Missed Enthusiasm: Why are Healthcare Workers Vaccine Hesitant?

From fear of adverse events to lack of transparency, here is why healthcare workers are vaccine hesitant. 

Updated
From fear of adverse events to lack of transparency, here is why healthcare workers are vaccine hesitant. 
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Despite the excitement over the COVID vaccination drive on 16 January, hesitancy among healthcare workers, a lack of coordination and technical problems with the Co-WIN app meant government targets were not met.

Three days since the drive began, only about 50 people were given shots per session which is half of the expected 100 as per data by the Union Health Ministry.

Many health workers, who had volunteered and received an SMS verification with details on where and when to come for their dose, did not turn up. This reporter spoke to resident doctors and frontline workers in Mumbai from hospitals like Sion, KEM, Bhabha, JJ, Cooper and Nair who were unaware of the process and who was getting vaccinated.

Missed Enthusiasm: Why are Healthcare Workers Vaccine Hesitant?
(Graphics: FIT)

Why the Low Numbers?

429,209 people have been vaccinated in India till Monday, 18 January reported Hindustan Times.

In Delhi, there were 4,319 healthcare workers who showed up on Saturday but this dropped to 3,593 on Monday. Worryingly, only eight people were vaccinated on Monday at the All India Institute of Medical Sciences.

It also must be noted that no vaccinations happened on Sunday, 17 January which also does play a part in the low overall numbers.

Another factor could be the slow roll-out. When reporting in Mumbai’s BKC Jumbo Facility, I noted that out of 15 active wards, only 5 were open for day 1.

Fear of Adverse Events

As of Monday, January 18, 580 Adverse Events Following Immunisation (AEFI) and seven hospitalisations were reported in the country since the launch of the coronavirus vaccine drive. This translates to just 0.014% of the total 381,305 inoculated.

AIIMS director Dr Randeep Guleria told HT,

“Initially, health care workers were very keen to get the vaccine. But then because of the infodemic, because of things doing the rounds on social media, because of side effects being highlighted more than what they were, it created a lot of anxiety not only among healthcare workers but also in public at large.”

FIT has fact-checked some Whatsapp forwards, which told half the story about vaccinations but managed to spread like wildfire on social media.

It’s important to remember in the talk of vaccine hesitancy that vaccines in general are a useful, affordable and effective public good. India has had great success with immunisations programs in the past for curbing the spread of diseases like polio. But in this case, there are doubts about the effectiveness of particular COVID vaccines.

Concern Over COVID Vaccines

Vaccine hesitancy in part stems from the lack of transparency and clarity regarding the approval process of the two vaccines approved for emergency use by the Drugs Controller General of India: Covishield and Covaxin.

FIT spoke to Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University, to understand the concerns over the Covaxin approval especially since phase 3 clinical trials are still ongoing and no efficacy data has been published.

The Covaxin consent form, which beneficiaries have to sign before they get the vaccine, acknowledges that “clinical efficacy of Covaxin is yet to be established and is still being studied in phase three clinical trial.”

Healthcare Workers Concerned About Covaxin

The Resident Doctors Association of the Ram Manohar Lohia (RML) Hospital in Delhi wrote to the medical superintendent on Saturday, 16 January, saying that the residents "are a bit apprehensive about the lack of complete trial in case of Covaxin and might not participate in huge numbers, thus defeating the purpose of vaccination."

"We request you to vaccinate us with Covishield which has completed all stages of the trial before its rollout," the letter read, coming on the day the vaccination drive against COVID-19 was launched across India.

Missed Enthusiasm: Why are Healthcare Workers Vaccine Hesitant?
(Photo: Accessed by The Quint)

However, senior staff members refuted the claim and, Dr Atul Krishna, General Secretary, RML Hospital, told The Quint here's no apprehension regarding Covaxin.

“Covaxin is being administered in central institutes, including RML... Senior staff is getting the vaccine first... We have faith in our administration and in our government... We will also get Covaxin, because we have full trust in the administration. There was apprehension earlier because Covishield has undergone more trials and studies... We had a doubt whether Covishield will be administered or Covaxin... That was our question and it wasn’t clear then. But now it is clear that we are being administered Covaxin.”
Dr Atul Krishna, General Secretary, RML Hospital

Still, echos of hesitancy were seen across healthcare workers who were worried about the lack of transparency.

"Both vaccines are publicly funded and both have issues with lack of data. For Covaxin, phase 3 trials are still ongoing and no raw data is available. For both Covishield and Covaxin, information around adverse events remains opaque. There is concern among doctor groups regarding the roll-out, especially around adverse events involving neurological symptoms," says Dr Sumit Ray, Critical Care specialist at Delhi's Holy Family Hospital.

Dr Anant Bhan added that the first priority group - health workers - were also more informed and their concerns needed to be paid attention to.

“People are anxious and some may be wanting to wait to see the effects, and besides there are glitches with the app which all contribute to the reasons why there were low numbers. But this should not translate into people being coerced into getting the vaccine in any way. That can further impact trust in the vaccine and that is not what we want.”

Amidst reports of health workers threatened with salary cuts if they do not take the jab, Dr Bhan says that such measures will only worsen public trust.

Dr Bhan added that “Vaccination only works when you have upkeep which requires you to work with communities to build trust in the process and to address any concerns. It’s important to deal with any concerns healthcare workers may be having.”

On 21 December 2020, Health Minister Dr Harsh Vardhan said that people cannot be forced to take the vaccine,

“Vaccine hesitancy issues will be addressed through education. The government will spread awareness and educate people about the vaccine that this is for their own good and benefit. The government will reach out to people to get their vaccines but if someone does not want to take the vaccine, they cannot be forced.”
Health Minister Dr Harsh Vardhan

Could We Have Waited till We Had Covaxin Data?

“Vaccination is a public health effort. The regulatory body and the ministry decided that there was enough data with Covishield and Covaxin and we went ahead. There was various interpretations of if there was enough data to be given approval. One way could have been approving one vaccine, namely Covishield, and adding more vaccines as adequate data was given, since anyway in a population as larger as ours we will need more vaccines.”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

One of the issues is the lack of choice, and Dr Bhan adds that this is complicated when one vaccine (Covaxin) has not released efficacy data. “People can then opt out, but offering both vaccines at all centres is difficult and costly logistically and would involve a lot of waste of precious resources, especially when we have many more people waiting in the queue to get vaccinated.”

It’s important to remember that there is no choice anywhere in the world currently, but the situation in India is more complicated because of the approval to Covaxin.

“Hopefully we will get efficacy data from Covaxin in a few weeks time. Yes, perhaps if we had waited for efficacy data, the uptake might have been better. ”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

Could this affect India’s overall trajectory in curbing the virus? What is the long-term effect of hesitancy?

“Of course more vaccine uptake, more coverage and faster we can counter the virus. We are wasting time since and vaccines need to be effectively used for them to be useful.”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

Dr Bhan adds that we do need to fix the current problems and be “nimble” in identifying issues all while waiting on more data. “The UK looked at patterns on Day 1 and fixed it. We should also act fast.”

‘Early Days’: Too Soon to Worry

“These are early days, for now, we should wait before interpreting the data as concerning right away,” says Dr Bhan.

“However, there are valid concerns being expressed by healthcare workers and those need to be addressed.”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

These healthcare workers are in general not hesitant about vaccines per say, but about these vaccines in particular. While we need to wait, in the larger picture, concerns about approvals, effectiveness and safety need to be addressed to counter hesitancy.

The dry runs could not identify the problems, and Dr Bhan said that the next few days and weeks will tell us if there are some patterns and give us some clarity on what problems we are seeing exactly - rollout issues, logistical problems or some patterns that indicate the vaccine uptake is not happening optimally.

The root cause of hesitancy is a lack of clear communication.

“Many of us had hoped for more rationale and more details put out that would help quell some concerns.”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

‘We Owe Transparency to the Family’: Moradabad Death

On the evening on 17 January, a ward boy, aged 46, who was vaccinated on 1 January, passed away. His family remains adamant that the death was linked to the vaccine although the post-mortem attributed the cause of death to cardiogenic shock / septicemic shock due to cardio-pulmonary disease.

This created fear about the adverse events, and raised concerns over the ethics of vaccine distribution: should the man have been administered the vaccine at all as reports say he had a fever and cough.

“See, as we roll out in larger numbers, there will be more such incidents and issues which won’t be known via clinical trials. This happens when we trust on lakhs and crores and start picking up rare issues,” says Dr Bhan, “currently, we do not know if the death is linked to the vaccine. In the UK, for example, they found out people have allergies or in Norway, they are tracking 29 deaths mostly in the elderly.”

In public health practices, there are standard procedures like committees which monitor adverse events to ensure due process is followed.

“Covaxin has updated the list of those people who should avoid the vaccine,” said Dr Bhan adding that we have to be vigilant of serious adverse events.

“It’s important that due process is followed transparently and that there is closure for the families involved. We should not repeat the situation in Chennai or Bhopal where the families felt their concerned was not listened to and they were not given any information. It is a public health exercise, even if the death is not linked to the vaccine, it is the least we owe to the families.”
Dr Anant Bhan, Adjunct Professor & Researcher in Bioethics at Mangaluru’s Yenepoya University

For each vaccine, information pamphlets must be given and for Covaxin there is an additional consent form, but it remains to be seen if the information is being understood by all those taking the vaccine.

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