COVID-19 vaccine hesitancy – reasons and solutions to achieve a successful global vaccination campaign to tackle the ongoing pandemic

ABSTRACT

The ongoing coronavirus disease (COVID-19) vaccination drive aims to achieve global vaccination coverage that will help to control the pandemic. Therefore, the individuals who are reluctant to be vaccinated or forego COVID-19 vaccination can delay the progress of overall vaccination coverage, leading to slower vaccination rates and may create obstacles in global efforts to control the circulation of SARS-CoV-2 as unvaccinated individuals can act as reservoirs of SARS-CoV-2 and could drive further outbreaks. Vaccine hesitancy is one of the major threats that directly impact global health as it challenges our ability to eradicate infectious diseases and achieve significant herd immunity through vaccination. One of the strategies to counter vaccine hesitancy is to follow a multisectoral approach that involves the collaboration between various stakeholders, such as government, private companies, religious groups, and other agencies, to leverage the knowledge, expertise, and resources, thereby enabling the creation of longstanding public trust of vaccines.

KEYWORDS:

• COVID-19
• SARS-CoV-2
• vaccine hesitancy
• vaccination

Introduction

Over centuries, vaccines have been demonstrated as an effective way to combat outbreaks and the only efficient and reliable method for disease prevention.¹ Past studies and ongoing clinical trials have shown that safe and effective vaccines for coronavirus disease (COVID-19) offer the best means to control the ongoing pandemic. In the past, vaccination campaigns were effective for infectious, emerging, and lethal pathogens. The Spanish flu epidemic of 1918 is one example. The available COVID-19 vaccines provide protection, with an efficacy ranging from 70% to 95%. Their availability is bringing people a sense of some relief that they can better safeguard their health. However, despite the existence of several possible vaccine candidates against COVID-19, several countries are still dealing with the rapid increase in cases and the development of mutations, which is a serious global concern. While attempts are being made to stop the virus from spreading, the vaccine is the only way to stop the ongoing pandemic.² However, not everyone wants to get vaccinated. Some people are reluctant to be vaccinated and could delay or forego COVID-19 vaccination entirely. This behavior, which is termed vaccine hesitancy, is not restricted or limited to any specific country, community, or religion. It is a global phenomenon.³ Furthermore, the rate of scientific exploration underlying COVID-19 is exceptional. Despite significant advancements in vaccines during the last years, the World Health Organization has identified vaccine hesitancy as a significant obstacle to fight against COVID-19.⁴

According to a recent survey, the Middle East, Russia, Africa, and many European countries have low COVID-19 vaccine approval and acceptance rates. This may be a devastating issue in the ongoing containment activities against COVID-19.⁵ Furthermore, the latest report in the Greek population reported that a large proportion of the population cannot undergo COVID-19 vaccination, emphasizing the need for public health authorities to take urgent public awareness steps.^6,7

Although several potential vaccine candidates are available in the market for the public, vaccine hesitancy or the vaccine hesitant people pose a serious question: Is it possible to achieve a global vaccination target? Hence, we outline many causes for vaccine apprehension and their negative implications for achieving global herd immunity in a significant number of populations. Besides, multiple mechanisms for reducing the damaging effects of vaccine hesitancy have been identified.

Possible reasons behind the vaccine hesitancy

Vaccine hesitancy can affect the progress of vaccination coverage, leading to slower vaccination rates that affect certain subsets of the population. There are many reasons for vaccine hesitancy. Understanding the reasons for vaccine avoidance or reluctance can help to enhance vaccination intentions in the general population. To attain significant number of positive results among the populations or communities, it is necessary to consider the arguments and explanations for vaccine avoidance or hesitancy.¹ It is important to have a comprehensive understanding of the reasons behind this reluctance. These include safety concerns, confusion over protection levels, perceived risk and fears, poor health literacy, lack of awareness about the virus, misinformation or lack of accurate knowledge about the vaccines, concerns about safety in elderly and people with various preexisting comorbidities, doubts about the efficacies of the available vaccines to the emerging SARS-CoV-2 variants, anti-vaccine myths and confusing messages about some severe side effects of few vaccines, under-representation in health research, deficient legal liability from the vaccine manufacturers, mistrust and suspicion of medical companies, and political and economic intentions that are perceived to be driving the pandemic or vaccine preparation. Collectively, these factors can erode the beliefs and trust that are important in the acceptance of COVID-19 vaccination.⁸

The disbelief in the efficacy of vaccinations can be the root cause of vaccine hesitancy. According to previous studies, vaccination belief is affected by the confidence in vaccine efficacy, faith in health care providers, and community health and medical delivery processes, and trust in lawmakers who develop vaccination requirements. In the past years, various researchers reported a significant fall in public trust in vaccines. Individuals’ psychological views, such as the perceived danger of vaccines, the associated risks and seriousness of the illness, the perceived necessity for the vaccine, and vaccination self-efficacy, as well as their assessment of the costs and advantages of vaccination affects vaccination complacency.^9,10 Surprisingly, it is to be noted the success of various clinical trials to elucidate the effectiveness of vaccine against COVID-19 has led to significant complacency by lowering the expected risk and seriousness of illness.¹¹

Moreover, age, employment status, literacy rate, poor interest in the COVID-19 vaccine, and disbelief in health care and government policies during the pandemic were all linked to rejection and delay in receiving the COVID-19 vaccine.¹² Furthermore, distrust and bigotry have been identified as major factors in the rise of vaccine apprehension in several communities. Black Americans have a high level of distrust in the healthcare system due to institutional bias, which can contribute to COVID-19 inequities.¹³ The most damaging characteristics that lead to vaccine hesitancy are negative behaviors and poor understanding. The poor management of awareness-raising approaches leads to the significant reduction of the population’s knowledge about the vaccines and their associated modes of action. It has been concluded in a recent survey that about 30% of people with negative views were anti-vaccination in general.¹⁴ Surprisingly, public opinion polls show a high level of suspicion about vaccines, and interestingly, vaccine apprehension was also discovered in medical students.¹⁵

Healthcare personnel are more likely to be more informed about vaccines and vaccination. Thus, they are least likely to be influenced by anti-vaccine myths, “although not always”, as anti-vaccination sentiment among healthcare workers does exist. Other members of the society, especially those not affiliated with healthcare, could be relatively less informed. Especially, people with comorbidities can have a great degree of fear of COVID-19 as well as a different attitude to COVID-19 vaccination. Some of these people at higher risk may be ambivalent about opting for vaccination. However, some medical professionals in developing countries don’t believe in the COVID-19 vaccine and consider it a myth or fabrication of science. Additionally, medical professionals engaged in treating patients and who are concerned about contracting COVID-19 are more likely to choose to have their shots administered. Parents, caretakers, and medical staff who did not care for SARS-CoV-2 positive patients, on the other hand, expressed higher degrees of vaccine apprehension.¹⁶ The negative attitudes of medical professionals from nurses to the consultants are seriously raising the concern of vaccine hesitancy even when efficient vaccine candidates are available. For these individuals, patient centered health counseling can be useful in for strengthening self-confidence and alleviating perceived risks of COVID-19 vaccination.¹⁷

Furthermore, misinformation in social awareness obtained from a range of sources such as the internet and social media platforms can boost vaccine hesitancy. When technology has advanced, social media has become more widely used worldwide and any misinformation and religious beliefs moving around on these platforms contributed to the vaccine hesitancy.^4,18

Consequences associated with the vaccine hesitancy

According to WHO, vaccine hesitancy is one of the greatest challenges to global health.⁸ The major concern associated with the vaccine hesitancy is that the unvaccinated individuals can act as reservoirs of SARS-CoV-2. They could drive further outbreaks, which would impede efforts to control the circulation of this virus. Therefore, vaccination of a large proportion of the total population (60–90%) is imperative in order to protect the entire population (a concept termed herd immunity).³ Persistent under-immunization can be directly linked to vaccine hesitancy and can limit our ability to achieve the best health outcomes.¹⁹ Vaccine hesitancy is challenging our ability to eradicate diseases like COVID-19 that can be eradicated using vaccines, and will continue to cause a greater rate of mortality in the unvaccinated population.

The flood of misinformation surrounding vaccines and their efficacy, safety, and utility has a global influence.²⁰ Belief in misinformation has significantly slowed or even prevented the acceptance of COVID-19 vaccines. Opposing opinions within communities is eroding the beliefs of people regarding vaccination, creating a near hostile attitude toward vaccines.^19,21 Inaccurate information is being shared via social media without evaluating the source and the scientific credibility of the information.²¹ The World Health Organization (WHO) has affirmed that vaccine hesitancy is one of the worst threats to global health. Understanding the origins of vaccine hesitancy by public dialogs in the form of online surveys, tweets, articles in the mass media (including news sources), and social-ecological frameworks and the real-time dissemination of accurate information would be valuable for effective COVID-19 vaccine promotion campaigns. Alleviating vaccine hesitancy also entails increased community partnership and participatory strategies, accelerated mass awareness regarding the benefits of vaccination during a pandemic, briefings about the potential low risk of harm and adverse side effects from the vaccine compared the risk of harm of being COVID-19 positive. The aims are to instill belief and trust in vaccination campaigns and sources of COVID-19 information, tailor campaigns that are independent of gender and race. The success of the foregoing could overcome vaccine hesitancy among a sufficient number of people to enable vaccination at a scale that will achieve herd immunity to COVID-19.^8,22–24

Furthermore, COVID-19 has significantly affected people belonging to ethnic minorities such as Asian and black communities having the worse disease incidence and death rates. A vaccination against SARS-CoV-2 can close the race mortality gap caused by COVID-19; however, vaccine apprehension among African-Americans threatens vaccination rates.^25,26

Strategies to fight against vaccine hesitancy

Vaccine manufacturers and government and health institutions at the national and international levels need to continuously be champions in propagating and promoting beliefs and trust in the public that will drive the acceptance of mass vaccination. This includes the dissemination of scientific facts, data and knowledge, while highlighting the benefits of COVID-19 vaccination and immunization.^27,28 Governments and health agencies should work together to strengthen connectivity and build trust.¹² The reality of repeated waves of COVID-19 infections makes the pursuit of herd immunity crucial. Appropriate and timely dissemination of information related to protection provided by vaccination could be effective in educating the public about the efficacy of COVID-19 vaccines both for self-protection and as a way of promoting the common good that prevention is better than cure, and to lessen the suffering from this pandemic disease. One of the proposed solutions to counter vaccine hesitancy is to follow a multisectoral approach that involves the deliberate collaboration between various stakeholders, such as government, private companies, religious groups, and other agencies to achieve a policy outcome. The strategy to engage multiple sectors (health, environment, and economy) will help to leverage the knowledge, expertise, and resources that will enable the creation of longstanding public trust of vaccines.²⁷ There is a compelling need to promote an atmosphere of shared interest between science and society, where scientific expertise is advocated, established, and maintained thanks to a keen awareness of citizens’ concerns, desires for assurances, and wellbeing aspirations.²⁹ Herd immunity can be achieved by developing urgent communication strategies focused on accountability and rebuilding confidence in medical authorities are necessary.³⁰

Since the availability of COVID-19 vaccines, the vaccine hesitancy of some people has abated. Some who were initially unwilling to be vaccinated from December 2020 through March 2021 have changed their minds and have opted to receive a vaccine.^31,32 The shift in attitude reflects public health awareness, and the effect of the growing number of individuals who have been vaccinated. Personal connections and optimistic discussions within local and regional level levels can aid in improving willingness to receive a vaccine by overcoming the major hurdles of COVID-19 vaccine hesitancy and pandemic mitigation.

A recent comparison research in the Italian population found that during the lockdown, regardless of their vaccination views, more people could get vaccinated for COVID-19, and as risk tolerance grew, so did the willingness to adopt the vaccine. After the re-opening stage, the vaccine’s approval grew. Furthermore, if there was prior flu vaccination activity, the desire to get vaccinations against COVID-19 increased but decreased at higher concerns about vaccinations in total.² Ensuring high levels of COVID-19 vaccination coverage and equitable access globally, consistent with the main values of universal health coverage and health equity, are the key priorities of various health agencies including WHO. The result could be millions of lives saved from the current pandemic. The ongoing pandemic has taught us the need to build strong and resilient systems for strengthening vaccine confidence within the population.¹⁹ Such systems will help to address the current threat and prepare for the future inevitability of further pandemics.

Several reports have identified vaccine refusal strategies that may be effective for COVID-19 vaccines. For example, combating the dissemination of misleading information and focusing on children and adolescents, who may not yet have strong feelings about vaccinations, may improve COVID-19 vaccine acceptance.^14,33 A new study used a behavioral science method to assess the evolving evidence around vaccine hesitancy in relation to COVID-19 using real-time public dialogue from Twitter. Health professionals and physicians may use this information to develop therapeutic strategies that address the needs of individuals who are afraid to get vaccinations.⁸

However, plenty of studies have emerged, suggesting various options for assisting officials in dealing with vaccine hesitancy, including adequate and efficient public coordination as a response. However, the localized public education and behavior modeling by public leaders and health agencies will go a long way toward restoring public confidence.¹⁵ Furthermore, it has been recommended that governments propose offering monetary or benefits to people to encourage them to get vaccinated. Hence, we conclude that focused public health communications and a greater openness to the needs of vaccine-hesitant people are the strongest strategies for addressing low vaccination rates.³⁴

Conclusions

A protected COVID-19 vaccine program, if adopted internationally, would have significant health and performance outcomes. Many people who expect the coronavirus vaccine to restore the sense of stability in their lives may be discouraged, leading to a growing anti-vaccination mentality or vaccine apprehension among the general public. The barrier of vaccine hesitancy needs to be broken completely for the benefit of safeguarding and sustaining global health amid the present crises due to the ongoing pandemic. COVID-19 vaccination is necessary and preferably has to be made mandatory for all, irrespective of the community and country. It must be kept in mind that the desired levels of defensive immunity and consequent herd immunity linked with community protection will never be achieved without vaccinating large numbers of people who are currently hesitant to receive a COVID-19 vaccine. Highly collaborative and cooperative efforts with supportive relationships at international levels to tackle COVID-19 pandemic would efficiently mobilize global vaccination campaign in the right directions.

Author contributions

KD and KS conceptualized the manuscript; KD wrote the first draft with input from KS; RT, MD, TBE, AAR and SA reviewed and updated the manuscript; all authors contributed to revisions and approved the final manuscript.

All the authors substantially contributed to the conception, compilation of data, checking and approving the final version of the manuscript, and agree to be accountable for its contents.

Acknowledgments

All the authors acknowledge and thank their respective Institutes and Universities.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Additional information

Funding

This compilation is a review article written by its authors and required no substantial funding to be stated.