COVID-19 vaccine hesitancy in India

INTRODUCTION Since its emergence in late 2019, the COVID-19 pandemic has spread across every part of the globe – especially leaving behind an unparalleled burden on the healthcare system.[1] Not only has our frontline service been dealing with COVID-19 infections and deaths, but they have also recently been tasked with conducting the world’s biggest vaccination drive ever.[2] The current emphasis is on developing effective COVID-19 vaccinations and restoring pre-pandemic normalcy.[3] Vaccination remains the most significant public health means of preventing the spread of disease and serious harm. Its success, however, has been questioned by various individuals and groups, and often denied, citing religious, scientific, and political conflicts.[45] The World Health Organization defined vaccine hesitancy as the reluctance or refusal to receive vaccines despite the availability of vaccines; this eventually threatens to reverse the progress made in tackling vaccine-preventable diseases. Vaccine hesitancy is multi-faceted and context-dependent and varies with respect to time, place, and disease. The five Cs to tackle vaccine hesitancy include confidence, complacency, convenience, communication, and context (sociodemographic characteristics).[67] Vaccine hesitancy has been one of the major barriers to the achievement of optimal disease control or even its eradication by many public health efforts.[8] Despite substantial evidence indicating that vaccines are safe, there is growing skepticism about the immunization process itself.[9] Owing to the lack of effective COVID-19 treatment options, mass vaccination appears to be the most promising strategy for combating the COVID-19 pandemic.[1011] As a result, there is an urgent need to understand the attitudes towards vaccination and the factors that influence the rationale of people’s decisions for or against vaccination, with a goal to appropriately modify public health messaging.[1213] Moreover, the expeditious pace of vaccine development, misinformation in the media, polarized sociopolitical conditions, and the intricacy of extensive nationwide vaccination campaigns have jeopardized trust in vaccination and increased complacency.[14] Herd immunity against COVID-19 is likely to be best attained through mass vaccination, rather than by widespread natural infection.[1516] Vaccine hesitancy has become a significant barrier in various countries to achieving the high coverage ratio required to attain herd immunity and flatten the curve.[1718] This article discusses the COVID-19 vaccine hesitancy in India, the factors that contribute to vaccine hesitancy along with the strategies to combat it. VACCINE ATTRIBUTES AND INTENTIONS Vaccine hesitancy is always complex, resulting from a number of structural and historical factors. Critical knowledge about vaccine properties, including the extent of immunity and immunogenicity, is progressively building up and ranges across manufacturers and populations.[192021] The immature knowledge of immunology and virology of the COVID-19 disease, along with the unparalleled pace of advancement of the vaccine has undermined public confidence.[22] All viruses mutate over time, and the SARS-CoV-2 is no different. When a virus is widely circulating in a community, the risk of it mutating and adapting increases, causes further illness.[23] As the virus gets more opportunities to circulate, it undergoes increased replications and further mutations, subsequently growing stronger and more virulent. Several interrelated and synergistic factors, such as demographic trends and dense urbanization, huge gatherings, diversified human behaviors, environmental variations with modification of the ecosystem, and insufficient global public health mechanisms, have enhanced the emergence along with the spread of viruses as existential threats.[242526] COVID-19 vaccines which are currently in development or approved produce an extensive immune response including a wide array of antibodies and cells, implying that they will provide at least some protection against future strains.[27] As a result, virus mutations or modifications should not render immunizations ineffective. High-risk groups should be vaccinated first to maximize global protection against novel variants and reduce the possibility of transmission. Furthermore, given the pandemic’s changing nature, providing equitable access to COVID-19 vaccinations is more crucial than ever. As more people get vaccinated, we expect the virus’s circulation to decline, resulting in fewer mutations.[28] GLOBAL SCENARIO Vaccine hesitancy exists in differing degrees globally. Depending on the extent of the health and socioeconomic consequences in each country,[29] the global COVID-19 pandemic may have a variable impact on the public trust in health organizations, research, and healthcare.[30] Globally, there are 24 COVID-19 vaccine manufacturers, and only 10 have been finalized and approved for use worldwide.[31] The United States public survey data conducted in July 2020, revealed the impact of political influences on uncertainty, such as lack of assurance in persons advocating the COVID-19 vaccine injection, its state of origin, and concerns regarding profiteering as well as political intentions which have increased distrust in the community.[1932] According to the surveys conducted in 33 countries to understand the rates of COVID-19 vaccine acceptance, the acceptance rates were the highest in low- and middle-income countries such as Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%), and China (91.3%), whereas high-income countries such as Kuwait (23.6%), Jordan (28.4%), Italy (53.7%), Russia (54.9%), Poland (56.3%), United States (56.9%), and France (58.9%) had the least acceptance rates.[33] Survey data showed that individuals having lower education levels, who were unemployed, younger, and belonged to certain racial and tribal minority groups had higher levels of vaccine hesitancy.[3435] The highest vaccine acceptance rates have been noted among Asian Americans (17%) and Whites (16%), whereas the lowest vaccine acceptance rates were among African − Americans (12%) and Hispanics (9%). More highly educated people have had better access to vaccination due to the vaccine’s complex distribution model.[36] INDIAN SCENARIO India, as one of the world’s most populous countries, has been battling the spread of the SARS-CoV-2 virus; as of September 15, 2021, India has more than 33 million cases and more than 440,000 deaths due to COVID-19; India has the second-highest number of cases after USA, and the third-highest number of deaths after the USA and Brazil.[3738] On January 16, 2021, India officially launched one of the world’s biggest COVID-19 vaccination campaigns to vaccinate its 1.38 billion population. In the primary phase, healthcare personnel and front-line workers were the first to be vaccinated. Beginning in May 2021, the rest of the population was to be covered, commencing with the elderly and those with comorbidities, adults in the age groups of 45–60 years and 18–44 years.[3940] In India, there are seven vaccines that have been granted Emergency Use Approval including the two most commonly available-Covishield (Oxford-AstraZeneca/Serum Institute of India) and Covaxin (Bharat Biotech/Indian Council of Medical Research). Also approved are the Sputnik-V (Gamaleya Institute, Russia/Dr. Reddy’s Lab), NVX-CoV2373 (Novavax/Serum Institute of India), BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna/NIAID), and Ad26.CoV2.S (Johnson and Johnson/Biological E).[41] The Ministry of Health and Family Welfare (MoHFW) through its “COVID-19 Vaccine Communication Strategy” intends to vaccinate the entire population of India by the end of 2021. The detailed report from the MoHFW, with actionable recommendations was intended to serve as a guide for officials at district, state, and national levels to combat vaccine reluctance.[42] Despite these efforts, as of September 17, 2021, only 13.73% of the country’s population has received both the doses of the COVID-19 vaccine and 28.34% has received only one dose of the vaccine, while in contrast, countries such as the USA, UK, and Canada have managed to fully vaccinate more than 50% of their population against COVID-19 [Figure 1].[43]Figure 1: Country wise population who are fully vaccinated and those who have received one dose (taken from Our World in Data)[43]Distrust in the safety of recently approved vaccines, fear of adverse effects, and rumors concerning infertility and death as a result of the COVID-19 vaccine, among other causes, are fueling high vaccine hesitancy. According to the “COVID Symptom Survey” conducted in India, the top five reasons provided for not getting vaccinated included, “Waiting for others to get it first” (42%), “Other individuals need it more than me” (35%), “Fear of any adverse effect” (34%), “Vaccines will not work,” (21%) and “Disbelief in the vaccine” (11%) [Figure 2].[44]Figure 2: Reasons for COVID-19 vaccine refusal in India. (derived from the COVID Symptom Survey)[44]Since India launched the world’s largest vaccination program, much attention has been focused on vaccine shortages, a price war between the central and state governments, the campaign’s overall slow pace, and patent and production restrictions.[45] Vaccine reluctance has been overlooked, with the implicit expectation that it will vanish once vaccine availability increases. However, as of September 17, 2021, official data from the MoHFW suggest that only 190 million people have been fully vaccinated out of the 1.3 billion population.[46] Vaccine hesitancy prevails and is becoming a problem with very few possible solutions. The initiation of the CoWIN(COVID Vaccine Intelligence Network) registration portal has significantly enhanced the vaccination campaign. Presently, from May 1, 2021, the fourth phase of the vaccination drive has kicked off, directed at all persons over the age of 18 years.[4748] Based on the reported statistics, vaccine hesitancy is rampant in remote areas and regions with restricted connectivity, where vaccination teams were unable to obtain 100% vaccination coverage after several visits, even when vaccine doses were available.[49] COVID-19 VACCINE HESITANCY STRATEGIES Vaccine hesitancy in India is a multifaceted and complex issue. Globally, including India, efforts are being made to increase the COVID-19 vaccination rates. India must take aggressive initiatives to address and build trust and eliminate vaccine hesitancy. In the current pandemic situation, myriad strategies have been employed by the MoHFW, Government of India, at various levels to spread awareness, improve the vaccination rates, reduce the vaccine hesitancy, and to curb the spread of COVID-19 across the country. POLICY LEVEL We need to learn from past immunization experiences for diseases that are relevant to the Indian scenario. Due to a historical distrust in the healthcare system and a lack of awareness, poor and marginalized populations have been hesitant to participate in India’s earlier vaccination campaigns, such as the measles and rubella vaccination drives.[50] In 1802, the first doses of the smallpox vaccine came to India. For a variety of factors, including the necessity to pay for the vaccine, lack of faith in the inoculation method, and the conviction that the illness was a manifestation of divine wrath, the uptake of the smallpox vaccine by the general public was low. In 1892, India implemented the Compulsory Vaccination Act in order to enhance smallpox vaccine coverage and with the goal of preventing a pandemic. In the late nineteenth century, the science of vaccine development spread around the globe, with India being one of the few countries to participate. In 1978, the Expanded Programme of Immunization in India was followed by the Universal Immunization Programme in 1985.[51] Smallpox has been eradicated in India since 1977.[52] Similarly, polio has been largely eradicated, and the successful management of measles has made the eradication of the SARS-CoV-2 virus an achievable target.[53] As a result, lowering the cost of the COVID-19 vaccine for college students can be a beneficial way to reduce COVID-19 vaccine hesitancy.[54] The government’s COVID-19 vaccination communication strategy has significant operational and structural flaws in its current form. The second wave of infections disrupted capacity-building for communication management at the national, state, district, and sub-district levels.[55] INTERPERSONAL LEVEL Interpersonal interventions focus on the interaction between the physicians and patients. Clinicians have regularly been shown to escalate the vaccination rates through a wide range of preventative behaviors. Doctors continue to be the most trustworthy source of information, in general as well as in the context of COVID-19.[56] Vaccination rates have also been reported to be influenced by the intensity and quality of clinician recommendations. Strong recommendations from recognized professionals can additionally enhance the confidence in the vaccine, alleviate safety concerns, and increase the acceptance of the COVID-19 vaccine. Individual-level interventions are aimed at healthcare members as well as the patients. Although training clinicians and patients individually may not be as successful, when integrated with organizational, interpersonal, and individual-level educational interventions, healthcare teams can better equip themselves to advocate vaccination and maximize efforts to resolve patient apprehension [Figure 3].[57]Figure 3: Factors influencing vaccine confidence in IndiaORGANIZATION LEVEL COVID-19 vaccination apprehension is currently spreading across a wide range of socioeconomic groups for a multitude of reasons including the lack of appropriate information on vaccine safety and efficacy, high cost of vaccines, vaccine shortage, and lack of digital access and distrust in the government actions.[58] The widespread prevalence of COVID-19 vaccine hesitancy must be tackled together by governments, health policy makers and various media sources.[59] Several organizational strategies have been created to increase immunization rates. Nurse visits, point-of-care prompts, reminder/recall systems, audit and feedback, and home visits are all examples of these interventions.[6061] Advocacy initiatives should be led by a variety of stakeholders and professionals at the district, state, and national levels. Organizers of advocacy events should include participation from religious leaders and faith-based institutions, including written appeals and amplified audio/video bytes distributed across electronic media, print and social media. Interpersonal communication training should be provided to auxiliary nurse midwives, Anganwadi Workers, Accredited Social Health Activists, traditional healers, local doctors, and other mobilizers. It is also important to maintain continuous, real-time monitoring of the digital media so that necessary and timely action may be taken to reduce vaccine hesitancy. The National Media Rapid Response Cell, which was developed as part of the COVID-19 vaccine communication plan, is responsible for informing district collectors across India about vaccination disinformation in real-time.[62] Misinformation about the vaccine’s advantages, medicinal composition, and side effects, which has been circulated through numerous routes, can have a substantial effect on vaccine reception and objection.[63] The adoption of vaccines is strongly linked to public trust in the government, which can help with public compliance with planned actions.[64] CONCLUSION The development and adoption of the COVID-19 immunization program is hampered by vaccine hesitancy. Vaccine hesitancy is an intricate and dynamic issue and is influenced by context-specific factors, necessitating both locally and internationally driven techniques to recognize early concerns. While individual approaches can be beneficial, the most effective interventions are likely to comprise a combination of well-integrated multi-component strategies to boost vaccine uptake, knowledge, and awareness, as well as a shift in attitudes toward vaccination. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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