The Djinn of vaccine hesitancy: Is it still out?

Ode Uduu, Shobha Shukla, Bobby Ramakant *

It was a busy day for Usman Mu’azu Yusuf as he negotiated with customers at his shop in the Nasarawa GRA area of Kano, Kano State, in Nigeria. The proximity between him and his customers was well less than the one-metre stipulated for the COVID-19 safety protocols.

All the COVID-19 protocols were the least of his concerns, as his primary aim was to make a sale. “I have not taken the COVID-19 vaccine… it has been a long time since I heard of any advertisement on the radio or television informing me where I can be vaccinated,” he said.

Poor sensitisation of the COVID-19 vaccine brewed resistance against the vaccine. Most of the Kano, Nigeria residents, had heard little of the vaccine and where they could take it.

At Na-Ibawa, Kano, Samuel Akintola, a computer operator, responded that he was yet to be vaccinated. For he had heard of the availability of the vaccine over the radio, but that was a long time ago. According to him, the advertisement was aired for just a week when the vaccine was initially released.

Vaccine coverage and its pace are far from ideal

As per current evidence, it is clear that all the people globally who are eligible for the vaccination should get it. That is the only way to end the severity of the pandemic. In 2021, the World Health Organization (WHO) set targets for countries to vaccinate 10% of their people by September 2021, 40% by December 2021, and 70% by June 2022.

But Nigeria is yet to meet the 70% vaccination target and was also late in meeting the 10% target. India, however, met the 10% target, but failed to meet the 70% target set by WHO. In Kano State, 8.05 million persons have been fully vaccinated, receiving both the first and second doses as of February 16, 2023. Another 3.02 million people have received the first dose, with 1.59 million receiving the booster dose. Analysis shows that only 48.89% of those eligible for vaccination in Kano State have been vaccinated.

In Uttar Pradesh, the most populated state of India, as of February 17, 2023, 168.97 million were fully vaccinated. However, only 9.39 million have received the booster dose yet.

Myriad reasons fuelled vaccine hesitancy

A random sampling of 20 taxi drivers, tricycle riders, business owners, and residents in Na-Ibawa, Nasarawa GRA, Post Office road, and Sabon Gari showed that none were vaccinated. Most of them had not heard of any advertisement on the availability of the vaccine and thus did not know where to get vaccinated.

However, the situation in Uttar Pradesh was some shades different, with high decibel COVID-19 vaccine awareness and promotion by the government right from the time the rollout began on January 16, 2021– but it remained confined to urban areas only. The vaccine rollout in the state has been riddled with various pre-existing inequities and structural and systemic issues that long ailed the state’s development.

Mahesh Kumar, a social activist who runs a home for children of brickkiln workers in outskirts of Kanpur, identified some reasons that fueled hesitancy. Mahesh said the uneducated ones were more likely to lean on the myths circulating regarding the vaccines to decide. For instance, the rumours of random unverified death because of the vaccines spur their decision against being vaccinated.

Mahesh Kumar also pointed out that half-baked messages regarding the vaccine fueled hesitance. Science has shown that COVID-19 vaccines reduce the risk of serious outcomes of COVID-19 disease and death. But the vaccine will not reduce the risk of getting infected with the virus. “Because of improper and half-baked messaging, many people had thought that if they take the vaccine, they will not get infected. So, when some vaccinated people contracted the virus, then some of those who were unvaccinated began doubting the vaccines,” remarked Mahesh. News of prominent doctors who headed government-run hospitals of ‘getting infected again despite full vaccination’ made it more difficult.

Prior online registration to get a shot in India was a challenge for many. "Sometimes, even after registration, people failed to get the shot as vaccines were out of stock,” said Mahesh. Even last month, Lucknow had reported vaccine stockouts which hampered rollout of booster dose (referred to as precautionary dose).

Vaccine hesitancy in healthcare workers

Dr Surya Kant, one of the Brand Ambassadors for COVID-19 vaccination, National Health Mission, Ministry of Health and Family Welfare, Government of India, and part of the special task force for COVID-19 control, said that vaccine hesitancy was a pan India problem, and not confined to the state of Uttar Pradesh. In some states, like Kerala, which has a very high literacy rate, robust healthcare infrastructure, and strong advocacy programmes around vaccination, hesitancy was less. It takes strong advocacy programmes to mitigate vaccine hesitancy.

He added that in Uttar Pradesh, there was a lot of initial hesitancy, even among the doctors, nurses, paramedical staff, and health services administrators, to take the vaccine. Many rumours were floating around. Some thought a COVID-19 vaccine had been given premature approval for public use even during clinical trials.

Confirmed Dr Raman R Gangakhedkar, who was the top scientist in the National Task Force on COVID-19, and Head of the Division of Epidemiology and Communicable Diseases at the Indian Council of Medical Research when the pandemic hit us in 2020. He said that vaccine hesitancy was stressed because in case of the indigenously produced one, its approval process hinged on immunogenicity-related data only based on phase-2 clinical trials results. Phase-3 clinical trials had not been done by that time and there was no data on its efficacy to prevent infection or preventing risk of hospitalisation and death. This created anxiety in people’s minds.

The situation is similar in Nigeria. In a study conducted across four specialised hospitals in the southern part of the country, only 55.5% of the medical personnel are willing to receive the vaccine.

Civil society at the frontline to decimate hesitancy and boost vaccine confidence

Civil society has raised awareness, dispelled myths, and mobilised communities to go for shots in India and Nigeria. In Nigeria, Sunusi Hashim, Executive Director of the Society for Child Support, spoke of the challenges in redeeming the misinformation about COVID-19 vaccines. According to him, havoc had already been done as lack of proper sensitisation created a lot of misconceptions about the vaccine. This led to a lot of resistance across different groups.

However, with support from partners, such as Pathfinder and Vaccine Network for Disease Control, his organization has been able to break the ice through community mobilisation. “We took the advocacy campaign to the communities where we addressed misinformation as much as it sprang up. We use traditional leaders to communicate with the people and penetrate the population. Gradually, we are making progress,” he concluded.

In Uttar Pradesh, “it was only towards the end of June 2021 that village-level camps were set up with the help of NGOs. My NGO helped vaccinate around 70,000 people in the districts of Sultanpur, Ambedkar Nagar, and Chandauli with the help of mobile vans,” shared Rahul Dwivedi, a noted health activist.

In Lucknow city, the capital of Uttar Pradesh, religious institutions (like Gurudwaras, Eidgahs, or Hindu temples), sports stadiums, or historical monuments, such as Imambaras, became the venue for vaccinating a large number of people closer to their homes, and at flexible hours. Munni, who works as a domestic maid, told us that she could only get her monthly food supply from the government-subsidised ration shops when she showed them her vaccination certificate (after getting the shots first).

Networks of people living with HIV led from the front too. “We conducted many virtual sessions at the district and state level among the community members and organised virtual capacity-building programmes for service providers with the help of doctors to bust the myths around COVID-19 vaccination and HIV. Our volunteers and staff helped make the communities aware of the importance of COVID-19 vaccination, including COVID-19 counselling. We provided counselling to 28,176 people living with HIV on COVID-19 vaccination and facilitated 7,445 of them to get vaccinated. Community members have taken booster doses as well,” confirmed Naresh Yadav, who leads Uttar Pradesh Network of People Living with HIV (UPNP Plus) and is the President of National Coalition of People Living with HIV (NCPI Plus). Daxa Patel who leads Gujarat State Network of People living with HIV coordinated with local government authorities to get her network office premises double up as a vaccination centre to encourage people to get their shots.

We should have addressed vaccine hesitancy before the rollout began

Vaccine hesitancy is not new or unique to COVID-19, rather evidence shows how it has riddled other vaccination programmes in several countries worldwide even before the COVID-19 pandemic had hit us, said Dr Heidi J Larson, noted anthropologist and the founding director of the Vaccine Confidence Project, in a session hosted by the US-based Population Reference Bureau for the Fellows of Public Health Reporting Corps.

In Kano State, Dr Shehu Abdullahi Muhammad, the State Immunisation Officer and Chairman of COVID-19 operations noted that there was no rigorous sensitisation at the initial stage. This led to a lot of resistance from the people as they were gullible to misinformation on the vaccine. According to him, this negative perception brewed strong resistance to the vaccine from the residents.

Dr Shehu, however, said that the government returned to the drawing board after the resistance was encountered. They set up a technical working group responsible for ensuring a rigorous campaign. They devised a strategy to penetrate the people through key influential stakeholders to ensure adequate response.

Dr Gangakhedkar, who was awarded the third highest civilian award Padma Shree and currently is the Dr CG Pandit National Chair of Indian Council of Medical Research, said: “In an ideal situation, one would like to have more community preparedness and mobilisation before beginning the vaccine rollout. But this was not easy initially when we were under a lockdown for almost six months, and there could not be any direct contact with the public to raise vaccine awareness. As time passed, community mobilisation improved, and newer approaches were used.”

In India, government doctors and decision makers, like Dr Surya Kant, led by example when they noticed vaccine hesitancy, even in healthcare service providers. “I was among the first doctors who took the vaccine in Uttar Pradesh. Other doctors and I showed by example that taking the vaccine was safe and essential. This was publicised by the media and instilled confidence in the public that if a doctor took the vaccine, it must be safe. This went a long way in reducing vaccine hesitancy,” said Dr Surya Kant.

Partnerships between media, government, and NGOs helped dispel myths and mobilise people to go for the shots. The government-run All India Radio’s daily broadcasts on COVID-19 helped a lot, as radio programmes have a much wider reach than TV, print, or social media, especially in remote and rural areas.

Adult vaccination was new for the public health system

In India and Nigeria, this was the first major rollout where adult vaccination was being done. “Even our healthcare systems were not used to handle adult vaccination of this scale. Despite all this, we did well in terms of providing vaccines,” said Dr Gangakhedkar, noting that India has delivered over 2.2 billion doses now.

He added: “For India, the most important step for future pandemic preparedness is to invest in developing rapid vaccine platforms of different types, such as mRNA, adenovirus, or protein subunit-based vaccines. We should adopt a transparent approach to regulatory approvals. We must reflect upon whether we should follow the US FDA approach where they have a public hearing when any drug or vaccine is being approved, and anyone can ask a question.”

He strongly called for bottom-up community engagement models and not top-down administrative ones in responding to public health emergencies in the future.

As the threat of disease outbreaks or public health emergencies will continue to loom over us, it is important that countries like Nigeria and India are solidly ready in terms of pandemic preparedness and global health security. Bottling up the djinn of vaccine hesitancy is a very doable and important step in this direction. So is regaining and strengthening the confidence of people in public services.