Some people are moving in search of food. Crops are destroyed by flooding. Most of the animals are dying due to flooding. Most of the population is displaced. They have been flooding since last July and it is still going on today. Many people have been displaced. There is different shift in the movement that people are looking for mainly food to survive. So, the families are moving and kept moving to higher land. And honestly some of people are leaving the country just to search for food. 

Another challenge we have is lack of awareness. People are not really informed about the importance of vaccines because of where they are. That is why we try to see if we can solve most of the challenges by having this outpatient. By having community sensitization. We also discuss with the county health departments to reach the people that where to reach them is not easily accessible. Some of them live very far from the river and you have to walk days or hours in the swamp, which is very difficult. So, we are working with the country health department to see how we can have volunteer health workers in each community. If they can have that that will be fine. So, the aim to have this is, is to allow these people to educate the community. So, inform them about the importance of immunizations which will prevent childhood diseases which are very infectious. But this is still under discussion. The county will have a new person in the position. So, we will now start again with a new discussion. 

Another thing we plan to do is see, we use our team, we use our staff in the community to tell the community the importance of immunizations. So that they will assess any of the clinics or outpatients or any of the organizations that are doing any of the routine immunizations. And just to add to what John and Mirjam said about immunization. We know it is very important like John said at the beginning, because it helps people with resistance from infectious disease. I remember in 2010 when we did the mass vaccinations in Malawi which was very awesome. We vaccinated millions of children. Our aim, as MSF, is to prevent the outbreak by ensuring people get vaccinated. Ensuring mothers get immunized. We have another component where we try to educate the women, because we also have tetanus vaccinations for mothers from 15 years to 49 years. As we give them health messages, we also explain to them start from the pregnancy period to explain to them about the importance of vaccination when they deliver. I think that is also going a long way to help. Honestly, the dropouts are still there. There are still dropouts. 

Another solution where we are like trying to bring in is the food insecurity. It is very challenging in Old Fangak because people are continuously looking for food and they are moving. If they could have this food, I think it would also make people to stay. They already have, routinely we do screening in our vaccination. We are already doing that. But, to catch the flooded area, we plan from these months to incorporate screening for malnutrition, so that we will be able to identify when malnutrition is going high in this area. 

Kate Elder:
Thanks Dorothy and thank you for sharing with us this really multipronged approach of any time you reach community members of what you are trying to do to educate, support and offer other health services like screening for malnutrition. It is interesting to hear that there is high demand where you are in Old Fangak but, sometimes, people have other priorities because they are facing so many other difficult situations like loss of livestock, their food source, their income stream. You are putting a wonderful illustration to the really tough circumstances in which you are working. Thank you for sharing that from Old Fangak. 

We have a lot of nurses and medical professionals on the chat. Some of them are now wondering what can they do and raise awareness about the value of vaccinations. John do you have any suggestions? I can just offer from my limited experience on vaccine hesitancy, I understand it is incredibly complex. There are good resources out there including the Center for Vaccine Confidence at the London School of Hygiene & Tropical Medicine, that uniquely studies the rise of vaccine hesitancy and the topography of why people might be vaccine hesitant. There is much that needs to be done to dispel misinformation and to counter the disinformation pandemic that many people are talking about. There are some very good resources on WHO's website. Please check back on our website too. But I think any activities in your day-to-day interactions to discuss with people the value of vaccination and to use scientific tools to counter that would be very useful. John do you want to add anything to that?

John Johnson:
Yeah, I would just say that a lot of vaccine hesitancy comes from people that haven't seen these diseases that vaccines prevent. You don't see this same kind of hesitancy in places where people know what measles is and what it can do. If you look at the last few months of COVID vaccination, there was hesitancy at first and then people see it doesn’t actually have that many side effects and it actually prevents this terrible disease. They come around pretty quick to saying it’s a pretty good deal and prevents you from getting sick. That's the obvious thing is people understanding the value of vaccines in that way. If you work in an area where people are less accustomed there are great resources, like you said. WHO is one, and one I really like is a website called Immunization Academy and they have lots of really practical videos for health professionals and that is one I tend to use. 

Mirjam Molenaar:
I totally agree with the importance of the education piece. I think no vaccination campaign can be successful without proper education first. That goes for us in anywhere in the western world or developed countries where people have heard a lot already about COVID. I was in Kabul last year when COVID came around at the beginning of the year. We worked with the ministry of health and we had two tasks there. We had one task to convince them to continue the under-five vaccinations for children, to keep doing this, putting in place COVID measures. And then we already started then to prepare them that maybe in the future there would be a vaccination and to think about that and to start educating the people. I think that is a crucial part about acceptance of vaccination and as John mentioned, the fact these diseases are real and there can be a comeback if people stop accepting vaccines. We will see a rise again in diseases that we had conquered. And they will come back. So, we need to remain vigilant and continue always with our education of people and help them realize the importance of vaccinations.

Kate Elder:
That's a perfect note, Mirjam, to end on. The importance of vaccination. That is all the time we have today. I really want to thank you, Dorothy, Mirjam, and John. These are the colleagues at MSF working day in and out and they will go back to their job’s tomorrow vaccinating people. Thank you for joining us for the discussion. It’s really been a pleasure to join you as host. We will be back in a month. Please join us Thursday, March 25th. We will be talking about the vaccine that every news source is publishing today, COVID-19 vaccines, and how people are getting access to those. If we didn't get in your question you can email us at [email protected] for more information. Also please feel free to visit our web site at doctorswithoutborders.org, and our international website msf.org. Thanks, Mirjam, thanks Dorothy, thanks John. Take care everybody and stay well.