Aye of the needle: overcoming vaccine hesitancy

By on 26/08/2021 | Updated on 26/08/2021
Try persuading him: ‘antivax’ protests, like this one in Sheffield, represent a small hardcore of diehard sceptics – but many others can be persuaded to get vaccinated. Pic by Tim Dennell

To end the pandemic, governments must persuade the vast majority of adults to get vaccinated – but apathy, health fears and conspiracy theories are holding down vaccination rates. Liz Heron explores how different governments are approaching the problem

Ever since French president Emmanuel Macron launched a mandatory vaccination health pass, people attending COVID-19 vaccination and test centres across the country have been encountering walls daubed with swastikas and slogans such as “Nazi” or “collaborator”.

The graffiti highlights the intense feelings sparked by the debate over how governments should persuade people to join national vaccination drives, bumping up the numbers of those vaccinated until the disease struggles to spread through the population.

At least 21 vaccination and test centres plus a medical lab have been defaced or vandalised since Macron announced that a health pass showing proof of vaccination or a recent negative test would be mandatory for entering bars, restaurants, cafes, trains, cinemas and other venues. At one vaccination centre in the Vercors, fire hoses were opened to cause a flood; at one in the Pyrenees, a temporary vaccination tent was set on fire.

Infuriated by the president’s move – which also requires all health professionals to be vaccinated or face suspension – France’s anti-vaxxers, who cluster around the far right and far left of the political spectrum, have also mounted weekly demonstrations where Nazi-themed placards protesting against the “health dictatorship” are a common sight.

Reaching ‘herd immunity’

Following extraordinary global efforts to develop safe vaccines on an accelerated timescale, COVID-19 vaccination campaigns have provided levels of public health protection that enable governments to ease or end lockdowns and take urgent steps to restore economic growth.

Vaccines provide individuals with a good level of protection: those jabbed with AstraZeneca, for example, are about 70% less likely to suffer symptomatic illness and 90% less likely to end up in hospital. However, to render everyone safe from a virus, governments need to prevent it from circulating in the population – and that means achieving ‘herd immunity’, with so few people vulnerable to infection that the disease’s spread is stifled and it eventually fades away.

So the ability of a vaccine to extinguish a disease in the longer term relies on a trade-off between the proportion of the population covered and the efficacy of the jab, given the basic reproduction rate – or R0 value – of the virus. Experts typically take 75% of the population as a realistic coverage level, meaning that in the case of COVID-19 – whose R0 value has been calculated at 2.87 – the vaccines would need to be at least 86.9% effective to bear down on the virus. Given that the recent, more infectious strains of COVID-19 have a significantly higher R0 value, even greater levels of coverage or effectiveness will be required.

Professor Erik Wengström, of Lund University in Sweden, tells GGF that there is still uncertainty about the percentage of the population that needs to be vaccinated to ensure effective protection against COVID-19’s variant strains. “But to achieve herd immunity, more than 80% or even 90% will need to be vaccinated or exposed to the virus through natural infection,” he says.

Hard levers in the USA

As a result, governments have scrambled to come up with strategies and campaigns to encourage people to get jabbed. Some have offered cash or gift incentives; others have mandated vaccination within public sector or health care jobs, or required health passes showing proof of a vaccine or recent test to access venues and public spaces.

After a slow start in tackling the virus, the United States has now adopted mandates in key areas, and the approach is spreading rapidly across different sectors. President Joe Biden announced on 29 July that all federal employees and contractors will have to sign forms stating that they have been vaccinated or comply with new rules on mandatory masking, weekly testing and social distancing. On 23 August, the Pentagon announced that it will make vaccines mandatory for all 1.4 million active-duty service personnel, after the Pfizer-BioNTech vaccine was given full approval by the US Food and Drug Administration.

‘Google’ to ‘learn the risk’: an anti-vax protester reveals how he gets his information at a 2020 Vancouver protest. Pic by GoToVan

More than 600 universities and colleges across the US also require students or staff to be vaccinated, while large employers including Google, Walmart and United Airlines have introduced mandates for all or some staff following encouragement from President Biden’s chief medical adviser Dr Anthony Fauci. The moves come despite a kick-back at state-level, with some states passing laws that bar vaccine mandates.

Meanwhile, New York City is to planning to introduce a scheme requiring proof of vaccination for access to indoor venues ranging from restaurants and gyms to concert halls from 13 September, and to phase in vaccine mandates ­– without a testing exemption – for all education employees from 27 September.

Softly softly in Europe

By contrast, most European countries have relied more on carrots than sticks to bring those who are slow or reluctant to get jabbed into vaccination centres, with young adults – who were last in the queue and face the smallest risk from COVID-19 – often the primary target of campaigns. Greece is handing out €150 vouchers valid for travel, hotels and arts event tickets to young people aged 18-25 who have had their first dose. Other public bodies are offering smaller incentives; the southern German city of Sonnenberg says it has boosted vaccination rates by offering free sausages.

In the UK, the government has teamed up with ride-hailing firms Uber and Bolt and take-away delivery company Deliveroo, offering discounts on taxi rides and fast food to customers who can prove they have been double-jabbed. Supermarket chain Asda and online travel agent lastminute.com have also joined the initiative. Premier London nightclub Heaven, which has a long association with the LGBT community, has hosted regular vaccination sessions for revellers during club dance nights, while pop-up vaccination clinics have been held at football matches and music festivals.

Same strategy, different tactics: Boris Johnson (left) has avoided using hard levers to drive up jab rates in the UK, but in vaccine-hesitant France Emmanuel Macron has controlled access to venues and transport. Pic by Number 10

The UK government has tiptoed gingerly around the question of mandates since prime minister Boris Johnson made a last-minute announcement on “Freedom Day” in July – when lockdown measures were fully lifted in England – that proof of two jabs would be required to enter nightclubs from September. In late July, changes were made to the NHS COVID Pass without a public announcement, leading to accusations that domestic vaccine passports were being introduced by stealth. A “Domestic” section was added to the app, stating that users may need to show it “at places that have chosen to use the service”.

Success in France

Warning that Macron’s policies may threaten his chances in next year’s presidential election, some commentators have compared the French anti-vaccine protesters to the Gilets Jaunes: the grassroots movement sparked by anger against fuel tax hikes that morphed into months of wider anti-government protests from 2018-19. But the statistics tell a different story.

After Macron announced the move on 12 July, the medical booking site Doctolib was jammed with calls; within 48 hours, 1.7 million people had booked appointments. By 20 August, according to Our World in Data, France had overtaken the United States in the proportion of the population that is fully vaccinated – with 55% compared to 51% in the US.

Traditionally, France has been one of Europe’s most vaccine-hesitant countries, with just 24% of French citizens voicing willingness to have a COVID-19 jab in December last year, according to a YouGov poll. However, the figure has risen steadily this year and had reached 80% by the time of Macron’s announcement, rising further to 87% by late July.

Individual v collective rights

A key question for policy makers is whether vaccine mandates or sanctions infringe personal liberties. Does one person’s right to refuse vaccination override another’s right to be protected against the SARS Cov-2 virus, whether at work, in a public place or at a leisure venue? For many, the answer is provided by classical liberal philosopher John Stuart Mill, who wrote in his defining work On Liberty, “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.” Yet even among those who agree that mandates are justified, there is disagreement about their effectiveness and whether they may be counterproductive.

Greek tragedy: the Greek government has been handing out vouchers in a bid to combat anti-vax messages, like this warning that the ‘forerunners of the antichrist’ want to mark individuals using the vaccine. Pic by aesthetics of crisis

“Basically, freedom is limited when others are harmed by your behaviour,” says Professor Arthur Caplan, head of the Division of Medical Ethics at New York University, who favours mandatory vaccines backed up with fines for non-compliance. “I’m not ready to send the vaccine police to your house to vaccinate you, but I do think we should mandate vaccination for schools, restaurants, sports events and gyms, and treat the plague for what it is: a real, serious, public health challenge.”

Let-out clauses in vaccination mandates should be restricted to health reasons or “reasons of utility” – meaning people who don’t respond to vaccines because their immune system is too compromised – says Caplan. “I would not let people out because they have strong beliefs that they don’t want to; that undermines the mandate,” he adds.

Melinda Mills, director of Oxford University’s Leverhulme Centre for Demographic Science, likewise argues that it is naïve to make the libertarian case that government should stay out of people’s private lives, when dealing with public health measures. “As with second-hand smoking, the government has a moral duty to stop the spread of COVID and promote the health and wellbeing of its citizens,” she wrote in The Guardian in August.

However, Mills cautioned that, while policies that curtail individual liberty for the greater public good can be powerful, they need to be properly scrutinised to ensure they work. Unjustly coercive measures can produce more harm than protection, she argued.

“There is a risk that a mandatory COVID pass will be seen as coercive, fuelling greater mistrust around vaccines,” Mills wrote. “Requiring an ID card or passport to enter a football match or nightclub could fuel suspicion for those against the use of COVID certification. For Covid conspiracists, a vaccine passport may have the same symbolic effect as the face masks that have so riled anti-lockdown protesters.”

A domestic vaccine passport for nightclubs and other mass events in England would be a “technical and ethical minefield”, she added, questioning whether it would work and citing trials of the CoronaCheck app – a similar initiative in the Netherlands that collapsed within hours of its launch.

Incentivising injections

Sanctions can also backfire by incentivising the sale of fake vaccination certificates, which is reportedly taking place in multiple jurisdictions. An investigation by the PoliticsHome news platform found that bogus NHS certificates were being sold for £200 (US$275) through the encrypted messaging app Telegram, in groups with up to half a million subscribers.

Professor Wengström is leading a study into whether cash incentives of 200 krona (US$23) can motivate people to get vaccinated in Sweden, where vaccination to date has been entirely voluntary, in line with the country’s light-touch approach to the pandemic.

“It is likely that mandates are more effective in boosting vaccination rates, but at the same time they may meet more opposition,” he said. “Communication and access are important, but there is likely a limit to how far information and communication can push the vaccination rate, in particular during later stages of the vaccination campaign.

“Incentives can perhaps be seen as middle way, preserving the voluntary aspect of the decision yet encouraging some people to get vaccinated. Small incentives are unlikely to convince serious sceptics, but might affect those that are postponing or haven’t found it worth the hassle to carry through with their vaccination intentions.”

Targeting and trust

While vaccine mandates, passports and incentives make headlines, many experts say that the most effective ways to address vaccine hesitancy and boost uptake are simply through clear communication, easing access to vaccination centres, and building trust.

In the UK, where the drive to vaccinate youngsters aged 16 and 17 has begun, public health campaigns led by high-profile ethnic minority MPs and celebrities or local community champions have been mounted – combating misinformation and building trust among ethnic minorities, after official UK statistics showed they were among the groups displaying higher vaccine hesitancy levels. Hesitancy has fallen across all groups since the vaccination drive began.

Right jab: falling vaccination rates, particularly among young people, threaten governments’ ability to stifle the virus’s spread. Pic by New York National Guard/Sgt Sebastian Rothwyn

Mills is one of five leading health experts who advocate a “five Cs” approach to tackling vaccine hesitancy worldwide in support of the COVAX global vaccination drive. These are: building confidence; tackling complacency; boosting convenience of vaccine delivery; improving communication with hesitant groups; and improving understanding of their socio-economic context.

“A recent study found that it wasn’t coercion that worked,” she said, “but the personal approach of a text reminder saying this vaccine is ‘reserved for you’ that was most effective in getting people vaccinated.”

You may also be interested in previous GGF features on related topics, such as the report on our webinar on COVID passports, and an earlier feature on the phenomenon of vaccine hesitancy.

About Liz Heron

Liz Heron is a journalist based in London. She worked on daily newspapers for more than 16 years as an education correspondent, section editor and general news reporter. She was Education Editor of the South China Morning Post in Hong Kong and has contributed to a wide range of British media including The Independent, The Guardian and the BBC.

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