All players must guard against messaging that erodes vaccine trust

On January 16, 2021, India began Phase-I of what may be the world’s largest vaccination drive, aiming to vaccinate nearly 300 million frontline workers against COVID-19. This rollout featured India’s indigenously developed Covaxin (Bharat Biotech/Indian Council of Medical Research) and indigenously produced Covishield (Serum Institute of India/Oxford-AstraZeneca), marking the beginning of the potential end to the pandemic’s 11-month siege.

Over the last year, the pandemic has served as a litmus test for functional public health policy and preparedness at global and national levels. While high-income countries focused initial efforts on expanding critical care services, low-and middle-income countries such as India turned their attention toward widespread COVID-19 surveillance and risk communication campaigns. With decades of training in responding to regional epidemics, India’s public health arsenal includes the use of communication strategies aimed at widespread social and behavioural change. For instance, a key component of the 2018 Poshan Abhiyaan is Jan Andolan (mass mobilisation). Now being adapted into COVID-19 communication, this consists of community dissemination of messages through existing platforms and unified transmedia narratives engaging all stakeholders. Over 2 million Accredited Social Health Activists (ASHAs) and anganwadi workers expanded their roles in maternal and child health to educate communities on COVID-19.

Between March and April, a total of 36 videos were telecast in Hindi and English on India’s national television channel, Doordarshan, even as more regional content continued to be developed. The first campaigns emphasised symptoms and travel warnings; subsequent messaging highlighted face-coverings and distancing, followed by tips for social and mental well-being, and, finally, vaccines. Journalists across the country played a crucial role in translating evolving scientific findings and guidelines. The widespread use of social media in cities, towns, and villages also meant real-time transmission of both COVID-19 information and misinformation.

A national COVID-19 vaccine communication strategy additionally identified approaches to transparently disseminate information, address vaccine hesitancy, and communicate the basis of a staggered vaccine rollout. India’s experience with mass-vaccination campaigns is marked by the successful implementation of the Universal Immunisation Programme that uses evolving mass-communication and social media strategies to build vaccine trust. This is reflected in a November 2020 survey showing that 87 per cent of Indians were willing to receive a COVID-19 vaccine. However, we should not take this hard-won trust for granted. On January 3, in a move that took by surprise vaccine experts and the public alike, the Central Drugs Standard Control Organisation (CDSCO) announced the approval of Covaxin, Bharat Biotech’s attenuated coronavirus vaccine candidate, for “restricted use in emergency situations in public interest”. Across the scientific community, experts raised doubts and concerns over the absence of Phase-III clinical trial data demonstrating vaccine efficacy, and the lack of publicly available Phase-II data on the vaccine’s demonstrated immune response in trial participants. More confusing was the language of the approval that referred to a “clinical trial mode” ostensibly requiring volunteers and a placebo arm; the current rollout does not meet either requirement and, instead, vaccinates individuals at centres marked for Covaxin, with follow-ups for adverse reactions.

To further muddy the waters, the CEO of Serum Institute of India and chairman of Bharat Biotech engaged in a heated back-and-forth exchange casting doubts on the safety, efficacy, and integrity of the clinical trial data for either vaccine, before finally issuing a joint statement demonstrating their shared commitment to supplying safe and effective vaccines. Despite months of largely unified COVID-19 messaging, this uncoordinated and chaotic introduction of India’s vaccine candidates may have put at risk, at the least, initial trust and public vaccine uptake.

This potential for erosion of vaccine confidence is further compounded by the ongoing COVID-19 infodemic. In India, myths surrounding the COVID-19 vaccine have resurfaced and mutated from those that accompanied prior vaccine rollouts, frequently capitalising on religious sentiment (for example, the alleged use of pig-gelatin in vaccines), science illiteracy (allegations that vaccines alter DNA), and mistrust of authorities (allegations that vaccines contain trackers).

Mistrust in vaccines and vaccine hesitancy has arisen in India in the past. The 2008 human papillomavirus vaccine trials were mired in controversy from a lack of transparency. Misinformation about the polio vaccine led some communities to believe that vaccinations cause sterility. Despite these roadblocks, childhood vaccination rates in India have continued to rise, owing in large part to the consistent communication of vaccine benefits and fear-reducing information. India’s successful eradication of polio in 2014 is still recent in our collective memory, and the nation has historically trusted vaccines that have demonstrably protected its children.

We rest now at a pivotal point in our efforts against COVID-19, a time in which public vaccine trust and confidence can yet be re-won by transparency, integrity, and accessible public health communication. Governments, experts, and media must prioritise real-time translation of scientific jargon into their most relevant and easily understood forms. They must reiterate at every step the facts we know, the facts we do not, and in every instance, how individuals and institutions can best protect themselves. The rise of fact-checking services is promising and replicable, and health literacy in journalism can be complemented by media communication training among scientists and academic experts. As India deploys what is hopefully a final means toward the end of the COVID-19 pandemic, we must continue to be both mindful and consistent with our messaging on vaccines and COVID-19 precautions, and not slide backwards on this last leg.

Pinnamaneni is a research fellow at the Harvard T H Chan School of Public Health. Seshasayee is a research analyst at MaineHealth, and has experience practising as a dentist in India

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