Researchers fear growing hesitation over COVID vaccine in developing countries


A dose of vaccine is administered in Kathmandu, Nepal. Credit: Dipendra Rokka / SOPA Images / LightRocket / Getty

Reluctance to the COVID-19 vaccine has long been recognized as a problem in high and middle-income countries. But in some of the world’s poorest countries, lack of access to vaccines has been a much bigger barrier. Today, researchers say that as doses pour in, resistance to vaccination is also becoming a major problem in these countries.

Scientists fear that persistent pools of unvaccinated people around the world may pose an increased risk of the emergence of new variants of concern, such as Omicron. “When you have a lot of community transmission, this is where variants will appear,” says Jeffrey Lazarus, a global health researcher at the Barcelona Institute for Global Health in Spain. Responding to people’s hesitation is therefore crucial to curb the viral spread and avoid hospitalizations and deaths, he says.

Scientists report that the reluctance may now be contributing to the slow uptake of vaccines in some countries where a large portion of the population is still unvaccinated. These include South Africa – one of the countries where Omicron was first detected – Tanzania, the Democratic Republic of the Congo (DRC), Papua New Guinea and Nepal.

“We have more hesitant people in the south of the world than we thought,” says Rupali Limaye, behavioral specialist at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Although in many countries, limited supply remains the main problem, according to the researchers.

Adequate dosage?

Until the end of October, the problem in many African countries “was that we just didn’t have enough doses,” says Salim Abdool Karim, director of the Center for the AIDS Research Program in South Africa (CAPRISA ) in Durban. “But we now have sufficient quantities of vaccines in most countries,” he says. According to the African Centers for Disease Control and Prevention, only 64% of the vaccines supplied to the continent have so far been administered.

In South Africa, for example, the number of doses given each week fell to less than a quarter of the doses given at the height of the vaccination campaign in September. This despite the fact that only 44% of adults were vaccinated with at least one dose.

Calls on social media for more doses from Western countries are puzzling, says Espoir Malembaka, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, based in Bukavu, DRC. Four types of vaccines are now available in eastern DRC, “but we don’t see people in a real rush to get the vaccine,” except for travelers preparing to board flights, says Malembaka. He thinks the problem is not access to vaccines, but mistrust of them.

Researchers say countries might have a hard time scaling up vaccines for many reasons – some of which have nothing to do with reluctance – including poorly funded health systems, the fact that doses are often close to their expiration date and logistical problems in getting vaccines to remote areas. But the delay or refusal of people to get vaccinated is also part of the puzzle.

Global hesitation

Studies have attempted to estimate the extent of reluctance around the world. Investigation1 survey of nearly 45,000 participants in 12 countries – conducted before the start of the COVID-19 vaccine rollout and published in July – found that reluctance was lower in the 10 low- and middle-income countries than in Russia and United States. But researchers say the situation has changed throughout the pandemic. In Nepal, for example, where the study found acceptance to be highest (97%), the pace of vaccination slowed, although only 40% of adults received a dose.

Another investigation2 survey of nearly 27,000 people in 32 countries conducted from October to December 2020 found that people’s intentions varied widely, with high levels of reluctance in some developing countries. At the extreme, 43% of those polled in Lebanon said they would definitely not be vaccinated.

Another survey of a few thousand people observed even lower acceptance in Papua New Guinea, where only 3% of people were vaccinated. The researchers found that more than 80% were not planning to get the vaccine or were unsure.

Similar but different

Some reasons for hesitation are shared globally, but there are also local differences. A major concern is safety, especially because vaccines have been developed and shipped quickly and recommendations for their use have often changed, the researchers say.

Confidence in governments is a related concern. The 32-country survey found that belief that a government was managing the pandemic well was associated with greater acceptance of vaccines. Another analysis3 found that increased trust in medical and scientific authorities made people more likely to agree to the vaccination.

The dissemination of inaccurate information has also hampered deployment in some developing countries. “Misinformation in many places goes beyond evidence-based information,” says Limaye.

But local differences also influence people’s opinions. In eastern DRC, for example, decades of war and devastating Ebola epidemics have fueled mistrust of the rulers and products of the West, says Malembaka. He also found, in a recent unpublished investigation, that hesitation over the COVID-19 vaccine may have spilled over to affect people’s willingness to accept other vaccines.

Global vaccine inequity could also have contributed to the reluctance, due to “the way we distribute vaccines in the south of the world,” says Limaye. “It’s kind of like – here are our leftovers, they expire in a week.”

The long wait for the doses could have encouraged hesitation, adds Kaushik Ramaiya, medical researcher and general manager of Shree Hindu Mandal Hospital in Dar es Salaam, Tanzania. People are starting to wonder if they even need to be vaccinated if they have so far avoided getting infected, Ramaiya says.

Call for vaccine

There are ways to overcome hesitation, the researchers say. Abdool Karim argues that South Africa has reached the point where people need incentives or even government mandates to get vaccinated.

In a recent unpublished survey of people in a number of countries, Lazarus and his colleagues found that mandates – like requiring immunizations for air travel or going to the workplace – can help influence decisions. . He revealed that of those who were reluctant to get the COVID-19 vaccine, a third said they would get the vaccine if needed in order to travel abroad.

Patrick Mdletshe, who heads CAPRISA’s community programs, says the South African government should learn from the HIV epidemic and engage directly with communities to persuade them, instead of investing in media campaigns.

Opportunities for vaccination should also be integrated into existing services for the treatment and prevention of other infectious diseases, such as screening for tuberculosis or distributing HIV drugs, which are accessible and familiar to people. “COVID-19 doesn’t have to be an isolated problem,” he says.


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