Fostering Collaboration Across Nations: Report of the 6th International Neonatal and Maternal Immunization Symposium (INMIS), Costa Rica, 2024

Following the great success of the 5 previous meetings of the International Neonatal and Maternal Immunization Symposium (INMIS) in Turkey in 2010 and 2013, The Gambia in 2015, Belgium in 2017 (https://doi.org/10.1128/msphere.00221-18) and Vancouver in 2019 (https://doi.org/10.1128/msphere.00862-20), the 2024 INMIS meeting’s theme “Fostering Scientific Collaboration Across Nations” was selected to underscore our support to advancing the field of maternal and neonatal immunization, and the concept that working together for the present and future of maternal and neonatal health through immunization can be achieved by building from our common experiences. INMIS 2024 (www.inmis.org), held for the first time in Latin America in Costa Rica, included keynote and invited presentations by expert faculty, interactive panels and audience discussions, oral abstracts and e-poster discussions. Satellite symposia and educational activities were conducted in partnership with the Sociedad Latinoamericana de Infectología Pediátrica, the European Society of Paediatric Infectious Diseases and the Immunizing Pregnant Women and Infants Network. The meeting benefited from the participation of an international audience of ≈300 scientists and researchers, health care professionals and trainees, vaccine manufacturers and public health representatives, coming from 35 countries and all continents. The conference was designed to encourage the exchange of knowledge and ideas across a broad range of disciplines and among learners and faculty. In summary, 24 abstracts were presented in the main program, 68 in moderated oral e-poster sessions and 10 research groups from Latin America, Europe and Africa participated in the first Research Master Class organized jointly by the European Society of Paediatric Infectious Diseases and the Sociedad Latinoamericana de Infectología Pediátrica. This report highlights salient presentations and key messages from the meeting. Opening Keynotes Her Excellency Laura Chinchilla, former President of Costa Rica (2010–2014), who also served as the Vice-President (2006–2008), Congresswoman (2002–2006) and Minister of Security and Justice (1994–1998), honored INMIS participants with a warm welcome to the country and opened the meeting with inspiring words and a thoughtful commentary highlighting the need for collaboration from all stakeholders, from the public to the government, to achieve the desired goals of disease prevention and improving the health of women and children worldwide. Professor Rebeca Martin (Emory Global Health Institute) started the meeting with an enlightening presentation on the status of immunization strategies to protect maternal and neonatal health and prevent disease after the COVID-19 pandemic. Despite successes in childhood vaccination coverage from 2000 to 2019, global gains became small or stagnant by 2019 and progress remained uneven with large and persistent inequities in the African region and regression in the Americas. Maternal immunization remains an underutilized platform and a missed opportunity with consistently low rates of vaccine uptake during pregnancy seen in many countries around the world. While health care provider recommendation is a key determinant for vaccine uptake, concerns about vaccine safety by health care providers and pregnant women are barriers to increasing vaccination coverage. In 2021, more people were vaccinated than in any other year in history, including pregnant women. However, with disrupted health systems around the world, more children were left at risk of vaccine-preventable diseases than before the pandemic, resulting in a resurgence, which indeed is now occurring. The 2030 World Health Organization (WHO) Immunization Action Plan (https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030) is a global strategy to leave no one behind. Key determinants to improving maternal immunization1 include the following. 1. Awareness of the vaccine, disease severity and susceptibility, vaccine benefits, side effects and risk of harm during pregnancy. 2. History of previous vaccination. 3. Recommendation from health care providers. 4. Access to health care, especially for marginalized populations. 5. Community education programs. 6. Targeted messaging that specifically highlights the benefits of vaccination during pregnancy. 7. Improved regulatory processes with more transparent labeling of vaccines. Global strategies suggested to reduce morbidity and mortality from vaccine-preventable diseases after the COVID-19 pandemic include2 the following. 1. Strengthening public health systems. 2. Strengthening national regulatory agencies. 3. Engaging independent national scientific advisory committees. 4. Strengthening clinical and mortality surveillance systems. 5. Using data to determine priority populations for vaccination. 6. Improving communication with populations as scientific data are available to develop or change public health policy or guidance. 7. Engaging community and individuals in decision-making. Session 1: Priorities for the Maternal and Neonatal Immunization Research Agenda In the past decade, maternal and neonatal immunization research has supported several evidence-based maternal immunization programs globally, yet there are numerous future challenges and opportunities with several new vaccines in advanced stages of clinical development. Professor Janet Englund (University of Washington, Seattle, Washington) highlighted the main areas for maternal immunization research, including considerations related to the pathogen, the vaccine product, the vaccination strategy, the research program and the implementation research and how these considerations can finally impact national and global policies. She emphasized that maternal vaccination strategies are pathogen-specific and that future research should inform decisions regarding the number of vaccine doses required in pregnancy, the feasibility of coadministration, reactogenicity and the optimal timing of vaccination in pregnancy. Multiple lessons have been learned from COVID-19 regarding how to generate data on various aspects related to maternal immunization. In the setting of the pandemic, pregnant populations were excluded from COVID-19 vaccine studies until after vaccines were rolled out, leaving much room for improvement. Therefore, planning implementation strategies in a timely way prior to the introduction of a new vaccine program is critical. Professor Marco Aurelio Safadi (Santa Casa de Sao Paulo, Brazil) described emerging and pandemic diseases that have the potential to impact pregnant people and newborns and how recent research has informed successful vaccine development. Chikungunya was highlighted as one such example. While the mosquito-borne Chikungunya virus had been endemic in Latin America for many years, there was a significant increase in disease in 2022 and 2023, with neonates and infants at very high risk of developing severe disease.3 Supportive data on a live attenuated vaccine4,5 have led to a recommendation from the Advisory Committee on Immunization Practices (https://www.cdc.gov/acip/vaccine-recommendations), which permits vaccination in pregnancy when risk-benefit is justified and successful manufacturing of the vaccine in Brazil to support a low-cost product. Oral abstracts were presented showing a growing interest in maternal immunization, generating research insights and new licensed vaccines for pregnant women. The recently approved respiratory syncytial virus (RSV) vaccine, as well as the (not licensed yet) new generation low-dose recombinant acellular pertussis (aP) vaccine containing a genetically detoxified pertussis toxin, showed promising results concerning safety and immunogenicity. Evidence generated through post-implementation safety assessment tools such as living systematic reviews and meta-analyses could support recommendations and help stakeholders make informed decisions regarding implementation. Session 2: Progress in Maternal-Infant Infectious Disease Prevention Through Maternal Immunization Professor Kirsten Maertens (University of Antwerp, Antwerp, Belgium) discussed the challenges, strategies and successes of maternal vaccines and maternal vaccination research. She emphasized the significant progress made over the past decade by highlighting how the maternal vaccination strategy has evolved from being controversial to being a well-established medical practice endorsed on a broad scale. Despite significant successes, ongoing research on maternal immunization is still needed to address remaining knowledge gaps. Specific domains in which additional knowledge is necessary include research on optimizing the timing of vaccination in pregnancy, characterizing mechanisms underlying reduced humoral immunogenicity of vaccines in infants following vaccination in pregnancy, and strategies for better training and communication on maternal vaccination to increase acceptance of the strategy. The global expansion of maternal vaccination programs underscores the need for continued research in the field and the need for education of health care providers to increase acceptance. Professor Marcela Pasetti (University of Maryland, Baltimore, Maryland) addressed the very relevant topic of protecting infants through breastmilk and the role of maternal immunization. Breast milk is a rich and complex tissue with innate and adaptive immunity components that change throughout lactation to support the development of infant immunity and provide crucial nutrition.6 While breastmilk IgG levels correlate with maternal serum IgG levels, secretory IgA is mainly produced by mammary gland plasmablasts and B cells. Dr. Pasetti’s studies have shown how maternal vaccination with the tetanus, diptheria and acellular pertussis (Tdap), Shigella and COVID-19 vaccines results in measurable IgG and IgA responses in breast milk, potentially providing infant protection. 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