Africa: Vaccine Hesitancy ‘Widens Immunity Gaps, Increases Risk of Outbreaks’

In 1999, Grade 5 brought for me a revelation like no other – vaccines! The idea that weak disease-causing organisms could transform our bodies into warriors against killer diseases was nothing short of miraculous. From the top of my head I remember that some of the killer diseases were polio, diptheria, measles, whooping cough, tetanus and tuberculosis.

The coolest thing while learning about these vaccines was that our teacher, Mr Selome, introduced an acronym for the very first time. ZEPI, short for Zimbabwe Expanded Programme on Immunisation. He made us sing it out and that way I never forgot it, even now as an adult I sometimes break into song and sing the ZEPI song. ZEPI was part of Zimbabwe’s Primary Health Care Programme with the overall objective of reducing morbidity and mortality due to the six killer diseases.

From a tender age I knew that getting vaccinated was not negotiable and it was for our own good. Getting vaccinated in Zimbabwe was not even optional during those days, at childbirth mothers were given yellow vaccine cards that everyone was proud to have. Parents used those cards as accompanying documents to apply for birth certificates and Grade 1 placement. Nurses would come to our schools and vaccinate us without even talking to our parents. I remember getting vaccinated for tetanus in Grade 5 or 6, we were so excited by the mass vaccination and watching our peers cry from the painless prick of the injection.

However, times have changed. People are now very hesitant to get vaccinated – the Covid-19 pandemic exposed most of this hesitancy. In the face of that global pandemic, the race to develop and distribute Covid-19 vaccines brought hope to millions. Despite the urgency for protection, some were cautious, questioning the speed of development and potential side effects. The battle against Covid-19 vaccine hesitancy became a delicate dance of trust-building and information dissemination, as communities grappled with the weight of uncertainty amidst the quest for immunity.

Vaccine hesitancy is defined as the reluctance or refusal to vaccinate despite the availability of vaccines. The WHO emphasises that vaccine hesitancy is a complex and context-specific issue that can vary across different populations and geographic locations.

“Among the minority who do not receive or accept vaccines, the reasons for this are multipronged and often complex, and vaccine hesitancy is just one of the contributing factors. The reasons for vaccine hesitancy in South Africa may include: (a) religious beliefs not being compatible with receiving clinical interventions including vaccines, (b) vaccine mis- and disinformation often through online media, (c) fear of injections in general or concern over causing children pain from injections, (d) misconceptions about natural immunity, and (e) unaddressed concerns about potential side effects of vaccines,” according to Dr Edinah Amponsah-Dacosta, a virologist, vaccinologist and health systems specialist at the Vaccines for Africa Initiative.

The American Psychological Association describes misinformation as false or inaccurate information – getting the facts wrong and disinformation as false information which is deliberately intended to mislead – intentionally misstating the facts.

“In some countries vaccine acceptance has been very low, in Tanzania, for example, initially because the government didn’t recognise the problem of Covid-19. If it’s not clear that the disease is there, nobody is interested. The DR Congo was also quite low at some point. In Benin we had at some point only 22% of the people wanting to be vaccinated, in Malawi 44%, and that was also partially because the disease’s presence was not really clear,” said Robert Colebunders, a professor of Infectious Diseases at the University of Antwerp.

According to Dr. Elizabeth O. Oduwole, a vaccinologist, some cultural or religious beliefs and norms may not be compatible with the use of clinical or “western biomedical” interventions, including vaccines. For example, individuals who rely on traditional or alternative medicines for healthcare may not accept vaccines as they could consider them to be foreign to the human body.

“Mistrust in pharmaceutical companies, the broader healthcare system, and the government also contributes to mistrust in vaccines. Vaccine hesitancy in South Africa has also been linked with media platforms (primarily, social media) that spread misinformation and disinformation about vaccines. These platforms often spread conspiracy theories which fuel fear and misconceptions about the safety and effectiveness of vaccines. In South Africa, this has been observed with human papillomavirus vaccination and the COVID-19 vaccine,” said Oduwole.

“Promoting self-reliance is an important step towards overcoming vaccine hesitancy in Africa,” said Colebunders.

Empowering countries to spearhead their own distribution efforts and vaccine production holds the key to addressing the reservations surrounding vaccines sourced from places like Europe and United States of America. International organisations should strengthen the local capabilities of African countries to produce their own vaccines. Local experts and researchers, who better understand their communities’ needs and concerns, can effectively convey the pros and cons of these vaccines. This approach lends credibility to the information, as it originates from their fellow countrymen’s experiences, according to Colebunders.

Amponsah-Dacosta said it would be very difficult to show direct links between vaccine hesitancy and the recent emergence of vaccine preventable diseases which were previously under control in South Africa.

“What we know is that prior to the Covid-19 pandemic, vaccine coverage rates had plateaued in most parts of the world including South Africa. The disruptions to vaccination services brought on by the Covid-19 pandemic (e.g., lockdowns, restrictions on travel and social gatherings) led to further reductions in vaccine uptake and coverage worldwide, leading to gaps in immunity within our populations. This then, was the perfect set of conditions for outbreaks,” said Amponsah-Dacosta.

“Some parents may have stayed away even after vaccination services were restored because of growing vaccine misinformation and disinformation during the pandemic. In this case, vaccine hesitancy further widens immunity gaps within our population, thereby increasing the risk of disease outbreaks. Ultimately, parents are encouraged to visit their nearest vaccination clinics to ensure that their children catch-up any missed doses. By increasing the level of protection within our communities, we can reduce opportunities for the spread of diseases and any further outbreaks,” said Amponsah-Dacosta.

According to Amponsah-Dacosta, misinformation and disinformation play a major role in influencing vaccine hesitancy in South Africa. “Without scientifically sound and reliable information from trusted healthcare providers, our communities are left uninformed, unprotected, and vulnerable.”

“To address vaccine hesitancy, Provincial and National Departments of Health communicate via traditional and social media, promoting vaccination as a means of addressing vaccine hesitancy both for routine immunisation and for vaccination campaigns. There are also special information sessions aimed at training healthcare workers on how to respond to misinformation from anti-vaccine groups,” said Oduwole.

“The 2022 survey conducted by The Vaccine Confidence Project shows that young adults between ages 18 and 24 years generally demonstrate the lowest confidence in vaccines compared to other age groups; 60-67% in this age groups believe that vaccines are important for children, safe, effective, and compatible with their beliefs,” said Oduwole.

In some cases, Oduwole said, younger people may use media platforms and social media to determine whether they’ll trust health information. Unfortunately vaccine misinformation and disinformation is freely available on such platforms and is spread at lightning speed, with just one click of the forward icon. Another challenge is that youth do not necessarily share health concerns with older people, which “might influence” their confidence in vaccines.

“Older age groups are more likely to have had experiences with vaccine preventable disease (i.e., may have been affected directly or witnessed the impact during childhood) and thus may have a more positive attitude towards vaccines,” said Oduwole.

“Previous studies have also found high levels of vaccine hesitancy among affluent communities who tend to access health information from online media sources. However, vaccine hesitancy is also prevalent among low-income societies in South Africa. Factors contributing to vaccine hesitancy in such populations include poor access to reliable vaccine communication often compounded by conflicting messaging from authorities, rumours and speculation spread by numerous social media platforms, and entrenched historical and political factors,” said Oduwole.

Colebunders said the issue of vaccine information is widespread, and while organisations like Africa CDC and WHO Africa are making “commendable” efforts, especially during the COVID-19 pandemic, to share the importance of vaccines, countering the influence of conspiracy theories remains a challenge. He said it’s very difficult to convince people that are involved in these theories, because they will not accept everything being said. While combating misinformation might not always yield immediate results, it’s crucial to ensure accurate information reaches everyone to prevent its spread.

Transparency is key – openly discussing potential side effects and benefits, along with transparently addressing any concerns, can build trust. By proactively sharing comprehensive information about both diseases and vaccines, the roots of misinformation can be prevented from taking hold thereby helping to foster informed decisions and avoiding potential backlash caused by concealed information.

According to Oduwole, some of the most effective methods of increasing vaccine uptake include removing access barriers to vaccination services. This includes strategies to reduce waiting times in health facilities, and the provision of more mobile clinics like ‘Vaxi Taxi’. Building back confidence in vaccines requires tailored communication strategies which carefully considers and addresses the concerns of our communities, and make time for meaningful engagement with communities to increase vaccine literacy. It also means increasing the access to reliable and scientifically sound information about vaccines and implementing policies to penalise or deter the spread of vaccine misinformation and disinformation and conspiracy theories which put lives at risk.

The combination of reduced vaccine coverage, overstretched healthcare systems, and the return to pre-pandemic levels of social contact have created a perfect storm for infectious disease rates to rise. Growing vaccine hesitancy is only likely to make this issue worse. Inequitable access to vaccines can also contribute to hesitancy. If communities feel neglected or excluded from vaccine distribution efforts, they may become hesitant to trust the vaccines when they eventually become available.

Efforts to address vaccine hesitancy in Africa require collaboration between governments, health organizations, community leaders, and public health advocates. Public health campaigns, community engagement, and transparent communication about vaccine safety and efficacy are essential strategies to combat vaccine hesitancy.

Declining trends in vaccine confidence come at a time when routine immunisation coverage for children has slumped to a decades-long low. With some of the largest losses in confidence experienced among young adults, this is a concerning trend with the potential for long-term implications, according to a study by the Vaccine Confidence Project.

In 2022, WHO and UNICEF reported the largest sustained decline in childhood vaccinations in approximately 30 years. The percentage of children who received three doses of the vaccine against diphtheria, tetanus and pertussis (DTP3) – a marker for immunisation coverage within and across countries – fell 5 percentage points between 2019 and 2021 to 81%. As a result, 25 million children missed out on one or more doses of DTP through routine immunisation services in 2021 alone.

In a cross-sectional modelling study in eight sub-Saharan African settings conducted between 2020 and 2022, declines in the perceived importance of vaccines for children were identified across all eight countries. COVID-19 vaccines were also perceived to be less important in 2022 than in 2020 in six countries, reports the Vaccine Confidence Project.

Logistical hurdles, like cold chain requirements for preservation, are significant obstacles in reaching remote and rural communities where roads are rough and access is limited.

Adding to these problems is the lack of information about the diseases that the vaccines are meant to prevent. This is particularly common in rural areas where people have less access to health education. However, some rural communities exhibit an eagerness to embrace vaccines better than in urban areas, where internet penetration is higher thereby increasing vaccine hesitancy due to conspiracy theories.

“Sometimes it can be even counterproductive if it’s too much international organisations that are stressing the importance of the vaccination…That can cause a negative effect on the population concerning the vaccines,” said Colebunders.

It is very important that stakeholders try to learn to improve vaccine education in general for people in Africa because the more people are educated, the better they can understand the advantage of vaccines. For people to accept any vaccine it needs to be well explained by the healthcare workers. Colebunders said in countries like DR Congo, during the height of Covid-19 pandemic, there was a lot of vaccine hesitancy among healthcare workers. People could see that the nurses or the medical doctors not taking the vaccine, and become reluctant to take it. So there needs to be capacity building at all levels, on levels of healthcare workers, on the level of researchers and there’s also need to improve the healthcare system in general and the distribution of the vaccines.

According to Colebunders, television plays a crucial role in spreading the word about vaccines. Local scientists can explain the good things about vaccines and even the possible side effects they might come with. Talking about these side effects is really important because if they happen during the time of vaccines, and no one talked about them before, that can be really bad for the whole campaign.

Local leaders, even religious leaders can play a role, Colebunders said, and it’s very important that people see examples that their leaders also get vaccinated. Like when the president is vaccinated live on television and it’s confirmed – these things are convincing for local people to accept the vaccines.

In Tanzania, for instance, there’s a programme where they talked about “community champions”. These were people who got the vaccine themselves and then told others about it. They shared their own experience and talked to the community, explaining that  they had some temporary side effects after the vaccine, but they are still healthy and didn’t get sick from the disease. When people see this, it makes them more likely to agree to get the vaccine too.

“At some point Uganda also had quite low acceptance…In one of our studies that we did there, among ophthalmologists (eye healthcare workers) during the Covid-19 pandemic. There we had an acceptance of 97%. This is a profession of command, they’re quite at risk for Covid-19 because they are very close to the patient, so they were very afraid of the risk, very well informed and very well trained and aware of this disease. So that is the reason acceptance is very high. But if people don’t know the disease, have not seen anybody with the disease and it’s not well explained then it results in hesitancy,” said Colebunders.

Witnessing the impact of the disease to develop a genuine fear of it is another suggestion from Colebunders, with the belief that this fear can prompt a desire to be vaccinated. Communities need to be informed with clear and honest explanations about side effects, which is often where misunderstandings arise.


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