Arm of young child with bandaids following vaccinations

Connector Articles, Vaccines

Vaccine Distribution and Hesitancy in the COVID-19 Era

July 29, 2020

by CCIH

by Taylor Carty, Pepperdine University Student and CCIH Communications and Advocacy Intern

Photo of college intern and biology student
CCIH Intern Taylor Carty

Since the rise of COVID-19 around the world, billions of dollars have been invested toward finding a vaccine. The unprecedented nature of this pandemic brings with it both familiar and unique challenges for the global health community, one of them being hesitancy to be vaccinated. Vaccine reluctance is deeply intertwined with public distrust, misinformation, and historical experience. In 2019, the World Health Organization listed vaccine hesitancy as one of ten major threats to global health. In today’s context, the phenomenon of vaccine hesitancy is especially relevant as we grapple with the effects of the COVID-19 pandemic.

The Realities of a COVID Vaccine

“The challenge is the trade off between clinical experience and the level of safety you want,” says Mark Chataway, Principal Consultant with Hyderus, a CCIH affiliate and communications and policy consulting firm. “The Ebola vaccine took approximately four years to be approved for use. If the highly anticipated COVID-19 vaccine is released in winter of 2020 or in early 2021, it will easily become the fastest vaccine ever created, a testament to both scientific advancement and the urgency surrounding this pandemic,”

According to Chataway, the case fatality rate of COVID-19 is low compared to Ebola, so the level of risk tolerated in a vaccine is very low. In addition, it is important to take into consideration the effectiveness of a potential vaccine in relation to human behavior. The COVID-19 vaccine may be only 30 to 70 percent effective, require multiple doses, or only provide short-term immunity.

Mark Chataway presents at the FICCI panel on health and vaccines
Mark Chataway speaking at a Federation of Indian Chambers of Commerce and Industry (FICCI) event on health, including vaccines. Courtesy of Hyderus.

Chataway says there is some evidence that when adults are vaccinated, they are more prone to disinhibition, or engaging in risky behaviors and taking fewer precautions and they may even take fewer precautions for the whole family. This is one of the issues being investigated in country-level implementation test introductions of a partially-effective malaria vaccine. Risky behavior could easily nullify the benefits of a semi-effective vaccine, and may not be worth the commitment of health resources required to produce and distribute it.

Image of virus through microscope

Another challenge about the COVID-19 vaccine is ensuring that distribution is comprehensive and equitable. Unlike traditional immunization programs, the COVID-19 vaccine would be intended for adults, who are less likely to get vaccinated than children. Chataway stated that the most practical way to do this may be through workplace immunization, beginning with front-line workers and then expanding to the general public after demonstrated success. Lastly, there is the question of whether people will trust the COVID vaccine.

The devastation and havoc COVID-19 has caused around the world make the vaccine seem like a saving grace, yet there are still those who fear that the process was too rushed. In a recent poll by the Associated Press and the University of Chicago,  only 50 percent of Americans said they would get a COVID-19 vaccine if it became available, with the other half either unsure or firmly opposed. Their reluctance is not a new problem for the pro-immunization community, and in order to address it we must look at the successes and failures of other global immunization efforts.

Providing Comprehensive Access

Vaccines are subject to some of the highest standards of safety and testing because they are given to healthy patients. And yet, the breadth of their use and acceptance varies greatly across the globe. The multitude of factors involved in the accessibility and acceptance of vaccines makes it difficult to pinpoint universal determinants of immunization. According to Chataway, vaccine uptake rates are not necessarily correlated with the socioeconomic status of a country. Some low-income countries like Malawi have high rates of vaccination coverage while certain wealthy regions of Switzerland have relatively low vaccination coverage. Organizations like Gavi, the Vaccine Alliance  and the Johns Hopkins Vaccine Initiative work to make vaccines accessible, even to those who cannot afford them.

At the global level, a tiered pricing system ensures that the cost of vaccines corresponds to the recipient country’s ability to pay, enabling lower income countries to prevent illness in millions of potentially vulnerable people. However, solving the issue of access does not guarantee full coverage. In order to promote the acceptance of vaccines at a local level, health providers must understand the reasons people choose not to vaccinate themselves or their children.

Overcoming Resistance and Inconvenience: Three Challenges

Inconvenience

In Chataway’s experience, there are three main sources of vaccine hesitancy. The first, which makes up the majority of immunization gaps, comes simply from inconvenience. “We often underestimate hassle as a deterrent for women bringing their children to a vaccination center,” says Chataway. In some countries, these facilities are undersupplied and may require travel or long waits outside, all in addition to the financial expense of being vaccinated. These challenges can be resolved by making the vaccination process easy, comfortable, and affordable so that it is less burdensome to those who want it.Heath worker about to inject a patient's arm with a vaccine.

Soft Resistance

Another type of vaccine hesitancy is soft resistance by those who are somewhat skeptical but not firmly opposed to vaccination. This resistance may be caused by indeterminate, low-level contributors, but can be overcome with education and encouragement from health professionals and trusted community members.

Firm Opposition

Lastly, a very small percentage of people are firmly opposed to vaccination. Evidence has shown that information campaigns targeting the anti-vaccination movement are mostly counterproductive, and fail to significantly promote vaccine acceptance. See a study published in the Official Journal of the American Academy of Pediatrics for more about this.

Addressing fears of parents is complicated, and studies show conflicting results. In some cases, telling parents specific stories of children harmed or killed by vaccine preventable diseases does encourage parents to vaccinate their children. However, the same stories may raise the anxiety level of other parents to the point that they take no action and do not vaccinate their children, a phenomenon known as “omission bias.” Omission bias is where people tend to feel that having a bad outcome they caused through action is worse than one caused by omission, or doing nothing. See more in Science Magazine about this phenomenon.

Historical Context of Vaccine Mistrust

Image of Milton Amayun President of International Care Ministries
Milton Amayun, MD, MPH, President of International Care Ministries

Although vaccines are meticulously tested for safety, there are instances of vaccines having adverse effects on healthy populations. One such case occurred in the Philippines with the release of Dengvaxia, a vaccine intended to protect children against dengue fever. After inoculating millions of children, data began to suggest that the condition was actually more potent in children who had received the vaccine. For children who had never been exposed to dengue, the vaccine made them more prone to plasma leakage syndrome, a dangerous complication of dengue fever. When this reaction was implicated in the deaths of 10 children, panic erupted and the government conducted investigations into the hasty launch of Dengvaxia.

These cases, although rare, damage the relationship and decrease trust between local populations and healthcare providers. By validating mistrust in pharmaceutical companies and other effective vaccination programs, the Dengvaxia incident fueled the expansion of the anti-vaccination movement in the Philippines.

“The Dengvaxia controversy created millions of mothers’ loss of trust in even the regular vaccines; many refused to bring their children for routine immunizations, thinking they would also fall victim to the side effects of vaccinations,” said Dr. Milton Amayun, a public health physician and president of CCIH member International Care Ministries (ICM)  in the Philippines. “This created a pool of unvaccinated children, fertile ground for a measles outbreak.” The outbreak occurred in early 2019 with more than 20,000 cases reported in four months.

This disaster serves as a lesson to health providers that ensuring consistent and transparent quality of care is essential to building local programs. Even with robust supply chains and delivery systems, public perception and trust are essential to local acceptance of vaccines and medical care.

Faith Leader Engagement

In this context of apprehension around emerging vaccines, faith leaders and organizations play a critical role. Public information campaigns are perceived to have an ulterior motive or agenda at play, and are therefore somewhat ineffective in encouraging vaccine uptake. However, local pastors and priests can serve as mediators between health facilities and the community by building trust and encouraging people to protect their children from preventable diseases. The support of everyday doctors, nurses, and church leaders has enormous potential to nudge those deterred by inconvenience or soft resistance toward vaccination.

Arm of young child with bandaids following vaccinationsFurthermore, faith-based organizations (FBOs) are in a unique position to influence governments regarding vaccine policy and distribution. “We underestimate the ability of FBOs to bring about transformative change in healthcare,” says Chataway. Organizations like the Christian Health Associations have built efficient models for vaccine distribution by establishing additional health clinics to, for example, administer the HPV vaccine, which protects against cervical and other cancers.

These clinics supplement government-funded facilities and give people more options of where to get vaccinated, a tactic which has proven effective in increasing vaccine uptake rates. According to Dr. Amayun, this was exactly what ICM did in the Philippines. ICM’s health trainers incorporated lessons on vaccination into their development activities and helped revive referrals for routine immunizations of young children to Rural Health Units with great success.

Faith-based organizations are driven by the moral obligation to stop children and other vulnerable populations from dying from preventable diseases, making them ideal advocates for immunization both locally and globally.

See more from Hyderus about antivaccination groups and the danger of conspiracy theories.

See CCIH resources on faith communities and vaccines.

About the author: Taylor Carty is studying Biology and Hispanic Studies at Pepperdine University and will graduate in 2021. She plans to attend graduate school for public or global health.

Photos: Top Image: Charles Deluvio/Unsplash; Image of Virus: Gerd Altmann/Pixabay; Health worker vaccinating patient: Gustavo Fring/Pexels



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