The rapid rollout of Covid-19 vaccination in the UK in December 2020 was a miracle of scientific endeavour and rapid decision-making, preventing thousands of deaths and hospitalisations due to life-threatening complications. By 2023 in the UK it was clear that the majority of people who died from Covid-19 (a novel coronavirus) or were admitted to hospital during the pandemic had never been vaccinated. So why do a small but significant minority still hesitate to take the jab? We must identify and publicise the distinct reasons for this continuing hesitancy and avoid a ‘one-size-fits-all’ message. Only then can we ever hope to reach population-level immunity (herd immunity).
To be or not to be vaccinated
During the UK pandemic, there was a tendency in some quarters to regard all who refused a Covid-19 vaccine as being lazy, selfish, ignorant, or brainwashed. Those who are genuinely undecided or fearful of the Covid-19 jab should not be confused with the staunch anti-vaxxers, who not only refuse point-blank to be vaccinated but also have been extremely vocal in trying to persuade others of their beliefs. They may claim vaccination infringes their human rights, and they even spread misinformation and bizarre conspiracy theories such as, for example, ‘the government is trying to plant microchips in our bodies.’ Even though they are a tiny minority, anti-vaxxers have influenced others during outdoor rallies and on social media where their message is amplified. They ignore the impact of their decision on others and risk prolonging epidemics and pandemics. However, the majority of people who are undecided are not diehard anti-vaxxers and do not go out of their way to influence others. Understanding the diverse reasons why this group still hesitates or does not agree to be vaccinated is crucial to persuading them to change their minds.
Novel Covid-19 vaccines
Before analysing the reasons for vaccine hesitancy, it is important to point out that all three of the Covid-19 vaccines differ greatly from conventional vaccines which employ heat-killed or live attenuated whole viruses. There are three basic types of novel Covid-19 vaccine. One uses mRNA (messenger RNA), an engineered form of genetic material that codes for the Covid-19 spike protein. When injected into muscle, the mRNA is ‘translated’ into the viral spike protein, which induces a protective immune (antibody) response to the foreign protein. Another utilises a harmless DNA vector which likewise encodes the viral spike protein and an antibody response ensues. The third method involves injection of a genetically engineered spike protein without introducing any foreign genetic material, and anti-spike antibodies are similarly synthesised.
Fear of needles and serious side effects
It is difficult to estimate the rates of Covid-19 vaccine refusal as they differ from country to country; they are age-dependent and vary over time. One study in 2021 in the UK suggested an overall 10-20% rate. A common reason is fear of needles. People in this group may understand the need to get the jab, but have a deep-seated fear of the injection. Fortunately, they can be persuaded.
Many people experience mild side effects shortly after Covid-19 vaccination – fever, arm soreness, headache, and mild flu-like symptoms that can last up to a day. Knowing this makes some people hesitate to be vaccinated. There have been reports of serious vaccine-related complications (blood clots and myocarditis) which are, however, rare compared with the millions of doses of Covid-19 vaccines given worldwide. While only a handful of such complications have been described, and not all can be blamed on the vaccines, they receive a disproportionate amount of publicity, which may influence those who are undecided about the vaccine.
Every infection with Covid-19, even a mild one, increases the risk of a complex debilitating post-viral syndrome known as Long Covid. The many common symptoms include brain fog, breathing difficulties, fatigue, digestive problems, and musculoskeletal pain. Long Covid may be milder in those who have been vaccinated and subsequently become infected with Covid-19, although this remains controversial. Importantly, people who have been hospitalised with Covid-19, the majority of whom are unvaccinated, appear to be at greater risk of Long Covid. This again emphasises the need to keep people informed of the specific risks of avoiding vaccination.
Many people are concerned about the long-term safety of the vaccines because they were developed, tested, manufactured, and approved for use in record time in the UK. Although mRNA vaccines were the first of their kind to be used in humans, it is worth noting that mRNA vaccine technology has been under development for over three decades. It is not unreasonable to be concerned about long-term deleterious effects, though after three years of use, there is scant evidence that should lead people to be unduly worried.
When the Covid-19 vaccines were first introduced in the UK, even one jab conferred surprisingly good protection against infection with the early strains of Covid-19. With the emergence of a succession of variants with mutations in the viral spike protein, it became clear that the vaccines conferred weaker protection against infection with these variants. By contrast, the vaccines were still very effective at reducing serious complications, hospitalisation and death. A significant number of breakthrough infections have been recorded; some people who had already been vaccinated became infected one or more times. It is hardly surprising that vaccine-hesitant individuals still question the effectiveness of the vaccines. In addition, people with preexisting health conditions such as diabetes may be concerned about efficacy and the effects of the vaccines on their health.
Distrust of governments and vaccines
During the pandemic, the UK government ministers, health officials, and scientists frequently had ongoing public disagreements about the type of vaccine to be deployed, which age group should be given priority, and how many injections (and how often) a particular cohort should receive. This all gave the impression that the government had been making policy ‘on the hoof’ and were not fully in control; and risked making the vaccine-hesitant postpone or resist being vaccinated.
In 1988 a paper was published in the prestigious Lancet journal falsely claiming a link between the widely used and safe MMR (measles, Mumps and rubella) vaccine and autism spectrum disorders. Despite overwhelming evidence to the contrary, and retraction of the Lancet paper, a precipitous drop was observed in the number of parents coming forward to have their children vaccinated as they still wrongly believed their child was at risk of developing autism. Some of these parents may distrust vaccines in general.
A surprising number of people cite inconvenience as a reason not to take the jab. It may be because attending the vaccine centre requires a long bus or car journey. Others say they cannot take time off work when the vaccinations take place during the working week. Mobile vaccination units and carrying out vaccinations at weekends have in some areas gone some way to addressing these issues.
Pandemic has receded
Now that the pandemic has receded somewhat, there is the temptation to skip booster vaccinations. People may think ‘I am no longer at risk of serious illness caused by the virus.’ Or ‘I did not catch Covid-19 so my immune system must be strong.’ Some say ‘Covid-19 is now just like flu.’ (Not true). The virus is on the rise again. In January 2024, a new contagious variant of Covid-19 (JN.1) is spreading around the world, and estimates suggest it represents roughly 7% of all new UK cases. JN.1 has a single mutation in the spike protein that renders it much more resistant to current vaccines. It is a derivative of ‘Pirola’, a variant of ‘Omicron’ which the World Health Organisation has designated a variant of interest. The war against Covid-19 is far from over.
Treating vaccination sensitively
We have discussed the reasons some people still hesitate to be immunised against Covid-19 which are varied, complex and often valid, aside from the diehard anti-vaxxers. Despite a wealth of data showing the benefits of vaccination far outweigh the risks of hospitalisation and death, a sizeable minority of the eligible population are still unvaccinated or prefer not to have a booster jab. Calling such individuals lazy, selfish, ignorant, or brainwashed is unhelpful and counterproductive. Policymakers and health officials must continue to call out such negative sentiments and treat hesitant individuals sensitively. Establishing why some people do not want to be immunised, and avoiding a one-size-fits-all message, has been key to persuading some to change their minds.