IFMSA Vaccination Training Manual

1. Introduction

Introduction to vaccination Objectives for the manual SWG membres

2. Part A: Knowledge part

2.1. Introduction to Vaccination and its Importance 2.2. Universal Vaccination Coverage and Vaccination Go vernance 2.3. Vaccine Hesitancy Movements and Education 2.4. Research in Vaccination for Prevention of Neglected Tropical Diseases and Emerging Infectious Disease 2.5. Quality of Vaccines and Handling

3. Part B: Capacity Building part

3.1. Methods for Capacity Building 3.1.1. Peer-to-Peer (P2P) 3.1.2. Advocacy 3.1.3. Small Working Group (SWG) 3.1.4. Debates 3.1.5. Role-playing 3.1.6. Simulation 3.2. How to organize a workshop 3.2.1. Logistics 3.2.2. Organizing Committee (OC) 3.2.3. Agenda Setting 3.2.4. Evaluation and Follow-up 3.3. Suggestions for the Capacity Building Activities 3.3.1. Introduction to Vaccination and its Importance 3.3.2. Universal Vaccination Coverage and Vaccination Governance 3.3.3. Vaccine Hesitancy Movements and Education 3.3.4. Research in Vaccination for Prevention of Neglec ted Tropical Diseases and Emerging Infectious Disease 3.3.5. Quality of Vaccines and Handling

4. Conclusion Summary Contacts

Dear IFMSA members, Across the world, vaccination has become a very important topic in the past few years. Hesitancy towards the use of vaccines and anti-vaxxer movements are growing, while infectious diseases are rising daily.

In IFMSA we have been working on vaccination in the past years, by organizing several workshops on the topic and creating campaigns to increase the awareness on the issues within the area. Vaccinations was furthermore been selected as a regional priority in the European region in the term 2018/2019.

Similarly in Asia-Pacific vaccination remains a very important topic as we have started to see a rise in anti-Vaxxer movements in the region along with an alarming number of cases of communicable diseases. The number of outbreaks, especially of multi drug resistant infections imposes a huge problem and is a burden for the economy. This needs to be tackled as soon as possible.

The main goal of this training manual is to provide information and resources to all members of our organization regarding the topic of vaccination. After finalizing our first training manual on Antimicrobial Resistance in the European Region in 2019, we realized that there is a need of such tools in other regions as well. Therefore we started preparing this second manual as a collaboration of two regions: Asia-Pacific and Europe. We selected a group of interested and dedicated people in order to fulfill our wish of covering the topic of vaccination. This manual comprises all the essential knowledge in order to work on vaccination, includes tips and tricks concerning campaigns, trainings and advocacy.

As a closing statement, we would like to accentuate the words that describe our work in IFMSA: “Think globally, act locally”. This manual will encourage you to think globally, while giving you the necessary resources to act locally and make an actual impact.

We hope you will enjoy reading this training manual, and that you will find it inspiring and useful!

“Life or death for a young child too often depends on whether he or she is born in a country where vaccines are available or not.”

Nelson Mandela Best regards

The coordinators Blanca Paniello & Viktoria Kastner (SCOPH Regional Assistant for Europe) Natasha Irfan (SCOPH Regional Assistant for Asia-Pacific) Abdulkarim Harakow (General Assistant for Europe)

2. Part A: Knowledge part 2.1. Introduction to Vaccination and its Importance Vaccination is a process of inoculation of preparation of killed microorganisms, living attenuated organisms, or living fully virulent organisms in order to produce or artificially increase immunity to a particular disease. (1) Often interchanged with vaccination, the term immunization whereas, is the process whereby a person is made immune or resistant to an infectious disease, not necessarily, but typically by the administration of a vaccine. (2)

A vaccinated child. Photo: WHO (3) Vaccines have one of the most revered success stories in science and in modern medicine. They are the most effective medical strategy to control infectious diseases.

They are the reason smallpox has been eradicated worldwide and poliomyelitis has been almost eradicated. They prevent 2-3 million lives each year, while preventing millions more from illnesses. (3) History The earliest documented examples of vaccination are from India and China in the 17th century CE, where vaccination with powdered scabs from people infected with smallpox was used to protect against the disease. (5) Although vaccination by this means could have originated in India or China in the 10th century CE, Edward Jenner is credited with discovering a means of safely conferring immunity to smallpox in 1798. (4, 5) Following his discovery of live attenuated smallpox vaccine, it was not until 1885 that another live attenuated vaccine was discovered for rabies in humans by Pasteur and his colleagues.

Another discovery toward the end of the 19th century that immunogenicity could be retained if bacteria were carefully killed by heat or chemical treatment led to the development of inactivated vaccines. They were first applied for pathogens such as typhoid, plague and cholera. Then the first half of the 20th century witnessed the development of purified protein and polysaccharide vaccines, while the rise in genetic discovery and research in the second half of the 20th century fueled the discovery of genetically engineered recombinant vaccines. (8)

Mechanism of Action Vaccines are a way of conferring active immunity to an individual. They work by artificially activating the immune system by introducing the body with immunogens that “imitate” infection without causing illness. (6) The immunity thus conferred is produced by an individual's own immune system and can often last for a lifetime. (7) In passive immunity, however, the antibodies produced by one human or other animal is transferred to another to temporarily protect against some infections.

Most vaccines are administered before a person contracts the disease. However, some vaccines (e.g. Rabies), when administered within a specific duration after exposure, can protect a person from developing a disease. This is possible because vaccines enable rapid development of immune response which can act against pathogens which the body has already been exposed to.

Ingredients of Vaccines Vaccines contain ingredients other than antigens that helps to ensure its safety and efficacy. They contain preservatives to prevent contamination, adjuvants like aluminum salts to help stimulate the body’s response to the antigens, stabilizers like gelatin to keep the vaccine potent during transportation and storage, and residual materials from the manufacturing process like cell culture materials, antibiotics and inactivating agents. (6) Types of Vaccines There are two basic types of vaccines: live attenuated and inactivated, which have different characteristics which determine how they are used. (7) 1. Live attenuated vaccines – They are made of artificially weakened microorganisms that stimulate immune response identical to natural infection, but without causing the disease. E.g. BCG, measles, mumps, varicella, rotavirus, etc.

2. Inactivated vaccines – They are made by growing microorganisms in culture media, then inactivating them with heat and/or chemicals. They are further classified into whole-cell, subunit, toxoid and polysaccharide based vaccines based on parts/ components of the microorganism used. E.g. Hepatitis A, diphtheria, tetanus, anthrax, influenza, etc.

Vaccine antigens which are produced by genetic engineering technology are sometimes called recombinant vaccines. This technology has been used to produce vaccines against Hepatitis B, Human Papillomavirus, etc.

Importance of Vaccination Although vaccination has a great history of time-proven effectiveness, its negative aspects gain much more publicity than its positive aspects. Below are some of the benefits of vaccination. (9) 1. Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better.

2. Vaccination has helped eradicate Smallpox and has almost been able to eradicate Poliomyelitis.

3. Many diseases that created havoc in the past have become rare due to vaccination.

4. High levels of vaccination in the community creates herd immunity which protects even the unvaccinated group in the population.

5. Some vaccines prevent cancer by immunizing against certain viruses such as Human Papillomavirus that are notable for causing cancer.

6. Vaccines prevent adverse fetal complications like congenital rubella syndrome, liver cirrhosis, cancer and even neurological lesions.

7. Continuous high levels of vaccination coverage is necessary until eradication of certain diseases after which vaccines for those diseases would no longer be required.

8. Some diseases like rabies which is always fatal without treatment have no treatment other than vaccines.

9. Routine vaccination is cheaper to the economy than controlling outbreaks which can occur in the absence of it. Mortality and morbidity prevented translates into long-term cost savings.

10. Vaccination prevents the development of antibiotic resistance by reducing the need for antibiotics.

11. Vaccination against influenza in elderly reduces the chances of cardiovascular diseases thus decreasing mortality and increasing life expectancy.

12. Vaccination against endemic diseases of travel destination ensures safe travel and mobility.

Adverse Events following Vaccination Vaccines used in national immunization programs are extremely safe and effective. However, like any other medical procedure, vaccination can cause both minor and, rarely, serious side effects. Despite concerns about vaccine safety, vaccination is safer than accepting the risks for the diseases these vaccines prevent. (8) The side effects from vaccines are almost always minor and go away within a few days. Serious side effects, such as a severe allergic reaction is very rare and health professionals are trained to deal with them. (6)

Reference 2.1.

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Merriam-Webster. “Vaccine�. Retrieved 2019. Accessible from: https://www.merriamwebster.com/dictionary/vaccine World Health Organization. Retrieved 2019. Immunization. Accessible from: https:// www.who.int/topics/immunization/en/ World Health Organization. Retrieved 2019. The power of vaccines: still not fully utilized. Accessible from: https://www.who.int/publications/10-year-review/vaccines/en/ Gross et al. 1998. The myth of the medical breakthrough: smallpox, vaccination, and Jenner re-

considered. Int J Infect Dis 1998 Jul-Sep;3(1):54-60. www.ncbi.nlm.nih.gov/pubmed/9831677 Lund et al. 2005. Immunological Bioinformatics. MIT Press.

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CDC. Retrieved 2019. Making the Vaccine Decision: Addressing Common Concerns. Accessible from: https://www.cdc.gov/vaccines/parents/vaccine-decision/index.html CDC. Immunology and Vaccine-preventable Diseases. Accessible from: https://www.cdc.gov/ vaccines/pubs/pinkbook/downloads/prinvac.pdf CDC. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Accessible from: https://www.cdc.gov/mmwr/PDF/rr/rr4512.pdf Andre et al., Vaccination greatly reduces disease, disability, death and inequity worldwide. Bu-

lletin of WHO 2008. Accessible from: https://www.who.int/bulletin/volumes/86/2/07-040089/ en/

2.2. Universal Vaccination Coverage and Vaccination Governance What is Vaccine Coverage?

According to the WHO, proportion of the children who receive recommended vaccine. It is the number of people who have received one or more vaccines in relation to the entire population. Vaccination coverage is one of the best indicators to the level of protection a country has against vaccine preventable disease.

DPT1 Coverage and number of unreached children by country. UNICEF (2018) (11)

By measuring the trends in coverage, the potential for an outbreak of vaccine preventable diseases can be identified. When the coverage rates drop in a population the chance of an outbreak occurring in that population rises- Herd immunity refers to the resistance to A disease within a population, if a majority of the population is immunized to the specific disease, thereby protecting the people not immunized to the disease. It is also needed to assess how many people are protected against vaccine preventable diseases in relation to the general population and identify the vulnerable population with low coverage in order to explore reasons for low coverage. It helps in recommending where public health should allocate its resources, for example where to improve access to immunization services or public education efforts. (1) In 2010, in order to achieve Universal Vaccine Coverage, the global health community declared the next 10 years as the Decade of vaccines with a vision of the world where individuals and communities can live free from vaccine preventable diseases.

The goals that were set includes Achieve a world free of poliomyelitis, Meet global and regional elimination targets, Meet vaccination coverage targets in every region, country and community, Develop and introduce new and improved vaccines and technologies, Exceed the Millennium Development Goal 4 target for reducing child mortality. (2) The Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. The GVAP mission is to improve health by extending by 2020 and beyond the full benefits of immunization to all people, regardless of where they are born, who they are or where they live.

The GVAP reiterates existing goals, sets new goals for the decade, and proposes strategic objectives and the actions that support their achievement. If the GVAP is translated into action and resources are mobilized, between 24.6 and 25.8 million deaths could be averted by the end of the decade, billions of dollars in productivity will be gained, and immunization will greatly contribute to achieving the Millennium Development Goal 4 target to reduce by two-thirds the under-five mortality rate.

Overwhelming evidence demonstrates the benefits of immunization as one of the most successful and cost-effective health interventions known. Over the past several decades, immunization has contributed tremendously to reducing mortality and morbidity of infectious diseases, including the eradication of smallpox, an accomplishment that has been called one of humanity’s greatest triumphs. Vaccines have saved countless lives, lowered the global incidence of polio by 99 percent and reduced illness, disability and death from diphtheria, tetanus, whooping cough, measles, Haemophilus influenzae type b disease, and epidemic meningococcal A meningitis.

Global Vaccination Coverage has remained stable for a couple of years. Despite the fact the 85% of infants globally received the DTP vaccine in its 3 doses, around 19.9 million children under the age of one never received it in different countries and regions of the world.

Global Vaccination coverage summary in 2017 is: • Haemophilus influenzae type b (Hib) has been introduced in 191 countries, with an estimated coverage to be 72%, highest in the Americas region at 91% and lowest in the Western-Pacific region at only 28% • Hepatitis B Vaccine introduced in 187 countries estimated coverage being at 84%, also 105 countries supplied the children with the first dose of the vaccine in the first 24 hours in life estimated at 43%, highest in the Western-Pacific region at 93% • Measles vaccine (2 doses) has been introduced in 167 countries as routine vaccine where 67% of children received the vaccine. Children under 5 deaths from measles, a major child killer, declined by 85 per cent worldwide and by 89 per cent in sub-Saharan Africa between 2000 and 2016 • As of March 2018, all but 14 countries have eliminated maternal and neonatal tetanus, a disease with a fatality rate of 70 to 100 per cent among newborns.

•

Polio has been stopped in all countries targeting its eradication after 85% of children around the world have received the vaccine except for three countries; Afghanistan, Pakistan and Nigeria where the disease is still endemic. Polio free countries have been infected by imported virus and all countries - especially those experiencing conflict and instability- remain at risk until polio is fully eradicated. (3)

Equally concerning is the continuing detection of circulating vaccine-derived poliovirus in 2017 and 2018, in the Democratic Republic of the Congo, Nigeria, the Syrian Arab Republic, Somalia and Papua New Guinea. This highlight worrying inadequacies in national immunization systems that leave countries at risk of importation and the emergence of circulating vaccine-derived poliovirus, and ill-equipped to monitor and maintain polio-free status in the future.

Currently, an outbreak of 2 strains of Poliovirus has been seen in Somalia where 15 children have been affected so far. The last case of polio seen in Somalia dates to August 2014. This calls the need for children to be vaccinated against polio even if the country they live in has been eradicated from polio. (4)

A vaccinator marks door of a home to show that the children in the house were vaccinated. Photo: WHO Somalia (4) Vaccination coverage in 2017 according to different regions based on WHO-UNICEF estimates published in September 2018 has been varying.

The percentage of children receiving diphtheria, tetanus and pertussis vaccine (DTP) is often used as an indicator of how well countries are providing routine immunization services. In 2017, global coverage rates for the third dose of diphtheria, tetanus and pertussis vaccine (DTP3) reached 85 per cent, up from 72 per cent in 2000 and 21 percent in 1980. Still, progress has stalled over the current decade, and 71 countries have yet to achieve the Global Vaccine Action Plan (GVAP) target of 90 per cent or greater coverage of DTP3. (5) In 2017, 10 countries had less than 50 per cent coverage for DTP3 or the first dose of measles containing vaccine (MCV1), many of which are fragile states and affected by emergencies: Angola, Central African Republic, Chad, Equatorial Guinea, Guinea, Nigeria, Somalia, South Sudan, Syrian Arab Republic and Ukraine. But more than half of all children unvaccinated for DTP3 lived in just five countries: Nigeria, India, Pakistan, Indonesia, Ethiopia. Note that populous developing countries may contribute significantly to the number of unvaccinated children despite achieving relatively high rates of immunization coverage. (11) Efforts to raise global immunization levels will require a strong focus on the countries where the highest numbers of unvaccinated children live – while also ensuring that countries where children are most likely to miss out on immunization are not neglected.

Also, looking at the graph, we notice that 5 countries have lost their 90% DPT3 vaccination coverage status. Thus, it is important to stress that countries should accelerate their vaccination coverage to the maximum but also ensure that whatever coverage gained is not lost in the future. (3) In order to increase coverage or to monitor vaccination delivered to public, various governments set up different strategies to tackle the entire public. In the EU, vaccination programs are being developed and implemented by agencies run by national government while the local government is mainly involved in the implementation of the vaccination and monitoring the vaccination coverage. However certain discrepancies occur within different countries where regional government has the right to modify and oversee the national vaccination programs like Denmark, Germany, Spain and Sweden.

Furthermore, there are also discrepancies on how the government measures vaccination coverage among different countries. (12) This may pose a difficulty in assessing whether there is an improvement in the coverage or rather just an increase in the population. The method used to measure the denominator (the people who could be vaccinated) and the numerator (the people who are currently vaccinated) is measured from different sources like population registers, health care reports etc. Upon studying, we come to realize that the vulnerable people, like the homeless, refugees may slip through these numbers and numbers may be either underestimated or overestimated.

Financing and provision of vaccine is an issue in middle income and low- income countries. In some countries, where people must pay out of their pockets for the vaccines, there may be a sign of less vaccine coverage when compared to countries where vaccines are provided free of cost. Towards the more developed countries, the main barrier causing a decreased coverage is Vaccine Hesitancy, which will be discussed in more detail later.

Another issue that is to be considered is the lack of awareness among the general public where people are unaware of the potentially serious consequences of infections. This needs to be looked closely upon by the government and rectified by awareness campaigns and improved training and communication skills among and between healthcare professionals and patients.

Coverage gaps persist between countries, as well as within countries. The average coverage with three doses of diphtheria-tetanus -pertussis-containing vaccine and with measles-containing vaccine in low-income countries was 16% and 15% below that of high-income countries in 2010, respectively. However, this represents a positive trend in comparison with the coverage gap of 30% for both vaccines in the year 2000.

Geographical distance from health centers is not the only determinant of low coverage; inequities are also associated with other socioeconomic determinants, such as income levels and the educational status of the mother. A special geographic focus is needed on lower-middle-income countries with large populations, where the majority of the unvaccinated live. Reaching underserved populations will be especially challenging, but inequities need to be tackled because these populations often carry a heavier disease burden and may lack access to medical care and basic services, with the fragile economies of individuals and their families suffering a severe diseaserelated impact as a consequence.

In order to achieve universal immunization coverage, multiple factors come into play.

In middle-income and low-income countries, in access to affordable, high quality vaccine is cited to be a reason for the low coverage. (13)

Conflicts between countries, unstable political and economic conditions, natural disasters, lack of primary health care all contribute to low coverage. in these cases, it is the vulnerable groups of migrants, refugees, homeless that is affected. Migrants and refugees lose the governmental protection and access to healthcare and the immunization program in many cases. Vulnerable groups within a country are not always protected by the government either, which leads to the unintended exception from vaccination due to a lack of resources. A recent study from Europe shows that immunization rates were lower in migrants and refugees than European born individuals, mainly because of the short vaccination coverage from their homelands, appended by overcrowding, lack of water, poor sanitation, and limited access to health care (3). It was reported that 33.5% and 40.1% of Syrian refugees residing respectively in Jordan and Lebanon had difficulties in getting childhood vaccinations. Venezuela experienced diphtheria outbreaks after 24 years of no case and is close to losing its measles elimination status due to the country’s unstable socioeconomic situation. (15) Vaccine and their legislations Reaching and maintaining high rates of vaccine coverage is not quite easy for public health institutions, and the spread of vaccine refusal and hesitancy is making this even harder. Governments may play a role in increasing vaccine coverage by imposing legislations on Vaccinations.

Enforcing mandatory vaccinations is one of the strategies that some countries adopted, and others are considering in order to face this issue.

Vaccine Legislations may be Mandatory, or Voluntary or Recommended. When Vaccines are imposed as Mandatory, it means vaccination that must be received by law, without giving the individual the possibility to choose and linked to law enforcement and legal consequences if avoided. How strictly a country is judging these immunizations varies from country to country. Certain countries like France and some states of Australia, where vaccination is mandatory, legal measures are applied if vaccination schedules are not followed. In some states of the United States, even though vaccination is not mandatory, proof of vaccination is required for entry into schools.

Mandatory Vaccination seems to be the easiest way for Governments achieve their target vaccination coverage in order to protect the population, especially for people who cannot be vaccinated themselves, and are relying on herd immunity. While legislations on vaccination seems the safest bet, there is no guarantee that mandatory vaccination increases vaccination coverage. In a European study no relationship between mandatory vaccination and rates of childhood immunization in the EU/EEA countries could be found. (16) Moreover, since only some vaccines are made compulsory, the risk of a decrease in vaccination coverage of non-compulsory vaccine may then have to be focused upon. Also, by enforcing vaccines to the public, vaccine opposition is bound to rise, which may lead to lower coverage rates.

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CDC. Retrieved 2019. Immunization Coverage Reports. Accessible from: http:// www.bccdc.ca/health-professionals/data-reports/immunizations WHO. Retrieved 2019. Global Vaccine Action Plan. Accessible from: https:// www.who.int/immunization/global_vaccine_action_plan/GVAP_Goals.pdf WHO. 2019. Immunization Coverage. Accessible from: https://www.who.int/ news-room/fact-sheets/detail/immunization-coverage WHO. Retrieved 2019. WHO and UNICEF Somalia and partners call on Somalis to vaccinate children against polio. Accessible from: http://www.emro.who.int/ som/somalia-news/who-and-unicef-somalia-and-partners-call-on-all-somalisto-vaccinate-children-against-polio.html WHO. 2018. Immunization, vaccines and Biological, Data and Statistics, African region.

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Action plan on Science in Society related issues in Epidemics and Total pandemics. Retrieved 2019. Accessible from: http://www.asset-scienceinsociety.eu/ reports/page1.html

2.3. Vaccine Hesitancy Movements and Education

Vaccines work. WHO Vaccination hesitancy movement, often referred as anti-vaccination movement is a term that describes refusal or reluctance to vaccines, despite the availability of vaccines. They are considered to be a regression in modern medicine and are acknowledged by World Health Organization (WHO) as one of the top ten threats to global health in 2019. WHO also promised to try to eliminate cervical cancer by increasing use of Human papillomavirus (HPV)vaccine, and to try to stop poliovirus in Afghanistan and Pakistan. (1) There are few reasons for growing of vaccine hesitancy movements and one of them is Andrew Wakefield’s 1998 paper “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children” that was published in Lan-

cet in which he connected MMR vaccine with autism. This paper led to a big drop in vaccination rates in the United Kingdom and Ireland and it is considered to be an important part in measles and mumps outbreaks that resulted in many deaths and serious injuries. This connection has been investigated in many studies afterwards and it has been shown to be false. (2) Wakefield’s paper was retracted in 2010, but vaccine hesitancy movements still to this day continue to link autism with vaccines and they continue to promote misinformation and conspiracy theories.

Similarly, thimerosal or thiomersal is a preservative based on mercury that is used to prevent contamination of multiple vials of vaccines. This vaccine ingredient has been discussed as a cause of autism and it has been studied specifically. However, the Centers for Disease Control and Prevention has funded or conducted nine studies since 2003 with the conclusion that “the evidence favors rejection of a causal relationship between thimerosal-containing vaccines and autism”. (3) Also, there was no link between MMR (measles, mumps and rubella) vaccine and autism in children. As part of an effort to reduce all types of mercury exposure in children, thimerosal was removed from most vaccines for children and can currently only be found in flu vaccines packaged in multidose vials.

One of the biggest problems with vaccination hesitancy movements is not the lack of information, it is the way people process that information. People get more information that they already agree with, which creates so called “online echo chambers” where so called “pro-vaxxers” and “anti-vaxxers” share information in their isolated groups where they only enhance and confirm their beliefs. Today it is easy to find answers online, but those answers aren’t always true and in many cases, no one moderates that flow of information, resulting in people “on the fence” to get wrong idea and false information. Content is generated by experts and amateurs alike, which makes it hard to know if given information is credible. Also, “anti-vaxxers” often share information from open access articles on social media to increase uncertainty in the broader population. Online messages about vaccines mostly focus on negative experiences because it is easier to perceive them than main benefit of vaccination, which is the absence of disease. (4) We could say that, in a way, vaccines are victims of their own success.

Younger generations tend to discredit vaccines because they never saw the damage poliovirus or measles can do. Young parents who are not willing to vaccinate their children (almost) never encountered someone with those infections, which is why it is hard for them to know just how important vaccines in preventing diseases are. This is probably going to be changed, should we encounter measles outbreak, but it is important to educate people before that happens.

A child with measles. CDC (1)

Another big problem that needs to be discussed is people’s distrust in pharmaceutical companies. “Anti-vaxxers” other say that these companies are trying to sell their products, even though they are not useful. Although it is true that pharmaceutical companies do earn money by selling their products, including vaccines, it is important to note that production of vaccines is very expensive process and that companies can earn a lot more money selling other products.

Regarding education, it is extremely important to educate high school and university students as well as young parents. By educating students, we are working on building more informed generation. The goal should be not only to teach basic principles about vaccination but also to teach students where they can find correct and unbiased information.

Young parents should also be aware of terms such as herd immunity and approved vaccines and should be taught where to find reliable information.During education, all types of communication channels should be used. That includes interpersonal, community-based and mass media channels. Today social media, such as Facebook, Instagram and YouTube play an important role in forming opinion and we should use that. Online campaigns, groups with “pro-vaxxers”, “anti-vaxxers” and medical experts, as well as educational videos should be used to share knowledge to broader population.

We should also teach fellow medical students and future medical professionals to be prepared to face patients and answer all their questions regarding vaccines once they start their medical practice. Project at the Medical University in Vienna and Charite University in Berlin have shown that students are interested in learning more about vaccines and want to be engaged in trainings regarding vaccines. (4) Many elements have been recognized as important in the education of future health professionals, including building factual knowledge about different types of vaccines, learning about immunological aspect of vaccines, learning about vaccine perceptions and differences in acceptance rates in different groups of the population, as well as critical reading and evidence-based analysis of vaccine safety. Regarding the last point, World Health Organization established “The Vaccine Safety Net”, which is a global network of websites that provide information about vaccine safety. (5) This network provides information in various languages and can be helpful to any health professional regarding questions about vaccination. Its’ goal is to provide unbiased information for users regardless of their geographic location, as well as to increase awareness about vaccines on international level. This global network can be helpful in communication about vaccination and can help with any questions health professionals may have.

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WHO. 2019. Ten threats to global health in 2019. Accessible from: https:// www.who.int/emergencies/ten-threats-to-global-health-in-2019 Taylor et al. 2014. Vaccines are not associated with autism: An evidence-based

meta-analysis of case-control and cohort studies. Vaccine 2014;3(29):3623-3629.

Accessible from: https://www.sciencedirect.com/science/article/pii/ S0264410X14006367?via%3Dihub CDC. Retrieved 2019. Vaccines do not cause autism. Accessible from: https:// www.cdc.gov/vaccinesafety/concerns/autism.html Rath et al. 2015. Teaching Vaccine Safety Communication to Medical Students

and Health Professionals. Current Drug Safety 2015;10: 23-26. Accessible from: https://monarchcollaboration.org/sites/default/files/pub/0007CDS.pdf Vaccine safety net.

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2.4. Research in Vaccination for Prevention of Neglected Tropical Diseases and Emerging Infectious Diseases The world is facing a constant rise of emerging and re-emerging infectious diseases.

Diseases which previously lost the status of public health concerns are now forming a huge proportion of diseases healthcare professionals have to deal with on a regular basis, the key example being measles. (1) The need of the hour is to invest resources into development of newer models of vaccines, which not only are more potent and more effective against virulent strains of most microorganisms, but have minimal side effects, even lesser than the ones existing currently.

When it comes to designing a vaccine, a lot of considerations have to be made, to ensure inclusion of various research questions. For example, the mechanism of response of the human immune system against that particular microorganism, the target population (including identification of high risk groups) and the constant search and trials for development of better technologies for creation of vaccines. (2) While assessing the different modalities concerning the creation of vaccines, researchers also have to keep in mind devising a structure/model which not only reaches maximum people, but also have minimal side effects, along with increased efficacy and higher potency, all of which ensures optimum resource utilisation. (2) Vaccine Development with Minimal Compounds Historically speaking, there has been a progression of vaccination development from whole cell vaccines to newer, more refined subunit vaccines. When we use only the immunogenic property of an organism, we tend to cause minimal side effects and hence, prevent development of disastrous consequences and result in more acceptability as well. Recent decades have brought major advances in understanding the complex interactions between the microbes that cause disease and their human hosts. These insights, as well as advances in laboratory techniques and technologies, have aided the development of new types of vaccines.For example, we have newer toxoids like DaTP, containing aceLlular pertussis component, which is safe for older children. Scientists have also devised subunit vaccines including those against H.influenzae, Pneumococcus, Meningococcus. These advances will provide an avenue for further research and advances in the field of immunization. (3, 4)

Preparation of measles vaccine. WHO (4)

Vaccine Development for Antimicrobial Resistant Organisms Development of drug resistance poses a huge challenge for doctors and scientist alike, as an increasing number of drugs are being rendered ineffective, and disease prognosis is worsening, therefore prevention is the best and sometimes the only solution.Due to the increase in the number of antimicrobial resistant strains of various microorganisms, it becomes exceedingly important for us to keep in mind the need for development of vaccines which are effective against these strains, and possibly develop vaccines in the future which can be protective against more than one strain of the virulent organism.

Furthermore, the development of adjuvants and conjugates which increase efficacy and decrease side effects is also of primal importance, as it would lead to more effective disease control and better acceptability. A key example here would be the development of a new vaccine for drug resistant typhoid.

Reports of resistance to antibiotics like cephalosporins(the last line therapy for typhoid) are increasing, leading to a shift in the treatment of suspected enteric fever from outpatient settings, where more than 90% of patients with typhoid are typically treated, to inpatient settings. The cost and effect on health systems in countries where typhoid is endemic could be devastating The recent development of a prequalified vaccine with durable immunogenicity that can be given to young children is what will help us combat the burden of typhoid which is known to be increasing.

To guide these efforts, we need to invest in improved surveillance efforts and accelerate conjugate vaccine introduction in countries where the burden of typhoid is known to be high. (3) Monitor and Evaluate for Development and Maintenance of Herd Immunity In the world of medicine, there is rarely an invention which comes without its side effects. It is always the bigger picture which is focused on, but the Immediate consequences cannot be overlooked.

Trolleyology refers to a series of moral dilemmas that reveal the tensions between utilitarianism, the idea that a behavior is moral if its consequences maximize public good, and our individual intuitions about right and wrong. “Vaccines not only lead to reduced incidence of diseases, but they also lead to reduced transmission and hence contribute to reduced levels of mortality and morbidity even of the unvaccinated/non immune ones, the concept of herd immunity.� (5) There is a need to constantly monitor and evaluate risks and benefits, and develop vaccines and sera which are devoid of the possibility of infection on administration.

With this we also realise, that certain endemic diseases pose a relatively big challenge to the world of medicine, and must drive us to work on creating better immunization strategies. An example of this can be the Oral Polio Vaccine (OPV), which on being shed in the stools, provides immunity to not only the person who’s been the recipient of the vaccine, but also to those around him/her. This concept has been massively exploited to achieve elimination of Polio from India.

However, no scientific invention can survive without modification, and everything has its pros and cons. We switched from using the trivalent polio vaccine to the bivalent polio vaccine. Many experts believed that vaccination against polio either would continue to evolve with strengthening of routine immunization or might be stopped by countries when they no longer had circulating wild-type virus. This view of the posteradication world changed with the first recognition, in 2000, of an outbreak caused by a virus resulting from the genetic reversion of one of the strains in OPV, which was subsequently named “circulating vaccine-derived poliovirus� (cVDPV). The logical inference from the detection of cVDPV outbreaks was that long-term use of OPV posed an ongoing risk. OPV vaccination also had to be stopped in order to ensure a poliofree world after eradication. OPV cessation evolved from concurrently stopping the use of all three OPV types to a modified serial plan in which the type 2 component of OPV would be removed first. and in April 2016 there was a coordinated global switch from the trivalent OPV to a bivalent OPV containing only the type 1 and 3 components.

(6) Neglected Tropical Diseases

A child being vaccinated. WHO

Tuberculosis, a disease which is endemic in many parts of South Asia, is still a public health concern, despite valiant efforts over the years. In regions of endemicity, nearly all medical health professionals, and all people are exposed to M Tb., which causes more deaths worldwide than any other infectious agent. Vaccines that prevent pulmonary tuberculosis infection in young adults could have a major effect on the control of drug-sensitive and multidrug-resistant strains of the disease by interrupting transmission,but the development of new vaccines has been hampered by the lack of validated preclinical models and human immune correlates of protection, strongly aidining the fact that the endemicity of Tuberculosis is regional and not global. (7) Hence, there comes a need for furthering clinical trials and using evidence based medicine to devise a new, better and more efficacious vaccine, which may provide protection against this deadly disease.

Effort is being put into developing multivalent vaccines, in order to ensure increased coverage of infectious diseases amongst an increasing target population, examples of which are the DPT vaccine(Diphtheria-Pertussis-Tetanus), the MMR vaccine (for Measles-Mumps Rubella) being used in India. (8) Future multivalent vaccine candidates are likely to be required for complex diseases like malaria and HIV. (9) There is increasing amounts of work being done, globally in the field of vaccination because most deadly diseases have and can further be prevented by universal vaccine coverage.

Emerging and Re-emerging Infectious Diseases When we speak about emerging infectious diseases, we speak about newer agents to which the human population has not been previously exposed or has had a hiatus of exposure of upto 20 years or more and hence, we need to realise that their immunity towards those is lacking, and there is again a need for immunization.

Modern human activity fueled by economic development is profoundly altering our relationship with microorganisms. This altered interaction with microbes is believed to be the major driving force behind the increased rate of emerging infectious diseases from animals. The spate of recent infectious disease outbreaks, including Ebola virus disease and Middle East respiratory syndrome, emphasize the need for development of new innovative tools to manage these emerging diseases.

Disseminating vaccines are one such novel approach to potentially interrupt animal to human (zoonotic) transmission of these pathogens. (10) An example could be the Ebola Epidemic of The Democratic Republic of Congo, which has caused a great number of deaths. To combat this, The rVSV-ZEBOV-GP vaccine was designed. It works in the post exposure setting. A ring strategy is used to identify contacts and contacts of contacts. In addition, high-risk groups such as health care workers are being vaccinated, and targeted geographic vaccination and pop-up vaccination are being undertaken in high-risk areas. This step is extremely crucial for controlling the spread of the virus and can be used as an example to develop newer strategies for more emerging infections throughout the world. (11) Hence we see multiple aspects of vaccination which require constant modification, evaluation and vigilance. This instills the importance of research which will not only help us devise a better immunization strategy, but also help us move forward into a world with less vaccine preventable diseases.

Reference 2.4.

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4.

5.

6.

7.

Center for Infectious Disease Research and Policy, University of Minnesota.

2019. Measles outbreaks continue to grow in US, Europe. Accessible from: http://www.cidrap.umn.edu/news-perspective/2019/05/measles-outbreakscontinue-grow-us-europe U.S. Department of Health & Human Services. Retrieved 2019. Types of vaccines.

Accessible from: https://www.vaccines.gov/basics/types National Institute of Allergy and Infectious Diseases, the U.S. 2019. Vaccine Types. Accessible from: https://www.niaid.nih.gov/research/vaccine-types The history of vaccines. Retrieved 2019. Different types of vaccines. Accessible from: https://www.historyofvaccines.org/content/articles/different-typesvaccines Andrews et al. 2018. Extensively Drug-Resistant Typhoid — Are Conjugate Vacci-

nes Arriving Just in Time? N Engl J Med 2018; 379:1493-1495. Accessible from: https://www.nejm.org/doi/full/10.1056/NEJMp1803926

Vaccines today. Retrieved 2019. What is herd immunity? Accessible from: https://www.vaccinestoday.eu/stories/what-is-herd-immunity/ Pallansch. 2018. Ending Use of Oral Poliovirus Vaccine — A Difficult Move in the Polio Endgame. N Engl J Med 2018; 379:801-803. Accessible from: https://

8.

www.nejm.org/doi/full/10.1056/NEJMp1808903 Health center, IIT Kanpur. Retrieved 2019. Vaccination schedule. Accessible

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from: https://www.iitk.ac.in/hc/vaccination-schedule Lauer et al. 2017. Multivalent and Multipathogen Viral Vector Vaccines. Ameri-

10.

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can Society for Microbiology Journals 2017. Accessible from: https:// cvi.asm.org/content/24/1/e00298-16 Rosenbaum. 2018. Trolleyology and the Dengue Vaccine Dilemma. N Engl J Med 2018; 379:305-307. Accessible from: https://www.nejm.org/doi/full/10.1056/ NEJMp1804094 Murphy et al. 2016. Self-disseminating vaccines for emerging infectious disea-

ses. Expert Rev Vaccines 2016; 15(1): 31–39. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4732410/

2.5. Quality of Vaccines and Handling Quality of vaccines and handling process All the hard work for the technical vaccine development will be useless without a thorough planning for delivering the vaccines and associated services. For example, in Ethiopia in 2003, only 30% of the equipment for vaccines needing certain treatment was found functional, and many of the functional units being aged or requiring repair.

Such equipment does not secure the proper and safe vaccine supply. (1) Maintaining the quality of vaccines at its highest at all steps is a crucial step for the realization of the optimal immunization plan. Ensuring the quality of vaccines via well -planned the handling processes requires numerous variables. Examples of the variables include the national immunization policy and strategies, delivery of the service, personnel, information on demand and supply, equipment, finances and ethics during the vaccine production. (2) The logistical part of this immunization plan can be divided into two procedures. One is the step of the delivery of the products and services, often called Good Manufacturing Practices (GMP), which is the focus in this chapter. The other step is the quality control of vaccines, which is the step of assuring the technical efficacy of vaccines against microorganisms. These two steps should enable the immunization plan to be credible, available, qualified and stable.

Good Manufacturing Practices (GMP) Good Manufacturing Practices (GMP) ensure that vaccines and related services can be delivered safely by establishing the appropriate facility, regulations and guidelines, qualified and trained staff, components and products tested through previous clinical trials and transparency on production methods and records. (3, 4) The WHO includes immunization supply chain and logistics as a key building block of the national immunization programs and systems and Expanded Programme on Immunization (EPI), the comprehensive immunization plans on certain communicable diseases by the WHO (5).

The WHO designated “six rights� to be achieved for managing supply-chain of the vaccines: Right product, right quantity, right condition, right place, right time, right cost. (5) The logistics itself demands a high degree of research for optimal and sustainable supply that reflects the burden of diseases for communicable diseases in each country.

Figure 1 shows the role of logistics in vaccines and service delivery for accomplishing universal vaccine coverage. The well-planned logistics will provide vaccines to all the areas, using out-reach strategy, namely supply of vaccines through a healthcare centers in the rural areas, as well as using mobile strategy, approaching the areas without health centers.

Figure 1. Role of logistics in service delivery (5)

It is important to notice that national authorities are key stakeholders in the process of the GMP. Responsibility of the vaccine supply lies not only on the storing or transporting facilities, but also creating the authority body for monitoring and controlling the vaccine supply itself, as well as legislation for securing the quality of vaccines and the ethics and quality control during the vaccine manufacturing. These will create the right way to go for the appropriate supply-chain.

The facilities storing vaccines are required to apply three key issues: standardization of equipment, development of five-year rehabilitation plan, establishment of sustainable equipment maintenance system and guidelines. (5) Equipment includes vehicles, storing media and containers, laboratory equipment used for making vaccines.

Cold Chain Different vaccines need different treatments along the supply-chain. (1) Cold chain is a supply-chain in controlled temperatures, including storage and transportation, from the production to the usage. This concept of cold chain applies to vaccines as well. (6) The cold chain is essential for maintenance of the function of vaccines. Figure 2 shows the relative heat stability and freeze sensitivity of some of the traditional vaccines in numerous national immunization programs. This indicates that each vaccine needs different treatment method.

Figure 2. Vaccines needing different temperature treatment (6) Settlement of a firm cold chain for each vaccine demands several issues to be solved as described below. (6) 1. Increasing knowledge on vaccine stability to find the most reliable temperature parameters; 2. Developing vaccines that are more stable and thus preserve their effectiveness in a wider temperature range; 3. Open access to vaccine temperature sensibility research; 4. Periodic international and national vaccine handling protocol/guideline review; 5.

Improve temperature control in transport units. Specially, attempting to avoid extreme cold temperatures for vaccine storage, as freezing can also rend vaccines ineffective; 6.

Appropriate capacity building for all the staff that is involved in the vaccine transport chain; 7.

Continued use of ice instead of cool-water packs for vaccine in-country transport in LMIC; 8. Adoption of out-of-chain vaccine use policies for mass immunization events; 9. Reducing human error through staff training.

Reference 2.5.

1.

2.

3.

4.

5.

6.

WHO African Region. Retrieved 2019. EPI Logistics. Accesible from: https://www.who.int/ countries/eth/areas/immunization/epi_logistics/en/index1.html Smith et al. 2012. Vaccine production, distribution, access and uptake. Lancet 2011; 378(9789): 428

–438. Accessible from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164579/

OIE. 2018. Manual of Diagnostic Tests and Vaccines for Terrestrial Animals. Accessible from: http://www.oie.int/en/standard-setting/terrestrial-manual/access-online/ 35.

WHO. Retrieved 2019. Guidelines for national authorities on quality assurance for biological products.

Accessible from: https://www.who.int/biologicals/publications/trs/areas/ biological_products/WHO_TRS_822_A2 .pdf?ua=1 WHO. Retrieved 2019. Immunization, Vaccines and Biologicals. Accessible from: https:// www.who.int/immunization/programmes_systems/supply_chain/en/ Kartoglu et al. 2014. Tools and approaches to ensure quality of vaccines throughout the cold

chain. Expert Review of Vaccines 2014; 13(7). Accessible from: https://www.tandfonline.com/ doi/full/10.1586/14760584.2014.923761

3. Part B: Capacity Building Part 3.1. Methods for the Capacity Building 3.1.1. Peer-to-peer (P2P) “Learning by doing, peer-to-peer teaching, and computer simulation are all parts of the same equation”.

Nicholas Negroponte

Peer education is a learning method in which well informed and motivated young people launch educational activities with their peers (those similar to them in age, background and/or interests).

These activities are organized with the goal to develop young people's knowledge, skills and attitude. Peer education can take place in many different settings, including schools, universities, workplaces or any other settings where young people gather. It can also take place through individual contact or in small groups with limited number of participants. Peer education is an important learning method because it is believed that a young person's peer group has a strong influence on said person and can help develop their beliefs and behaviour.

One of the most important things when it comes to peer education is credibility of peer educators. This means that the selected peer educators should be trustworthy and credible opinion leaders within the target group. The information can be transferred more easily because of the shared backgrounds between educator and students. Also, peer educators are not likely to be seen as authoritative or judgmental figure, which helps in creating more casual atmosphere. Students feel as if they are getting advice from a friend or colleague and are more likely to receive and comprehend the message that is being sent.

There are many theories that talk about the importance of peer education in reinforcing positive behaviours and developing new recommended behaviours, but here we are going to be talking about a few most prominent ones: 1. Theory of reasoned action: it is believed that the likelihood of a person adopting recommended behaviour is determined by a person's subjective and normative beliefs. Subjective beliefs include person's own stance toward the behaviour, while normative beliefs include norms and standards of society that shape a person's attitude.

This means that young people's attitude is influenced by their perception of what their peers or peer educators do, hence the importance of peer education.

2. Social learning theory: people learn not only from their direct experience, but also from observing others that they identify with. This means that peer educators can be influential in creating young people's confidence to carry out behaviour. Interactive and experiential learning are important in creating self- efficacy, the ability to overcome barriers to perform the behaviour.

3. IMBR model (information, motivation, behavioural skills and resources): this model focuses on the information (the ’what), the motivation (the ‘why’), the behavioral skills (the ‘how’), and the resources (the ‘where’). It is important for activity to include all four of these components in order for young people to be completely educated and to receive the message that is being sent.

Figure: Peer Education Training of Trainers manual - UN interagency Group on Young People's Health Sub-Committee on Peer Education, p.17 (2003) 3.1.2. Advocacy Advocacy can work as a capacity building exercise in many ways. Let’s begin this discussion by asking ourselves what capacity building actually means.

Capacity Building refers to a process which leads to development of future leaders, and this happens by sharing of information, improved interaction and attainment of skills which lead to improvement and sustainability of resources which are needed to do a task competently.

Advocacy on the other hand refers to a process which works on bringing about change, which works on influencing minds and ideas, and working towards a goal, while keeping track of all stakeholders.

When we put these two together, we realise that the entire process of advocacy essentially revolves around good leadership skills and it, in turn leads to development of future leaders.

Advocacy entails 1. A needs assessment 2. A stakeholder analysis

A “Needs assessment� is essential for initiation of any process. It paves way to adequate research and understanding of what the current situation is, and what are the gaps that are yet to be bridged. Moreover, it helps us assess the degree of disparity and hence helps us prioritise and decide our course of action.

A stakeholder analysis refers to the process where we understand who will be impacted by our decision/change. It could involve people, governments or organisations who could be affected by our course of action, or could help us achieve our goals.

Having gone through the above two processes, one becomes extremely well aware of the issue at hand, and can be trusted to be the voice of change.

Making young voices heard is one of the cornerstones of IFMSA, as we are the official voices of medical students worldwide. Training our members in student representation shapes not only the quality of our future doctors, but also the quality of healthcare by becoming change agents in the Health Systems of the world.

As the end result of capacity building using advocacy, we must ensure that our participants/readers are well aware of the intricacies associated with the entire process, which involves the two broad categories mentioned earlier.

We must enable the people to be voices of change and be able to use the tools and resources present with them in optimum ways to start the process of change, as well as enable others to do the same.

Advocacy enables us to bring about relevant change, which enables future leaders to take up leadership roles by providing them the right environment and resources and hence the cycle sustains itself.

3.1.3. Small Working Group (SWG) In workshops or training sessions with a large number of people, SWGs can play a critical role for ensuring effective functioning and maximum participation among the audience.

What exactly is a Small Working Group?

A small working group is designed to bring together individuals possessing the relevant knowledge and skills who will act either individually or collectively to undertake assigned tasks and activities in order to achieve the project objectives.

Having a SWG during a training or workshop has multiple benefits: • Firstly, it acts as a brilliant icebreaker and facilitates better interaction amongst the group members and creates a positive learning environment.

• Since everyone in the audience is in a SWG, all the participants get to have more airtime in the sense that they contribute more of themselves to the task in hand. They express their ideas, give opinions and ask questions.

• Members get to learn from each other and teach others as well. So, the learning becomes more dynamic and active in small groups.

• Small groups encourage participants to know each other better, breaking down barriers and creating a more positive learning atmosphere. If the goal is to provide participants with the opportunity to meet and work with a variety of people from different backgrounds, cultures, education, change small-group formations from activity to activity.

• Allows the trainers to receive feedback at a more personal level in a SWG. • If there are multiple trainers, one trainer can be allocated for a single SWG, or more if required. Instead of the typical training approach, the trainer facilitates the members by encouraging discussions, solving doubts, providing feedback contributing to an improved learning process.

With SWG, countless activities can be suggested. They can be asked to create a role play, have a mini presentation, select sides in a debate and many more. The essential goal of a SWG is to achieve all activities with the maximum participation.

In order to maximize interaction among participants, cross-over groups can be carried out, the class is subdivided into two or more smaller groups with transfers of some students between groups at appropriate times. For example, students begin part A of a task in groups of four, after completing this, two people from one group swap places with two people from a second group – to form a new group of four.

The task then continues to part B Furthermore, to improve team building, snowballing can be done. This is where individuals, then pairs, then fours etc. gather to generate wider views on a topic progressively. You effectively grow the size of the working group and draw in an increasing range of views

Last piece of advice when forming Small Working Groups: Arrange participants in small groups prior to giving activity instructions. If you begin with activity instructions and follow with instructions about how you want small groups to form, many participants will have forgotten the initial instructions by the time they have settled into their small groups.

3.1.4. Debates “Those who cannot understand how to put their thoughts on ice should not enter into the heat of the debate.”

Friedrich Nietzsche Debate is a learning method that can be traced back to ancient Greece and it refers to a discussion in which two or more people plead opposing positions on a subject with the goal of making the audience accept their position. Debate requires a question, statement or idea with at least two opposing positions, each of which is defended against the others by an advocate, often with an impartial moderator ensuring that the discussion remains focused.

Debating allows participants to develop their communication and argumentation skills, as well as critical thinking. It also helps students to understand various points and to further explore the subject. However, it is not imperative that position that students are fighting for is their own, and making participants research, learn about and stand for a position they do not personally hold can be powerful learning opportunity.

It is useful to measure the audience’s overall view during and after the debate in order to figure out which participant and which argument was more persuasive. It is extremely important for moderator of the debate to insure that participants remain focused and that debate does not become personal. In order to prevent any undesirable incidents, set of rules should be determined beforehand.

An important point to remember when debating is that the medium can sometimes be more important than the message. Charismatic or well-spoken participant can get the audience on their side despite their opponent(s) having better arguments. It is crucial for students to learn about this and to prepare for debate as best as possible.

Videos and articles about public speaking and reasoning can help and so can prepare as much facts as possible to prepare for debate.

When preparing the debate, few questions should be answered: • Are there any controversial or divisive topics that the students could explore through debating the various positions?

• How can you ensure that the debate is a learning experience and doesn’t simply create confrontation and animosity?

• What time-scale should the debate use? Real-time (‘Live’) or an extended period of time?

• Should the students defend their own position or play ‘Devil’s Advocate’ by defending the opposite viewpoint? Should it be a group or individual activity?

• How much technology should be involved? Which tools are most suited? What support would be needed?

• Are the students (and other tutors) ready for this?

Before organizing and hosting a debate, you should attend or watch a few debates in order to see how they are held and what can go wrong, as well as what can be done should undesirable doings occur.

3.1.5. Role-playing “Every Role you play comes with its own set of challenges ” A Role Play is an experience where one learns the art of empathy, what it is like to be in someone else’s shoes. It helps one understand different perspectives and enables us to see beyond our own viewpoint. It also helps us analyse the various possible outcomes, that the different courses of action may result in.

While we may have our own set of ideals, while we are assigned a particular role, with a particular set of duties, we tend to start thinking in a different direction, one that is more in line with our designated role, which may or may not synchronise with our own thought process. Hence, one learns about various stakeholders, the duties and responsibilities of different members of a team/organisation, and subsequently understands their capacities and why certain decisions have to be made. It is an incredible activity to understand the different roles within a team and their relevance, which helps one to understand the different stages various roles need to be prominent in and how they can contribute.

All in all, this activity teaches us various things about leadership; 1.

2.

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7.

8.

It helps us understand the various roles within a team.

Helps us become a better listener.

Improves decision making, by allowing us to visualise various possibilities and choosing the best possible course of action.

Helps us understand and implement conflict resolution.

Helps us understand the power of negotiation.

Enables us to project our voices and opinions.

Gives us better perspective.

Helps us become better facilitators

Why Role Play?

1.

It is fun

2.

Extremely Interactive

3.

Ensures active participation.

4.

It facilitates better understanding of the issue at hand.

5.

It is an innovative way of delivery of opinions.

6.

It also has the power to attract masses and be more influential than a simple talk or a group discussion.

It is also a brilliant way of learning for visual and kinaesthetic learners. However, it is best done in smaller groups of people to ensure equal participation and optimum interaction.

3.1.6. Simulation Simulations are instructional scenarios where the learner is placed in a "world" defined by the trainer. They represent a reality within which participants interact. The trainer controls the parameters of this "world" and uses it to achieve the desired instructional results. They aim to provide an experience as close to the ‘reality’ as possible. Participants experience the reality of the scenario and gather meaning from it.

Why use simulations?

1.

A simulation is a form of experiential learning. It promotes the use of critical and evaluative thinking. Since the scenarios in simulations are open ended and ambiguous, they encourage the trainees the contemplate the implications of their decision and search for more alternatives.

2. By the usage of simulations and upon gathering the response of the trainees, the trainers can analyze the shortcomings within the topic for the trainees and the training system so that necessary changes can be modified.

3.

When trainees use role playing in simulations, they step in the shoes of the stakeholder and thus are forced to think as the stakeholders. The trainees will subsequently be more aware of the role played by each party and will understand better how to tackle situations in the future.

In cases when the subject involves multiple stakeholders, simulations play a great role in understanding the responsibility of each stakeholder and how each stakeholder can affect a decision.

The approach is often used in ‘real-time’, with participants fully immersed in the scenario for a period. However, it is possible to slow down or speed up the scenario, if appropriate. This could happen in situations where, in reality, a series of decisions need to be made rapidly and the students need to be given time to contemplate each decision, or where a very slow process is being simulated and there would be lots of time waiting for the effects of each decision to appear. Being able to adjust the timescale of the simulation allows students to make more considered decisions, reflect on their choices and analyze the results in greater detail than would be possible in a fast, real-time situation.

Building a simulation is very time consuming and requires loads and loads of preparation. Here are some steps that can be followed to ensure the simulation plays well.

PREPARATION: Goals of the simulation must be written clearly beforehand, and explanation of how simulation is tied to the goals. If possible, conduct a practice test before the actual session to ensure smooth running.

Roles are assigned to the participants after being divided into groups. Printed rules provided to the participants to ensure everything is completely understood. Make sure that every participant understands thoroughly the role they are supposed to play.

Frustration may arise when there are too many uncertainties. Scenarios are prepared thoroughly. Proper understanding is ensured, while capturing the participants attention. In order to be thoroughly prepared, try to anticipate questions before they are asked.

MONITORING: When the simulation is going, trainers should monitor the process to ensure that the participants are learning the goals of the training. Ask yourself: •

Does this simulation offer an appropriate measure of realism for my group of participants?

•

Is the level of ambiguity manageable for this group?

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Does the student demonstrate an understanding of his/her role?

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Are my participants demonstrating problem solving techniques?

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Does the research being generated match the nature of the problem?

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Is cooperation between participants evident?

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Has the student been able to resolve the issue satisfactorily?

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Does the student provide meaningful answers to probing questions?

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Will follow-up activities be necessary?

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Are all participants taking part actively in the simulation?

•

What needs to be improved for future use?

POST SIMULATION DISCUSSION: This is a crucial aspect in simulations. Create a discussion for the participants to reflect on and analyze on what they have learnt from the simulation. Provide ample time for the students to relate the simulations to the topic of discussion.

3.2. How to organize a workshop

A Workshop is a usually brief intensive educational program for a relatively small group of people that focuses especially on techniques and skills in a particular field, which in our case is vaccination. The first important thing before organizing a workshop is to realize and question the necessity of organizing the workshop in this particular theme. There should be something that is lacking in current practices or education system that the workshop will address.

Many a time, the importance of the theme of the workshop is understood only by a small number of individuals among the target population for the workshop. In that case, it will be important to make people aware of the existing gaps in their knowledge and skills which will be addressed by the workshop. For a workshop for vaccination capacity building, it could be useful to introduce the target participants with facts regarding vaccination that emphasize on how the current practices that are not sufficiently addressing the gaps of vaccine coverage put people at risk of contracting infections.

It is always helpful to answer the following questions before we organize a workshop: • Why do we want to run the workshop? What are its goals and objectives?

• Who are our target participants? What number of participants will be optimal for the workshop?

• How many facilitators will we require? Who will we contact them for?

• What skills and sessions are most important to the participants?

• How long of a workshop will be optimal to organize?

• What is our budget for the workshop? How will collect the required budget?

Meanwhile, it is important to contact people who realize the importance of the workshop and are motivated to organize it. This will form a core group of preliminary organizers who will then plan the overall workshop and everything that surrounds it including logistics, budgeting, financing, promotion, etc. They will also recruit more members as per the need to form the final organizing committee.

3.2.1. Logistics The key to a successful workshop is good coordination. While planning the event, it is helpful to define all the goals beforehand, so we can tackle them one by one.

1.

Venue: The most suitable place will be located not too far from lodging. It will have enough space for all participants and/or multiple spacious rooms if different sessions are to be held simultaneously. For a workshop with session full of energizers and interactive activities, we have to make sure the chairs can be moved. Also it should be possible to hang up flipcharts and project onto a screen that everyone can view. There should also be a dining hall big enough to hold all the participants.

2. Food: A person with a hungry stomach will be distracted quickly. It will be important to provide food on site during breaks. Free access of water on site will keep everyone properly hydrated. Try to get food which is nutritious and which also appeals to the taste buds so it does not get wasted away. Dietary restrictions like vegetarian, vegan, gluten free or any allergies among participants should be considered and the food planned accordingly.

3.

Lodging: The lodging should ideally be at a short walking distance from the venue. It should be decided if the lodging is to be provided by the organizers or the participants have to manage it themselves. If the latter, help the participants by providing information about their possible lodging choices. Also make sure the lodging has Wi-Fi to stay connected and decent facilities for a comfortable stay.

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Travel: People might need to travel from different cities or countries to attend the workshop. Make sure you know when people are arriving so you can pick them up. If you are not picking them up, let them know in detail where and how they are supposed to go. A pre arrival booklet that has all the instructions and directions with photographs or geographical landmarks would surely make participants feel more comfortable and less lost in a new place.

Make sure that the facilitators of the workshop know in detail how you are planning to hold the sessions, how much time will be available for activities, what materials and facilities will be available and what won’t be. They will input their ideas and suggestions according to their needs. By discussing with the facilitators early, instead of going for one-size-fits-all rule, each session can be custom tailored to deliver the most out of each session.

3.2.2. Organizing Committee (OC) As it has been said earlier, forming a preliminary organizing committee is one of the first things you do for organizing a workshop. The preliminary organizing committee then works out on the structure of the final organizing committee (OC) and recruits members as required. The work, duties and responsibilities should be clearly divided amongst the members. The two most essential positions in the OC are the Chair and Treasurer. The Chair is mainly responsible for the training and then coordinating, overseeing and assisting the OC wherever necessary and will make sure that everything is done in time. The treasurer is responsible and accountable for the budget and finances of the whole event, declarations and for checking the payments.

Although there is no best way to compose an OC, task can be divided among OC members as follow: • Public Relations: Contact with externals and promotion.

• Fundraising: Approach sponsors and apply for grants.

• Marketing & Publications: Creating corporate identity and needed marketing materials and designs. Also responsible for online marketing and presence on social media.

• Social program and field visits: Offering participants social program on some nights and sight-seeing, field visits to boost team dynamics and make the event less hectic.

• Information Technology: Creating online registration forms, updating or creating any websites, helping with design and record keeping.

• Academics: Contacting facilitators, creating workshop format, topics to be covered As delivering a workshop by a single facilitator can be really exhausting, it is suggested to have more than one facilitator. Try to keep the participant to facilitator ratio low, preferably 7:1 to 10:1. For instance, for a group of 15-20 participants, 2-3 trainers could facilitate the workshop in rotation. While one of the trainers delivers the sessions, others can support him/her to deliver the best sessions. Try to have more experienced facilitators who are not only knowledgeable about the topics, but have also delivered capacity building sessions before.

Logistics: • Venue: finding a suitable venue, having contact with the venue and dividing the sleeping rooms amongst the participants.

• Visa applications: Invitation Letters and possible contact with relevant ministry and government departments.

• Transportation: Arranging transport from and to the venue and during the event.

• Registration: Coordinating the registration progress, keeping track of the payments in cooperation with the treasurer, sending out the information package and arranging the certificates.

• Meals: Ensuring meals are available during the whole event.

• Materials: Ensuring that all the needed material (welcome package for participants, training materials, etc.) is available on time.

3.2.3. Agenda setting Setting up the agenda for a workshop ensures the quality and smooth progress of the whole workshop. It is important to consider not only the overall flow of the workshop, but also the agenda for each workshop as well.

1. Needs and Knowledge Assessment The perfect agenda starts from assessing the needs and previous knowledge of the participants on vaccination. It is smart to send out a questionnaire or a survey to understand what the participants would like to learn, how much they know about vaccination already and possibly take suggestions about workshop content. The chapters in Part A can be

helpful for this purpose.

Examples on the questions can be as follows: • How familiar are you with the concept of Universal Vaccination Coverage? (1 Very Poor - 5 Very Well) • How well are you aware of anti-vaccination movements in your country?

2. Setting up the Agenda According to the needs, interests and knowledge, the agenda for the workshop can now be finalized. The important variables to consider here are the available time for the workshop, contents for the workshop, interactivity, variation in workshop methods, the gradual level of difficulty, logical flow of nearby workshops, etc. Participants should be able to gain what they expected from the workshop, preferably in an interactive way.

Here are some examples on the agenda for 1-day and a weekend workshop. Please refer to the part 3.3. for specific examples of each theme.

1. Agenda for 1-day Workshop (7 hours) • 0.5 h: Warm-up, Icebreakers, get to know each other • 1 h: Introduction and history of Vaccination • 1.5 h: Universal vaccine coverage • 1.5 h: Vaccine hesitancy • 1.5 h: Assessment of vaccination program in each country and SWOT analysis for possible student activities 2. Agenda for a Weekend Workshop (2.5 days) • Friday 0.75 h: Warm-up, Icebreakers, get to know each other 2 h: Introduction to vaccination, important themes and and history of Vaccination 0.75 h: Interactive session on vaccination program in each country • Saturday 0.5 h: Warm-up 2 h: Universal Vaccination Coverage 2 h: Vaccine hesitancy movements and education 2 h: Comprehensive assessment of vaccination in each country • Sunday 0.5 h: Warm-up 1.5 h: Vaccination research on NTDs and EID 1.5 h: Quality of vaccines and handling 2 h: Vaccination governance 0.5 h: Wrap-up 3.2.4. Evaluation and Follow-up

Development of any workshop depends entirely on proper evaluation and follow-up.

Evaluation will contribute to the sustainability of the workshop by assessing what participants obtained from the workshops and diagnosing the good and the bad aspects, and subsequently coming up with modifications that improve the workshop structure in the future. Follow-up is the procedure to assess if participants are utilizing the knowledge and skills they gained from the workshop.

Evaluation can take place both on-site and/or online after the workshop. While onsite evaluation is useful for checking the immediate and fresher responses, online evaluation is advantageous for a more comprehensive assessment for the improvement and outcomes of the whole workshop retrospectively.

Here are some of the examples of on-site evaluation.

• Prepared questions after the workshop: Facilitators can ask already prepared questions adjusted to the workshop contents right after the workshop by using any online platform. The questions will have to be preferably quantifiable and easy to answer. Examples of questions can be: Did you get to learn something new about general background on vaccination? Would you be able to explain why vaccination is a public health issue and why it is important to take vaccines after the workshop?

• Feedback: Asking participants about feedback on the workshop in a private setting is the most in-depth evaluation method to be used if time allows. Facilitators can ask questions on what the participant has learned, what can be improved from the workshops, personal feedback regarding the training styles of the facilitators, if they got any ideas for the concrete plans at home, etc.

• Post-it evaluation: Everyone is asked to write one post-it note on the good things about the workshop and one post-it note on the improvement points about the workshop and stick them on a flipchart where there is a border for the good parts and the improvement parts.

• Pizza chart: In a flipchart, facilitators can draw a big circle with four main parts, session format, content, dynamics and trainer, and make smaller circles inside the circle for assessing each part. Participants can mark their scores on each part and facilitators can see immediately what the participants thought was good and what can be improved on each part.

• Evaluation form: Evaluation form is the most comprehensive way to evaluate the workshop as facilitators can add as many questions as possible. The questions will be concise, clear and not redundant from previous questions so that participants can answer them within 5-10 minutes and facilitators can obtain the data to evaluate the workshop. The categories can be the session format, content, dynamics, trainer and self-evaluation and follow-up questions.

Here are some of the example questions that could be enlisted on the evaluation form after the workshop.

• (Session format) Was the session designed to keep up the concentration high the whole time?

• (Session format) Was the activity e.g. simulation in the workshop appropriate for gaining knowledge and/or skills on the theme?

• (Content) Did you learn something new about the specific vaccination theme from the workshop?

• (Content) Are there any different parts of the theme you would like to learn more about?

• (Dynamics) Was the session interactive enough between trainer and participants, or among participants?

• (Dynamics) Did you get to exchange ideas or work in a group with other participants well enough?

• (Trainer) Was the trainer clear in the communication for the workshop?

• (Trainer) What can be improved from the trainer? E.g. communication method, interactivity, ...

Here are some of the example follow-up questions for the participants. It is recommended to be performed some time later after the workshop, for example 3 months, to give participants some time to work on digesting the contents and preparing for action.

• Have you arranged any campaigns, workshops or activities at home using the knowledge and skills from the vaccination workshop?

• If not, do you concrete plans for arranging any activities? And any reasons why you could not perform this activity earlier?

• What kind of activities were held and how did you arrange the workshop?

• What were the indicators and exact outcomes from the workshop?

3.3. Suggestions for the Capacity Building Activities 3.3.1. Introduction to Vaccination and its Importance • Module 1. Participants can understand the concepts of vaccination and immunization and their importance.

2. Participants are aware of the types of vaccines and their mechanism of action.

3. Participants are aware of the possible adverse effects that can follow vaccina tion in people with known risks.

• Example: An interactive session on introduction to vaccination and their importance Instructions: 1.

The facilitators prepare some simple statements relating to vaccination, which the participants have to identify as “True” or “False”.

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The room is divided into two halves; the “True” half and the “False” half. Par ticipants have to go and stand at the corresponding half of the room based on what they choose.

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Participants at both halves get to justify why they think their answer is cor rect.

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The facilitators deliver the final conclusion including brief introduction to the subject matter/topic that the statement was concerned about.

Some of the statements that the facilitators can provide could be: a.

Vaccination and immunization mean the same thing. (False) b.

All vaccines confer lifelong immunity. (False) c. Some vaccines can work if administered within a specific time after a person contracts infectious agent. (True) d.

Vaccines cannot prevent cancer. (False) e.

Vaccines are not hundred percent safe to be used on anybody without determining the risk factors. (True)

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After the above session completes, participants are divided into groups of 4 or 5.

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They brainstorm on the importance of vaccination within their group for 1015 minutes.

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Each group now tells the importance of vaccination one at a time in rounds.

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If something remains missing at the end of the rounds, the facilitators des cribe them briefly.

Expected result: Participants are more familiar with vaccination and its importance.

They are ready to proceed with other topics relating to vaccination.

3.3.2. Universal Vaccination Coverage and Vaccination Governance • Module 1.

Participants are equipped with universal vaccination coverage and uses of vaccination coverage.

2. Participants are aware of the variances of UVC among different countries and the reasons behind the differences 3.

Participants are aware of the different roles governments may play to improve vaccination coverage 4.

Participants are capable of advocating for improved vaccination coverage according to the needs and requirements of the area.

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Example: A simulation for the improvement of Vaccination coverage in a developing country.

Situation: A developing country which recently had unstable political standing, falls victim to a couple of attacks between different parties within the country causing death of many civilians. Outbreak of Polio has occurred even though the country was declared eradicated of polio a decade ago. As a result of the instability in the country, people are hesitant in trusting external parties with good claims, living conditions have worsened, more diseases and illnesses among the general public.

Instructions: Participants are taught about universal vaccination coverage, the benefits of UVC, the variances of different VC among different countries, causes of reduced vaccination coverage in developing and developed countries. They are briefed about the various stakeholders that can affect the vaccination coverage and what roles they play while advocating for universal vaccination coverage Participants are divided into groups of the stakeholders affected by the situation.

For example, - Government of the developing country - Government of the neighbouring developed country - Doctors and nurses of hospitals - Pharmaceutical company having IPV or OPV vaccines.

- General Public Each group will receive instructions and rules on what their role is on a paper and they will have to think about how the scenario affects them and make decisions in order to improve vaccination coverage in the developing country.

The participants will be given scenarios on the different instances affecting the country and based on these, each group will have 5 minutes of preparation time to determine what their role and stance is going to be. They will have to advocate for their stance to other stakeholders and receive an approval or rejection from the other stakeholders based on the interest of the other stakeholders. This process goes on until a middle ground is reached.

Expected Result: Participants try to find ways in improving vaccination coverage which is in mutual agreement with the necessary stakeholders.

3.3.3. Vaccine Hesitancy Movements and Education •

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Module Participants are aware of the importance of vaccination and the role vaccines have in preventing various diseases.

Participants are aware of vaccination hesitancy movements, what they stand for and how they pose a global threat to health.

Examples: Debate between medical professional who is taking pro-vaccination stance and participant of vaccination hesitancy movement Situation: Debate is being held at a medical university. There are two advocates: a medical professional who is giving arguments about the importance of vaccines and their role in disease prevention („pro-vaxxer“) and participant of vaccination hesitancy movement who is giving arguments about noxiousness and risks of vaccination(„anti-vaxxer“). The audience consists of people from various aspects of life who are not sure where they stand when it comes to vaccination or are curious to see how the debate plays out.

Instruction: Participants are divided into four groups: „pro-vaxxers“, „anti-vaxxers“, the audience and the moderator. Each group gets a detailed description about their role in the debate, as well as most important points that should be addressed during the debate. Each group has a leader who divides tasks to his group members, advises them to further explore certain points that they believe will help them win the debate, as well as appointing one member as their advocate in the debate. Audience and the moderator need to explore and learn about both sides and prepare questions for both advocates, once the debate starts. Make sure all names that are used are fictional.

After 30-45 minutes of preparation, the debate begins. The moderator presents various points about vaccines (8-10 points total would be optimal) and both „pro -vaxxer“ and „anti-vaxxer“ advocate take turns in reasoning their side. Each advocate has up to 3 minutes to provide arguments for their side and 2 minutes to respond to other advocate's arguments. During this time, it is the moderator's job to secure advocates do not exceed their time and that they respect the rules, and it is the audience's job to observe. After all points were addressed, the audience has an opportunity to ask as many questions as they have and it is advocates' taks to answer them. If at any time during the debate advocate does not know how to respond or needs help from their group, an assistance from their group members is allowed if the moderator estimates that it will help continue the debate.

After the debate, the audience secretly votes for who they believe brought up better arguments. It is important to emphasise that they are not voting for what they believe but for who was better at debating and reasoning. They can give advice to both advocates and comment on where they can improve.

Expected result: Participants are more familiar with vaccination hesitancy movement participants way of thinking,and more ready to debate them in real life.

Participants learned about how debates are held, how to prepare for debates and how to approach their opponents.

3.3.4. Research in Vaccination for Prevention of Neglected Tropical Diseases and Emerging Infectious Diseases • 1.

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Module: Participants become aware of the various tropical diseases and emerging infectious diseases in the world.

Participants are aware of the status of vaccination for the same ie whether it exists or not, whether it is under research etc.

Participants understand the various stakeholders involved while creating vaccines and conduct research for the same.

Participants can think of challenges that could arise in the world of research for vaccination.

Examples: Role Play on the technicalities involved with creating and developing newer vaccines.

Situation: Medical students are at a panel discussion whereby Different stakeholders involved in the process of vaccine development are talking about the need to develop newer vaccines taking the example of Ebola and Dengue. The conversation began from the existing situation on these diseases and overall, the status of vaccination for the neglected and emerging diseases. Different stakeholders talk about their views, their limitations and their plans in this field. There are multiple views on the table and the medical students, as part of the audience have multiple questions.

Instructions: Briefing: The participants are briefed about the emerging and neglected tropical diseases, and their impact on public health, while also talking about the status of vaccination for each of them. They are also briefed about the requirements for vaccine development and the various stakeholders that can be involved.

The whole workshop is divided into 5-6 groups, each representing the following stakeholders. Make sure all the names used during the workshop are fictional.

Scientists Involved in Vaccination Research Government responsible for sanctioning money and resources for the research and development.

Representatives from WHO talking about their roles during the Ebola outbreak Pharmaceutical companies’ representatives involved in vaccine development.

Doctors involved in field practice.

Public Health Specialists.

Each group gets notes about what their roles are(preferably written instructions) and then they are told what to do in the field for research for vaccination as well as vaccine development(the pros, cons, prerequisites, drawbacks etc.)

Each group is given 15 minutes to prepare and come up with different possible viewpoints Expected result: the different stakeholders reach a mutual agreement whereby all pros and cons are discussed and a decision is made keeping the best interests of citizens at hand, and providing the best possible solution keeping in mind the resources that need to be invested and the gains and benefits one can expect..

3.3.5. Quality of Vaccines and Handling •

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Module Participants are aware of the importance of vaccine logistics for ensuring vaccination safety and quality.

Participants are aware of the different components of logistic steps for optimal provision of vaccines.

Participants are familiar with the concept of cold chain and various storage methods for each vaccine.

Participants can think of challenges for delivering safe vaccines in Low and Middle Income Countries and try to solve the problems.

Examples: Press Conference for Securing the Safe Vaccination Delivery in Developing Countries Situation: Citizens of a developing country were fortunate enough to get vaccination with donation from a developed country. However, the corrupted government of the developing country want to take profits from donation by not handling the vaccines properly, when the pharmaceutical company providing the vaccines gave clear instructions on how to handle the vaccines. Vaccines are sensitive to heat and need to be stored in 4°C the whole way and the government and the company intend not to care about the handling method and just keep the vaccines at room temperature and save the costs for cooling the vaccines for their own benefits.

Instruction: The whole workshop is divided into 5-6 groups, each representing the following stakeholders. Make sure all the names used during the workshop are fictional.

Citizens of developing countries in immediate need of Vaccination Government of a developed country donating money for Vaccination Government of a developing country trying to take benefits from the Donation Pharmaceutical company providing the vaccines with a clear protocol on vaccination storage but does not want to be engaged further International NGO watching over the vaccination handling process Each group gets notes about what their roles are and the group leader tells everyone who they represent and what they intend to do for securing vaccine quality.

Each group gets notes about the bad situation and express their concerns and stands on the press conference.

Citizens become sick with the infectious disease even though they got vaccinated The government of the developed country is concerned about the disease and requires investigation The government of the developing country tries to cover the corruption and pretends to have done everything right Pharmaceutical company insists on giving the right protocol and instructions and remain indiferent International NGO discovers the critical step of storing vaccines in 4°C is missing and reports it on the press conference Expected result: the corrupted government apologizes and the vaccination quality for citizens of the developing country is secured with the right storage method.

4. Conclusion According to World Health Organization, vaccination programs help prevent more than 2.5 million deaths of children each year. Vaccines help remove major diseases and they help healthy people to stay healthy. They save lives and they are related with reducing mortality in the last few decades. Also, vaccinations reduce medical costs and their benefits can be measured in millions of dollars. Should vaccination rates drop any lower, the consequences for global health could be tremendous.

Every parent undoubtedly wants their child to be as healthy as possible. The reason for the vaccination hesitancy can be found in lack of knowledge or misinformation that they are getting. Whatever the reason, it is our job as future medical professionals to teach them the importance of vaccines, to show them what could happen should vaccination rates go lower and what has happened in the past when vaccines were not in use or when they were not available.

As doctors of the future, it not only falls upon us to treat illnesses of the patients but rather to play a role in contributing our knowledge and skills to the community.

We have a huge responsibility amongst ourselves to provide actuals facts of vaccination and to erase the misconceptions gathered over the past years. Often trusted by the community, we need to step up to reassure them the necessity of vaccination to eradicate the world from vaccine preventable diseases. In the manual, various dynamics and medias are provided through which medical students can develop activities to advocate for vaccination. According to the methods to be used, the suggestions can serve as a ground upon which students can build up their activities.

Universal Vaccination Coverage has been a vision for the WHA since 2010. Albeit the vast improvements in the past few years, more change needs to take place in order to achieve the goal. The phrase, Think Globally, act locally comes to play here. It is our duty as medical students living across the world to stand up for the cause we believe in. We must raise our voices for vaccination and inspire others to do the same. We hope this manual will serve as a tool for medical students to advocate for the betterment of the society and for the creation of a safer future.

Contacts: •

ra.scoph.europe@ifmsa.org: Vicky & Blanca (SCOPH Regional Assistants for Europe 2018/2019)

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ra.scoph.asiapacific@ifmsa.org: Natasha (SCOPH Regional Assistant for AsiaPacific 2018/2019)

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ga.europe@ifmsa.org: Abdulkarim Harakow (General Assistant for Europe 2018/2019)