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Demonstrate results from countries with a successful vaccination program

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Demonstrate results from countries with a successful vaccination program

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According to exploratory analysis of Covid-19 repository data, countries with more than 80% of the population fully vaccinated are  UAE (86.7%), Chile (75.1%), Portugal (86.5%), Qatar (77%), Denmark (75.9%) and Spain (79.5%)
-Revati

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Prevent deaths from Covid-19 by increasing the proportion of  UK population fully vaccinated. 

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Prevent deaths from Covid-19 by increasing the proportion of  UK population fully vaccinated. 

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New bar chart for 10 selected countries - Katalin

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Share of population fully vaccinated against Covid-19 in selected countries

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Share of population fully vaccinated against Covid-19 in selected countries

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The coronavirus (COVID-19) vaccine. Your best protection against coronavirus. NHS Scotland strongly recommends you get the vaccine when offered it.

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The coronavirus (COVID-19) vaccine. Your best protection against coronavirus. NHS Scotland strongly recommends you get the vaccine when offered it.

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The vaccine is your best protection against coronavirus. Your local NHS health board will be in touch to arrange your vaccination appointment when you are eligible.

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Countries with higher vaccine uptake have a lower death rate from covid_19

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Countries with higher vaccine uptake have a lower death rate from covid_19

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My main concern with this is clear enough for the public to understand.  (Simon)

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'The UK has lost its place as Europe’s vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.'

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'The UK has lost its place as Europe’s vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.'

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The UK has lost its place as Europe's vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.

Throughout September, the UK was vaccinating an average of 1,461 people per million a day, much lower than the 3,925 being jabbed in Italy, 3,694 in France, 3,280 in Spain and 2,305 in Germany.

The UK's rate of vaccination was the fastest in Europe until the end of April, according to data from Our World in Data. At that point, the UK had fully vaccinated more than one in five people (22.5%), compared with a maximum of 10.3% among Germany, France, Italy and Spain.

But the subsequent slow down in the UK's vaccine rollout meant it lost its place as Europe's leader in vaccination coverage in July.

Ten months after the first coronavirus jab in the UK was administered to 90-year-old Margaret Keenan at University hospital Coventry, the UK's vaccine coverage has stalled in recent weeks and stands at about 86% of those who are eligible for a jab.

Figures suggest this is largely due to slow uptake among younger people. There are still significant numbers of people under 40 unvaccinated, according to the latest data from Public Health England. Just 64% of those aged 18-29 were fully vaccinated as of 9 October compared with 96% of those in their 70s. For those aged 30-39, coverage was higher but still a long way off targets, with 77% second-dose uptake.

The increase in uptake among 18 to 29-year-olds has also slowed in recent weeks, PHE data shows. In the month to 9 September the second-dose rate increased by 26 percentage points, while in the most recent month the dial has only been shifted by 8 percentage points.

Chart showing vaccine coverage by age over time

Increase in uptake was even slower among those aged 30 to 39, with coverage rising by just four percentage points from to 77% in the month to 9 October.

Dr Kit Yates, senior lecturer in Mathematical Sciences at the University of Bath, said: "It's a common misconception that the UK's vaccination programme has allowed us to open up more successfully than other similar nations.

"By the beginning of October England had fully vaccinated about two-thirds of its population, which is much lower than countries like Portugal, Spain, Denmark and Ireland. Part of the reason is that many other European countries vaccinated teenagers during the summer in time for the return to school, while the UK dithered over making the decision."

After weeks of mounting political pressure, the UK's chief medical officers agreed to extend jabs to children aged 12-15 in September, going against advice from the Joint Committee on Vaccination and Immunisation, which recommended such a move was unnecessary.

Martin McKee, professor of European public health at the London School of Hygiene & Tropical Medicine, said: "The delay in extending [the vaccine] to 12 to 15-year-olds was a serious mistake and contributed to mixed messaging. So [did] the failure to expose and confront the networks promoting anti-vaccine messaging, some regrettably with links to certain politicians."

"As winter approaches there is an urgent need to reinvigorate the push to vaccinate as many people as possible."

A study for the ONS recently found those aged 16-29 were the most vaccine-hesitant age group, with 8% reporting vaccine hesitancy compared with 5% and 2% in those aged 30 to 49 years, and over-50s respectively.

The data also shows less than one in five 16 and 17-year-olds have been fully vaccinated, however this age group has only been eligible to receive a vaccine since August. Nearly two-thirds of 16 and 17-year-olds have received their first dose.

More than 330,000 younger children - or 12% of 12-15-year-olds - have now received their first jabs. The government has recently begun publishing data for this age group after the education secretary, Nadhim Zahawi, came under fire for admitting he did not know how many younger children had been vaccinated.

Uptake also varies widely by geography, with those in deprived parts of England much less likely to be vaccinated. While a number of areas have fully vaccinated all those aged 16+, in Harehills South in Leeds just 40% of adults have had both jabs.

Harehills South is among the most deprived 10% of areas in England, according to the Indices of Multiple Deprivation, which measures relative poverty. Of the 10 areas with the lowest coverage, seven were also categorised as the most deprived in England.

A chart showing vaccine coverage by Indices of Multiple Deprivation deciles

Several deprived parts of Birmingham were also among areas with the lowest second-dose rates, including Ladywood-Summer Hill, Hockley & Jewellery Quarter and Winson Green & Gib Heath, which all had around half of their 16+ population fully jabbed.

Looking at the whole country, nine in 10 adults in the most affluent 10th of areas are fully vaccinated, compared with just 71% in the poorest 10th.

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Explainer: why has the UK's vaccination rate slowed down?

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The UK has lost its place as Europe's vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.

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'Health communicators hoping to encourage vaccination may be effective by appealing to the personal and collective health risks of not vaccinating.'

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'Health communicators hoping to encourage vaccination may be effective by appealing to the personal and collective health risks of not vaccinating.'

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Revati

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It's a miracle of modern medicine that scientists were able to develop multiple successful vaccines against Covid-19, a disease that wasn't even on their radar a year ago. But so far, the global effort to roll out these vaccines and distribute them to vulnerable people is off to a slow start.

According to a tracker developed by OurWorldInData -a research partnership between the University of Oxford and the British non-profit Global Change Data Lab-three countries have vaccinated a higher proportion of their populations than the rest of the world: Israel, the United Arab Emirates (UAE), and Bahrain.

These Middle Eastern states have administered the jabs to 20.93%, 10.99%, and 5.25% of their populations, respectively, while the US, Denmark, and UK trail further behind at 2.02%, 1.98%, and 1.94%. The rest of the world hovers around 0.5%. (These are based on population estimates from the United Nations World Population Prospects, so other trackers, such as Bloomberg's, may show slightly different proportions.)

What's their secret?

Structural factors

First, Israel, the UAE, and Bahrain are small countries with populations of between 1.5 and 9.3 million people. For Israel and parts of the UAE, which are using the vaccine developed by Pfizer and BioNTech, that's a logistical boon: Since the vaccine doses need to be stored at -70 to -80 degrees Celsius, short distances are key to preventing spoilage during transit. (Abu Dhabi and Bahrain are using the vaccine developed by China's Sinopharm.)

The countries' universal healthcare systems are also helping get people vaccinated quickly, says Tinglong Dai, an associate professor of operations management at Johns Hopkins University Carey Business School, because it "makes it easier to match [vaccine] supply and the demand." Healthcare data are centralized and digitized effectively, so citizens can either access an app or call a hotline and receive an immediate appointment for a jab if they are eligible.

In Israel, every citizen has to be part of one of four major health insurance funds, called HMOs. These funds are incentivized to compete with one another for patients in order to obtain more funding from the government. And Israelis can switch their HMO memberships every six months if they're not satisfied, so the funds "have every incentive to have their members get vaccines as soon as possible," Dai explains.

Medical authorities in the three countries approved the jabs early. Bahrain was the second country in the world to approve the Pfizer/BioNTech jab, and it approved the Sinopharm vaccine in November. Israel was the third to approve Moderna's jab on Jan. 5 and it has secured 6 million doses of it already. It certainly helps that the three countries can afford it.

Israel began to trial the transportation and delivery of the vaccine on Dec. 9 and launched its vaccine rollout on Dec. 19, more than a week before the European Union. It hasn't said how much it paid for doses of the Pfizer/BioNTech, Moderna, and Oxford-AstraZeneca vaccines, but health minister Yuli Edelstein told The New York Times that even if his country overpaid, it will have been worth it to reopen the Israeli economy early.

Population attitude

A key factor of the success of any vaccination rollout is the population's attitude towards it. In France, for example, vaccine skepticism, fueled by disinformation, is seriously impeding the country's efforts to vaccinate people. In a survey conducted by the Kaiser Family Foundation in the US, 29% of respondents who work in a healthcare delivery setting said they probably or definitely wouldn't get the vaccine.

Israel, the UAE, and Bahrain have invested resources in reassuring the public that the vaccine is safe and effective. That starts at the top: Israeli prime minister Benjamin Netanyahu was the first Israeli to receive the shot, and he did so on live television, while the king of Bahrain also received the jab early on.

Health authorities in the countries liaised with religious leaders to make sure their communities turned up to get their jabs. For example, the UAE's Fatwa Council issued an Islamic ruling in favor of the vaccine and its chairman, Abdullah bin Bayyah, was vaccinated in public. Israeli health officials consulted with ultra-Orthodox media and community leaders, although there is still a lack of trust among Muslim Arab and Christian minorities there.

Yoel Hareven is international and resource development director at Sheba Medical Center, the largest healthcare center in Israel and a major vaccination hub. He argues that the mood in Israel right now is evocative of wartime. "Everyone in Israel understands that this is a crisis," he told Quartz. "And because we know how to act in crisis time, everyone is gathering, and unifying to fight Covid-19."

What can the rest of the world learn?

At Sheba, Hareven is part of a team that collects lessons learned from Israel's vaccination drive. He highlights a few:

1. First, reach out to the leaders of minority communities who are more skeptical of the vaccine, wherever they may be. Get them on board and "earn their confidence."

2. Second, recruit volunteers to alleviate the strain on overworked healthcare staff. For example, Sheba called on retired staff to vaccinate the elderly in retirement homes so that frontline healthcare workers could stay in hospitals and clinics. "You will find out that in crisis times, people want to volunteer. You just need to ask them."

3. Third, invest in good digital infrastructure to process and centralize large volumes of health data-like shares of immunized people in a given area-in real time. But "don't do heroic IT efforts," he warns. "Play with what you have and adjust it for Covid."

But Dai argues that while there's lessons to be learned from the early successes of Israel, the UAE, and Bahrain, countries who are frontrunners now shouldn't rest on their laurels. "Two months from now, the focus will shift to [vaccinating] the general population, and that's where we're going to see even more challenges," he explains. "So it's not clear who is a leader yet."

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Three countries have pulled far ahead of the rest of the world in distributing Covid-19 vaccines

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It's a miracle of modern medicine that scientists were able to develop multiple successful vaccines against Covid-19, a disease that wasn't even on their radar a year ago. But so far, the global effort to roll out these vaccines and distribute them to vulnerable people is off to a slow start.

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Demonstrate to the public who are yet to be vaccinated that vaccination reduces risk of death from Covid-19,  and encourage them to take up the vaccine against Covid-19

Katalin

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Bar chart for selected countries comparing % of population fully vaccinated against Covid-19

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Bar chart for selected countries comparing % of population fully vaccinated against Covid-19

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Vaccination reduces the risk of dying from Covid-19. Despite a successful start in the UK, vaccine coverage is lower than several other countries. 

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Vaccination reduces the risk of dying from Covid-19. Despite a successful start in the UK, vaccine coverage is lower than several other countries. 

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Improving public awareness through the distribution of information and data is one of the recommendations to increase COVID-19 vaccination uptake.

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Improving public awareness through the distribution of information and data is one of the recommendations to increase COVID-19 vaccination uptake.

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Vaccination hesitancy is one of the major barriers against the vaccinations programme.
Improving public awareness through the distribution of information and data is one of the recommendations to increase COVID-19 vaccination uptake.

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COVID-19 immunisation programme

The national COVID-19 immunisation programme began in December 2019. It was designed to balance protecting the people most vulnerable to the disease against the need to deliver a national programme quickly and practically. The approach is vaccinating groups of the population to reflect age-related risk. There are two phases:

Phase 1: completed on 13 April 2021, this targeted at-risk individuals including those aged over 50, healthcare and social workers and the clinically vulnerable to reduce the incidence of death and severe disease (see POST rapid response changing the UK COVID-19 vaccine dosing schedule).

Phase 2: aims to offer vaccines to the remaining adult population (divided into age cohorts) by the end of July 2021. Individuals aged 18 and above are currently being invited for vaccination. As of 14 April 2021, it was reported that 3 million people who had been offered a vaccine had not received it. PHE suggest barriers to access to be the main factor, followed by vaccine hesitancy and refusal.

Public Health England estimated that 13,200 deaths and 39,700 hospitalisations have been prevented following the launch of phase 1 and 2. In April, the Joint Committee on Vaccination and Immunisation (JCVI) published their advice for phase 2 of COVID-19 vaccinations for all adults aged over 18. To vaccinate adults as quickly as possible, the programme will continue to offer vaccines by age cohorts rather than subgroups based on other risk factors:

all those aged 40 to 49 years

all those aged 30 to 39 years

all those aged 18 to 29 years

The JCVI identified the following groups to be at higher risk of morbidity and mortality from COVID-19 and advised public health services to prioritise and promote vaccination to these individuals:

In March 2021 SAGE discussed the risk of a third wave of COVID-19 infections among vulnerable groups who are not directly protected, either because they are not vaccinated or because the vaccine offers insufficient protection. Depending on regional and local-level vaccine coverage, vulnerable groups may be indirectly protected by the wider vaccine uptake in the community.

However, if there are communities with lower vaccination levels, they may be more susceptible to infection and disease. Consequently, the dose schedule was changed to accelerate 2nd doses and therefore increase two dose coverage.

What is vaccine coverage?

Vaccine coverage is a term used to describe how many people in a population have received a specific vaccine. Vaccination coverage data is important; when a larger proportion of the population is vaccinated, the more protected it is.

COVID-19 vaccines reduce the risk of infection, transmission, severe morbidity and mortality (See POST Rapid Response COVID-19 vaccines and impact on transmission). The current UK approved COVID-19 vaccinations require two doses of a COVID-19 vaccine, given on separate occasions, to afford the highest level of protection. PHE cites evidence (June 2021) that shows a single dose is between 55-70% effective against symptomatic disease.

Current data on COVID-19 vaccine coverage in England

In England, as of 1 July 2021, the Government coronavirus data dashboard showed that for adults over 18 years:

85% (37,618,263) had received one dose

62.8% (27,776,520) had received two doses

This data is updated daily on the dashboard and can be sorted according to region.

What do we know about how COVID-19 vaccine coverage varies?

NHS England collects data on COVID-19 vaccinations for people aged 18 and over. There are geographic differences in coverage.

As of 1 July 2021, the lowest coverage rates were in London where 62.5% of adults had received one dose and 41.2% had received two doses. Coverage rates increase to 79.2% and 60.6% in the North East of England, with the highest rates of coverage seen in the South Western region with 81.5% having received one dose and 61.6% receiving two doses.

The ONS reported on vaccine coverage on 15 May 2021. It found that disparities are associated with:

Socioeconomic deprivation: vaccination coverage is lowest in the most deprived areas - 84.1% compared to 93.6% in the least deprived areas. NHS data shows that coverage is 75% for those aged 50-54 in the most deprived areas of England compared to 90% in the least deprived areas.

Ethnicity: 92.6% of White British people aged over 40 were vaccinated compared to 63.6% of Black Caribbean, 67.8% of Black African, 70.3% of Pakistani and 72.8% of White other people in the same age group.

Age: of individuals over 90 years old, 96.0% are vaccinated. This compares to 76.6% of those aged between 40-49 years.

Religion: People of Muslim religion or those who identified as having an 'Other' religion had lower vaccination rates (71.8% and 79.9% respectively) compared to those with Christian and Jewish religion (92.1% and 91.0% respectively). Those with no religion displayed a vaccination rate of 87.3%.

Household tenure: Homeowners had a higher rate of vaccination (92.8%) compared to private rented (77.7%) and social rented (83.6%) householders.

An Understanding Society UK study (April 2021) found that disparities were also associated with pre-pandemic mental and physical health diagnosis. Individuals who have been prioritised for COVID-19 vaccinations due to physical medical conditions were more likely to accept the vaccine.

Why is vaccine coverage lower in some groups?

There are numerous reasons why someone may have chosen not to be vaccinated or to have delayed their vaccination. These include barriers to access and attitudes towards a vaccine including vaccine hesitancy.

Barrier to access

The ONS reports on barriers to COVID-19 vaccination and other studies (including the Nuffield Council on Bioethics report on vaccine access and uptake) show that individuals' access to vaccination are influenced by numerous factors:

timing, availability, and location of appointments;

accessibility of transport to and from facilities where vaccines are offered;

childcare responsibilities, particularly for larger families;

forgetting appointments;

indirect costs associated with vaccination, such as transport or taking time off work;

accessibility of information, including language barriers and the ability to access and use digital systems; and

changing address frequently is common among some groups, including traveller communities and the homeless, resulting in inaccurate or incomplete NHS records.

Some of these barriers are common and have been documented in previous vaccination programmes as highlighted in the PHE immunisation inequalities strategy (2021).

Attitudes towards a vaccine

Attitudes to COVID-19 vaccination have changed over the course of the pandemic. Data from the ONS recorded from January 2021 to May 2021 show that COVID-19 vaccine hesitancy has decreased, and positive attitudes around vaccines increased in the first three months of the COVID-19 vaccine rollout. Research from the Ipsos MORI UK Knowledge Panel confirms an increase in vaccine confidence and shows a month-by-month increase in willingness to be vaccinated (December 2020 to March 2021). Vaccine confidence refers to the level of trust individuals have towards vaccination.

In a study by the University of Oxford in autumn 2020, 58.1% of ethnic minority participants were likely or very likely to take the vaccine, and this increased to 80.5% by February 2021 after the vaccination programme began.

Vaccine hesitancy

Understanding Society's UK longitudinal study investigating the predictors of COVID-19 hesitancy (see definition of longitudinal studies here) identified a number of characteristics associated with increased vaccine hesitancy: lower educational attainment; coming from an ethnic minority group; being younger; being female; and coming from a socioeconomically deprived background. These findings have been reflected in many other surveys.

The Opinions and Lifestyle ONS Survey May 2021 found that:

13% of adults aged 16 to 29 years reported vaccine hesitancy, the highest of all age groups, whilst 9 in 10 reported positive sentiment towards a COVID-19 vaccine;

21% of Black or Black British adults reported vaccine hesitancy, the highest compared with all ethnic groups;

8% of adults in London reported hesitancy: a higher percentage than most other regions in England;

12% of adults in the most deprived areas of England (based on the Index of Multiple Deprivation) reported higher vaccine hesitancy, compared with 4% of adults in the least deprived areas of England.

A paper prepared by SPI-B (Independent Scientific Pandemic Influenza Group on Behaviours) for SAGE analysed a series of data and made a recommendation to examine vaccination rates in more nuanced subgroups moving beyond broader categories like age or ethnicity to understand more clearly the factors influencing vaccine uptake and to develop better messages.

Reasons for COVID-19 vaccine hesitancy

The ONS commissioned an in-depth qualitative study carried out by IFF Research that investigated vaccine refusal and uncertainty amongst 50 individuals, between February and March 2021 in the UK. It included individuals who were parents, on a lower income, who had low education attainment, belonged to an ethnic minority or were clinically vulnerable. Research suggests that factors affecting COVID-19 hesitancy include:

Mistrust

Some participants displayed a lack of trust in the Government's reporting of COVID-19 cases and the approach to vaccine roll out. Participants expressed a lack of trust towards vaccine manufacturers on account of them being granted some legal protection against civil liability where vaccine consequences may occur.

Mistrust is a significant concern amongst some ethnic minorities. According to the HealthWatch VacciNation report, one aspect of mistrust is related to alleged systemic oppression within UK institutions and recent events like the Windrush scandal. An article in the Lancet also reports that vaccine hesitancy among people from some minority ethnic backgrounds has been linked to a lack of trust resulting from institutional racism, discrimination and historical abuses, such as the Tuskegee syphilis study.

A review by the Nuffield Council on Bioethics found that lack of trust was also related to suspicions about motives and interests driving vaccination programmes. They report that some groups lack trust because they view vaccination as an 'attempted 'quick-fix' technical solution which fails to address deeper structural social and cultural problems that affect health and disease, such as inequalities of wealth, housing and education.'

The Lancet article found that trust can also be affected by previous interactions with healthcare systems, for example, where people have experienced inequality of access to, and quality of, healthcare. The Oxford COVID-19 vaccine hesitancy study, found that if participants had positive healthcare experiences with 'supportive doctor interactions and good NHS care' they were more positive about vaccination.

Safety and risks

Participants in the ONS/IFF study believed that the COVID-19 vaccines were developed more quickly in comparison to other vaccines and that any long-term side effects were not yet understood.

In the UCL-Penn Global COVID study, safety concerns and side-effects were a key reason that study participants gave as the reason why they were unsure about taking the vaccine. In the Healthwatch report, participants were also concerned about the potential impact of vaccines on fertility. Similar findings were found in ONS opinions and life survey where fears of long-term effects on health, side effects and how well the vaccines work were the top three reasons on reporting negative attitudes.

Although the national vaccine programme monitors safety (see POST Rapid response monitoring COVID-19 safety in national immunisation programmes) surveys show some individuals feel that there is a lack of transparency in safety monitoring. This is also seen in the UK household longitudinal study (2021), where the main reason for hesitancy was fear over unknown future effects.

Information

Some participants reported stories linking the COVID-19 vaccine rollout to conspiracy theories relating to population control. This experience is supported by evidence from surveys investigating hesitancy and attitudes to COVID-19 vaccines, which found that exposure to conspiracy theories was associated with vaccine hesitancy.

Some participants were keen to have more and clearer information on COVID-19 vaccines, and specifically on: side effects; their contents; how they were developed; and the differences between the COVID-19 vaccines. The participants admitted they would re-think their sentiment toward the vaccines if there was accessible information available about the side effects. There was some confusion and concern about the different types of COVID-19 vaccines. Media coverage with different news stories about each vaccine made it harder for individuals to understand whether they were all safe. Similar concerns were presented in the UCL-Penn Global COVID study.

The Nuffield Council on Bioethics' briefing states that recent studies have found that individuals that source information from mainstream media are generally more positive towards vaccines, whereas those who rely on the internet and social media platforms, where misinformation and contradictory messages may be rapidly circulated, are less positive (See POST Rapid Response COVID-19 vaccine misinformation).

Societal attitudes, beliefs, and values

Some participants were worried about the vaccine development processes and contents of the COVID-19 vaccines, and whether these conflicted with religious and ethical beliefs. These include beliefs around the purity of the body or animal rights. A Lancet study looking at global trends in vaccine confidence and investigating barriers to vaccine uptake found that an individual's religious belief was the most common factor associated with vaccine uptake.

However, the study also found that some participants who were unwilling and uncertain about getting a COVID-19 vaccine felt vaccination was unnecessary since they believed they were less likely to catch or develop serious symptoms from COVID-19. This was because they were young or felt they were taking precautionary steps like natural remedies or relying on their immune system.

Interventions and recommendations to increase vaccine coverage

The Nuffield study set out several strategies being used by different governments to address barriers and to improve access to vaccines. These strategies include education, information campaigns and policies that aim to incentivise vaccination or penalise those who do not get vaccinated (such as by restricting access to certain services).

The evidence of using simple and positive information as a technique to improve vaccine sentiment was reported in a randomised control trial studying the effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III). This provided evidence on how providing in-depth information on a personal level increases the vaccine confidence and willingness across all participants including those from different ethnic and socioeconomic backgrounds. There is are also some research suggesting interventions which protect against online misinformation (See POST Rapid Response COVID-19 vaccine misinformation) .

The Government's equalities office published the second quarterly report on progress to address COVID-19 health inequalities (March 2021), summarising target interventions for COVID-19 vaccinations. It also reports on government pilots of community-led, localised, asymptomatic testing at places of worship in ethnically diverse areas with the aim of removing some of the main identified barriers to engaging with Test and Trace, including trust and access. The success of community approaches to testing engagement could offer a model for improving vaccine coverage.

However, the Healthwatch report cautioned that targeted communication campaigns can be "counter-productive". It noted that some Black and Asian individuals had felt that information aimed at them had created a "sense of blame" and in some it had raised suspicions about the motivations behind the campaign. It reported that pressure to get the vaccine "felt very oppressive for some".

Current and prospective projects in the UK to increase vaccine uptake

In February 2021 the Government published the UK COVID-19 vaccine uptake plan. This described the four key "enablers" to improving vaccine uptake across all communities:

Working in partnership: using a community-led approach supported by the Government, NHS England and local authorities.

Removing barriers to access: directly working with hard-to-reach and deprived communities.

Data and information: publicly sharing data frequently and targeting information and advice via social media, tv, radio and printed materials whilst acting against incorrect claims about the virus and anti-vaccination messages.

Conversations and engagement: providing advice and information at every opportunity in a simple format people can understand, leveraging role modelling, peer education and champions across society and sharing these examples.

The Government is also reviewing whether COVID-status certification or "vaccine passports" could be used to enable access to settings or to reduce restrictions. The consultation closed in March 2021, the review has not yet been published. The Government also ran a consultation on potential vaccine mandates for staff working with individuals of older adult care residents, which closed in May 2021. The Government responded to the consultation on 16 June. It stated that it will be bringing forward regulations to require all Care Quality Commission-regulated service providers of nursing and personal care, in care homes in England, to allow entry to the premises only to those who can demonstrate evidence of having had a complete course of an authorised COVID-19 vaccine. Entry will also be allowed for those with evidence that they are exempt from vaccination.

Some experts have raised concerns that vaccine passports could inadvertently discriminate or exacerbate existing inequalities and vaccine hesitancy. For example, if people for whom vaccination is unacceptable, untested, inaccessible, or impossible are denied access to essential goods and services. Some experts claim that it will have ' significant implications across a wide range of legal and ethical issues. They argue that these examples signal the need for alternatives and exemptions (see COVID-19 vaccines and virus transmission).

The Local Government Association has produced a briefing on guidance and recommendations for local authorities on increasing uptake for COVID-19 vaccinations with key guiding principles being to 'engage to understand, engage to empower and engage to evaluate'.

In order to improve public health communications with those communities most at risk from COVID-19, the Government released £23.75 million in funding in February 2021 to local authorities under the Community Champions scheme. This funding is to enable local authorities to work with community groups to tailor public health communications and to use trusted local voices to promote healthy living, encourage vaccine uptake and counter misinformation. This seeks to complement current communication campaigns aiming to engage with all communities through champions. For example, the London Borough of Southwark introduced vaccine vans and pop-up clinics in mosques and churches to reach people in familiar local locations. This approach has now been implemented by other local authorities.

The UK Government recently announced a partnership with dating apps to improve vaccine uptake. This includes online communications and online rewards and bonuses such as extra credits to boost an individual's profile and show an individual's support for vaccination.

The NHS has enrolled celebrities to influence and increase COVID-19 vaccine uptake in particular groups as well as the general public. A video and signed open letter featuring high profile individuals from Black British and Asian backgrounds was released to increase engagement amongst those communities - although concerns have been raised about the effectiveness of this approach as mentioned in the Healthwatch report.

A prospective 18-month research study funded by the UK Research and Innovation's Economic and Social Research Council has been approved and will investigate the factors limiting vaccine uptake in minority ethnic groups through interviews and focus groups with community members. This in-depth exploration aims to use a behavioural sciences framework to evaluate campaigns across the UK and 'develop evidence-based messaging which support vaccination decision making.'

Acknowledgements

POST would like to thank Dr Ben Kasstan (University of Bristol) and Dr Keri Wong (University College London) who acted as external peer reviewers in preparation of this article.
A correction was made on 06.07.2021. POST corrected a sentence in the section on reasons for vaccine hesitancy under the subsection of safety and risks. It previously read 'Participants were also concerned about the potential impact of vaccines on fertility. Safety concerns and impacting fertility was also a reason stated in participants of the UCL-Penn Global COVID study and the Healthwatch report' and now reads 'In the UCL-Penn Global COVID study, safety concerns and side-effects were a key reason that study participants gave as the reason why they were unsure about taking the vaccine. In the Healthwatch report, participants were also concerned about the potential impact of vaccines on fertility.' Under the same section, under the subheading 'information', in the second bullet point, a sentence was added at the end which states 'Similar concerns were presented in the UCL-Penn Global COVID-19 study'. These changes were applied to improve the accuracy of citations regarding the data and information produced from the studies cited in the rapid response.

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COVID-19 vaccine coverage and targeted interventions to improve vaccination uptake - POST

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The COVID-19 vaccination programme launched in January 2021. All adults over 18 have now been offered the vaccine, although it was reported that 1.3 million people who had been offered a vaccine had not received it. Some people are vaccine hesitant whilst others experience barriers to accessing vaccines.

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Demonstrate results from countries with low vaccine rollout

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Demonstrate results from countries with low vaccine rollout

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According to the exploratory analysis of Covid-19 repository data, two countries with low vaccine rollout were South Africa (18.6%) and Russia (32.4%).
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An article from Johns Hopkins Medicine advice uptake and effectiveness of available COVID-19 vaccines

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An article from Johns Hopkins Medicine advice uptake and effectiveness of available COVID-19 vaccines

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Featured Experts:

Yes. The two mRNA vaccines, Pfizer and Moderna, authorized by the U.S. Food and Drug Administration (FDA) and recommended by the Centers for Disease Control and Prevention (CDC), are very safe and very good at preventing serious or fatal cases of COVID-19. The risk of serious side effects associated with these vaccines is very small.

Lisa Maragakis, M.D., M.P.H., senior director of infection prevention, and Gabor Kelen, M.D., director of the Johns Hopkins Office of Critical Event Preparedness and Response, answer questions about the safety of the COVID-19 vaccines.

COVID-19 Vaccine Safety - What We Know

The Pfizer and Moderna vaccines are strongly recommended as safe and effective at preventing serious illness or death from COVID-19.

From December 2020 to December 2021, about 470 million doses of COVID-19 vaccine have been given in the U.S.

Roughly 12 months of data, including data from tens of thousands of participants in clinical trials, show that the vaccines are safe and effective at preventing serious disease or death due to COVID-19.

Additional shots and boosters are also authorized for those who meet the guidelines.

mRNA technology used in the Pfizer and Moderna vaccines has been in development for over 15 years.

The Pfizer and Moderna vaccines received full FDA approval, which means more data show how well that particular vaccine works.

Due to potential blood clots following administration of the Johnson & Johnson vaccine, the CDC updated its recommendations in December 2021. The CDC noted that the two mRNA vaccines, from Pfizer and Moderna, are preferred over the Johnson & Johnson vaccine.

Are there risks or safety concerns regarding the COVID vaccines?

To help catch risks or safety concerns, the CDC and FDA monitor possible safety issues with the COVID-19 vaccines. This ongoing work has led to revised recommendations for the Johnson & Johnson vaccine and information about rare side effects tied to the Pfizer and Moderna vaccines.

Johnson & Johnson/Janssen. In December 2021, the CDC updated its recommendations and stated that either of the two mRNA vaccines is preferred over the Johnson & Johnson (J&J) COVID-19 vaccine. The CDC explained that the Pfizer and Moderna vaccines are preferred due to a greater risk for developing rare but severe blood clots, called thrombosis with thrombocytopenia syndrome (TTS), following administration of the J&J vaccine. The CDC noted that there are some situations when a J&J vaccine may still be used, if the recipient understands the risks and benefits of the J&J vaccine. Read about side effects related to the rare blood clot.

At Johns Hopkins Medicine, we offer Pfizer and Moderna vaccines throughout our vaccine clinics.

Pfizer and Moderna. After observing rare occurrences of myocarditis following the second injection of the Pfizer and Moderna COVID-19 vaccines, the CDC released information for the public. Most of these myocarditis events happened in teens and young adults, and the majority of the cases were mild and cleared up on their own. Read about side effects related to myocarditis.

This review process continues to monitor vaccine safety. Potential risks of COVID-19 vaccines are reviewed and weighed against the benefits of protection that the vaccines offer as well as the known, serious risk of harm due to COVID-19.

What if I got a J&J vaccine? Should I worry about blood clots?

If you received a Johnson & Johnson vaccine more than three weeks ago, you do not need to watch for side effects related to blood clots.

If you received the J&J vaccine within the last three weeks, you should watch for possible symptoms of TTS and get medical help immediately if you have any of the following:

Severe or persistent headaches or blurred vision

Shortness of breath

Chest pain

Leg swelling

Persistent abdominal pain

Easy bruising or tiny blood spots under the skin near the injection site

Is there a risk of an allergic reaction to a COVID vaccine?

According to the CDC, anyone who has a severe allergy (e.g., anaphylaxis) to any of the mRNA vaccine ingredients should not receive this vaccine. The CDC says people with allergies to certain foods, insects, latex and other common allergens can safely receive the COVID-19 vaccine. Those with a history of severe allergic reaction (anaphylaxis) to injectables or other vaccines should discuss the vaccination with their doctor, who can evaluate and assess their risk.

The COVID-19 Vaccines: What you need to know | Las vacunas anticovid-19: información imprescindible

How was the COVID-19 vaccine developed so quickly?

The relatively quick development of these vaccines does not mean safety measures were skipped. There are several reasons why the COVID-19 vaccines were developed faster than other vaccines:

The technologies used to develop the COVID-19 vaccines have been in development for years to prepare for outbreaks of infectious viruses. The manufacturing processes were ready very early in the COVID-19 pandemic.

Countries shared genetic information when it was available about SARS-CoV-2, the coronavirus that causes COVID-19, which gave vaccine developers an early start at finding a vaccine.

The testing processes for the vaccines didn't skip any steps, but the vaccine developers conducted some stages of the process simultaneously to gather as much data as quickly as possible.

Governments gave money to vaccine developers in advance, so the companies had resources they needed.

Some types of COVID-19 vaccines were created using messenger RNA (mRNA), a new technology that allows a faster approach than the traditional way vaccines are made.

Social media enabled companies to reach out to and enroll study volunteers, and plenty of people wanted to help, so there were enough research participants to test the COVID-19 vaccines.

Because SARS-CoV-2 is so contagious and widespread, many volunteers who got the vaccines were exposed to the virus, and with so many exposures, it took a shorter time to see if the vaccines worked.

Companies began manufacturing vaccines ahead of their authorization or approval so some supplies would be ready if authorization occurred.

What steps are taken to help make sure the COVID-19 vaccines are safe?

Safety is always a top priority as federal agencies work with vaccine manufacturers and independent scientific organizations to develop, study, authorize and approve new vaccines. Here are some of the steps taken for COVID-19 vaccines, as well as other vaccines:

Careful testing. All vaccines go through clinical trials to test safety and effectiveness. For the COVID-19 vaccine, the FDA set high safety standards for vaccine developers to meet. This graphic from the National Institutes of Health shows the four phases a vaccine goes through before it is released to the public.

Authorization for emergency use. If a vaccine or medicine is needed to address an emergency situation such as the COVID-19 pandemic, once it is shown to be safe and effective, the FDA can grant it an emergency use authorization (EUA). An EUA allows a vaccine, treatment or medication to be used before the formal FDA approval.

Continuous monitoring for problems and side effects. Once a vaccine gets an EUA and is being given to people, the FDA and the CDC continue to watch carefully in case problems arise. Data on the vaccine's safety record accumulates over time, as more and more people who receive it report on their experience and any side effects. One important way to report adverse events after vaccination is through the Vaccine Adverse Event Reporting System.

Learn more from the CDC about the safety steps for the COVID-19 vaccine.

Demographics of the COVID-19 Vaccine Trials

Do I still have to wear a mask if I get a vaccine?

The CDC continues to monitor the spread of COVID-19 and makes recommendations for wearing face masks, both for those who are fully vaccinated as well as people who are not fully vaccinated.

The CDC also recommends that masks and physical distancing be required when going to a doctor's office, hospital or long-term care facility, including all Johns Hopkins hospitals, care centers and offices.

Johns Hopkins Medicine's mask safety guidelines have not changed, and we still require everyone to wear masks inside all of our facilities.

Can I get COVID-19 from the vaccine?

You cannot and will not get COVID-19 from any of the vaccines. The COVID-19 vaccines do not have any virus or other infectious material in them.

What about the safety of COVID-19 vaccination for diverse groups of people?

The FDA and other reviewers closely consider diverse populations and include them in the trials. The clinical trials for the first two COVID-19 vaccines included members of underrepresented minorities and older age groups, and people with conditions such as obesity, diabetes, and heart and respiratory conditions.

Does Johns Hopkins Medicine recommend that I get a COVID-19 vaccine?

Yes, we recommend that everyone who is eligible get vaccinated with one of the currently authorized mRNA COVID-19 vaccines: Pfizer or Moderna. We view both as highly effective in preventing serious disease, hospitalization and death from COVID-19 (including disease caused by the very contagious delta and omicron variants of the coronavirus), and we believe that their benefits outweigh their risks.

At Johns Hopkins Medicine, we offer Pfizer and Moderna vaccines throughout our vaccine clinics.

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Our experts answer some frequently asked questions about vaccine safety.

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Covid: Vaccines '90% effective' at preventing Delta variant deaths

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Covid: Vaccines '90% effective' at preventing Delta variant deaths

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This report was based on research at The University of Edinburgh.

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Prof Aziz Sheikh, director of the University of Edinburgh's Usher Institute and EAVE II study lead, said: "With the Delta variant now the dominant strain in many places worldwide, and posing a higher risk of hospitalisation than previous variants seen in the UK, it is reassuring to see that vaccination offers such high protection from death very shortly after the second dose.

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Covid: Vaccines '90% effective' at preventing Delta variant deaths

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Prof Aziz Sheikh, director of the University of Edinburgh's Usher Institute and EAVE II study lead, said: "With the Delta variant now the dominant strain in many places worldwide, and posing a higher risk of hospitalisation than previous variants seen in the UK, it is reassuring to see that vaccination offers such high protection from death very shortly after the second dose.

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Robertson E, Reeve KS, Niedzwiedz CL, Moore J, Blake M, Green M, Katikireddi SV, Benzeval MJ. Predictors of COVID-19 vaccine hesitancy in the UK household longi

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A field trial shows that text-message ‘nudges’ encourage people to get vaccinated against COVID-19.

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A field trial shows that text-message ‘nudges’ encourage people to get vaccinated against COVID-19.

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A field trial shows that text-message 'nudges' encourage people to get vaccinated against COVID-19. To be effective, nudge approaches such as this must combine three aspects: they must prompt, enable and motivate behaviour.

Mitesh S. Patel

Mitesh S. Patel is in the sections for Behavioral Insights and Clinical Transformation, Ascension Health, St Louis, Missouri 63134, USA.

Nudges are subtle changes to the way in which choices are offered or information is framed that can have an outsize impact on behaviour. As the supply of COVID-19 vaccines increases around the world, many nations are faced with the challenge of how best to encourage people to get vaccinated. Although various campaigns to do this have been implemented, little is known about which types of approach work and which do not. Writing in Nature, Dai et al. present findings from a large field experiment that reveal new insights into the three key elements that must be combined in strategies aimed at increasing the likelihood that people will get their vaccination against COVID-19.

Dai and colleagues set out to determine whether a single text message from a person's health-care provider could change COVID-19 vaccination rates. In addition, they tested whether vaccination rates differed when recipients were told the vaccine was already theirs - that is, when they had psychological ownership of the vaccine. These text messages included phrases such as the vaccine has "just been made available to you", and encouraged recipients to "claim your dose". Such an approach has been used successfully to nudge influenza vaccination, but has not previously been tested for vaccination against COVID-19.

In the main clinical trial, more than 93,000 individuals in a large health-care system who had not organized an appointment by the first weekday after an initial invitation were randomly placed in a control group or a test group and then followed for 4 weeks. These individuals were among the first wave of people eligible for vaccinations (owing to age or pre-existing medical conditions). Of the control-group individuals who did not receive any text-message reminders, 13.9% got vaccinated. Among individuals who received a simple text-message reminder with a link to a website where they could schedule a COVID-19 vaccine appointment, the vaccination rate increased to 17.1%. Adding language to induce psychological ownership further increased vaccination rates to 18.2%.

Before this clinical trial, the investigators conducted an online experiment with individuals participating as hypothetical patients. They found that asking individuals to watch a two-minute educational video on the vaccine led to slightly higher stated intentions to get vaccinated than were seen for individuals who had not watched the video. However, unexpectedly, when the authors added a link to this video in the text-messaging experiment, it led to slightly lower vaccination rates than did sending text messages alone.

These conflicting results might be explained by some key differences between the two studies. For example, the online group of hypothetical patients had a mean age of 37 years, and 100% were required to watch the video, whereas individuals in the clinical trial had a mean age of 73 years and only 21% watched the video. Although the precise reasons for the inconsistent effect of the video are unclear, these findings demonstrate the value of conducting rigorous testing of approaches in real-world groups of individuals, rather than hypothetical ones.

So, how can we apply these findings to future vaccination efforts? According to the Fogg Behavior Model (see behaviormodel.org), three key aspects need to be combined to successfully nudge behaviour: ability to act, motivation and a prompt. Moreover, the best nudging approaches to use will vary depending on individuals' attitudes towards the COVID-19 vaccine (Fig. 1). For example, individuals who are hesitant about the vaccination often have a strong emotional response to the risks and benefits of the vaccine, whereas those who are apathetic about it have weakly held attitudes and often have not invested much effort in considering vaccination. Appropriately tailoring interventions to the population of interest is likely to lead to higher success than is a one-size-fits-all approach.

First, interventions should aim to make the intended behaviour easier. In this case, the text messages provided a link to schedule an appointment. This made setting up vaccination quick and convenient. This aspect of the intervention boosted vaccination rates the most and probably addressed barriers among people with vaccine apathy who were unlikely to go out of their way to look up scheduling information (Fig. 1a).

Second, interventions should focus on increasing an individual's motivation for the intended behaviour. The text-message reminders that invoked psychological ownership probably boosted vaccination by increasing motivation. However, compared with the simple text-with-link intervention, the increase in vaccine uptake following this intervention was relatively small (about 1 percentage point). The investigators also tried sending a second text-message reminder after another eight days to those who had still not scheduled an appointment. Individuals in this group were probably more hesitant than were those who had already set up their vaccine appointment, and that second reminder did not change overall vaccination rates compared with the control group. Individuals with vaccine hesitancy thus might often require further approaches to increase motivation (Fig. 1b), either through other types of nudge or different approaches, such as incentives,.

Third, interventions should prompt action. Sending a text message to consider vaccination forces a person to think about the decision 'now', rather than relying on them to remember to think about it on their own. The best channel for sending the notification will probably vary for different groups of people. For example, someone who is not tech-savvy might respond better to a phone call.

Although even the best text-messaging approach in the clinical trial increased vaccination by only a few percentage points, one must keep in mind that these approaches were very low cost and, if applied on a broader scale, could lead to millions of extra vaccinations that might otherwise have been delayed or not occurred at all. Nudges can be an effective tool for changing an individual's behaviour, but they must be carefully designed. As health systems, public-health agencies and other stakeholders look for methods to increase COVID-19 vaccination rates, they should consider ways to implement nudges that make getting a vaccine easier, that increase motivation and that prompt action.

Competing Interests

The author is the owner of Catalyst Health, a behaviour-change and technology consulting firm, and is an advisory board member for Life.io, Healthmine Services Inc., Holistic Industries and Humana.

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Text-message nudges encourage COVID vaccination

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A field trial shows that text-message 'nudges' encourage people to get vaccinated against COVID-19. To be effective, nudge approaches such as this must combine three aspects: they must prompt, enable and motivate behaviour. Prompting people to get their vaccinations against COVID-19.

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1. Mohammad S Razai , academic clinical fellow in primary care 1,

2. Umar A R Chaudhry , clinical teaching fellow 1,

3. Katja Doerholt , paediatric infectious diseases consultant 2,

4. Linda Bauld , professor of public health 3,

5. Azeem Majeed , professor of primary care and public health 4

1. 1Population Health Research Institute, St George University of London, London, UK

2. 2St George's University Hospitals NHS Foundation Trust, London, UK

3. 3Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK

4. 4Department of Primary Care and Public Health, Imperial College London, London, UK

Correspondence to M Razai mrazai{at}sgul.ac.uk

What you need to know

Lack of confidence in vaccines for covid-19 poses direct and indirect threats to health, and could derail efforts to end the current pandemic

Concerns about unknown future effects, side effects, and a lack of trust are common reasons given by people who say they are unlikely to have a covid-19 vaccine

No single intervention is likely to be able to address vaccine hesitancy

Consider barriers to uptake of vaccination at a population level and in groups who have lower rates of vaccine uptake

Develop local approaches by engaging members of the community and co-producing communications and materials that meet population needs

What is vaccine hesitancy?

The World Health Organization defines vaccine hesitancy as a "delay in acceptance or refusal of safe vaccines despite availability of vaccine services." 5 It is caused by complex, context specific factors that vary across time, place, and different vaccines, and is influenced by issues such as complacency, convenience, confidence, and sociodemographic contexts. 6 Vaccine hesitancy may also be related to misinformation and conspiracy theories which are often spread online, including through social media. 7 8 In addition, structural factors such as health inequalities, socioeconomic disadvantages, systemic racism, and barriers to access are key drivers of low confidence in vaccines and poor uptake. 5 9 10 11 The term vaccine hesitancy, although widely used, may not adequately convey these wider determinants that influence decisions to delay or refuse vaccination.

How common is vaccine hesitancy?

Vaccine hesitancy is a global problem. Surveys in 2021 report that between 50% and 60% of all respondents worldwide would be willing to receive a covid-19 vaccine, with wide variations across countries. 12 13 In the UK, surveys have found variation in willingness to have a vaccine between ethnic groups. The UK Household Longitudinal survey asked 12 035 participants (in November 2020) "how likely or unlikely would you be to take the vaccine?" Overall only 18% of respondents were hesitant (answering unlikely or very unlikely), in contrast with high levels of hesitancy in people of Black ethnicity (72%) followed by South Asians of Pakistani and Bangladeshi heritage (both 42%), and mixed ethnicities (32%), though levels of vaccine hesitancy were comparable with White people in respondents of Chinese ethnicity. 14 UK data (as of 11 March 2021) show lower vaccination rates (among those eligible for vaccination) in Black African and Black Caribbean (58.8% and 68.7%, respectively), Bangladeshi (72.7%), and Pakistani (74%) ethnic groups compared with White British (91.3%), and lower vaccination rates in people who live in more deprived areas (most deprived 87%, least deprived 92.1%). 15

Higher vaccine hesitancy is also reported among women (women 21%, men 15%), younger age groups (28% in 25-34 years, versus 14% in 55-64 years), and in people with a lower education level (24% in secondary school graduates; 13% in university graduates). 14 These data follow a historical trend in the UK of lower uptake of pneumococcal, influenza, rotavirus, and shingles vaccines among socioeconomically disadvantaged individuals 16 17 18 and ethnic minorities. 11 19 Similarly, a lower uptake has been observed with childhood immunisations in ethnic minority populations. 11 Variation in covid-19 vaccination rates is also seen between religious groups. Vaccination rates have been lower in Muslim (72.3%), Buddhist (78.1%), Sikh (87%), and Hindu (87.1%) groups compared with Christian (91.1%). 15

Vaccine hesitancy among healthcare workers (HCWs) is an area of concern because of HCWs' roles as trusted sources of health information, and because of their greater personal exposure to infections acquired in a healthcare setting. This is particularly the case in HCWs of ethnic minorities, who comprise a high proportion of NHS workers in the UK. Data from one NHS trust show lower rates of covid-19 vaccination in ethnic minority HCWs (70.9% in White workers versus 58.5% in South Asian and 36.8% in Black workers; P<0.001 for both). 2 20

What are the causes of covid-19 vaccine hesitancy?

Confidence in the importance of vaccines has the strongest association with vaccine uptake; however, confidence in the importance (necessity and value), safety, and effectiveness of vaccines fell in many countries between 2015 and 2019. 21 WHO listed vaccine hesitancy among the top 10 global threats to health in 2019. 22 Drivers of low confidence in covid-19 vaccination are listed in box 1. The 'Understanding Society' UK Household Longitudinal survey highlighted that the main reason for hesitancy was concerns about future unknown effects, with 42.7% of respondents specifying this. 14 Less common reasons included those under the bracket of "other" (12.2%), worries about side effects (11.4%), concern that others are in more urgent need of the vaccine (7.7%), and lack of trust in vaccines (7.6%). 14 However, the survey found that people of Black ethnicities were more likely to state that they "don't trust vaccines" compared with White people (29.2% v 5.7%), and people of Pakistani and Bangladeshi ethnicities often cited concerns about vaccine side effects (35.4% v 8.6%). 14 Some reports indicate a rise in vaccine hesitancy following the AstraZeneca vaccine safety scare across Europe and Africa. 24 25 Historical precedents show that widely publicised safety scares can have profound and long-lasting effects on vaccine confidence. 26

How to approach covid-19 vaccine hesitancy

Approaching vaccine hesitancy is complex, and therefore no single intervention can address this entirely, especially in the context of covid-19 where evidence for effective strategies to address it is currently limited. 27 When considering the most effective methods to increase vaccine uptake, we advocate comprehensive multi-component approaches tailored to the local population, combined with good communication at an individual level. 27 At a broader national level, a multifaceted, non-stigmatising approach is needed to share communication (in a variety of mediums) from trusted sources. 11 This includes traditional media channels (for example, television, radio, public transport advertising, and internet) to engage different groups regarding public health policies and counter any misinformation. 28 29

Recognising barriers to uptake ( box 2) helps to inform appropriate interventions to address them ( box 3). The key is to build confidence, particularly listening to people's concerns, being respectful of different religious or cultural beliefs, and being aware of historically rooted understandable mistrust, as well as other ethical considerations around clinical interventions. 11 They will usually be open to engage in dialogue about vaccine safety, efficacy, and importance, and discuss the risks and benefits of vaccination.

HCWs are a trusted source of information on vaccination and can influence local vaccination rates in individuals and at a population level. HCWs working alongside local authority members, faith leaders, and "community champions" can facilitate engagement, guide household decision makers, and make vaccine recommendations. 11 33

Improving access and removing barriers

Historically, interventions based on reminder/recall notifications have improved vaccination uptake in several groups and settings, although limited evidence supports their use specifically for addressing hesitancy. 23 34

Offering appointments in the evenings or weekends may improve accessibility for some. People with disabilities or those who have been shielding may find it particularly hard to attend a vaccination appointment. Considering an individual's distance from the vaccination site, offering to arrange appropriate transportation, or using home visiting facilities can maximise access for these patients. 11 Vaccination sites away from formal healthcare settings, such as places of worship and work based environments, can offer a degree of familiarity and enable reach within communities that distrust government or medical sources. 33 They also offer the opportunity for peer support from friends, family members, and colleagues who have agreed to be vaccinated.

Discussing vaccination with a patient

Discussion and engagement with patients who are vaccine hesitant should be conducted in an open, honest, and non-judgmental manner ( boxes 5, 6). 39 HCWs are well placed to have these conversations given their expertise in communication skills and biomedical training, although evidence is lacking to say whether vaccination uptake is greater if HCWs discuss vaccinations, versus staff in administrative roles. Various approaches have been studied, 23 from calling patients who have not received a vaccine to supplying online or paper based resources to inform patients of benefits and safety issues. One simple example is the "elicit-share-elicit" approach. 32 The HCW asks open ended questions to identify concerns and then offers to share their expertise about this concern. Tailored education based on specific attitudes, and previous experiences have also been shown to be beneficial. 39 This approach maintains an empathetic relationship, and provides an opportunity to communicate risk and support for decision making. For example, if a patient tells you they are concerned about the speed of the vaccine rollout, you might highlight the accelerated collaborative international drive that has taken place, which has occurred without compromising on scientific rigour to establish safety and efficacy including through ethics approval and expert peer review and will be continuously monitored by regulators. Recent concerns over a possible link between coronavirus vaccines and rare blood clots show that this monitoring is taking place, and can even detect serious side effects as rare as one in 250 000 people vaccinated. 40

Exploring the person's priorities-what they have looked forward to, or missed most during the current pandemic-can help to contextualise the importance of the vaccination programme as a collective effort to enable society to come out of lockdown, reverse restrictions, and minimise economic hardships.

One of the key difficulties can be communicating risk, for example, the risk of developing severe infection from covid-19 versus the risk of developing symptoms following vaccination. Understanding a patient's perceptions of risk and health beliefs is key to establishing a shared dialogue through which HCWs can discuss data clearly, using simplified language where appropriate. Engaging with patients on the dynamic, evolving, and at times uncertain nature of scientific evidence is also imperative, especially in the context of covid-19 and vaccines.

This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

View Abstract

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What you need to know Rollout of covid-19 vaccination is well underway, with more than 700 million doses given worldwide as of April 2021.1 Vaccination is highly effective at reducing severe illness and death from covid-19.

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As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.
Learn more: PMC Disclaimer | PMC Copyright Notice

Can Fam Physician. 2019 Mar; 65(3): 175-181.

Clinical guidance for primary care physicians working with parents

Shixin (Cindy) Shen, MD MPH CCFP

Resident in the Public Health and Preventive Medicine program at the University of Toronto in Ontario.

Vinita Dubey, MD MPH CCFP FRCPC

Associate Medical Officer of Health with Toronto Public Health and Adjunct Professor in the Dalla Lana School of Public Health at the University of Toronto.

Abstract

Objective

To provide primary care physicians with clinical guidance for addressing parental vaccine hesitancy.

Sources of information

The PubMed database was searched for English-language articles published in the 10 years before January 1, 2018. Search terms included vaccine hesitancy or confidence or acceptance, parents or children, and communication, counseling, or clinical practice. References of identified articles were assessed for additional relevant articles. A separate gray literature search was conducted using Google to find best-practice guidelines from public health and health care organizations, knowledge translation materials for health care providers, and resources that could be used in discussions with parents about vaccines.

Main message

Practical tips for addressing parental vaccine hesitancy in primary care include starting early, presenting vaccination as the default approach, building trust, being honest about side effects, providing reassurance on a robust vaccine safety system, focusing on protection of the child and community, telling stories, and addressing pain. Also provided are statements that providers could use in vaccination-related conversations; answers to commonly asked questions on benefits, safety, and immunologic aspects of vaccines; and links to a number of online resources for physicians and parents.

Conclusion

Vaccine-hesitant parents who are on the fence far outnumber vaccine refusers; therefore, counseling this group might be more effective. Reasons behind vaccine hesitancy are complex and encompass more than just a knowledge deficit. As a trusted source of information on vaccines, family physicians play a key role in driving vaccine acceptance.

Vaccination is one of the most successful public health interventions.1,2 It has led to the elimination and control of diseases that were once common in Canada.1 Before vaccines, many Canadian children became severely ill or died from infectious diseases such as smallpox, polio, diphtheria, measles, and pertussis. Since the widespread use of vaccines, smallpox has been eradicated worldwide and endemic polio, measles, rubella, and congenital rubella syndrome have been eliminated in the Americas.2,3

Continued vigilance is required given recent outbreaks of vaccine-preventable diseases (VPDs) in Canada.4 Sufficient herd immunity, which can be established by adequate vaccination rates, is required to prevent person-to-person transmission of infectious diseases.5 Many recent outbreaks of measles, mumps, rubella, and pertussis have been linked to undervaccinated communities.6 Adequate vaccine coverage is especially critical in the age of growing antimicrobial resistance and global travel.7,8

Parental concerns about vaccines are on the rise.9 Recommendations from health care providers are important for vaccine acceptance; yet more than one-third of vaccine providers in Canada reported feeling uncomfortable counseling vaccine-hesitant patients.6 Here we provide information on parental vaccine hesitancy and practical clinical guidance for addressing it in the primary care setting.

Case description

A parent brings her child to a family medicine clinic for the 2-month well-child visit. The parent is unsure about having the infant vaccinated. She is worried about additives such as aluminum in vaccines. She has read stories on the Internet of children who were harmed by vaccines, including those on aluminum-related neurotoxicity. She does not consider herself "antivaccine" but has many questions.

Sources of information

We conducted key word searches that identified studies on parental vaccine hesitancy, with a focus on provider-patient communication. The PubMed database was searched for English-language articles published in the 10 years before January 1, 2018. Search terms included vaccine hesitancy or confidence or acceptance, parents or children, and communication, counseling, or clinical practice. References of identified articles were assessed for additional relevant articles. A separate gray literature search was conducted using Google to find best-practice guidelines from public health and health care organizations, knowledge translation materials for health care providers, and resources that could be used in discussions with parents about vaccines.

Main message

Childhood immunization rates in Canada.

In Canada, childhood immunization rates are generally high, with only 1.5% of children having never received vaccines.10 However, vaccine coverage remains below the target of 95% for many VPDs, including measles, mumps, rubella, varicella, diphtheria, pertussis, and tetanus.11 Compared with other affluent countries, Canada was ranked 28th among 29 countries by a UNICEF pediatric vaccination metric, which measured vaccine uptake at 2 years of age.12

This is especially concerning given recent outbreaks of measles, mumps, and pertussis in Canada. There were 9 notable outbreaks of measles between 2005 and 2013, with the largest outbreak in the Americas since 2002 occurring in Quebec in 2012.4 Owing to outbreaks in multiple locations across the country, there has been a 7-fold increase in the national incidence of pertussis in 2012.13 In 2017, 4 provinces experienced outbreaks of mumps, with a higher number of cases reported starting in the fall of 2016.14

What is vaccine hesitancy and why is it important?

The World Health Organization defines vaccine hesitancy as a "delay in acceptance or refusal of vaccines despite availability of vaccination services."15 Most vaccine-hesitant parents are in the middle of a spectrum and underimmunize their children instead of not immunizing them at all.16 According to a recent Canadian survey, although only 3% of parents refused all vaccines for their children ( vaccine refusers), 19% consider themselves to be vaccine hesitant.8 Vaccine-hesitant parents are a larger and more attentive group compared with vaccine refusers.16,17

Decision making around vaccination entails a complex mix of cultural, psychosocial, spiritual, political, and cognitive factors.18 Reasons for vaccine hesitancy fit into 3 categories: lack of confidence (in effectiveness, safety, the system, or policy makers), complacency (perceived low risk of acquiring VPDs), and lack of convenience (in the availability, accessibility, and appeal of immunization services, including time, place, language, and cultural contexts).19 According to recent Canadian surveys,8 70% of parents were concerned about potential side effects of vaccines and 38% believed that a vaccine could cause the disease that it was supposed to prevent. Canadian parents whose children were not immunized cited the lack of perceived necessity of vaccines (28%), concerns regarding vaccine safety (17%), and the perceived number of side effects (12%) as top reasons for not immunizing.20 Another Canadian survey conducted on the measles-mumps-rubella vaccine in particular revealed that 14% of parents believed that it caused autism and another 14% were not sure.21 Other commonly cited safety concerns include vaccine additives, long-term health problems, and overwhelming the immune system.22

What is the role of family physicians?

Sixty-three percent of Canadian parents look for information about immunization on the Internet; of these, close to half perform a Google search.20 This is concerning, as information about vaccination on websites and social networks is predominantly inaccurate or negative.18 A large number of antivaccine websites exist that propagate a range of antivaccine messages.23

Fortunately, more than half of Canadian parents continue to receive information about vaccination from their physicians.20 In addition, Canadian parents consider health care providers to be the most trusted information source about vaccination despite the increased use of Internet searches.8 More than two-thirds of parents believe that physicians are the most reliable and trustworthy source of information on vaccination, while only 27% believe the Internet is the most reliable.20 Parents who received information about vaccines from physicians were less likely to have vaccination concerns compared with those who received information from family and friends.24 Therefore, family physicians can play an important role in counseling vaccine-hesitant parents and establishing vaccine confidence.

Discussing vaccination and encouraging vaccine-hesitant parents.

Multiple approaches for communicating with parents about vaccination have been recommended in the literature,25-28 and different counseling strategies have been proposed.8,29 However, these might be difficult to put into practice, and a Cochrane review reported insufficient evidence to recommend any specific face-to-face intervention.30

Practical, evidence-based counseling tips are provided below, in addition to concrete statements that can be used in conversations ( Table 1 ),25,31-33 answers to commonly asked questions ( Table 2 ),25,31,33-43 and online resources that provide up-to-date information ( Table 3 ).1,44-48

Table 1.

APPROACH

SAMPLE STATEMENTS

"Today we are going to give your child the recommended vaccines to keep the child healthy"
"Your child needs 3 vaccines today" (instead of "What do you want to do about the shots?")

"I strongly recommend your child receive these vaccines today"
"These shots are very important for protecting your child from serious diseases"

"Vaccines work. Serious diseases can occur if your child is not immunized"

"There is a risk with vaccines just as with everything we do in life, like driving a car or riding a bike"
"The risk of anaphylaxis after vaccination is approximately 1 in a million, the same as the yearly risk of being struck by lightning"

Table 2.

QUESTION

SAMPLE ANSWER

Benefits of vaccines

"Your child might never need the protection offered by vaccines, but you do not want her or him to be lacking the protection needed in the event of an outbreak, which still happens in Canada for diseases such as measles, mumps, and whooping cough. Vaccination is similar to wearing a seat belt; you do not expect to be in a collision, but in the unlikely event that you are in one, you want to be protected. Even if right now your child is able to avoid infectious diseases as everyone around is vaccinated, what if she or he decide to work elsewhere in the world later in life?31 Even if your child never travels internationally, others in your community travel and can bring back diseases"

Safety of vaccines

"Inactivated or killed vaccines, which make up most vaccines, cannot give you the disease from the vaccine itself. Live vaccines contain viruses that are weakened, so occasionally you might get a mild case of disease (for example, a few spots of what look like chickenpox or measles). This is not harmful and actually means that the vaccine is working"

"Some ingredients in vaccines might be toxic, but only at much higher doses. Remember, even water can be toxic at high enough doses. The ingredients in vaccines are there to keep them from getting contaminated by bacteria and to make them work better"

"Aluminum is used to boost the immune system.34 It is commonly ingested from food, drinking water, and medicine. In fact, the amount of aluminum found in a vaccine is similar to the amount present in breast milk and infant formula"38

"Formaldehyde is used as a preservative. It is found naturally in foods.42 In fact, more formaldehyde is present in a pear than in all the vaccines a child receives"31

* "Doesn't the MMR vaccine cause autism?"38,39,41

Immunity related

* "Can't so many vaccines overwhelm my child's immune system?"25,34,42

"A child's immune system has to deal with thousands of germs on a daily basis starting at birth. Scientists estimate that babies can handle up to 10 000 shots at one time.25 By stimulating the immune system to do what it is naturally meant to do, vaccines make your child's immune system better at fighting off these diseases"38

Table 3.

SOURCE, YEAR LAST MODIFIED

RESOURCE

WEB ADDRESS*

For health care providers

* Public Health Agency of Canada, 2018c
Canadian Immunization Guide1 www.canada.ca/en/public-health/services/canadian-immunization-guide.html

* NACI, 2018

NACI recommendations, statements, and updates
www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci.html

* Canadian Paediatric Society, 2017
www.cps.ca/en/documents/position/vaccine-safety-system

* Canadian Medical Protective Association, 2017
www.cmpa-acpm.ca/en/advice-publications/browse-articles/2017/how-to-address-vaccine-hesitancy-and-refusal-by-patients-or-their-legal-guardians

* Immunization Action Coalition, 2018

Unprotected People Reports
www.immunize.org/reports

For parents

* Public Health Agency of Canada, 2018
A Parent's Guide to Vaccination46 www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/parent-guide-vaccination/pgi-gpv-eng.pdf

* Immunize Canada, 2017

CANImmunize app
www.canimmunize.ca/en/home

* Canadian Paediatric Society, 2016

Choosing not to vaccinate your child?
Know your risks and responsibilities47
www.caringforkids.cps.ca/uploads/handout_images/CFK_tearsheet-ENG(post).pdf

* Canadian Paediatric Society, 2015

Your Child's Best Shot. A Parent's Guide to Vaccination. 4th ed48
bookstore.cps.ca/stock/details/your-childs-best-shot-a-parents-guide-to-vaccination-4th-edition

Start early: Take advantage of prenatal appointments and the first few postnatal appointments.39,49 A mixed-methods study showed that parents who delayed or refused vaccines were twice as likely to start thinking about vaccines before their children's births.50 A randomized controlled trial showed that adherence to the immunization schedule improved with a single prenatal education session, and another showed benefit from stepwise education interventions prenatally, postnatally, and 1 month after birth.51,52 At these appointments, parents can be provided with opportunities to ask questions and with credible take-home materials, websites, or tools.

Present vaccination as the default approach: The Centers for Disease Control and Prevention recommends a presumptive approach to discussions about vaccinations ( Table 1 )25,31-33 and restating the recommendation after addressing parents' concerns.31 A cross-sectional study found that parents were significantly more likely to resist vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (odds ratio of 17.5, 95% CI 1.2 to 253.5) and that when providers pursued the original recommendations, almost half of initially resistant parents subsequently accepted the recommendations.32 While a follow-up cross-sectional study showed that the presumptive initiation format had a lower-rated visit experience, it was still associated with higher parental vaccine acceptance at the end of the visit.53

Be honest about side effects when asked, and reassure parents of a robust vaccine safety system (Table 1 )25,31-33,40,54: A 2014 systematic review showed that serious adverse events associated with vaccines are extremely rare.55 Perceived risk might be lowered by acknowledging that vaccines might result in mild side effects and very rarely serious adverse events.56 The Canadian vaccine safety system has 8 components, including an evidence-based approval process, manufacturer regulations, independent recommendations for vaccine use, and ongoing monitoring of adverse events.44 It has been shown in a randomized controlled trial that providing general information on the adverse event reporting system might increase trust and vaccine acceptance among adults.57 However, no similar study was found for childhood immunization.

Tell stories in addition to providing scientific facts33,58: According to a survey of primary care physicians in the United States, the most common communication practices deemed very effective for convincing sceptical parents were personal statements by physicians about what they would do for their own children and about their personal experiences with vaccine safety among their patients.59 Stories and images highlighting the effects of VPDs improved attitudes toward vaccination according to a randomized controlled trial, especially for individuals who had lower confidence in vaccines.60 However, another randomized controlled trial showed that dramatic narratives and images resulted in no significant change in intention to vaccinate and even decreased intention among those who had the least favourable perception.61 However, this study tested Web-based messages only. Although more evidence is needed on the topic, storytelling, which has commonly been used by the antivaccine movement, has been proposed as a possible messaging technique to supplement evidence-based information.62

Build trust with parents: A recent review found that parental trust in a provider helps ensure vaccine compliance.63 A qualitative study reported that a mother's trust is obtained when a provider spends time discussing vaccines, does not deride her concerns, is knowledgeable, and provides satisfactory answers.64 Other qualitative studies identified respect, empathy, and tailored information as aspects of communication competence.63

Address pain: Pain associated with vaccination is a concern for many parents and children.9 Evidence-based clinical practice guidelines have been developed to reduce vaccination-associated pain ( Table 4 ).65

Table 4.

TYPE OF INTERVENTION

STRONGLY RECOMMENDED INTERVENTIONS

Procedural

For all children, no aspiration during intramuscular vaccine injections; inject the most painful vaccine last

Physical

For children aged ≤ 2 y, breastfeed during vaccine injections. For children aged ≤ 1 mo, encourage skin-to-skin contact

Positioning

For children aged ≤ 3 y, encourage holding during injections, and if holding is not used, encourage patting or rocking after injections. Encourage children > 3 y to sit up during injections

Pharmacologic

For children aged ≤ 12 y, consider topical anesthetics before injections. For those aged ≤ 2 y, consider sucrose or glucose solutions before injections

Process

Educate parents of children of all ages about pain management for vaccine injection before or on the day of vaccination. For children aged ≤ 10 y, parents should be present during vaccine injections

Focus on protection for the child and community: Necessity of vaccines is the top concern from Canadian parents, and a study conducted in Quebec found that one of the strongest factors associated with parental vaccine hesitancy was the belief that VPDs were not serious.66 A study conducted in the United States had similar findings.67 To highlight the importance of individual protection, the use of motivational interviewing could be considered.68 A recent Canadian randomized controlled trial showed that motivational interviewing on maternity wards increased the intention to vaccinate by 20% and the likelihood of complete vaccination status by 9%.69 A systematic review concluded that there might be some parental willingness to vaccinate children for the benefit of others; however, its relative importance as a motivating tool is uncertain.70

Limitations of evidence.

Vaccine hesitancy is an emerging area of research, and literature on ways to counsel vaccine-hesitant parents is currently limited. Many research studies have qualitative designs, and some quantitative studies are observational in nature. Future studies should aim to supplement existing literature with larger and higher-quality quantitative studies on the specific types of counseling interventions identified in this article.

Case resolution

The physician carefully listens to the parent's concerns. She empathizes and is not dismissive or judgmental. She explains to the parent that additives are put into vaccines for specific reasons; aluminum is added to help the vaccine work better by boosting the immune system. She reassures the parent that aluminum is commonly found in the environment, and the very small amount in vaccines, which is similar to levels found in breast milk and infant formula, is not harmful. She reassures the parent about the robust vaccine safety system in Canada. She explains that because others in the community travel, many of the diseases that had disappeared in Canada have come back and made Canadian children very sick. She makes a strong recommendation that the child receive the vaccines today. The parent is still unsure, so the physician offers take-home resources and schedules another longer appointment in 2 weeks to answer any additional questions, with plans to vaccinate the child at that time.

Conclusion

Parental vaccine hesitancy is an important issue in Canada. Decision making around vaccination is complex. As the most trusted source of information on vaccination, physicians are uniquely positioned to sway parents from vaccine hesitancy to acceptance. Facts are not enough to change the views of vaccine-hesitant parents. Present vaccination as the default approach early on; be honest about side effects; maintain trust; focus on protection; and address pain. Be prepared to answer commonly asked questions and know where to find answers to unfamiliar questions. Provide credible resources to parents, especially if they ask.

Notes

Editor's key points

▸ Vaccine hesitancy is a delay in acceptance or a refusal of vaccines despite the availability of vaccination services. Parental vaccine hesitancy is on the rise, and childhood vaccination coverage appears suboptimal for several vaccine-preventable diseases in Canada. The reasons behind it are complex.

▸ The authors suggest practitioners consider focusing counseling on vaccine-hesitant parents who underimmunize their children instead of on firm vaccine refusers who do not immunize their children at all.

▸ Although parents use the Internet to look for information on vaccination, physicians remain the most trusted information source. When discussing vaccination with hesitant parents, it is not enough to provide facts and numbers. The authors suggest telling stories, building trust with parents, addressing pain associated with vaccination, presenting vaccination as the default approach early on, focusing on the benefits of protection, and being honest about side effects when asked.

Footnotes

Contributors
Both authors contributed to the literature review and interpretation and to preparing the manuscript for submission.
Competing interests
None declared

This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

This article has been peer reviewed.

La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2019 à la page e91.

References

10. Public Health Agency of Canada . Vaccine coverage in Canadian children: results from the 2013 Childhood National Immunization Coverage Survey (CNICS) Ottawa, ON: Public Health Agency of Canada; 2016. [ Google Scholar]

16. Busby C, Jacobs A, Muthukumaran R. Commentary 477. In need of a booster: how to improve childhood vaccination coverage in Canada. Toronto, ON: CD Howe Institute; 2017. [ Google Scholar]

27. Autism Science Foundation . Making the CASE for vaccines: a new model for talking to parents about vaccines. New York, NY: Autism Science Foundation; 2015. [ Google Scholar]

29. Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr. 2012;(12):154. [[ PMC free article] [ PubMed] Google Scholar]

43. Institute of Medicine (US) Immunization Safety Review Committee . Immunization safety review: vaccines and autism. Washington, DC: National Academies Press; 2004. [[ PubMed] Google Scholar]

48. Moore DL, editor. Your child's best shot: a parent's guide to vaccination. 4th ed. Ottawa, ON: Canadian Paediatric Society; 2015. [ Google Scholar]

68. Betsch C. Advocating for vaccination in a climate of science denial. Nat Microbiol. 2017;(2):17106. [[ PubMed] Google Scholar]

69. Gagneur A, Lemaître T, Carrier N, Farrands A, Petit G. Post-partum vaccination promotion intervention using motivational interviewing techniques improves vaccination coverage during infancy. stract presented at: European Society for Pediatric Infectious Diseases 2016; 2016 May 10-14; Brighton, UK. [ Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

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Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents

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To provide primary care physicians with clinical guidance for addressing parental vaccine hesitancy.The PubMed database was searched for English-language articles published in the 10 years before January 1, 2018. Search terms included vaccine hesitancy ...

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We can also talk about waning immunity in order to convince audience that we are entering endemic stage.

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COVID vaccine immunity is waning — how much does that matter?

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As debates about booster shots heat up, what’s known about the duration of vaccine-based immunity is still evolving.

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Younger generations are more likely to be vaccine hesitant ( Freeman et al., 2021), partly because they perceive themselves to be at lower risk of developing a severe form of COVID-19.

In the section below, we provide a set of behavioural insights that could be relevant when encouraging younger generations to get vaccinated.

Behavioural insights

Highlight the pro-social benefits of vaccination

Behavioural Insight: Emphasising the pro-social benefits of vaccination is particularly effective among young people. Prosocial benefits include achieving herd immunity and protecting others, especially those that vulnerables and cannot get vaccinated. Combining both informational and emotional content can be effective (Pfattheicher et al., 2020 ; Betsch et al., 2017).

Potential application: Focus on prosocial benefits of vaccination in communications tailored to young people
Highlight the importance of getting vaccinated. Provide facts while eliciting empathy towards others.

Highlight social norms about vaccination

Behavioural Insight: Highlighting that there are growing intentions to get vaccinated, that most people are getting vaccinated and that they approve doing so, can effectively encourage vaccine take up (Moehring et al., 2021; Palm et al., 2021; Bish et al., 2011; Bavel et al 2020). Since young people tend to be more susceptible to peer influence (Steinberg & Monahan, 2007) , it is likely that social norms can be particularly effective when targeting this group.

Potential application: Emphasise Social norms in communications targeted towards young people. Make vaccination visible to other young people by setting up vaccination centres in university campuses or schools. Launch an 'I will get vaccinated'-pledge on social media.

Highlight the long-term health consequences of COVID-19.

Behavioural Insight: People are more likely to get vaccinated if they believe COVID-19 is serious and if they believe that they risk contracting it (Brewer et al., 2017; Godinho et al., 2016; Williams et al., 2020).

Potential application: Since young people are less at risk of developing a lethal form of COVID-19, highlight the potential long-term consequences of the illness.

Use trustworthy and relatable messengers

Behavioural Insight: People are influenced by who delivers a message. 'Soft messengers' are figures that are influential because they are perceived as similar, relatable and trustworthy (Martin & Marks, 2019).

Potential application: Use messengers that young people relate to deliver vaccine messages. These, for example, can be social media influencers that are in their age group.

Make vaccination as easy as possible

Behavioural Insight: Reducing physical or logistical barriers to vaccination can encourage take-up (Brewer et al., 2017).

Potential application: Set up vaccination centers in locations that are convenient for young people (e.g. near schools, universities, areas with young demographics).

Motivate vaccination through financial incentives

Behavioural Insight: Financial incentives can motivate vaccination, especially for people that perceive the risks of infection as low, such as young people (Bronchetti et al. 2015, Betsch et al., 2015). Financial rewards are considered more acceptable if delivered as vouchers over cash, smaller values over large, and certain rewards as opposed to lotteries (Hoskins et al., 2019). However, be cautious when offering financial incentives as they can undermine people's intrinsic motivation to get vaccinated (Frey & Jegen, 2002), and could be perceived as a confirmation that vaccination is risky or undesirable.

Potential application: Invite people to participate in a vaccine take up support programme offering a small reward for receiving both vaccine doses.

Find out how to increase adherence to COVID-19 preventative behaviours among young people.

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Encouraging vaccine take-up among younger people

# data[].attributes.attachment_link.description
Younger generations are more likely to be vaccine hesitant ( Freeman et al., 2021), partly because they perceive themselves to be at lower risk of developing a severe form of COVID-19. In the section below, we provide a set of behavioural insights that could be relevant when encouraging younger generations to get vaccinated.

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vaccine confidence and uptake strategies

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field guide for public health professionals covid-19 vaccine

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covid-19 vaccine policies and procedure templates

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12 COVID-19 Vaccination Strategies for Your Community

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We can demonstrate the relation of deaths with vaccinations in Russia
-Revati

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Low uptake in Russia of the country's domestically manufactured COVID-19 vaccine Sputnik V reflects systemic mistrust in vaccination and the state health-care system. Ed Holt reports.

Despite being the first country in the world to register a COVID-19 vaccine, Russia's own vaccination campaign is faltering amid problems with vaccine hesitancy, supply issues, and even high rates of infection possibly affecting uptake, local disease experts have said.

Russian authorities registered the Sputnik V vaccine, produced by the Gamaleya Research Institute, part of Russia's Health Ministry, in August last year. But despite beginning a mass vaccination campaign in December, and approving two other domestic vaccines (EpiVacCorona and CoviVac), vaccination rates remain notably low compared with many other countries.

Although official statistics for SARS-CoV-2 infections and COVID-19 deaths are released daily, federal authorities are not regularly making public any data on vaccinations, although government officials and state institutions make statements on vaccination rates from time to time. On April 26, Deputy Prime Minister Tatiana Golikova said 11·9 million people, or around 10% of Russia's adult population, had received at least a first dose of a COVID-19 vaccine. According to the Our World in Data vaccination tracker, as of May 11, Russia had administered 14·93 doses per 100 people, compared with 39·29 per 100 people in the EU and 78 per 100 people each in the UK and the USA.

The reasons behind the low rates of vaccination in the country are varied, local disease specialists say. Surveys since the start of the mass vaccination programme have shown that many Russians are reluctant to get vaccinated. Research by the Levada-Center published in March showed that 62% of Russians did not plan to get vaccinated. Such widespread aversion to vaccination is unsurprising, said Vassiliy Vlassov, an epidemiologist at Moscow's Higher School of Economics University. "Vaccine hesitancy is quite prevalent in Russia. There are anti-vaxxers here and some journalists and influential people, even medical people, dance to the antivaxxers' tune."

A general mistrust in the population of vaccines for any disease and towards the state health-care system, rooted in childhood experiences of Soviet health care, is another factor behind apparent hesitancy. "It is not common for adult Russians to get vaccinated for anything, COVID or any other disease", said Anton Barchuk, an epidemiologist at the European University at St Petersburg.

However, there is not just hesitancy among the general public. Research last year suggested as many as 50% of doctors were unwilling to take the vaccine. It is unclear whether there remains such high scepticism among Russian doctors today. Some do not think so. "The general message from doctors is that you should get the vaccine", said Barchuk.

But others say there are many doctors who will not take any COVID-19 vaccine themselves nor recommend patients do so. One doctor who works at a private medical facility in Novorossiysk told The Lancet Infectious Diseases that he would not be getting vaccinated because he was deeply sceptical of the benefits of "Sputnik V or any other so-called COVID-19 vaccine" and the motives of pharmaceutical companies, politicians, medical institutions, and the global media in promoting their use. The doctor, who spoke on condition of anonymity, said: "I know other doctors will disagree, but I also know many who do agree with me".

But hesitancy is not the only issue affecting uptake. Whereas people in cities such as Moscow and St Petersburg can get vaccinated with relative ease-walk-in vaccination centres have been set up in many shopping malls-in more remote places, the situation is more difficult. Russian media have reported shortages in regions outside major cities, with some describing this as a "systematic problem" that temporarily halted vaccinations in some areas.

Demand for the vaccine abroad-as of April, Sputnik V had been approved for use in 60 countries-is also believed to have contributed to shortages at home. "There has been demand for Sputnik V in other parts of the world, and it has been sent to many countries, even though there may be problems with not having enough in Russia", said Vlassov.

It is also thought that the extent of the spread of COVID-19 among the population and misconceptions over post-infection immunity might be behind low vaccine rates. Studies by Barchuk and colleagues using antibody testing showed that in February there was evidence that up to 50% of people in St Petersburg had the disease, compared with 24% in November. He said that individuals infected during the winter months-when the vaccination programme was first being rolled out-are still waiting before they can get their jabs. Many doctors recommend people should not be vaccinated before at least 90 days after infection. But Barchuk also said, "there is this idea among the lay population that once you have been infected you don't need to get vaccinated", and that this might be contributing to low vaccination rates.

Article Info

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Low uptake in Russia of the country's domestically manufactured COVID-19 vaccine Sputnik V reflects systemic mistrust in vaccination and the state health-care system. Ed Holt reports. Despite being the first country in the world to register a COVID-19 vaccine, Russia's own vaccination campaign is faltering amid problems with vaccine hesitancy, supply issues, and even high rates of infection possibly affecting uptake, local disease experts have said.

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Nelle ultime settimane si è parlato molto, in Europa e in Italia, di quello che sta succedendo in Romania e Bulgaria. In quei due Paesi la quota di vaccinati è inferiore al 30% e il numero di morti giornalieri per Covid-19, rapportato alla loro popolazione, è talmente elevato da aver superato persino i peggiori picchi della prima ondata in Italia. Per intenderci, sia in Romania che in Bulgaria, il numero di decessi osservato equivarrebbe a registrare circa 1.200 morti al giorno in Italia. Italia dove, invece, di decessi giornalieri negli ultimi sette giorni se ne sono registrati in media 40.

Nello stesso momento in cui Romania e Bulgaria sbarcavano sui giornali italiani, si è parlato molto anche del Regno Unito: raccontando che gli ospedali del Paese sembrano già sotto forte pressione, e che martedì i decessi giornalieri hanno fatto toccare i massimi dallo scorso marzo. A qualcuno potrebbe legittimamente sorgere un dubbio: ma come, dunque a Londra i vaccini non funzionano?

Eccome, se funzionano! Nel grafico qui sopra mostriamo una comparazione tra 33 Paesi del continente europeo. Sull'asse orizzontale trovate la media della quota di popolazione che era stata pienamente vaccinata in un periodo che comprende all'incirca gli ultimi quattro mesi (dal 1° luglio al 27 ottobre 2021), mentre sull'asse verticale viene mostrato il numero di decessi per milioni di abitanti occorso nello stesso lasso di tempo. Come è possibile notare, in tutti i Paesi con uno scarso livello di vaccinazione il numero di decessi per milione di abitanti tra luglio e oggi è stato nettamente più alto rispetto a quello fatto registrare nei paesi più vaccinati. A Bulgaria e Romania va ad aggiungersi anche la Russia (altro Paese in cui il numero di decessi inanella da settimane record su record), così come molti paesi dei Balcani occidentali non appartenenti all'Unione europea.

Nella parte destra del grafico si trovano invece i Paesi con il più alto tasso medio di vaccinati nel periodo. Si può facilmente constatare come, quasi sempre, il numero di decessi per milione di abitanti rimanga molto più basso. Oltre a ciò, è possibile però notare anche una netta variabilità di "risultato", con alcuni Paesi con numeri molto bassi e altri con numeri (relativamente) più alti. Come mai succede? Semplice: questo grafico mostra il numero di decessi per milione di abitanti, che è una misura molto imprecisa dell'efficacia dei vaccini nel proteggere una popolazione. Il numero di decessi dipende infatti non solo dall'efficacia dei vaccini (che viene calcolata come riduzione nella probabilità di decesso qualora si incontri il virus) ma anche dalla probabilità stessa di venire in contatto con il virus, cioè dalla circolazione virale.

È ovvio, perciò, che in Paesi come il Regno Unito, dove la scelta politica da diversi mesi è stata quella di lasciare che il virus circoli con maggiore "libertà" rispetto ad altri Paesi (per esempio l'Italia), anche il numero di decessi inevitabilmente sia destinato a crescere malgrado i vaccini restino altamente efficaci. In concreto, negli ultimi quattro mesi a Londra il numero di decessi per milione di abitanti (177) è stato più che doppio rispetto a quello fatto registrare in Italia (72), eppure rimane lontanissimo dai numeri di Bulgaria (801 decessi per milione di abitanti), Romania (747) e Russia (658).

La lezione da imparare, dunque, è che persino in Paesi molto vaccinati che ci appaiono "in emergenza" la situazione non è in alcun modo comparabile con ciò che sta accadendo nei Paesi poco vaccinati. Per questi ultimi le conseguenze non sono semplicemente sanitarie, ma anche sociali ed economiche. Un numero eccessivo di casi in una popolazione scarsamente vaccinata porterà a un numero intollerabile di decessi, e dunque a nuove, forti chiusure e restrizioni che i cittadini fanno sempre più fatica ad accettare e i governi a imporre, anche considerate le loro conseguenze economiche.

Anche per questo è poco comprensibile che governi come quello romeno o bulgaro, che di dosi pro capite a disposizione ne hanno avute tante quante tutti gli altri paesi dell'Unione europea, non facciano qualcosa per spronare maggiormente la propria popolazione a farsi vaccinare. A perderci di più, in ultima analisi, sono sempre i cittadini dei Paesi in cui ci si vaccina di meno.

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Dal Regno Unito a Romania e Bulgaria. Persino in Paesi molto vaccinati che ci appaiono "in emergenza" la situazione non è in alcun modo comparabile con ciò che sta accadendo nei Paesi poco vaccinati. Per questi ultimi le conseguenze non sono semplicemente sanitarie, ma anche sociali ed economiche. Ecco perché.

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Interim Pre-pandemic Planning Guidance:
Community Strategy for Pandemic Influenza
Mitigation in the United States (CDC, 2007).

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Diverse vaccine attitudes amongst UK healthcare workers suggest hesitancy may remain after vaccine acceptance

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In a recent paper, the phenomenon of vaccine hesitancy is further explored amongst UK healthcare workers.

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Revati

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Shortlist countries for comparison based on exploratory analysis

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Shortlist countries for comparison based on exploratory analysis

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-Countries with successful vaccine rollout
-Countries with low vaccine rollout /Population hesitancy
Revati

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Bar chart comparing UK and other countries with successful vaccine rollout

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Bar chart comparing UK and other countries with successful vaccine rollout

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-Revati

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“As winter approaches there is an urgent need to reinvigorate the push to vaccinate as many people as possible.”- Revati

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Diagnosis and treatment

Yaws (Endemic trepanomatoses)

Traditionally, laboratory-based serological tests such as Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) are widely used to diagnose treponemal infections (for example, syphilis and yaws). These tests cannot distinguish yaws from syphilis however, and the interpretation of results from these tests in adults who live in yaws endemic areas needs careful clinical assessment because of syphillis.

Rapid point-of-care tests that can be used in the field are widely available.
However, most of them are treponemal-based and cannot distinguish between past and current infection. Recently dual treponemal and nontreponemal rapid tests have become available, thus simplifying diagnosis in the field. These tests are able to detect both present and past infections to guide treatment of people with active infection.

Polymerase chain reaction (PCR) can be used to definitively confirm yaws by detecting the organisms in the skin lesions. It can also be used to monitor azithromycin resistance and this test will be very useful in the last phase of the eradication programme.

Either of 2 antibiotics - azithromycin or benzathine penicillin - may be used to treat yaws:

Azithromycin (single oral dose) at 30 mg/kg (maximum 2 gm) is the preferred choice in the WHO "Yaws Eradication Strategy" (the Morges Strategy) because of the ease of administration and logistical consideration in large-scale treatment campaigns.

Benzathine penicillin (single intramuscular dose) at 1.2 million units (adults) and 600 000 units (children). For patients allergic to penicillin and azithromycin, doxycycline 100mg (1 tab) orally, b.d. twice daily for 7 days may be used.

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Yaws (Endemic trepanomatoses) Traditionally, laboratory-based serological tests such as Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) are widely used to diagnose treponemal infections (for example, syphilis and yaws). These tests cannot distinguish yaws from syphilis however, and the interpretation of results from these tests in adults who live in yaws endemic areas needs careful clinical assessment because of syphillis.

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Vaccine rollout slower in young age groups

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Vaccine rollout slower in young age groups

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Revati

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Shortlist countries based on
1) successful vaccination program
2) population showed hesitancy or having low vaccine rollout
Revati

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Line chart of people fully vaccinated in UK

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Line chart of people fully vaccinated in UK

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The graph shows the trend of vaccination in UK over time.
-Revati

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The UK has lost its place as Europe's vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.

Throughout September, the UK was vaccinating an average of 1,461 people per million a day, much lower than the 3,925 being jabbed in Italy, 3,694 in France, 3,280 in Spain and 2,305 in Germany.

The UK's rate of vaccination was the fastest in Europe until the end of April, according to data from Our World in Data. At that point, the UK had fully vaccinated more than one in five people (22.5%), compared with a maximum of 10.3% among Germany, France, Italy and Spain.

But the subsequent slow down in the UK's vaccine rollout meant it lost its place as Europe's leader in vaccination coverage in July.

Ten months after the first coronavirus jab in the UK was administered to 90-year-old Margaret Keenan at University hospital Coventry, the UK's vaccine coverage has stalled in recent weeks and stands at about 86% of those who are eligible for a jab.

Figures suggest this is largely due to slow uptake among younger people. There are still significant numbers of people under 40 unvaccinated, according to the latest data from Public Health England. Just 64% of those aged 18-29 were fully vaccinated as of 9 October compared with 96% of those in their 70s. For those aged 30-39, coverage was higher but still a long way off targets, with 77% second-dose uptake.

The increase in uptake among 18 to 29-year-olds has also slowed in recent weeks, PHE data shows. In the month to 9 September the second-dose rate increased by 26 percentage points, while in the most recent month the dial has only been shifted by 8 percentage points.

Chart showing vaccine coverage by age over time

Increase in uptake was even slower among those aged 30 to 39, with coverage rising by just four percentage points from to 77% in the month to 9 October.

Dr Kit Yates, senior lecturer in Mathematical Sciences at the University of Bath, said: "It's a common misconception that the UK's vaccination programme has allowed us to open up more successfully than other similar nations.

"By the beginning of October England had fully vaccinated about two-thirds of its population, which is much lower than countries like Portugal, Spain, Denmark and Ireland. Part of the reason is that many other European countries vaccinated teenagers during the summer in time for the return to school, while the UK dithered over making the decision."

After weeks of mounting political pressure, the UK's chief medical officers agreed to extend jabs to children aged 12-15 in September, going against advice from the Joint Committee on Vaccination and Immunisation, which recommended such a move was unnecessary.

Martin McKee, professor of European public health at the London School of Hygiene & Tropical Medicine, said: "The delay in extending [the vaccine] to 12 to 15-year-olds was a serious mistake and contributed to mixed messaging. So [did] the failure to expose and confront the networks promoting anti-vaccine messaging, some regrettably with links to certain politicians."

"As winter approaches there is an urgent need to reinvigorate the push to vaccinate as many people as possible."

A study for the ONS recently found those aged 16-29 were the most vaccine-hesitant age group, with 8% reporting vaccine hesitancy compared with 5% and 2% in those aged 30 to 49 years, and over-50s respectively.

The data also shows less than one in five 16 and 17-year-olds have been fully vaccinated, however this age group has only been eligible to receive a vaccine since August. Nearly two-thirds of 16 and 17-year-olds have received their first dose.

More than 330,000 younger children - or 12% of 12-15-year-olds - have now received their first jabs. The government has recently begun publishing data for this age group after the education secretary, Nadhim Zahawi, came under fire for admitting he did not know how many younger children had been vaccinated.

Uptake also varies widely by geography, with those in deprived parts of England much less likely to be vaccinated. While a number of areas have fully vaccinated all those aged 16+, in Harehills South in Leeds just 40% of adults have had both jabs.

Harehills South is among the most deprived 10% of areas in England, according to the Indices of Multiple Deprivation, which measures relative poverty. Of the 10 areas with the lowest coverage, seven were also categorised as the most deprived in England.

A chart showing vaccine coverage by Indices of Multiple Deprivation deciles

Several deprived parts of Birmingham were also among areas with the lowest second-dose rates, including Ladywood-Summer Hill, Hockley & Jewellery Quarter and Winson Green & Gib Heath, which all had around half of their 16+ population fully jabbed.

Looking at the whole country, nine in 10 adults in the most affluent 10th of areas are fully vaccinated, compared with just 71% in the poorest 10th.

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Explainer: why has the UK's vaccination rate slowed down?

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The UK has lost its place as Europe's vaccine leader in recent months as countries such as France, Italy and Spain have leap-frogged it in terms of the share of people who are fully vaccinated.