Increasing COVID-19 vaccine acceptance among the general population while maintaining autonomy

ABSTRACT

The accelerated dissemination of coronavirus disease, its effects on the general public and healthcare system have been unparalleled. COVID-19 vaccination is critical for reducing the alarming incidence of the infection, promoting herd immunity, preventing associated mortality and morbidity, and maintaining public health and safety. Through the development of COVID-19 vaccines, many people are keen to protect themselves against the virus; however, the willingness for vaccination especially in Africa, is far below what is required to stop the ongoing COVID-19 pandemic. As a result, there is an immediate need to implement plans aimed at increasing population vaccine willingness. The slippery slope is whether sanctions, bans and restriction should be imposed on hesitant persons, since transmission of the epidemic can be prevented through stringent enforcement of the control barriers, while eradicating the disease would necessitate vaccination. This commentary provides recommendations about how to increase population vaccine acceptance while maintaining autonomy.

KEYWORDS:

• Autonomy
• COVID-19
• vaccination
• vaccine acceptance
• vaccine hesitancy

Introduction

The superspreading nature and impact of coronavirus disease (COVID-19) on the general population and healthcare system have been unprecedented.¹ The pandemic has attained rapid global transmission partly owing to the high number of asymptomatic carriers interacting in a world interconnected by supply chain, communications technology and travel.² Movements to workplaces, urbanization, daily human connection, the mingling of families in communities and international travels intensify the transmissibility of the virus.³ Such undertakings pose a challenge for mitigating the spread and predispose close contacts of COVID-19 patients to the infection.

Recent report revealed that the family household infection rate is estimated between 16.3% and 30%.⁴ The aged, as well as the elderly, with certain underlying medical condition, are at high risk of serious infection from the virus, which, and can result in hospitalization, admission to intensive care units, intubation and even death. The threats posed by COVID-19 are immense, but everyone must remain vigilant, follow the mandatory protection precautions and most preeminently, get vaccinated as this would keep the pandemic under control while still shielding individuals and families in the community from the deadly virus.

COVID-19 vaccine hesitancy

COVID-19 vaccination is critical for reducing the alarming incidence of the infection, promoting herd immunity, preventing associated mortality and morbidity, and maintaining public health and safety.⁵ Numerous persons are eager to defend themselves against the virus now that the COVID-19 vaccines have been developed and made available; however, certain families and individuals may deliberately opt not to be immunized. Vaccine hesitancy is known to be caused by a number of factors, especially when new vaccines are being produced. These factors include misconceptions regarding the need for vaccines, vaccine protection and efficacy, negative health effects, lack of confidence in the health system, and lack of community awareness about vaccine-preventable diseases.^6–8

Although the World Health Organization approved COVID-19 vaccines have undergone stringent testing and clinical trials to demonstrate their safety and success in controlling the pandemic, a report from the United Kingdom stated that one of every five persons was unlikely to take the COVID-19 vaccines for a number of reasons.⁹ Summarily, a study that assessed hesitancy to a COVID-19 vaccine in Cameroon and its global implication among 2512 participants shockingly reported vaccine hesitancy rate of 84.6% citing communication and media environment, perception of pharmaceutical industry, reliability and/or source of vaccine and cost as influencing factors.¹⁰ Another study investigating the level of willingness for COVID-19 vaccination in the Democratic Republic of Congo (DRC) reported that, of the 4131 responses, 2310 (55.9%) indicated their willingness to be vaccinated and income status, COVID-19 status, COVID-19 community vaccine acceptance and acknowledging the existence of COVID-19 were associated with an increased willingness to be vaccinated.¹¹

The slippery slope between COVID-19 vaccine autonomy and uptake enforcement

Every person has the right to confidently refuse vaccination and this decision must be understood and respected. Therefore, managing COVID-19 reluctant individuals and their families’ actions may trigger conflict between honoring and promoting a person’s decision-making autonomy and upholding of professional duty to encourage evidence-based decisions, aimed at achieving optimal outcome for both families and individuals. The slippery slope is whether sanctions, bans and restriction be imposed on people that resist COVID-19 vaccination, since it is already commonly recognized that the transmission of the epidemic can be prevented through stringent enforcement of the control barriers, while eradicating the disease would necessitate the uptake of a vaccine. The willingness for vaccination especially in Africa, is far below what is required to stop the ongoing COVID-19 pandemic, as a result, there is an immediate need to implement plans to increase population vaccine willingness.

Recommendations to increase population vaccine acceptance

Educational campaigns

Outreach campaigns aimed at improving awareness and dispelling some of the vaccine’s well-known stereotypes must be extended to build more optimistic perceptions and decisions toward the vaccine use. An educational strategy of this kind should include factual information, discuss various vaccination issues, and provide answer to questions regarding COVID-19 vaccine misconception. People must be persuaded that the system for developing, testing and regulating vaccine demands that every vaccine shows both safety and efficacy prior to licensure, and therefore the safety of the current COVID-19 is well assured and monitored.

The campaigns should also emphasize the benefits of the vaccinations to the recipient, immediate family, neighbors, society and the world at large. The advertisement should appeal to the emotions and fears of individuals but not to scare anyone into taking a specific action. It must also be greared towards protecting the general population’s vulnerability and effective enough to encourage vaccination. If the morbidities, mortalities, and realities associated with the virus are intensely communicated, the public would recognize the growing burden and be willing to take the vaccines.

Strategic communication

Health communication must reach all communities, especially the most vulnerable, educating them about the safety of the vaccines and the potency to prevent future infections and deaths. Communication about the vaccine can be promoted through community van mobilization, radios, televisions, leaflets and telephone hotlines, to enlighten the general public about vaccine-related information like accessibility, availability, efficacy, known side effects, benefits, protocols and triage decisions. Respected community-based organizations and non-governmental agencies, such as the Red Cross, Faith leaders and religious leaders, which are widely regarded as neutral, are critical in fostering interest in COVID-19 vaccine uptake.

Health professionals’ ‘self-vaccination’ strategy

Health professionals’ self-vaccination strategy can influence families and individuals who refuse COVID-19 vaccination. Vaccine acceptance depends on public trust and confidence in the safety, efficacy of the vaccines and immunization. The recommendation of healthcare providers and trust in the healthcare system are most often cited explanation for general public approval for vaccination.^8,12 This implies that the public relies on the expertise judgment and willingness of health professionals to view these results accurately and in the best interests of the public. Therfore, the uptake of COVID-19 vaccine by healthcare providers in the presence of their patients will build trust and affirms the safety of the vaccine.

Healthcare professionals ‘patients’ vaccination’ strategy

Health professionals should prescribe the COVID-19 vaccines for those unwilling to vaccinate. The key reasons for healthcare professionals prescribing vaccinations to their patients include a belief in the benefits of vaccines and a sense of responsibility to encourage protection and vaccination. One research found that recommending vaccines to patients requires a trusting doctor–patient partnership.¹³ Healthcare professionals have the responsibility of continuously engaging COVID-19 hesitant families and individuals during the provision of healthcare services and public health education sessions in an attempt to modifying their behavior to reconsider vaccination. Healthcare providers must be capable of articulating the safety and efficacy of the vaccine to their clients and also refrain from suggesting that refusing vaccination may be safer.

Recent study on acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public, reported that respondents who received positive advice from a primary care physician for vaccination were more likely to accept the pandemic vaccine, and those who did not receive positive advice were more likely to decline the vaccine.¹² Safety information must be presented in a non-confrontational dialogue. Opel et al.¹⁴ reported that hesitant families do accept vaccination after their healthcare practitioners have provided a rationale for vaccine administration.

‘COVID-19 vaccination passports’ or proof of COVID-19 vaccination

The introduction of ‘COVID-19 vaccination passports’ or proof of COVID-19 vaccination, however this topic is highly debatable. Travel restrictions are public health emergency measures to reduce the spread of pandemics and other highly infectious diseases like influenza, yellow fever and polio. The revised International Health Regulations (IHR) in 2005 expanded the scope of internationally important diseases from three (cholera, plague and yellow fever) to include all “events which may constitute public health emergencies of international concern”.¹⁵

In the yellow fever antecedent, prior to the availability of a vaccine in 1937, the key tactic used in an attempt to limit its dissemination was to rely on old-fashioned methods of isolation and quarantine.¹⁶ Vaccine entry requirement became the key disease prevention mechanism of the post-vaccination period. Vaccine entry requirement are provisions for travelers to present evidence of vaccination for specific diseases in order to enter a country. These conditions extend to all travelers or visitors coming from areas where the disease is at risk of spread.

Likewise, issuing ‘COVID-19 vaccination passports’ or proof of COVID-19 vaccination could mean that persons would be allowed to travel freely outside their home country provided they have evidence of immunization. This will promote the resumption of air transport and help in the revitalization of national economies. However, there are several arguments as to whether it is ethically permissible to impose such practice on people who refuse vaccination. This will depend on factors like the level of vaccination in the general population, vaccine supply, the nature of restriction and how the restrictions are operationalized.

COVID-19 vaccine certificates

The general public should be required to have COVID-19 vaccine certificates to gain access to some essential public services and places within the country. Just as children must show-up their immunity certificate against certain diseases before they can be enrolled at a new school and also similar to ‘no mask no entry’ advocacy. This will reopen the economy, make people adapt to the new normal, remind others to get their shots and also improve the safety of staffs and customers in such public places. The pre-pandemic freedom for individuals who refuse to vaccinate against the COVID-19 should not affect others negatively or cause more serious cases of coronavirus disease.

It is therefore justifiable to restrict vaccine refusers to reduce onward transmission. A section of the population will accept vaccination if given the choice between immunization and restrictions at essential public services. However, these restrictions must be conducted in a manner consistent with established health guidelines and prior official notification must be provided to all and sundry involved. In situations where there is limited ability to restrict hesitant people, as is the case of a hospital environment, established organizational policies should be followed and all necessary services must be rendered regardless.

Conclusion

The COVID-19 vaccines can contribute to the control of the deadly pandemic, although the vaccines may not be fully protective. Refusal of the vaccine will trigger re-emergence of the pandemic, which can be harmful to individuals and the general populace. Hence, public health authorities, health providers and all stakeholders involved in the fight against this pandemic have a professional responsibility to provide scientifically proven information in managing encounters with non-vaccinating families and individuals. The approach should identify the basis of people’s decisions, address concerns and execute the recommended actions to encourage vaccine uptake while upholding ethical responsibilities.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.