Webinar: Vaccine Confidence in the Time of COVID-19

"...keeping our finger on the pulse and talking with with people listening to what their sentiments are will be important as we plan out our preparedness moving forward..." - Heidi Larson, Director of the Vaccine Confidence Project (VCP), London School of Hygiene & Tropical Medicine (LSHTM)

Part of a Vaccine Confidence Project (VCP) webinar series, taking place in July and September 2020, this video: explores what we know from the various surveys around the world that give a glimpse into what people are thinking and anticipating around a potential COVID-19 vaccine; offers a landscaping of the state of vaccine development; gives some regional perspectives on the COVID-19 response and implications for a vaccine; features a moderated question and answer (Q&A) session on the regional presentations; and looks at the potential challenges and opportunities of a new action initiative called CONVINCE.

Heidi Larson, VCP Director, begins by observing how volatile public sentiment is around a potential COVID-19 vaccine, which is not unlike vaccine sentiment in general. She points to data the VCP project and others have gathered. For instance, in March 2020, a nationally representative sample in France indicated that 26% would not use the vaccine, with 60% saying they would; there was a group of uncertainty in between. In contrast, in China, 87% said they would take a vaccine. However, experience in vaccine acceptance research shows that surveys on intended acceptance really give only an indicative sense; the reality is that, when the vaccine is there and offered, people's behaviours may change - particularly in the highly uncertain context of the novel coronavirus. Sentiments also change over time; for example, in the United Kingdom (UK), in mid-march 2020, 7% of the population said they would not take a vaccine if it became available, but 2 weeks later, that dropped to only 5% refusing. Larson explains such a finding by pointing to the fact that that was the peak of COVID-19-related fatality rates. Then, as the background number of COVID-19-related deaths started to decline, the willingness to take a vaccine also started to decline. The VCP is working closely with the African Centres for Disease Control and Prevention (CDC) and the Africa Union to get a more representative sense of public sentiment around a potential COVID-19 vaccine on that continent, where there are some very low numbers in different countries in vaccine confidence generally (e.g., Togo, Mauritius, and Burkina Faso).

Next, Beate Kampmann, Director of the LSHTM Vaccine Centre, provides an update on the status of COVID-19 vaccines. She discusses the state of the vaccine landscape from a development perspective, offers background on where the vaccine pipelines are, and points to plans to address major obstacles to implementation that might present later on. The vaccine tracker showed at the time of this webinar that there were 218 candidates, of which 189 are in pre-clinical development. Kampmann reflects on the process through which these vaccines are evaluated in light of the fact that safety is at the forefront of a lot of people's minds (as is efficacy - we need both in order to combat this pandemic). Kampmann observes that, a few days prior to the webinar, there were already media reports about the data from an Oxford vaccine that hadn't even been published or announced by the Oxford team. Kampmann cautions that scientists need to be very mindful about being approached by journalists to comment on data that are not yet in the public domain; this, she says, is a cause for concern, as we know that not every vaccine candidate makes it.

Kampmann also explores issues of vaccine availability and uptake. It is quite unlikely there will be enough vaccine for the entire world and also unlikely that it will only be one particular type of vaccine, so we need to consider whether the goal is to prevent severe disease or to prevent transmission. Other questions arise around effectiveness of the vaccine once it's actually launched, as well as its acceptability, its costs, and the gains for the individual versus the gains for the community. Gavi and the Coalition for Epidemic Preparedness Innovations (CEPI) are leading an initiative (COVAX) around ensuring global equitable access, because countries that have significantly contributed to the funding of the vaccine research will also want to have a first pick at the crop. This might leave low- and middle-income countries (LMICs) behind. Thus, many players are contributing to thinking about advanced market agreements and how we can commit countries to funding of access to COVID-19 vaccines beyond their own borders. Kampmann concludes by reminding the audience that there's a fair amount of fallout ("COVID collateral") because immunisation efforts worldwide have already suffered from the fact that immunisation programmes are not working as effectively as they normally do, and there are many thousands of children already out there who are not currently receiving licensed, safe vaccines.

Three experts go on to offer different regional perspectives to highlight the implications of the COVID-19 response in affecting the trust and willingness of the public in various contexts to take up an anticipated COVID-19 vaccine:

• Hailing from Brazil, Clarissa Simas, Lead for Latin American Research at the VCP, gives a brief overview of different COVID-19 responses in the region and then shares 3 key messages of what she thinks we should focus on in terms of COVID-19 vaccine acceptance. She notes that there were a lot of variations in responses in Latin America, so some countries (e.g., Uruguay and Peru) had very strict measures early in the pandemic, whereas other countries (e.g., Brazil and Mexico) have not taken coronavirus measures very seriously at a federal level. Overall, the outcomes have not been great. First, long-sustained social and economic inequalities make it structurally difficult for people to comply with those measures; second, there is a pervasive mistrust in government that is very common in the region. Simas explores these key points about building trust for a COVID-19 vaccine:
  1. Though levels vary from country to country, there has been an overall drop in vaccine confidence in Latin America in the past 5 years; this is particularly concerning when these drops happen in countries that have been historically confident. Simas stresses that vaccine hesitancy will play a role in current situation, especially given that new vaccines - and one that is being produced at a record speed - are likely to bring up feelings of uncertainty doubts about safety and efficacy.
  2. We know from previous research in Latin America and in other lower-income settings that long legacies of systematic neglect and sometimes even abuse by government and health services, alongside weaker health system configurations, negatively impact vaccine confidence.
  3. A COVID-19 vaccine could become highly politicised not only by vaccination groups in the region but also by federal governments. It is not uncommon to see vaccine debates being co-opted for political reasons, particularly with more populous leaders; this adds another layer of concern.
• Hailing from Taiwan, Leesa Lin, Assistant Professor, Public Health Emergency Preparedness & Response, LSHTM, discusses the ways in which many East Asian and Southeast Asian countries responded to the "first wave" of COVID-19 (January - March 2020). Grounded in their experiences with other epidemics (e.g., SARS in 2003 and MERS in 2015), these countries are aided by universal healthcare systems and a clear goal to eliminate the disease. Despite distinctive differences in political structures, the Asian responses share similar features: a rapid containment effort supported by strong public consensus and support. The general public in these areas demonstrate high levels of awareness and cooperation with epidemic prevention measures, including those said to be restrictive or even draconian. A lot of these measures are mandatory instead of advisory, versus in the United States (US). In that country, the federal government has given ambiguous and often conflicting messaging and has mostly relied on local governors to navigate the response - with limited national coordination in terms of data sharing, containment or reopening strategies, or contact testing and quarantine. With regard to vaccines, Lin highlights 2 features we should address: (i) COVID-19 denialism (e.g., by top government officials, including in the US); and (ii) communication inequalities (how people access, interpret, and use risk information, which is greatly associated with their social-demographic situation). Lin suggests that it would be helpful to conduct more research and identify key public populations and underlying reasons for denying COVID-19's seriousness and then to identify mitigation strategies, such as community engagement. This might involve asking: Who are the key messengers, and what ethnically sensitive efforts are needed to maximise uptake of vaccines in countries with diverse communities and religious practices?
• Hailing from Nigeria, Ayoade Alakija, former Chief Humanitarian Coordinator, Nigeria, reflects on COVID-19 in the relation to the Ebola experience. Though there were lessons learned - as well as certain institutions, structures, and mechanisms in place such as CEPI - that are helpful now, Alakija suggests that the understanding of COVID-19 is somewhat skewed due to Ebola. She had a conversation earlier with a colleague who commented that COVID-19 is a subtle disease - it's a very covert enemy - and Africa is not a continent that does not do subtle very well, with its vibrant colours and culture. Ebola was very dramatic in its manifestation, so there was an instant fear factor; now, we have a situation with COVID where we don't understand the disease, so how on earth are we going to convince millions of people to accept a vaccine? Testing mechanisms are not in place, and there hasn't been the political will across many of the African nations. The misinformation coming out from the Global North has also been a major contender because so many African nations do look to the leadership there. Meanwhile, Africa is sort of sitting in complacency at the moment, thinking that COVID-19 hasn't or isn't coming or isn't going to hit Africa hard. People are dying in huge numbers, but because of the weak health systems and infrastructure, there isn't a clear counting of the dead; nor are there massive graveyards like those seen in Brazil. Alakija indicates that the response to a vaccine depends very much on us having the tools to educate populations in local languages about the disease itself. As a global health community and as a scientific community, we need to achieve fluency in the situation before we can communicate effectively the need to vaccinate against it.

The Q&A session piggybacked on the above regional perspectives:

• Latin America: There was a question about whether the issue is trust in science and scientists or is it more about trust in authorities and politicians. Simas opines that it depends, but she would definitely not try to to put them in silos.
• Asia: Another question focused on the confidence levels in China and India related to COVID-19 vaccine acceptance.
• Africa - examples include:
  1. Would empowering countries in Africa to make their own vaccine help build trust? Alakija said this would take a much longer conversation and discussion about the education system, STEM (science, technology, engineering, and math), vocational skills, etc. COVID-19 has focused the magnifying glass on so many of the faultlines and inequities in our system.
  2. Do you think anti-COVID-19 vaccine narratives from the US and Europe are influencing Africa? Alakija said yes but clarified that the misinformation also comes from countries within the African continent (and is often spread by WhatsApp). For example, polio wasn't eradicated from Northern Nigeria sooner because of superstition within the culture and belief that the vaccine was actually intended to sterilise people. With COVID-19, the rumour is circulating (even among the highly educated) that the vaccine will contain microchips.
  3. Is there a sort of distrust in government due to a feeling that the response to COVID-19 is disproportionate versus other epidemics that are also fatal, like meningitis? Illness and death are not unusual for many communities and families in Africa, Alakija asserted. She relayed a story about a cholera epidemic in Northeast Nigeria, during which time she phoned a state's health official, who said, "why are you disturbing me? That's what happens...poor people die every day." Though we need to value human life more, it is not just a matter of life versus death - we also need a greater understanding of the longer-term effects of COVID-19.

Next, Nancy Lee, Programme Director, Wilton Park, and Scott Ratzan, Editor, Journal of Health Communication, and Associate Professor, City University of New York (CUNY) discuss a new initiative with the VCP called COVID New Vaccine Information, Communication and Engagement (CONVINCE). In short, the vision is to ensure that the vaccines we are investing in are optimised and are able to end and mitigate future outbreaks. To achieve these aims, we must prepare a vaccine-literate public and persuade policymakers and the general public (in all its diversity) to trust the science. CONVINCE takes a whole-of-society approach, recognising that it can't just be the health sector that bears the responsibility for this; rather, Wilton Park, CUNY, and VCP are harnessing the power of different stakeholders with fresh ideas (e.g., creatives, social scientists) to help craft strategic communications around how to address vaccine literacy. The idea is to support multi-sectoral commitments to bolster trust, to prepare accurate and convincing information sources about vaccines, and to create innovative multimedia and interpersonal approaches to communicate and engage with all audiences, including people on the ground, where we find them. CONVINCE also works by engaging with the private sector - e.g., networking with the international chamber of commerce, employers and business partners, the World Economic Forum, and others to see how we can leverage these communities to get employees, for example, on board with a COVID-19 through their recommendation.

Reflective of this vision, the CONVINCE call to action seeks to get everyone involved because the entirety of society has a role to play - whether you're in big business or a community healthcare worker or a mother - to ensure we're all protected if and when there's a new COVID-19 vaccine. One of the messages that has run throughout the webinar is that, while we need global connectedness and global approaches, we also need a lot of local nuance and local understanding. Platforms have become diversified; there is no one place that all people go, so we can't assume that any one platform is going to be where the action is. We need to recognise social media and communication as a kind of ecosystem. People may take photographs of a WhatsApp screen and read it on the radio or read it from the pulpit, or an imam might photocopy it and tack it on a tree. If there's one thing we've learned in 10 years of vaccine confidence research, it's that we need to pull the lens back (keep an eye on the big picture, which changes over time) but never neglect the local nuances.