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Are vaccine mandates required in Africa? Shifting from vaccine inequality to vaccine hesitancy.

The first cases of a mysterious respiratory infection were in late 2019 in Wuhan, China. A novel disease known as COVID-19 caused by the coronavirus SARS CoV-2 had spread to over 112 countries with close to 125,000 cases and 4,500 deaths and by March 2020 the World Health Organization (WHO) had declared it a pandemic. Scientists and policy makers knew that the most effective way to control this infectious disease would be by vaccination. Vaccines have played a vital role in shaping modern society. Without vaccines our probability of surviving childhood would be lower, our life expectancies shorter, and our communal health would be poorer. Many thought that the ability to develop an efficacious vaccine and get shots in arms within 12 months to be ‘ridiculously optimistic’.

Today, two and a half years later we have those efficacious vaccines. Over 11 vaccines across multiple platforms have been approved by the WHO and an ambitious target to have over 70% of Africa vaccinated by end of 2022 has been set. Close to 800 million doses have been received to date in Africa, but only 63% of those doses have actually been administered. Currently, 24% of Africans have received at least one dose of vaccine and 18% are fully vaccinated.

Although service delivery is challenging in many parts of Africa and this is the first time that most national immunization programs have had to administer adult vaccines, it is also becoming increasingly evident that vaccine hesitancy is an important driver of low vaccine uptake. Vaccine hesitancy is defined as a ‘delay in acceptance or refusal of vaccination despite the availability of vaccination services’. Perhaps it is now time for us to ask ourselves if voluntary vaccination will be sufficient to achieve vaccination coverage goals. Vaccine mandates may be necessary.  Childhood vaccine mandates and employment related vaccination mandates for healthcare workers have been highly effective at improving coverage rates. The low uptake in COVID-19 vaccinations led several governments and employers to introduce vaccine mandates to gain certain privileges. The privileges ranged from accessing theaters and restaurants to having the right to return to work and interface with the public. Some African governments have taken a similar approach but it has not been widespread and data on attitudes to vaccine mandates in African populations is limited.

We assessed attitudes to mandates in a cohort of urban African adults. Close to 70% had positive attitudes to COVID-19 vaccine mandates for use of public spaces such as public transportation, for employment and for school attendance. Increasing wealth, education and use of social media-based information sources was associated with increased resistance to mandates. Various models of health seeking behavior show that people can regulate uptake of interventions by considering perceived risk, seriousness of the condition, barriers to the behavior as well as self-efficacy. Mandates do not necessarily undermine self-determination but encourage prompt behavior engagement in a timely manner particularly for a disease that is causing social harm. The anti-vaccination movement has been highly effective at modulating perceptions of risk using powerful messaging techniques which undermine public health communication. The movement has global reach and our data suggests that these may be driving a slow erosion of vaccine confidence in Africa. It is important for African public health experts and policy makers to start to proactively counter this trend. It would be tragic that an unintended consequence of the COVID-19 pandemic is the emergence of new vaccine hesitancy in Africa with consequences on the coverage rates for other vaccine preventable diseases. Vaccine mandates will likely help with COVID-19 vaccine uptake, improve coverage rates, and minimize the burden of disease enabling communities and economies to thrive. They will be largely acceptable to much of the population. However African governments and communities will need to be vigilant and develop effective approaches to counteract what may a new trend in vaccine hesitancy in Africa.

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