In 2019, the World Health Organization (WHO) named ‘vaccine hesitancy’ – the unwillingness to accept vaccinations against diseases even when they are available – in the top ten threats to human health. That threat has become more visible since COVID-19 entered, profoundly reshaping our world. At the time of writing (September 2020), the novel coronavirus has caused over 1 million deaths worldwide and put the livelihoods of millions more in jeopardy. Our hope of returning to life as it was therefore rests on developing a vaccine and, in turn, on people’s confidence in its efficacy and safety. That confidence is not a foregone conclusion, but not always for the reasons which receive so much media coverage; namely, anti-vaxx movements. Lizzie, for example, is pro-vaccination. She works in the National Health Service (NHS) and she even helped get approval for her Trust’s participation in UNICEF’s Get a Jab, Give a Jab campaign to encourage NHS workers to take up their free flu jab. But Lizzie, in her 60s, has avoided getting vaccinated herself since one of her friends got sick and put it down to the vaccine’s side effects. Lizzie is far from alone with these fears, and they need to be sensitively and thoroughly addressed when it comes to a vaccine for COVID-19.

A poll by the Royal Society for Public Health (RSPH) in April 2020 found that one in five (19%) either would not get such a vaccine (4%) or are not sure whether they would (15%). But while many commentators are quick to point the finger at antivaccination campaigns online, far more respondents attributed their hesitancy to concerns about the vaccine’s safety and effectiveness, given the speed with which it might have gone through development and testing, or anxiety about the side effects from vaccines in general, than to messages they had seen on social media. This confirms the findings from RSPH’s 2019 report, Moving the Needle, which found that the greatest reason for choosing not to vaccinate was not ideological opposition to immunisation but the fear exemplified by Lizzie: that the side effects might be worse, or more likely, to occur than the illness itself.i Certainly, in other countries, anti-vaccination movements are powerful and boast influential proponents. For instance, in Italy’s 2018 election campaign, the populist Right successfully exploited resistance to the Government’s decision to obligate children to receive ten compulsory vaccinations after a sixfold rise in the number of measles cases that year. Similarly, President Trump has tweeted in support of the disproven claim that the MMR (measles, mumps, and rubella) vaccine can cause autism, and vaccination is becoming an increasingly politicised issue in the US, dividing the public along party lines.

Concomitantly, a poll by Pew Research in September 2020 found that nearly half of Americans would ‘probably’ or ‘definitely’ get a vaccine against COVID-19, a fall from 79% in May. Both polls revealed a divide along party lines: fourteen percentage points more Democrats than Republicans saying they would ‘probably’ or ‘definitely’ get a vaccine against COVID-19 in both polls (79% vs 65% in May and 58% vs 44% in September).3 But, here in the UK, we should be cautious to not read our declining levels of vaccine uptake through the lens of other countries’ politics without substantial evidence. Compared to these countries, for example, vaccine confidence and trust in healthcare professionals and scientists in the UK are reassuringly high. Nurses and doctors are the two most trusted
professions in Britain, and high levels of trust in scientists are more prevalent in the UK than all other EU countries and the US. Thus, while we should not be complacent about anti-vaccination messages taking hold in the UK, especially via social media, policy-makers and healthcare professionals should avoid prematurely politicising immunisation by seeing anti-vaxx bogeymen behind every missed appointment. The best pre-emptive strike would be for politicians of all stripes, and a wide range of influencers, to come out unwaveringly in favour of a COVID-19 vaccine so that resistance does not become enmeshed in any particular political identity. Given that lockdown measures in the UK hindered the delivery of immunisation services6 – to the extent that the WHO and UNICEF estimate there are now 54,000 unvaccinated children in the UK, the third highest figure in Europe, reducing our diphtheria–tetanus–pertussis (DTP3) coverage to 93% – it is imperative that any new vaccine against COVID-19 is not seen as an either/or to the usual immunisation schedule. Accordingly, the Government should take measures to encourage those who cancelled their vaccination appointments during lockdown to re-book them through a call/recall system, with healthcare professionals prepared to address any concerns about being immunised for multiple diseases at the same time. Given parents’ hesitancy about using healthcare services during lockdown, the Government should also increase and diversify the locations where vaccines are administered. Otherwise, we may see an outbreak of infectious diseases which we thought were consigned to history, on top of COVID-19.

Political opposition to immunisation must be distinguished from vaccine hesitancy so that the misgivings any misunderstandings actually present among the general public can be taken seriously. Indeed, fears about the efficacy and side effects of a COVID-19 vaccine cannot be dismissed as baseless. As Bill Gates, who has pledged over US$350 million into research for a COVID-19 vaccine, cautions, ‘the initial vaccine won’t be ideal in terms of its effectiveness against sickness and transmission. It may not have a long duration’. ii Communication from the NHS, the Government and the media about such a vaccine should be open and transparent on this front, taking the opportunity to educate the public about how vaccines work and the vaccine safety systems they have in place, before urban myths, rumours, and misinformation have a chance to take hold.

Returning to Lizzie as an example: she wears a face mask, religiously uses hand sanitiser and, where possible, practises social distancing. But suppose her friend has the COVID-19 vaccine and experiences side effects. Suddenly, after months of hoping for a vaccine, she gets cold feet and finds reasons to avoid getting the jab herself: containment measures have protected her well enough so far; she might even have had the virus when tests were unavailable, making her already immune; and surely enough people around her will get the vaccine to kill off the virus. In other words, it wouldn’t take an army of anti-vaxxers to jeopardise herd immunity to the coronavirus. It doesn’t take vociferous hostility to vaccines; it could just take a lethal dose of nervousness and confusion.

One reason often given for declining rates of vaccination coverage in countries like the UK is complacency: the very success of immunisation in making diseases less prevalent means people underestimate their risk. The introduction of a vaccine against COVID-19 would, therefore, be the first time in several generations that a whole population could witness how they both save lives and underpin a whole society’s social and economic activity. It would be an educational opportunity like no other – if the Government can make the most of it by enabling rapid take-up, investing in robust vaccine safety systems, and using figures in the community that are highly trusted by the general public to calmly address people’s concerns. Done well, a COVID-19 vaccine programme could prevent the anti-vaxx movement finding a home in the UK’s party politics, protecting the population not just through this pandemic but from future threats as well. Done badly, we risk becoming a population even more socially distanced from each other.

Notes
i. This was the greatest reason given for all vaccines and all age groups, with the exception of parents with regard to the childhood flu vaccine where it was the second-most common reason for avoiding the jab.
ii. The number of MMR (measles, mumps, and rubella) vaccines delivered in England dropped by 20% during the first 3 weeks of the lockdown, and of 752 health visitors surveyed by the Institute of Health Visiting in May 2020, over 60% reported contact with families who had considered cancelling or postponing their child’s vaccinations.