Towards understanding the complexities of vaccine hesitancy in South Africa

To vaccinate, or not to vaccinate, this has become a pertinent question facing all of us as South Africans and global citizens during the times of the coronavirus disease COVID-19pandemic. While vaccine coverage across the country is steadily increasing, infections and deaths attributed to the virus remain. Recent reports from major hospitals have shown that hospital admissions accompanied by serious illness and fatalities almost exclusively involve unvaccinated individuals. Are these deaths to a certain extent unnecessary and could any of these be avoided through interventions aimed at reducing vaccine hesitancy?

Through our continued commitment to the betterment of the lives of all South Africans and in the interest of knowledge transfer and research translation, the South African Medical Research Council’s (SAMRC) Prof Charles Shey Wiysonge, Director of Cochrane South Africa, appeared in an interview for the Bhekisisa Center for Health Journalism, addressing issues around vaccine hesitancy in South Africa. This has been well-received and has contributed to allaying fears and provided valuable information and insight into what is required to tackle this contentious topic.  

What is vaccine hesitancy?

Vaccine hesitancy refers to a delay in acceptance, or refusal of vaccine despite the availability of vaccination services. It is complex and often context-specific, varying across time, place and different vaccines and can be affected by factors such as complacency, convenience, a fear of needles, or due to lack of understanding about how vaccines work. The term also covers outright refusals to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others. Although vaccine hesitancy has existed among a small percentage of people for centuries, its harmful effects have become more pronounced than ever before during the COVID-19 pandemic and it is considered one of the greatest threats to global health.  

Vaccine hesitancy is pervasive, misinformed, contagious, and is not limited to COVID-19 vaccination. The speed of global information exchange has been significantly boosted by social media, leading to viral sharing of fringe opinions and disinformation, with the World Health Organization (WHO) Director-General describing this very aptly, stating “We’re not just fighting an epidemic; we’re fighting an infodemic too.” Prof Charles Wiysonge mentioned that vaccine hesitancy is a complex and dynamic social process reflecting multiple webs of influence, meaning, and logic. People’s vaccination views and practices usually comprise an ongoing engagement that is contingent on unfolding personal and social circumstances, which can potentially change over time. “With regards to vaccination, whichever stance is taken, it involves a complex social process that is deeply embedded in the wider social worlds in which people live. Through their vaccination choices, individuals are often communicating not just what they think about vaccines, but also who they are, what they value and with whom they identify. Taking these social worlds seriously and placing them at the center of efforts to reduce hesitancy and promote COVID-19 vaccine acceptance in SA are critical” added Wiysonge.

Therefore, as COVID-19 vaccination rolls out globally, scientists and decision-makers need to investigate the scale and determinants of vaccine hesitancy in each setting; so that tailored and targeted strategies can be developed to address it.

In South Africa, prior to COVID-19 there was already a “baseline” level of vaccine hesitancy. For example, in 2009, national and provincial managers of the vaccination programme identified vaccine hesitancy as a major barrier to the achievement of optimal childhood vaccination coverage in SA. Measures that had been prescribed, that could curb this scourge, include amongst others, educational approaches promoting vaccine literacy. These involve answering questions related to how vaccines work and the benefits the world has seen because of vaccination, which has led to the eradication of smallpox and dramatic reductions in the occurrence of many other diseases. It had been known that a vaccine related event (such as an extremely rare adverse event related to a vaccine or temporary suspension of a study as experienced during the Sisonke Study, could cause an escalation in vaccine hesitancy levels, with this spike often subsiding at a slower rate.

It is important to recognize that the people hold a constitutional right to decide whether to vaccinate or not. While incentives being offered to increase vaccination coverage should be applauded, efforts that lead to a penalty or penalization of unvaccinated individual should be avoided. Rather, to get to the root cause of vaccine hesitancy, the concerns of vaccine hesitant individuals need to be understood and subsequently clarified. Prof Wiysonge mentioned in this regard that interventional efforts need to involve more than just information and education and should factor in that people develop their vaccine beliefs through their life experiences and that culture, structural conditions, personal background, religion and politics all shape people’s reactions to facts supplied to them. “Proper understanding, and grounding of interventions within localised contexts and value systems are therefore important. Such efforts should also recognise that vaccine beliefs are often rooted in distrust of institutions, and associated with historical and contemporary experiences of inequality, injustice and exploitation” added Prof Wiysonge

Evidence and Education with Empathy

It has been seen that countries with high vaccination coverage have already eased restrictions, allowing public gatherings and have returned to relative normality, following the witnessing of low infection rates and almost no newly reported cases.

Reports from South Africa’s biggest hospitals, show that almost 99% of hospital admissions, resulting in serious illness or death due to COVID-19 affected unvaccinated individuals. COVID-19 vaccine hesitancy, specifically, poses a substantial risk for both people who delay or refuse to be vaccinated and the communities in which they live. It can result in communities being unable to reach thresholds of coverage necessary for herd immunity, thus unnecessarily perpetuating the pandemic and resulting in untold suffering and deaths.

Another concern is that failure to improve vaccination coverage will mean further infections that carry with them the threat of driving the development of mutations and new COVID-19 variants that can create large-scale outbreaks and be even more deadly.

To decrease hesitancy and increase vaccine uptake, requires not only the provision of accurate information, but also, COVID-19 vaccine communication strategies need to form part of broader trust-building measures that focus on relationships, transparency, justice, community engagement and participation. Such efforts also need to be cognisant of the fact that people often have many needs and priorities, and that acceptance of vaccines may depend on these other concerns also being met. It is important that messages are delivered with empathy, compassion and kindness.

Prof Wiysonge said that it is easy for people to forget that diseases like smallpox, polio, yellow fever, and others, used to cause millions of deaths and disabilities in many parts of the world, which are now (virtually) free of these diseases, largely thanks to vaccination. Vaccines could have a similar impact on the COVID-19 pandemic, if there is optimal and equitable uptake of COVID-19 vaccines.

“In conclusion, this pandemic affords a unique opportunity to positively intervene and reduce vaccine hesitancy trends more generally in South Africa and potentially elsewhere. We could use COVID-19 to drive education with regards to vaccine literacy as well as the process of immunisation as a whole, keeping in mind the very complex social aspects of individuals and the community at large. This can lead to improved vaccine uptake, as a result of reducing the level of vaccine hesitancy not only toward COVID-19 vaccines but others as well” added Prof Wiysonge

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