Published on Investing in Health

Finding Exemplars of Restored Vaccine Confidence: A Pathway for COVID-19 Recovery

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These are troubling times. We are in the throes of a disabling pandemic that has sparked a cascade of effects. Beyond health, efforts to stop COVID-19 have caused wider societal disruption and exacerbated both inequities and growing distrust in government while, in the background, one question persists: what’s next?

One antidote to so much uncertainty is to rebuild public confidence by recognizing needs beyond COVID-19: normalizing life by slowly reintroducing familiar health interventions. As the Bill & Melinda Gates Foundation’s 2020 Goalkeepers Report called out, “we’ve been set back 25 years in 25 weeks.” Catching up on millions of missed childhood vaccinations is one tangible way to make up for lost time, but also to use the opportunity to talk with parents about other concerns, including access to a possible COVID-19 vaccine.

Ten years ago, I founded the Vaccine Confidence Project to measure the complicated issue of public sentiment surrounding vaccines. We knew that emotions, individually and collectively, were already taking a toll on vaccine uptake, disrupting immunization programs in some settings. But we did not have a sense of the scope or scale of their impacts. Nor did we have a measure of public confidence in vaccines that we could track over time to anticipate future changes.

In 2015, a broader team launched  the Vaccine Confidence Index (VCI)TM to investigate vaccine confidence and reasons for low confidence in five countries with histories of vaccine crisis: Georgia, India, Nigeria, Pakistan, and the United Kingdom. Based on our analysis, we narrowed down what had the most influence on vaccine acceptance – including whether vaccines are important, safe, effective, and compatible with religious beliefs. And recently, we incorporated COVID-related questions into VCI surveys to explore sentiment around government response and the public’s anticipated willingness to accept a COVID-19 vaccine.

Covid graph


This month, the VCP published new research in The Lancet mapping trends across 149 countries and over 284,000 adults. We modelled the relationship between vaccine uptake in each country and demographics (i.e. age, sex, religious beliefs), socioeconomic factors (e.g. income, education), and source of trust (e.g. family, friends, health professionals) from 2015-2019.

We found that overall confidence in the safety and effectiveness of vaccines was mixed, similar to COVID-19 vaccine acceptance surveys (see chart above). We found that vaccine confidence – including perceptions of safety, effectiveness, and importance – has fallen in Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, the Philippines, Serbia, and South Korea.  It remains high in India and is growing in many European countries. Brazil showed a trend of slightly declining confidence. These changes suggest that trust building to support routine vaccination – and a potential COVID-19 vaccine – is still needed.  

The Philippines provides some guidance on how this could be achieved. In 2018, a reported risk from a dengue vaccine (Dengvaxia), a year after its introduction, led to a dramatic drop in public confidence and routine vaccine uptake. The Philippines dropped from being in the top 10 countries with the highest overall vaccine confidence in 2015 to ranking no higher than 70th in 2019. But, concerted efforts by health authorities, including innovative online resources and conversations around vaccines and the health system more broadly, led to a rebuilding of confidence (see below).

Covid graph 3
© de Figueiredo A, et al. Lancet 2020. Used with permission.


Indonesia also witnessed one of the largest falls in public trust on vaccinations. This was triggered by some Muslim religious leaders that questioned the safety of the measles and rubella (MR) vaccine, and issued a fatwa (religious ruling) claiming the vaccine was forbidden, as it contained ingredients derived from pigs. In an effort to build confidence, the government and partners produced videos featuring other Muslim leaders persuading parents to vaccinate their children, and created other targeted communications to garner acceptance.

These are different kinds of “Exemplars.” They are countries that invested in recovering from a vaccine confidence crisis and in doing so, built more resilience to potential future shocks, including one that might be felt by an eventual COVID-19 vaccine. But like in all “Exemplars,” they proved that targeted investments can lead to results.

It’s why I’m hopeful that the World Bank’s recently approved $12 billion to finance the purchase and distribution of COVID-19 vaccines will also help us answer what’s next. By focusing some of that investment on deployment, including large-scale communication and outreach campaigns that target communities and households in low-income countries, this will help build trust and make up for some of the time we’ve lost time in other health interventions. Because to get us out of this pandemic, we must optimize uptake of not only life-saving vaccines, but health efforts more broadly.  Trust will be fundamental if we are to regain the 25 years of progress lost in 25 weeks.

This article first appeared on Exemplars in Global Health, a new initiative incubated by Gates Ventures and its partners to research positive outliers in global health so that other countries might learn from them and improve health outcomes.


Heidi J. Larson

Director, The Vaccine Confidence Project

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