WHO’s head of polio eradication explains how to over come vaccine hesitancy
Fear of vaccination has existed for as long as vaccines have been around – critics circulating false information about their health risks, side effects, and the nefarious “real motivations” of the organisations and people distributing vaccines. The response to the arrival of the coronavirus vaccine has proved no exception with conspiracy theories flying thick and fast – a disturbing new manifestation of the explosion in “fake news” we have seen in recent years.
These concerns are watched closely in the developing world where the AstraZenaca vaccine is perhaps their best hope – it being the only vaccine to be sold at cost. Cameroon and Congo have already suspended their distribution of AstraZenaca due to the worries raised about blood clots. Politicians in Nigeria have backed out of prior commitments to be vaccinated on TV. After this, convincing fearful publics to take the vaccine once it has been approved will only be harder.
The potential death toll that hesitancy could extract is horrifying – an extra 236 deaths per million of the population over a two year period, according to a study released by the Imperial College COVID-19 Response Team. Difficulty supressing the virus also means more and longer lockdowns.
In seeking to overcome this challenge the government would do well to look at how vaccine hesitancy has been dealt with by the global polio vaccination campaign. Started in 1988 and lead by the World Health organisation it is one of the biggest global health initiatives ever undertaken. Today wild polio is thought only to exist in Afghanistan and Pakistan were eradicating the final redoubts of the disease has been complicated by widespread conspiracy theories about the vaccine.
To get a sense of how doctors working in these regions operate, Reaction contacted Dr Hamid Jafari, the WHO’s Director of Polio Eradication Programme in the Eastern Mediterranean Region, to discuss his work.
Joseph Rachman: One of the difficulties the polio eradication programme has had to work to overcome is vaccine hesitancy and even strong anti-vaccination sentiment. In your experience what are the factors that drive people to be suspicious of and refuse vaccines?
Dr Hamid Jafari: The polio programme “has overcome” vaccine hesitancy and anti-vaccine sentiment in many communities around the world, but we know we have some way to go in certain communities in Pakistan and Afghanistan. In WHO’s Eastern Mediterranean Region, as in much of the world, anti-vaccine sentiment presents a significant and ongoing challenge to immunization programmes. There are a variety of drivers: sometimes it’s fear of the unknown, but more often there’s some element of misinformation at play, whether that is falsehoods circulating about vaccines on social media, presenting fallacious ‘evidence’ connecting any number of ills to vaccination, or the anti-West rhetoric that connects these vaccines to non-existent but sinister political aims. Some people believe vaccines are not halal – for that we rely on a robust network of trusted community leaders and imams and religious scholars to talk to them and try to convert those refusals. This network is supported by the statements and guidance of the most senior Islamic scholars who have been brought together in the Region as members of the Islamic Advisory Group.
I think the most challenging opposition, though, are refusals based not on any real issue with the vaccine, but with the local or state or national authorities. In this case, a parent or community in a deprived or insecure area refuses the vaccine until other services are delivered – for example, until a well is dug or a road is fixed. In a sense, you can understand this: they are living in areas that are deprived of basic services, with little to no health and civic infrastructure. But health workers are continually engaging them in the polio vaccination campaigns. This is their last move: holding polio, and their children’s health, to ransom in order to negotiate more services. But as a pediatrician, it makes me wring my hands. If it weren’t for this vaccine, we would still be dealing with hundreds of thousands of paralyzed children around the world every year. Yes, tackling anti-vaccine sentiment is exhausting and expensive, but this is the cost we have to incur to vaccinate all children. If we don’t do this, the costs will be unimaginable for the programme but even more so for the poorest communities in the world.
JR: When attempting to persuade people who are reluctant to be administered the polio vaccinated what methods seem to be effective in getting them to change their minds? What lessons might governments seeking to convince people to be vaccinated against coronavirus learn from this experience?
Jafari: The most effective approach is to listen. It takes time, but parents and communities need to be heard – you can’t work with them to find a way forward without hearing their side. This is what builds trust, and without trust, parents will not open the door and allow vaccinators to put drops in their children’s mouths. The polio programme is a door-knocking programme. And knocking on doors gives you a chance to meet parents and find out what they fear and what they need. We’ve tried a lot of approaches that stem from the idea that vaccine-hesitant parents need to have their concerns heard: we set up social listening initiatives, parent engagement groups, we engage and partner with religious leaders and enlist them in reaching out to parents. For example, National Islamic leaders in Pakistan have issued at least 28 fatwas (religious decrees) promoting the safety of the polio vaccine and the importance of vaccinating children. Local religious scholars in Pakistan also give support and protection to frontline polio workers at the Union Council and community levels.
An important element of trust is rooted in who is knocking on the door and offering the vaccine. Ensuring frontline workers are trusted members of the local community is important, but the most important success factor is local female vaccinators and supervisors who serve as the most effective bridge for the programme and are crucial agents for building trust with the communities.
Countering propaganda online is difficult. A partnership with Facebook in Pakistan has been very productive, but when someone believes anything from WHO or the CDC or their national ministry of health is ‘conspiracy’, it’s tough to counter that. One effort I am very optimistic about is a programme in some of the most intractable pockets of refusal to offer goods and services beyond polio as a way to build bridges with these communities. The polio programme’s experience in this area can be useful to all vaccines and immunization – COVID-19 vaccines included.
JR: One of the key drivers of vaccine hesitancy seems to be misinformation – such as the video which went viral in Pakistan in 2019 claiming children had fallen sick after being administer the polio vaccine and current conspiracy theories about the coronavirus vaccines. Are there ways that governments might seek to combat misinformation either countering it effectively or impeding its spread?
HJ: Frankly, we are deeply concerned about how quickly false information can spread on social media and we are committed to countering inaccuracies with fact-based information about polio vaccines. The Peshawar incident is a harrowing example of how quickly misinformation can spread, and the impact that can have on demand for vaccination – nearly two years on, we are still feeling the impact of that in Peshawar.
An important shift in the government’s approach is a strict avoidance of any coercive measures by local administrators to force vaccination on families that refuse the vaccine.
To build trust in vaccines among parents and caregivers and combat misinformation, the polio programme is engaging with local politicians and influencers, religious leaders, educators, health care institutions and providers, tribal elders and the media. These community-tailored approaches are playing a critical role in increasing confidence in the polio vaccine and in immunization broadly. I mentioned previously that the programme is also collaborating with social media platforms like Facebook, especially in Pakistan, to curtail the spread of false and misleading information online and communicate positive messaging around vaccines. Furthermore, the government of Pakistan has launched an initiative dedicated to combating polio misinformation and increasing vaccine acceptance, including a WhatsApp hotline where people can call with questions and concerns regarding the polio vaccine and the national programme.