Pneumococcal disease – spread through coughing, sneezing and close contact – causes 1.6 million annual deaths across the world. Older adults, regardless of their health status, are particularly at risk as our immune systems naturally decline with age.

Pneumococcal disease also has a significant economic impact: from 2004 to 2040, the economic burden of pneumococcal pneumonia will increase by $2.5 billion (USD) each year due to healthcare costs alone. In reality, the wider negative effect on productivity, unpaid care and volunteering means a much bigger cost to society.

But the most common strains of pneumococcal disease can be prevented.

Yet policy to drive action and improve uptake is lagging. Indeed, only 31 countries include adults in their pneumococcal schedule. Of the countries with a programme in place, coverage rates can be poor.

In March, MSD and the International Longevity Centre UK organised a hybrid pneumococcal vaccination roundtable alongside the 13th Meeting of the International Society of Pneumonia & Pneumococcal Diseases (ISPPD-13). In the session, we explored the strategies to improve adult pneumococcal vaccination coverage by strengthening immunisation policies and programmes in high and upper-middle-income countries by speaking to experts from science, advocacy and policy backgrounds. Here we discuss the issues raised among stakeholders at the forefront of the debate and what’s next. You can also view a short video on the highlights from the discussion here.

1. There is a lack of investment in systems and structures designed for preventative health.

There is suboptimal funding.

The first step to improve adult pneumococcal vaccination coverage is adequate and sustained investment. Currently, only a very small proportion of health budgets are earmarked for preventative health, and an even smaller budget within that is allocated to immunisation. In the context of an ageing population and a growing burden of preventable disease, this approach is short-sighted and unsustainable.

On average, OECD countries spend less than 3% of their total health budgets on preventative healthcare and less than 10% of their preventative healthcare budgets on immunisation programmes.

We need governments to move into action and make financial commitments to improve access to immunisation.

There isn’t enough long-term policy planning.

Keeping consensus and momentum going is more difficult when budgets are stretched and the returns on investment can seem diffused or a long way off in the future. This is especially true for adult immunisation, where the positive effects of immunisation can develop over time and may be masked by insufficient attention, funding and coverage compared to childhood immunisation.

It is crucial to demonstrate to policymakers that, while the upfront investment can be high, the returns over time are multiplicative.

“Healthier populations result in higher economic productivity and more societal cohesion.” Dr Sipho Dlamini, Associate Professor of Medicine, University of Cape Town

The economic benefit of immunisation is one of the strongest tools preventative health advocates have at their disposal to persuade policymakers to invest, but more must be done to convey this message. For instance, including advocates from civil society to businesses who also recognise the critical role immunisation plays in public health. Indeed, even countries considered leaders in healthy ageing are lagging. In Norway, which ranks 3rd on the ILC-UK’s Health Ageing and Prevention Index and does particularly well on life span and health span, the Norwegian Institute of Public Health has advised government on implementing an adult pneumococcal vaccination programme, but the nation is still yet to do so.

Policymakers are unaware of the true cost of failing to vaccinate.

Policymakers too often underestimate the full value of vaccination, with a tendency to focus on immediate problems and overlook the larger costs associated with failing to immunise against disease, such as antimicrobial resistance or compounding viral infections. The knock-on effect preventable diseases can have on the healthcare system and our economy can’t be overstated. For instance, productivity loss when individuals take time-off work themselves or to care for a child or adult family member.

Previous ILC-UK research found that across the G20, preventable conditions cost the economy 1.02 trillion USD in yearly productivity loss among those aged 50-64 alone. This is roughly the equivalent of the estimated loss in global worker income for the first half of 2021 as a result of COVID-19. Increasing preventative health spending by just 0.1 percentage points can unlock a 9% increase in annual spending by people aged 60 and over and an additional 10 hours of volunteering.

In truth, vaccination pays dividends in the long term by preventing illnesses like pneumococcal disease. We must, therefore, ensure policymakers recognise that a failure to immunise adults affects the entire community and has significant consequences.

There are unclear recommendations.

Unlike flu, which is consistently administered on an annual basis, the pneumococcal vaccine isn’t. In some countries, it is recommended individuals only need to be vaccinated once, in others, it’s every five years, and if you’re clinically at-risk, a different schedule is recommended. These differences are likely contributing to low vaccination coverage.

“Pneumococcal vaccination isn’t consistent. there are changes and unclear recommendations; there’s ambiguity of recommendation guidelines.” Arunima Himawan, Senior Health Policy and Research Manager, International Longevity Centre UK

Vaccine recommendation should aim to close disparity, not widen the existing gap. When we create age-based recommendations, this decreases inequities. In the USA, Black populations aged between 50 and 65 have a greater risk of pneumococcal disease than non-Black populations. A modelling study found that expanding pneumococcal vaccination to adults over the age of 50, instead of over the age of 65, would reduce inequities in pneumococcal diseases between Black and non-Black populations.

It is imperative all professionals tasked with administering vaccination be involved in immunisation policy decisions and can advocate and dispense based on unanimous advice. This was achieved for the adult pneumococcal vaccination programme in South Africa where haematologists, allergy specialists, respiratory physicians, geriatricians, and infectious disease specialists came together to produce a one-stop-shop document. This meant any clinician anywhere could easily consult the document and administer the vaccination with confidence.

2. Awareness must be improved

Awareness of pneumococcal disease and vaccination is still dangerously low.

With lower awareness, people are less likely to get vaccinated. Recent ILC research surveyed nearly 4000 adults over the age of 50 in West and Southern Europe and found knowledge of vaccines other than influenza and COVID-19 is relatively low: while 94% of respondents had heard of the flu and COVID vaccines, only 42% had heard of the pneumococcal vaccine. Vaccine uptake was even lower in this survey – at just 18%.

However, where there is knowledge of the vaccine, there remains a perception that the pneumococcal vaccine is for children only. As older adults are most at risk of pneumococcal disease, it is imperative that awareness for the vaccine as well as which individuals and communities are most at-risk is heightened to improve uptake.

False narratives around who and what immunisation is for need to be addressed.

“There is still this perception that many vaccines are for children and not for older adults.” Lois Privor-Dumm, Senior Research Associate, Johns Hopkins Bloomberg School of Public Health

Health care professionals, advocates, as well as policy and decision makers need to move away from talking about childhood and adult immunisation as separate issues. Instead, there must be a focus on a life course approach to immunisation and recognise that a failure to vaccinate adults is a failure in helping people lead healthy lives.

3. Access to immunisation must be democratised.

There are deep inequalities permeating across pneumococcal vaccination coverage.

Often the communities most at-risk of pneumococcal disease are unable to access healthcare in line with other groups, meaning these underserved groups may not be accessing consultations from a health provider or be told where they can get vaccines. Previous ILC research found marginalised groups and underserved communities, including ethnic minorities, indigenous populations, low-income groups and undocumented or unhoused people, are all at higher risk of poor vaccine uptake.

In the USA, pneumococcal vaccine coverage is significantly lower for Black, Hispanic and Asian people compared to white people, with an 18-24 percentage point difference. A similar inequality can be seen between Black African and Black Caribbean populations in the UK.

Systemic barriers, including geographical location, poor health literacy and lack of communication from governments with the public, all contribute towards lower uptake. Additionally, often due to legitimate reasons such as lack of time, there’s a failure by doctors to prioritise administering pneumococcal vaccines.

There is often a higher level of distrust towards governments and healthcare systems from ethnic minority and indigenous populations as well. Some marginalised groups may also distrust the location or service provider by whom they would get vaccinated. Widening access to providers such as to pharmacists who are well trusted within the community, is vitally important to improve uptake.

“People don’t have the trust. They perceive that they may not get the respect that they hope for, they may not speak their language, they’re worried about insurance. They’re worried (for government programs particularly) of undocumented immigrants to be turned in.” Lois Privor-Dumm, Senior Research Associate, Johns Hopkins Bloomberg School of Public Health

Businesses and vaccination champions play a role in democratising access too, but aren’t being leveraged.

It’s not just governments that need to promote vaccination. With the productivity and income loss associated with illness, civil society, businesses and vaccine ‘champions’ all have their part to play as we campaign for better vaccination uptake.

Some businesses and industries have historically promoted vaccination and health. In 2005, a group of multinational South African companies launched a programme with the World Economic Forum to help their smaller supplier companies combat the threat of HIV/AIDS. At the time, small businesses accounted for over 50% of total jobs and 22% of GDP, but HIV/AIDS was having a crippling effect on the country’s workforce. HIV/AIDS workplace programmes helped provide free access to existing education resources and training initiatives. Barclays Bank Africa bought medication in bulk from Europe to create a “Barclays Pharmacy” and reduce the cost of treatment.

In the UK, there are incentives for businesses to ensure their employees are vaccinated against influenza. If an employer offers a vaccine in the workplace or provides employees with a voucher to receive the vaccine at a pharmacy, the cost of vaccination is exempt from taxation, provided the cost per employee is less than £50.

Champions and figureheads of vaccination are also important to democratise access.

Professor Ian Frazer had a significant impact on the federal HPV vaccination roll out and was named Australian of the Year in 2006. Still today, Australia has one of the highest HPV coverage rates worldwide.

“One of the inventors of that vaccine has been a huge influence on the community as well as on government – Professor Frazer.” Dr Michael Moore, Distinguished Fellow, The George Institute and Adjunct Professor, University of Canberra

Both businesses and champions need to have a bigger role in advocating as they could be instrumental in improving coverage rates for disadvantaged groups.

4. Robust data needs to inform national immunisation strategies and improve coverage.

Vaccine decisions aren’t being led by robust data.

When looking at the burden of pneumococcal disease, we still see significant gaps in data availability. We need better data to better understand uptake. Moreover, without it, it’s unlikely governments will prioritise vaccination as there is limited evidence demonstrating immunisation as a worthwhile investment of their public funds. Suboptimal data also prevents targeted approaches to population health management. However, while this initial data is crucial, it is only a first step. Data must feed into existing infrastructures to inform decision making and roll out.

Communicating clear and robust data on the long-term effects of pneumococcal disease can also demonstrate to policymakers the true cost savings of vaccination.

“It’s not just that single episode that you were worried about preventing. You’re worried about what happens after that; the further decline.” Lois Privor-Dumm, Senior Research Associate, Johns Hopkins Bloomberg School of Public Health

Data on inequalities in uptake is lacking. In the UK and the USA, ethnic minorities and particular demographic groups have a generally lower uptake of flu and pneumococcal vaccination. Yet suboptimal data is a significant barrier to improving health outcomes.

5. What happens next

Despite these challenges, there are some tangible steps policy makers can take to address them.

To improve investment in systems and structures designed for preventative health:

• The WHO should call on all EU member states to implement an annual coverage target of 75% for adult pneumococcal vaccination, similar to the existing target for flu.
• Governments must ensure lower age-based recommendations for adults are in place to reduce inequities and simplify the process for patients and healthcare professionals alike.
• Governments must increase spending on prevention to at least 6% of health budgets.[1]

“The framing of vaccination should be a life course vaccination.” Dr Sipho Dlamini, Associate Professor of Medicine, University of Cape Town

To inspire and engage individuals to vaccinate:

• Governments should implement a “call and recall” system for adult pneumococcal vaccination so adults are reminded when and where to get vaccinated.
• Ensure health system stakeholders and the general public are cognisant of the benefits of adult immunisation. Communication must be co-produced, consistent and communicated by local leaders and disseminated in partnership with national authorities so it is relevant to, and resonates with, the wider population.

“We need clean, clear messages which can be used by our public health groups.” Dr Michael Moore Distinguished Fellow, The George Institute and Adjunct Professor, University of Canberra

To democratise access to immunisation:

• Governments must work towards ensuring cost is not a barrier to vaccination.
• Healthcare systems need to involve a broader range of healthcare professions, including pharmacists, to administer vaccinations.
• Healthcare systems should explore allowing individuals receive multiple vaccinations during one clinic visit, so long as coadministration is supported by clinical research.

“We need to make it easy for people to go, and almost guarantee that they’re going to get the service that they’re looking for.” Dr Sipho Dlamini, Associate Professor of Medicine, University of Cape Town

To better use data to inform national immunisation strategies and improve coverage:

• Governments and healthcare systems should use community and population-level data to drive improvements in health.
• Governments need to mandate regular reporting of adult pneumococcal vaccination in their national immunisation register.

“We need data that is easily accessible, and also data on specific groups. We know in some countries that are huge inequalities in uptake. Having that data helps us really be able to understand who it is that we need to target.”  Arunima Himawan, Senior Health Policy and Research Manager, International Longevity Centre UK

 

[1] This figure is based on a 2019 pre-COVID analysis which found Canada was a global leader in preventative health spend at the time. Once this is achieved, countries should continue to align prevention spending to the preventable disease burden, which includes immunisation.

 

You can view video highlights from the discussion here.