What we know about vaccine hesitancy in South Africa

• A recent survey found that scepticism about a Covid-19 vaccine is higher in South Africa than the global average
• South Africa has also shown consistent low uptake of the seasonal influenza vaccine
• The survey found that the distrust of vaccines in South Africa mirrors low confidence in public institutions

Fewer than two-thirds or 64% of South Africans would accept a Covid-19 vaccine when and if it becomes available, a recent Ipsos survey has found. Of that 64%, only 29% “strongly agreed” to a vaccine while the rest “somewhat agreed”.

This is lower than the average of 74% of about 20 000 adults surveyed in 27 countries who said they would agree to get a vaccine. 

The survey conducted on behalf of the World Economic Forum (WEF) found that most adults (59%) did not believe a vaccine would be available before the end of the year and the number one reason for rejecting a Covid-19 vaccine was fear of adverse events (side effects) followed by concerns about the effectiveness of a vaccine against Covid-19.

Building confidence

Arnaud Bernaert, Head of Shaping the Future of Health and Healthcare at the WEF, said in a statement that “the 26% shortfall in vaccine confidence is significant enough to compromise the effectiveness of rolling out a Covid-19 vaccine”. The forum urged governments and the private sector to build confidence and ensure that manufacturing capacity meets the global supply of a Covid-19 vaccination programme. This would require public funding arrangements that remove restrictions to vaccine access.

South Africa falls in the group with the least intention to get vaccinated (below 70%), which includes Russia (54%), Poland (56%), Hungary (56%), France (59%), South Africa (64%) and Italy, Germany, the USA, and Sweden (all at 67%). The group most willing to get a Covid-19 vaccine includes China (97%), Brazil (88%), Australia (88%), and India (87%). 

Of the 5 000 participants globally who would reject a Covid-19 vaccine, 56% said they were worried about adverse events. Over half (53%) of the 180 South Africans who would not accept a Covid-19 vaccine, were also concerned about safety. It is not clear how representative of the general population the South African study participants are.

Initial target group

Professor Rose Burnett, a scientist, and head of the South African Vaccination and Immunisation Centre (SAVIC) at the Sefako Makgatho Health Sciences University in Pretoria, points out that the initial target group for a Covid-19 vaccine will be frontline healthcare workers, the elderly, and those with comorbidities putting them at high risk. “This is more or less the same target group for influenza vaccination, for which coverage is dismal worldwide,” she says. 

South Africa has shown consistent low uptake of seasonal influenza vaccine with published surveys estimating 25% to 34% of healthcare workers who received influenza vaccination in the previous season. Burnett says SAVIC’s yet to be published surveys on healthcare workers, have shown low coverage is mostly because employers do not provide free flu vaccines, so access is limited by cost, time constraints, and stock-outs. There is also misinformation about vaccines, which results in vaccine hesitancy.

The National Department of Health has prioritised healthcare workers to receive free flu vaccines this year because of Covid-19, she says, adding, “I think healthcare workers, especially those working at the frontline, are likely to be more willing to accept the future Covid-19 vaccine because they have first-hand experience of the severe outcomes of the disease amongst their patients and colleagues.”

The Ipsos survey results show that the 19% of South Africans (just more than half of the 36% who said they would refuse a Covid-19 vaccine) who do not want a vaccine and who say they are worried about vaccine safety, correlates with the vaccine confidence findings of the Wellcome Global Monitor 2018 report on public attitudes to science published last year.  

Only 82% of South Africans said they thought vaccines were safe, compared to 94% of Rwandans and 91% of Nigerians, according to the UK-based Wellcome Trust survey of 144 000 people in 140 countries. The African average was 87%. In Western Europe, only 59% of people expressed trust in vaccines. Vaccine hesitancy led to major measles outbreaks in that region. 

Distrust mirrors low confidence in public institutions

The survey found distrust of vaccines mirrors low confidence in public institutions. In South Africa, 32% of citizens said they had no confidence in hospitals and clinics compared to 27% in Africa and 24% globally. South Africa is also well below the World Health Organization’s Global Vaccine Action Plan 2020 target of 90% coverage for all vaccines in the immunisation programme.

The WHO World Health Statistics 2020 report, using the third dose of the combined diphtheria, tetanus and pertussis (DTP3) vaccine as a measure, puts South Africa’s vaccine coverage at 76% compared to Rwanda (97%) Uganda (93%), and Zimbabwe (89%). By 2019, 125 WHO member states had reached at least 90% coverage of the DTP3 vaccine, according to a WHO statement. 

The most recent Department of Health figures previously released to Spotlight  show that national immunisation coverage of children under five years of age (which includes measles second dose) dropped from 82,3% in April last year to 61.5% in April this year when Level 5 of the lockdown was in place.

Burnett says introducing a new Covid-19 vaccine in South Africa, which will target adults at least initially, is unlikely to affect the implementation of infant vaccination programmes. However, “declining trust in government and public institutions”, she says, “can affect the uptake of vaccines and this has been further eroded by the social media misinformation frenzy around Covid-19”.

“Even if we never introduce a Covid-19 vaccine, we may see an increase in overall vaccine hesitancy, and a negative impact on infant immunisation coverage rates because of the deepening of mistrust,” says Burnett. She points to a Human Sciences Research Council survey in July, which found an increase of mistrust in the ability of government leadership to manage the pandemic, a polarising effect from lockdown restrictions (related to alcohol and tobacco), and public dismay at wide-scale theft of pandemic relief funds.

Different income groups

The Wellcome Global Monitor report found lower rates of vaccine hesitancy in low- and middle-income countries than in high-income countries, suggesting wealthier people are more vaccine-hesitant. 

Burnett says there is no data available yet for different income groups in South Africa. “Unfortunately, caregivers living in homes in leafy suburbs have proven to be inaccessible when conducting household surveys, so all SAVIC’s infant vaccination coverage surveys have been based on poorer communities where we have found almost no evidence of vaccine hesitancy,” she says.

Missed vaccinations were mainly caused by vaccine stock-outs and other health facility obstacles in these communities, Burnett says. In contrast, SAVIC’s online human papillomavirus (HPV) vaccination coverage survey of caregivers of age-eligible girls (nine years and older in grades 4 to 7) attending private sector schools, found that caregivers’ reasons for not vaccinating their daughters were mainly related to vaccine hesitancy.

“Being an online survey, clearly all caregivers had access to the internet, and we found that caregivers of unvaccinated girls were statistically significantly more likely to have based their decision on online articles than caregivers of vaccinated girls,” says Burnett.  

The HPV vaccination survey also found that caregivers of unvaccinated girls were more likely to have taken advice on vaccines from alternative rather than allopathic medical practitioners. 

This, Burnett says, is supported by a 2015 article on South African internet-based anti-vaccination lobbying which found that the authors of webpages discrediting vaccination included complementary/alternative medicine (CAM) practitioners (23.1%), medical professionals practising CAM (7.7%), and medical professionals practising only allopathic medicine (5.8%), with many of these people having financial interests in discrediting vaccines, since they make their living selling products/services as “alternatives” to vaccination or that “heal” the so-called “vaccine-injured” child. 

Vaccine safety

The suspension last month of the Oxford/AstraZeneca Covid-19 candidate vaccine trials after a volunteer developed a neurological problem while on the trial may have added to concerns about vaccine safety. 

Professor Hannelie Meyer, acting head of the Division of Public Health Pharmacy and Management at Sefako Makgatho Health Sciences University, attributes vaccine safety concerns, in part, to a general lack of scientific literacy and understanding of vaccine development.

She says the suspension of the trial by the University of Oxford researchers “shows that the safety of the vaccine is considered very important, taken very seriously and that the trial is not being rushed”. 

The trials of the candidate vaccine in the various countries including in South Africa were resumed soon after an independent expert safety committee found that the condition was not caused by the trial vaccine and was unrelated to the vaccine. 

Meyer, who is also Chair of the National Immunisation Safety Expert Committee which advises the National Department of Health on vaccine safety issues, says that because vaccines are administered to healthy individuals, safety is a major issue in clinical trials which are therefore conducted under very strict guidelines and regulations.

Monitoring adverse reactions

“All vaccines need to go through the three phases of a clinical trial and will only be licensed for use by the national regulatory authority in the country where it is manufactured after adequate clinical studies have been conducted to confirm that the vaccine is effective and safe for use,” says Meyer.

“Monitoring adverse vaccine reactions is a major safety component of clinical trials. Pre-licensure studies often identify common and acute undesirable adverse reactions. However, the sensitivity to detect uncommon, rare events or those with delayed onset is low in these trials. Even large Phase III clinical trials with several thousands of participants are not generally designed to detect these very rare, vague, or delayed onset reactions.”

For this reason, she says continuous monitoring of vaccine safety post-marketing is needed to detect and evaluate such rare adverse events that might be related to the new vaccine.

She says it is essential that the public and healthcare workers understand that adverse outcomes or disease events can be expected when large numbers of people are vaccinated, as will be the case with a possible Covid-19 vaccine. 

Adverse outcomes that would have occurred even in the absence of vaccination will raise public concern, she says. “These events may occur coincidentally to the vaccination and should not be misinterpreted as being caused by the vaccine, as it can really harm public confidence and implementing the vaccine. Having background (expected) incidence rates of these events available will assist when reviewing safety data to assess whether there is a causal link to the vaccine.” 

Systems for safety surveillance

Meyer says any vaccine safety signals should therefore be thoroughly investigated and interpreted to differentiate between events temporally related (i.e. one event coincidentally follows another event) to the vaccine, but not caused by the vaccine, and real adverse reactions to the vaccine.

“When any events occur that are temporally associated with the vaccine, but these events have other causes and they appear at the expected background incidence rate, communication reassuring the public regarding the safety of the vaccine is of utmost importance to maintain confidence in the vaccine,” she says.

“Systems for vaccine safety surveillance and assessment of safety data should be part of the planning and preparation for the roll-out of a possible Covid-19 vaccine. The vaccine will most probably be introduced while Covid-19 is still circulating. Therefore, any safety concerns and adverse events following immunisation,” Meyer says, “need to be rapidly assessed to distinguish between health outcomes as a result of the disease itself, adverse events caused by the vaccine and coincidental events”. 

*Adele Baleta is an independent science writer, WHO vaccine safety communications advisor, and Internews pandemic advisor.

*This article was produced by SPOTLIGHT – health journalism in the public interest. SIGN UP for our newsletter.

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