Is COVID Vaccine Hesitancy still an Issue in India?
By Arunima Rajan
The answer lies in infodemic management and building an effective communication strategy.
In Anna Nagar, one of the prime residential areas of Chennai, 60-year-old *Prabhakaran spends hours cleaning cars and pruning the garden of his employers. Named after Tamil leader N Annadurai, the neighbourhood is home to several prominent doctors, lawyers and politicians.
"I didn't take COVID vaccination. People like us don't contract coronavirus, and we are immune due to our exposure to other viruses. It's difficult to wear a mask when the temperature is 37 degrees in Chennai," explains the informal worker.
India has been reporting an average of 93,207 cases and 529 deaths every day since April 1. As per the country's health ministry, more than 6.87 crore beneficiaries have been vaccinated on April 2.
Reasons reported for ‘Definitely Not’ getting a Covid-19 vaccine
Source: COVID-19 Symptom Survey
Infodemic
Manish Wadhwani, Consultant Intensivist, Masina Hospital, points out that the main reason behind vaccine hesitancy is a misinterpretation of vaccine data available on the internet by WhatsApp university experts. "They try to manipulate data that is still under research and arrive at a negative conclusion that spreads faster to people by social media, resulting in vaccine hesitancy. Another reason is due to some religious belief that people are not getting vaccinated, as their spiritual gurus have told them. Some people believe they are superheroes and nothing happened to them in the 1st wave, so that nothing will happen now. They don't understand even if nothing happened to them due to their immunity, but they can transmit the infection to susceptible groups of individuals, which can be disastrous," he adds.
Challenges not New
Since the Expanded Programme on Immunization in 1974, vaccination programmes have been one of the world's most cost-effective public health strategies. It reduces the burden of infectious disease and serves as a critical building block for health systems.
"In the past also, vaccination programmes confronted several challenges; low and stagnant coverage levels, under-utilization of vaccines and a communication environment filled with contradictory information about vaccine safety. These are urgent challenges that could further undermine our country's great COVID-19 vaccine achievements if not effectively and quickly addressed," says Dr Sujeet Ranjan, Executive Director of The Coalition for Food and Nutrition Security (CFNS).
Ranjan believes that India's COVID vaccination drive, which started on January 16, is a cause for celebration. "We are still learning how well vaccines prevent an individual from spreading the virus that causes COVID-19 to others, even if a person does not have symptoms. We could rely on an alternative that can protect the lives of many.”
Effective Communication Vital
Ranjan points out that effective communication is vital to dispel fears, address concerns, and promote vaccination acceptance. "Vaccine hesitancy is not only in urban or rural areas but is a complex, rapidly changing problem that varies widely across the country. In some areas, concerns are related to myths of religious or philosophical objectors. When it comes to awareness generation or sharing reliable information about the coronavirus vaccine, governments have a wide range of channels at their disposal. Policymakers can use media platforms, online advertising, celebrity endorsements to influence public opinion. Public service messages over the phone (such as India's COVID-19 caller tune), text messages (such as the Kerala government's SMS campaign on COVID-19), or a combination of these elements is also another option,” he explains.
Ranjan believes that having a solid information system that provides reliable information about the vaccine is equally essential, as there is a fear of vaccination among many. Not everyone is readily going for it. "Fear could be due to a lack of awareness about these products' potential benefits or the adverse consequences of not adhering to health directives. Lack of demand may also be due to existing social norms, general misinformation, or behavioural biases that make individuals less likely to invest time or money in the present to realize a future benefit," he explains.
Myths regarding Vaccines
Dr Arun Kumar, who works in Muzaffarpur Bihar, points out that it was too early to launch the COVID vaccine on January 16 by India's government with emergency use authorization without completing phase 3 trial as in Covaxin. "There is a lot of unpredictability about the side effects and efficacy of the vaccine. Anti-vaccine lobby is highlighting the uselessness and hazards of the vaccine. Media plays a significant role in projecting side effects post-vaccination very prominently though most side effects are minor and coincidental. Irresponsible attitude of politicians/religious leaders and celebrities as film actor Akshay Kumar promoting Chawanprash for protection against COVID giving the impression as a substitute of the vaccine also makes the situation worse," he adds.
Dr Joyeeta Das, co-founder and consultant physician of Doctors Hub in Gurgaon, seconds his views. "Vaccine hesitancy is there because there are genuine concerns regarding their record-breaking timescales and whether their development has followed the same stringent requirements for safety and efficacy as other medicines," says Das.
Das adds that the development of the COVID-19 vaccines did not cut corners on testing for safety and efficacy. "The vaccines were made using processes that have been developed and tested over many years, and which are designed to make — and thoroughly test — vaccines quickly in case of an infectious disease pandemic as we see with COVID-19," she says.
She points out that the vaccines do not contain live coronavirus, and one cannot get COVID-19 from getting vaccinated. "After the shots, you might experience a sore arm, a mild fever or body aches, but this doesn't mean you have COVID-19. These symptoms, if they happen at all, are temporary. It is a sign that your body's immune system is making antibodies," she notes.
Acknowledge Uncertainty
To address this hesitancy, what should policymakers do? "Firstly, acknowledge the uncertainty. People react very strongly to any new or perceived risk from something they have no experience with. But it's not the case that we go through life never facing risk. It's been over a year of pandemic closures/lockdowns, and everyone is eager to think about returning to normalcy. Though no one is sure when the pandemic will be over, every person who gets protection from the coronavirus by getting a vaccination helps us move closer to normal life. As the COVID-19 pandemic continues, getting the vaccine is a powerful step in taking charge of one's health. Even if the vaccines don't have 100% efficacy in preventing one from getting the disease, the vaccine 100% prevents a person from getting severe disease and hospitalization. And let me tell you, that ever since the vaccination drive started for the HCWs, our mortality rates, we who are most exposed to the virus, are now down to almost zero," she explains.
Information Campaign
So, what does it take to get reliable information about the coronavirus vaccine to more people?
"With so many sources chiming in across all social media, we have learned to take every new information coming our way about coronavirus vaccines with a pinch of salt. We currently rely on research journals and credible international government agencies for our information, especially with the guidelines constantly changing as more data comes up," says Roshan Radhakrishnan, an anesthesiologist. He also adds that online vaccine myths fortify people's fears. "Much like with the false beliefs about battling the coronavirus that caused so many avoidable deaths in 2020, we are seeing the next stage in 2021 with wrong concepts of vaccines making eligible people hesitant to take the vaccine and tragically, succumbing to the disease later," he adds.
Vaccine hesitancy across states and union territories in India
Source: COVID-19 Symptom Survey data
Are we exaggerating vaccine hesitancy in India? Is it more an issue of access rather than vaccine hesitancy? Radhakrishnan adds that he is not convinced that it is about taking a day off. "Access due to limited stocks at a centre is possible surely because we were always going to be playing catch up, considering our population. I fear a larger part is still to do with hesitancy to take vaccines. We have come across folk of all ages who outright refused to take the vaccine, often citing the rarest side effects noted or outdated conspiracy theories. We can try to convince them otherwise, but we are facing resistance.”
So, what has been the most effective tool/government initiative to increase vaccination rates in India? "I cannot comment about initiatives taken, but like with most things in recent years, using social media to influence an audience (that audience being India, now) is yielding results. I watch so many people put images of themselves getting vaccinated and usually follow the thread of conversations with those images. So many apprehensions and doubts are cleared just by discussing with those who have taken the vaccine. More than any one-sided initiative which allows no option to answer queries, I see this having a positive impact on convincing those sitting on the fence about taking the vaccine," he explains.
So, is compulsory vaccination the way to go?
Maharashtra government issued a notification that transport workers, delivery service providers, roadside vendors, factory workers and construction workers must get vaccinated as soon as possible as per government guidelines. "My personal opinion is against creating compulsion at a mass level for preventive measures as it widens the trust gap between the government and the public. Even though it may seem tempting to use such coercion in a crisis state, its overarching and far-reaching effects may prove more costly. Delivering transparent messages in simple language/graphics and taking people in confidence at a mass level should be the way forward.
"Another thing to note is the availability of vaccine doses with respect to the country's population. We see reports of a demand-supply gap in this regard. So, all the more reason to tread with caution," says Dr Khan Amir Maroof, Professor, Department of Community Medicine, University College of Medical Sciences and GTB Hospital, Delhi.
Dr Sujeet Ranjan, Executive Director of The Coalition for Food and Nutrition Security (CFNS), notes that the COVID vaccination is very different from routine immunization because the fear of the spread of COVID-19 is not only in the community but also among the service providers. "I strongly recommend that authorities should deploy additional human resources in the field; Social Mobilization Network and field volunteers are also vital.
Their function should be to:
Provide greater on-site attention and focus on the underserved population in hard-to-reach areas
Improve micro planning with local details of population distribution
Provide high-quality training for vaccinators
Increase community involvement
Assure quality through intensified monitoring
Establish a network of informers
"COVID-19 vaccine may be effective in reducing community spread and preventing disease in individuals. Mandatory vaccination could be justifiable when there are benefits to both the individual and preventing transmission. Vaccination will prevent exhaustion of healthcare services in an emergency and protect children and others who cannot decide for themselves," he concludes.