Hesitancy, ignorance or uncertainty? The need for effective communication strategies as Zimbabwe's uptake of COVID-19 vaccine booster doses remains poor.

Dear Editor

Zimbabwe started an ambitious COVID-19 vaccination programme in February 2021, aiming to vaccinate at least 60% of its eligible population by December 2021. The efforts to protect the population from the devastating effects of COVID-19 were remarkable, especially given that the country was not a part of the COVID-19 Vaccines Global Access (COVAX) initiative, and the government had to seek alternative sources of vaccines. The trajectory of COVID-19 vaccination in the country followed a very slow initial uptake from February to early June 2021. A sharp rise in demand and uptake followed between June and August 2021, coinciding with a harsh Delta variant-driven epidemic. However, as the situation stabilised and the cases plummeted, the uptake of the vaccines fell again, and by the beginning of December 2021, reports from the Ministry of Health and Child Care (MoHCC) of Zimbabwe show that the daily uptake had significantly gone down [1].

In December 2021, the MoHCC approved the administration of booster (third) COVID-19 doses to at-risk populations, including healthcare and other frontline workers, the elderly above 65 years of age, and those with comorbidities such as diabetes mellitus and hypertension. However, statistics from the MoHCC show that as of 16 February 2022, only 0.894% of the population had received the booster dose, with 44.7% overall coverage for the first dose and 34.7% for the second dose [2]. 14 650 934 vaccine doses consisting of Sinovac, Sinopharm, Covaxin and Sputnik V vaccines were available in stock. Furthermore, the daily situation reports from the MoHCC show that in the preceding seven days, the daily uptake of the first dose did not exceed 5000 while the daily uptake of the booster dose did not exceed 3000 [2]. The vaccine uptake is significantly depressed (Fig. 1 ) despite the wide availability of vaccines, and against a background where the initial logistical challenges in distributing vaccines even to the marginalised areas of the country have been overcome. A crude analysis of vaccine uptake by province shows a near-equitable distribution of vaccine uptake throughout the country’s ten provinces [3]. Therefore, understanding why the uptake, especially of the booster dose has remained suppressed despite widespread availability is critical to inform the vaccination programme appropriately. The biggest question is whether these are signs of vaccine hesitancy, lack of knowledge or uncertainty as to why the boosters are needed. In this letter, we highlight the irreplaceable need for clear and effective communication strategies to ensure the success of key public health interventions and optimise the uptake of vaccines in the country, including the booster doses.

Fig. 1

First, second and third COVID-19 vaccination doses administered in Zimbabwe.

The Risk Communication and Community Engagement (RCCE) pillar in the MoHCC is the key pillar responsible for the propagation of crucial COVID-19 prevention messages in Zimbabwe, including vaccination messages. Unfortunately, this pillar has been relatively subdued, invisible and ineffective regarding COVID-19 vaccination messages. The population was sceptical about receiving the initial doses, and without clear communication, many have remained unsure of the need for booster doses. This is especially so as the Omicron variant-driven fourth wave was short-lived in Zimbabwe and caused clinically attenuated disease compared to the previous Beta- and Delta-variant driven waves. There were no reports of increased deaths, hospitalisations, intensive-care unit admissions or adverse COVID-19 outcomes during this period. Anti-vaxxers have continued to advocate for natural immunity, especially with clinically mild disease. Others have also believed that hybrid immunity from natural infection and the first two doses confer significant protection.

The government and its relevant departments such as the RCCE pillar must communicate effectively, using and taking advantage of the diverse forms of media available to the people. Most Zimbabweans have access to some form of communication media such as radio, television, newspapers, and the different social media platforms, including Whatsapp, Facebook, Twitter, TikTok and others. Additionally, there are several strategic places such as shopping centres, schools, churches and community halls throughout Zimbabwe where tailored information, education and communication (IEC) material in colourful and understandable languages can be placed. Unfortunately, these places have not been effectively utilised and instead, the space has continued to be filled with rumours, myths, misconceptions, falsehoods and conspiracy theories. Sadly, two years into the pandemic, anti-vaxxers and conspiracy theorists have remained ahead of official boardies in terms of communicating COVID-19 messages. Proactive approaches are needed where public health stakeholders are ahead.

The communication messages must clearly explain the need for vaccination, avail safety and effectiveness data and local pharmacovigilance data to boost the population’s confidence in the available vaccines. Some segments have remained hesitant to take the currently available vaccines [4], hoping for Western vaccines such as the Pfizer BioNTech, Janssen and Oxford AstraZeneca which are not available locally. Additionally, the government still hasn’t come up with clear guidance for certain populations such as pregnant and lactating women, and this has been perceived as one of the local drivers of vaccine hesitancy. Engaging influential people, religious and opinion leaders who are trusted by the population could improve the uptake [5]. Persuasive, rather than coercive approaches are also critical.

There is a need to understand the vaccine uptake patterns by age, gender, level of education, socioeconomic status, geographical location, and other key granular population characteristics to inform the future and design appropriate interventions. The daily uptake data provided by the surveillance pillar in the MoHCC does not provide such critical information. Repeated local surveys to understand the drivers of vaccine uptake and hesitancy are very important; unfortunately, these have generally been lacking. Moving forward, intersections between different public health stakeholders involved in the control of COVID-19 in Zimbabwe, including vaccination are essential to devise effective communication strategies that can drive the vaccination programme forward, including improving the uptake of the current and subsequent COVID-19 vaccine booster doses.

Disclaimer

The views presented in this piece are of the authors and do not necessarily represent the official position of their institutions.