Having initially been hamstrung by low and uncertain supplies of Covid-19 vaccines, government is arguably now in a better position to campaign actively to accelerate vaccine demand, albeit in the midst of an often-harmful viral “infodemic”.

Dr Peter Benjamin, co-founder of HealthEnabled, a firm of “digital health architects”, and Professor Glenda Gray, CEO of the South African Medical Research Council (MRC), say with a more secure vaccine supply in the last two or so months, the focus has shifted to overcoming vaccine hesitancy and accelerating the roll-out. Gray also played a critical role in getting the Sisonke study off the ground. Close to 500,000 healthcare workers were vaccinated in the Sisonke study prior to the launch of South Africa’s mass vaccination programme on 17 May.

Dr Caroline Lee, the founder of the Healthcare Workers Care Network and an anaesthetist at the Covid-19 coalface, also shared with Spotlight how anti-vaccine protests and sentiment have sowed despair and hopelessness among many beleaguered medical professionals dealing with severely ill and dying patients at the peak of Covid-19 waves.

What emerges from these experts and several social listening surveys appears to be an evolving answer to the slow vaccination uptake dilemma. The evidence suggests that hesitancy, mistrust, and conspiracy theories actually contribute far less to vaccine hesitancy than vaccine accessibility.

Access to vaccination is limited by barriers such as the location and numbers of vaccination sites, difficulties getting time off work, the cost of transport, not having an ID book, and lengthy vaccination queues, especially in lower-income and more rural areas.

Those rural provinces that have taken vaccination teams from village to village (like Limpopo) have recorded the best vaccine uptake, especially among the vulnerable elderly.

Residents wait socially distanced for their Covid-19 vaccine inside the Discovery Ltd. mass vaccination site at the Cape Town International Convention Centre in Cape Town. (Photo: Dwayne Senior/Bloomberg via Getty Images)

50% ‘tipping point’

Benjamin says that global research reveals that once the magical figure of 50% of a population is vaccinated, hesitancy declines fast and “getting the jab” becomes “the new societal norm”.

“At that stage, (50% vaccinated), everyone knows someone who’s been vaccinated, and their leg hasn’t fallen off 30 minutes later nor have they broken out in hives or something equally terrible. Attitudes at this point shift to a fear of missing out (Fomo),” he says.

Some 26.4% of people in South Africa have received at least one jab so far.

Surveys by the MRC and University of Johannesburg suggest that over 70% of South Africans are in favour of being vaccinated. A “moveable middle”, or some 20% of people are equivocal, want more data, and believe some of the misinformation or disinformation — and often inadvertently and/or carelessly spread it. The surveys suggest that only 10% (possibly even fewer) of people in the country are die-hard anti-vaxxers. Some of this 10%, says Benjamin, are extremely vocal on social media and advocacy platforms, grabbing headlines and creating the false belief that their numbers are large and growing.

Vaccine Demand Acceleration Team

Benjamin is one of 600 people trained by the World Health Organization (WHO) in “infodemic management” and sits on the national health department’s 12-person Vaccine Demand Acceleration Team, formed in late August. The team is headed by former LoveLife chief, David Harrison.

The Vaccine Demand Acceleration Team includes specialists in media, statistics, and behavioural science. Dr Benjamin says they’re busy setting up networks, “whether they’re faith-based, women or youth organisations — we’ll find a way to connect”.

“We’ll also work closely with the Department of Co-operative Governance and Traditional Affairs and the GCIS (Government Communication and Information Systems), among a host of other outfits,” he says.

Benjamin has also led South Africa’s social listening team since January this year. This team is embedded in the Risk Communications and Community Engagement Working Group of the Department of Health. It produces weekly reports on “vaccine sentiment, rumours, and misinformation. (You can see the report for 21 September here.)

“Our motto is to listen, understand, and engage,” he says.

Vaccine supply and demand creation

Stimulating demand for vaccination is, however, not only a matter of countering vaccine hesitancy and anti-vaccine sentiment.

“It’s very hard to create demand when you’re unsure of your supply. So, in my view, the whole vaccination response was tempered by this uncertainty. Then we had lots of setbacks,” says Gray.

These included reports of very rare blood clotting related to the Johnson & Johnson (J&J) vaccine that caused a temporary delay in its use, contamination of batches of J&J vaccine at a factory in the United States that led to millions of doses (some of which were to be used in South Africa) having to be destroyed, and suppliers suddenly stopping scheduled deliveries without explanation.

“You can’t be in a situation where our demand outstrips our supply and you have tens of thousands of people mobbing vaccination sites to get jabbed,” says Gray.

Professor Glenda Gray is the President and CEO of the South African Medical Research Council. (Photo: en.Wikipedia.org)

She adds that the government’s communication strategy had to be tempered, and the roll-out modulated because of the supply issues.

Gray says that a media strategy around addressing people’s concerns is now both timely and urgent. “It’s time to understand the hesitancy in those we’ve not yet reached and address some of their concerns. At a global level, everyone is getting vaccinated — South Africa is not special with worse side-effects than anyone else (of 29 adverse reactions reported to Sahpra for probing, not one has been linked to Covid-19 vaccination). The very same vaccines have been rolled out to billions of people worldwide with very few adverse reactions, which indicates their safety,” she adds.

Who is getting vaccinated?

Benjamin says the Electronic Vaccination Data System (EVDS) was being used to monitor daily vaccination numbers by, among other things, health facility, district, province, and age groups — and whether people had private medical insurance or not.

“Medical aids are a close proxy for wealth and our socio-economic disparities are huge. Most vaccination is among public sector healthcare users, yet those with health insurance are twice as likely to vaccinate, with Limpopo being an outlier. An anomaly but not a contradiction is that more education is associated with vaccine hesitancy. It’s the white, educated middle class who don’t want the vaccine, yet they can generally get it more quickly and easily than other race groups, so their vaccinated percentage is higher,” he says.

Impact on healthcare workers

Lee says healthcare workers were hard hit by anti-vaccine sentiment when they saw patients succumbing to the virus.

“Obviously we treat everyone equally, vaccinated or not, but it’s hard when you walk through protestors outside a hospital (referring to the placard-bearing protestors outside Groote Schuur Hospital some months ago supporting cardiologist, Dr Susan Vosloo’s anti-vaccination public utterances), and then you go straight into an ICU environment where two or three people can be dying at once during a surge,” she says.

She describes the fear anaesthetists and other emergency care workers feel while intubating patients as they cough and splutter, even while wearing personal protective gear. “You end up thinking, don’t you know that you’re contributing to this? That you’re actually killing people?” she says.

When a pandemic peaks, operating theatres are closed to all but emergency surgeries, leaving most anaesthetists helping out in ICUs, high care wards and emergency departments.

Return to normal

Lee believes fear lies at the root of most anti-vaccine sentiment and that the best persuasion is to show protagonists countries where vaccination has led to a return to packed sports stadiums, busy restaurants and pubs and social normality.

She believes sharing relevant data like vaccination uptake and mortality in specific areas — in easily accessible visual form, plus pictures of revived economies, and freely moving populations will help.

“Just don’t give them too much information or try and counter the anti-vaxxers with data. You need to find out what questions people are asking and answer them, help them persuade themselves. When you push too hard, they don’t listen completely and push back harder and harder. For so many, it’s easier to stay frozen in inaction and not try something new when it sounds so scary. Many are not anti-vaxxers but just want to wait and see. Give them little steps at a time, incentivise with discounts, get them to want it, expand and open up all the vaccination centres, drive-throughs, vaccine passports — the whole world is doing it. So what if there’s an increase in infections? So long as people don’t die,” she says.

The Healthcare Workers Care Network, which she co-founded, provides a 24/7 helpline and free sessions with volunteer psychologists and psychiatrists on hand countrywide. Between the start of the Covid pandemic and the current third infection wave, the helpline, which provides “psychological first aid” had taken over 2,000 calls from healthcare workers, initially for information but increasingly of late for emotional support, she said. DM/MC

*This article was produced by Spotlight – health journalism in the public interest.