Vaccination in Ghana. Picture credit: WHO

What’s driving vaccine hesitancy in Africa and how can we overcome it?

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By Adaeze Aroh, Bola Asaolu and Chioma T. Okafor

The World Health Organization-backed COVID-19 Vaccines Global Access (COVAX) scheme has been supporting many African countries with their vaccine distribution efforts since February 2021. However, the process has been wrought with logistic inefficiencies and mismanagement, including issues around equitable access and distribution. Vaccine misinformation and misconceptions have also been a major barrier to uptake across the globe, but particularly on the African continent where several myths abound regarding the efficacy and validity of the vaccine. False messaging and conspiracy theories discouraging the public from getting vaccinated are spreading rampantly on social and mobile media platforms like WhatsApp.

A survey conducted by the Africa Centres for Disease Control and Prevention (Africa CDC) and the London School of Hygiene & Tropical Medicine across 15 African countries has detailed the need to increase confidence in COVID-19 vaccination on the continent. It surveyed more than 15 000 respondents over August-December 2020, and found that the majority (79%) of them would take the vaccine “if it were deemed safe and effective”. However, vaccine willingness varied from 59% in the Democratic Republic of Congo to 94% in Ethiopia. Respondents provided several reasons for being hesitant to take the vaccine, including the belief that COVID-19 was a planned event by foreign actors and Africans being used as guinea pigs for vaccine trials. It is important to note that vaccine hesitancy is not a new phenomenon: during the re-emergence of the wild poliovirus in northern Nigeria, religious leaders boycotted the national immunisation days organised in the context of the global polio eradication initiative due to widespread rumours that the vaccines could be contaminated with antifertility agents, HIV and carcinogens. This resulted not only in an increase in the incidence of polio in Nigeria but in the outbreak of the disease across three continents.

Vaccine mistrust in Africa is not entirely misplaced, as there has been a history of medical experimentation such as the Pfizer meningitis vaccine trial in Kano State, Nigeria. In South Africa, HIV vaccine trials were quickly halted in the early 2000s due to multiple recipients developing more vulnerability to the disease. The COVAX facility, through the WHO, has provided 36 African countries with vaccine doses, but some countries have suspended the use of the AstraZeneca brand due to reports of blood clotting cases in the US and Europe. However, the WHO still considers the benefits of receiving the AstraZeneca vaccine greater than the risk of contracting COVID-19. To address vaccine hesitancy and skepticism on the continent, public health authorities must work to address some of the prevalent myths that hinder uptake and counter them with accurate information.

Addressing myths

Globally, several myths and rumours have arisen since the announcement of successful vaccine candidates to combat COVID-19. With each myth comes an additional layer of challenge especially for healthcare and geared toward minimising the transmission and further spread of COVID-19 and increasing vaccine uptake. In January 2021, the late Tanzanian president John Magufuli claimed: “Vaccines are not good. If they were, then the white man would have brought vaccines for HIV/AIDS.” Such myths create distrust in communities, and an environment for increased transmission of COVID-19. Vaccine hesitancy, fueled by myths and false information, is particularly concerning in Sub-Saharan Africa which has had its own share of viral outbreaks and resistance to prior vaccination efforts. To tackle the community and culturally based misconceptions that shape vaccine hesitation, we highlight a few prevalent myths and misconceptions in this region.

1) Vaccines cause infertility in men and women

According to the Regulatory Affairs Professional Society, there are at least 10 different vaccines across three platforms that have been authorised for use in countries across the world while 102 are currently in clinical development. To date, none of the vaccines have been reported to cause infertility following vaccination. A likely source of this misconception is a letter that was sent to the European Medicines Agency (EMA) by two European anti-vaccination propagandists that erroneously claimed that the vaccine contains a spike protein called synctin-1 that is vital for the human placenta in women. Pregnant women were excluded from the vaccine’s clinical trial during the initial development; however, the trials are being expanded to include them in the population groups of new clinical studies. Vaccine safety profiles have also been very encouraging for each vaccine group that has been authorised by agencies such as the Food Drug Administration (FDA) in the United States and the EMA. The US Centers for Disease Control and Prevention (CDC) also issued a statement that the vaccines are unlikely to pose reproductive health risks to anyone looking to get pregnant in the short term or long term.

2) Different vaccines are being developed for Africa that encourage depopulation

In December 2020, a misleading video emerged claiming that Bill Gates funded vaccine innovation to forcefully vaccinate Africans for the purpose of depopulation. It claimed that the vaccine will contain microchip surveillance technology by Gates’ funded research. These claims have been debunked. The vaccines were created using approved biotechnological research methods and tested in clinical trial subject groups that consisted of a large and diverse subset of people. These vaccines have been approved by the WHO and adopted by multiple national Centers for Disease Prevention and Control.

In another incident, a picture of a medicine box with a label that stated “Not for distribution in the US, Canada or EU” was being circulated on social media in East Africa, with many claiming it was the COVID-19 vaccine that would only be given to Africans who were being used as “experiments”. COVID-19 vaccines were not developed for any specific regions or demographics. A fact-checking report confirmed that the image of the medication being circulated was actually not of the COVID-19 vaccine but of Remdesivir, an antiviral drug that is used to treat patients who are infected with severe cases of the COVID-19 virus.

3) The COVID-19 vaccine is not safe because it was developed so quickly

Prior to the arrival of the new coronavirus, SARS-CoV-2, there was much research done on similar coronaviruses called SARS and MERS. As COVID-19 became a global pandemic, governments and companies put resources toward prioritising COVID-19 treatments and vaccines. Researchers have been developing and researching an mRNA vaccine platform for over 10 years as the pre-existing technology with an already working process that had been studied for the production of Ebola vaccines was evaluated for other vaccine uses, such as in the fight against dengue. Thus, once the SARS-CoV-2 was sequenced, it took just a few days to make the mRNA vaccine candidates.

4) The vaccine contains aborted fetuses

The claim that the vaccine contained aborted fetuses stemmed from the fact that the vaccine contains fetal cell lines, which are completely different from fetal tissue. Fetal cell lines (not fetal tissue) are sometimes used in the development, confirmation or production process of making vaccines – including the COVID-19 vaccine. Science Magazine has reported that cells derived from elective abortions have been used since the 1960s to develop vaccines such as chickenpox, hepatitis A, shingles and rubella, as well as drugs for diseases like cystic fibrosis, hemophilia and rheumatoid arthritis. It is important to note the moral dilemma this may create for faith-based groups against abortion; however, the Vatican in December 2020 deemed the use of vaccine derived from fetal cells as morally acceptable given the grave danger of the pandemic.

The Socio-Ecological Model approach

COVID-19 vaccine hesitancy is an emerging and complex issue, with few proven strategies to address it. The WHO suggests that a comprehensive approach targeting multiple facets of social interaction is more likely to dispel COVID-19 myths and address vaccine hesitancy. Based on this suggestion, we recommend community-based approaches guided by the Social-Ecological Model (SEM) to reduce vaccine hesitancy. The SEM is an ideal framework to guide the recommendations for reducing vaccine hesitancy as it attributes the outcomes of health behavior to multiple factors within and external to an individual. It uses a multi-level approach to target multiple factors that influence behaviors responsible for vaccine hesitancy.

Individual: If an individual believes that they are not at risk of contracting or dying from COVID-19, the probability of taking the vaccine becomes very low. As such, targeted awareness campaigns about the present and imminent risks and complications of contracting COVID-19 are needed in African countries. Effective campaigns such as the “COVID is closer than you think. Take Care” campaign implemented in Zimbabwe to increase risk perception of the coronavirus and vaccine acceptance can be adapted by other African countries.

Interpersonal: Peer-to-peer communication or communication with family, friends, and even acquaintances has been revealed to be initial sources of information for individuals before seeking professional counseling. Resident community champions of COVID-19 vaccines should be identified and included as stakeholders and collaborators in awareness campaigns for reducing vaccine hesitancy. These vaccine champions should undergo training on having authentic dialogues and perhaps town hall meetings with vaccine-hesitant individuals, groups and communities. Healthcare provider-patient interactions must center and engage patients in efforts to empower them for shared decision-making. Additionally, training healthcare workers on vaccine risk acknowledgment and dispensing of evidence-based vaccine information is paramount.

Organisational: More public-private partnership initiatives such as that between the World Health Organization (WHO) and Journalist (Journalists Initiatives on Immunisation Against Polio (JAP) in Nigeria should be formed. This partnership was created to counter the spread of negative messaging associated with poliovirus vaccines. Similar alliances can be formed to mitigate against the spread of negative information around the vaccine. The Africa CDC has been particularly essential in the continent’s response to the pandemic, assessing attitudes on the vaccine uptake and engaging faith-based and behavioral change agents to contextualise community concerns to improve vaccine messaging.

Community: African government leaders should adopt lessons learned from the Ebola virus epidemic, engage community leaders and solicit input from communities to develop social mobilisation campaigns to increase communities’ understanding of the importance of the COVID-19 vaccine and improve communications for the uptake of the vaccine. Community leaders/members can be mobilised and trained to carry out engagement and dissemination of these messages through door-to-door visits, community-based dialogues, different age group meetings, traditional women societies, and religious leaders. In addition, free short message service (SMS) should also be utilised along with radio messages, posters, and flyers in local languages which are easy to understand. African youth play a vital role in the diffusion of information amongst their social networks. They should be trained on how to identify COVID-19 vaccine misinformation and disinformation on social media, and encouraged to disseminate resources for accurate information among their peers and family members.

Society/Policy: African governments need to focus on collaborative efforts and the use of the local capacity for vaccine production, storage, pharmacovigilance and vaccine distribution to reduce vaccine hesitancy. If vaccines are produced in Africa, the fear of Western influences or unknown ingredients would be dispelled to a large extent and the cost of and dependency on Western countries for vaccine procurement will be greatly reduced. The Africa CDC and other country-specific Centers for Disease Control should make evidence-based information available to dispel the myths that currently exist in different African countries. The Africa CDC lists a few resources including AfricArXiv, a pan-African community-led repository of COVID-19-related research that also hosts a chatbot to answer users’ questions regarding COVID-19 in multiple African languages. The site highlights research and technical innovations related to the pandemic to aid the COVID-19 response.

African leaders should institute policies similar to those in other countries such as Britain to clamp down on public disinformation and misinformation, including imposing heavy fines on individuals and establishments such as churches who publicly spread false information about COVID-19 vaccines. Finally, African governments should collaboratively and, through their specific drug safety regulatory agencies, set up functional Vaccine Adverse Event Reporting Systems to collect and analyse data on reported COVID-19 adverse events. This data will inform further studies to determine if the adverse event is a side effect of the vaccine or not. Once it is proven that a vaccine causes adverse effects, this information should be used by governments to decide on the next steps such as discontinuing the vaccines or including all information to warn the public. Such information should be shared with the vaccine manufacturer for further scientific actions.

It is important to note that every medication, treatment and vaccine carries risks. The use of antibiotics can cause several side effects including nausea and stomach pain. Pain relief medications containing acetaminophen can cause liver damage. Common corticosteroids used to treat arthritis can cause elevated blood pressure and bone death. Some common side effects of the COVID-19 vaccine include muscle pain, nausea and fever However, millions of people have received the vaccine so far and these unpleasant side effects outweigh the risk of contracting COVID-19. In the United States, data has shown that among senior citizens, two-thirds of whom are fully vaccinated, hospitalisations have plunged by 70% and deaths have tumbled 50% since the beginning of 2021. Africa, whose 1.3 billion people represent 16% of the world’s population, has received less than 2% of the COVID-19 vaccine doses administered around the world. As the popular Nigerian Igbo proverb goes “Otu onye tuo izu, o gbue ochu” (two heads are better are one). Thus it is integral that Africa governments and public health institutions deploy a multilayered approach to vaccine hesitancy, which includes collaborating with faith-based groups as well as community gatekeepers to reach vulnerable populations. – Africa Portal