By Patricio V. Marquez and Sarah Eyman

As the COVID-19 vaccination drive intensifies in the rich world, progress in low- and lower-middle-income countries lags far behind due to limited access to vaccines.  As of mid-June 20201, about 21.8% of the world’s population, or 1.71 billion people, had received at least their first dose of one of the COVID-19 vaccines. Yet only 0.9% of people in low-income countries and 9.5% in lower-middle-income countries can say the same. Vaccination coverage varies significantly among regions: in Africa only 2.45% of the population has received at least one dose, 22.23% in Asia, 26.15% in South America, compared to 47.40% in the European Union countries, 53.03% in the United States, 63.53% in the United Kingdom, and 63.54% in Israel.

On top of limited access to COVID-19 vaccines, a looming challenge is the lack of vaccine confidence in some countries and population groups, particularly minorities—risking new waves of infections which could derail efforts to end the pandemic. To continue to make progress in vaccinating the world against COVID-19, we must remember that vaccine confidence is as important as vaccine efficacy.

What is behind COVID-19 vaccine hesitancy?

As defined by the World Health Organization,  vaccine hesitancy is a “delay in acceptance or refusal of vaccines despite availability of vaccination services.” It refers to a continuum of beliefs and behaviors around whether or not to accept vaccinations, ranging from complete refusal to information seeking.

Vaccine hesitancy is nothing new and is almost as old as vaccines themselves. Recorded episodes of anti-smallpox vaccination date back to the mid-19th Century in Victorian England.  More recently, a published study that falsely claimed a link between autism and the vaccine for measles, mumps and rubella vaccine, fueled the anti-vaccination movement and led to the sharp drop in immunization rates in some countries.

Today, several factors contribute to the high level of COVID-19 vaccine hesitancy.  Typically, the development of new vaccines requires years of research and testing, while in the case of the new COVID-19 vaccines, scientists produced vaccines in less than a year. Further, the COVID-19 vaccine rollout is the largest vaccination campaign in history, which, unlike other vaccines, targets almost the entire world population. As noted by Heidi Larson, an expert on the topic, “One reason vaccines are so fraught is because they touch every person on the world. They have been invented by scientists who speak in jargon that many people do not understand, are sold by drug companies that engender little faith, and are pushed by governments that people trust even less.”

Magnitude of the challenge

In 2021, surveys reported  that between 50% and 60% of all respondents worldwide would be willing to receive a COVID-19 vaccine, with wide variations across countries that tend to cluster geographically and/or culturally. Results of an Ipsos survey of nearly 10,000 unvaccinated adults in 15 countries show that vaccine hesitancy tends to be more prevalent among those with lower incomes or lower levels of education, younger generations, and/or females.

The problem is acute among minorities in some countries.  In the United States, racial minority groups are most negatively impacted by pandemic, with COVID-19 mortality rates nearly three times higher than the rate among white individuals, and higher hospitalization rates. These inequities, which occur in a system that is not reliably trustworthy for many populations due to its a painful legacy of health care discrimination, medical research exploitation, and unconsented experimentation on Black, American Indian/Alaska Native, Latino, and other marginalized communities, fuels distrust in government-sponsored medical research.

Similar patterns of distrust are observed in other regions of the world. A recent Africa CDC survey in 15 countries found two of the top four reasons cited by respondents for not wanting a COVID-19 vaccine were beliefs that the virus is not real and that they were not at risk of infection.

Lessons from past vaccination programs

The Global Smallpox Eradication and the Polio-Free Effort in the Americas offer valuable lessons. In the 1970s, involving local communities and engaging non-partisan actors was critical for eradicating smallpox —a landmark global public health victory. During the U.S. polio vaccination experience, transparency, independence, and trust of “outside” organizations and individuals—ranging from The March of Dimes to King of Rock n’ Roll Elvis Presley—helped overcome vaccine hesitancy. In conflict-driven Central America of the 1980s, the PAHO’s “Health as a Bridge for Peace” initiative helped achieve one-day cease fires among combatants and also supported extraordinary social mobilization efforts, as health workers convinced the population to take their children to be vaccinated.

Some global experiences

To achieve its target of vaccinating 70% of the total population with at least one shot, the United States is working with community groups and others to target populations that are skeptical of the vaccine. The Biden Administration’s campaign slogan is “We Can Do This” and relies on messengers from community-based organizations to press the importance of the vaccine, especially in underserved populations. Clergy and hospital associations, as well as civic, agricultural, and business groups, will receive grants and resources to promote the vaccine.

Israel, UAE, and Bahrain are among those currently leading the world in the vaccination effort. Their rapid and effective COVID-19 vaccination drives are anchored in universal health coverage arrangements which enhance both access and utilization of healthcare and contribute to quick vaccination. Effective public communications and public buy-in are also critical elements of effective vaccination campaigns.  Health authorities in the three countries have enlisted the support of religious leaders to mobilize their communities to get vaccinated. The Prime Ministers of the UAE and Israel, as well as the King of Bahrain, were vaccinated in public view to encourage others to follow in their footsteps.

Moving forward – What can be done to address vaccines hesitancy?

Global experience shows that no single intervention is likely to be able to address vaccine hesitancy, as many cultural, social, and political factors, individual and group factors, and vaccine-specific factors all influence vaccine decision-making.

Public engagement and messaging, including through risk communication and community engagement campaigns are critical to promote public confidence and trust in the COVID-19 vaccines. Understanding perspectives through social listening, securing high-level political and community support, and working with key stakeholders, influencers, and champions, all help promote vaccination by building a foundation of trust. Evidence from consumer research and behavioral economics can inform strategies for an effective vaccination-promotion effort.  Public communication about COVID-19 vaccinations should aim to influence populations to: trust the information received from national and local public health institutions; understand the benefits and risks in order to make informed decisions; and know how and where to get a COVID-19 vaccination.

Complementing these efforts, support for combating vaccine-related misinformation under national vaccination programs and projects funded by international organizations, must not be ignored. In the information age, health systems and practitioners can address misinformation through effective interventions such as deploying social listening tools online and offline to identify and analyze rumors, beliefs, and concerns, as well as by identifying and engaging key influencers such as religious leaders, celebrities, youth champions, and women associations, to improve vaccine confidence and uptake.

Pharmacovigilance or post-vaccination surveillance also needs attention from policymakers and program managers given the risk of adverse vaccine and vaccination events. In the case of COVID-19 vaccines, which are being administered to such a wide population, continuous vigilance is vital during the post-vaccination period to identify and assess any reported adverse events and inform public communication activities designed to build vaccine confidence. Unfortunately, such monitoring is not always the case, which makes some communities suspicious about the vaccination programs.

Simply put, if vaccines are not administered, they are not useful. Vaccination saves lives – not only for the individuals vaccinated, but also for the community by reducing the spread of disease within a population.

 

This article first appeared on pvmarquez.com: To Vaccinate or Not to Vaccinate? The COVID-19 Vaccination Dilemma | Patricio V. Marquez (pvmarquez.com)