Vaccine uptake will be driven by consensus not penalties, Nphet told

Vaccine uptake in Ireland will be driven more effectively by campaigns based on knowledge and consensus than by penalties and enforcement, the National Public Health Emergency Team (Nphet) has been told.

A review of international evidence by the Health Information and Quality Authority (Hiqa) advised Nphet that the vaccination campaign should “build on what Ireland has already achieved in relation to Covid-19”, which has been based upon knowledge and consensus, rather than penalties and enforcement.

“Trust, communication and knowledge are core to informed decision making,” the review found.

It advised that prior to any campaign launching, healthcare workers should be targeted with the necessary information to make decisions for themselves, and to act as a trusted source of information for others.

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Similarly, “given the importance of social influence on an individual’s behaviour”, key opinion leaders inside and outside the medical profession, including sports leaders and religious figures, should be provided with similar tools.

The paper identified several concerns that might affect uptake, including misconceptions about the use of new techniques in developing the vaccines, and the rigour of the regulatory approval process.

The paper submitted to Nphet is based largely on existing research relating to flu, given time pressures involved. It involved two overviews of existing reviews in the scientific research, one focused on factors affecting uptake of flu vaccines, and a second looking at the effectiveness of interventions designed to improve uptake.

The existing evidence suggests barriers or “facilitators” include perceived risks or benefits of vaccines, access or other contextual factors, psychological or internal factors, perceived risk or susceptibility to flu, perceived responsibility, social influences, past behaviours, knowledge, socio-demographic factors and health behaviours.

Targeted interventions

The review found that for those at high risk of severe disease, perceived responsibility was not a barrier or a facilitator, while in pregnant women, that factor, knowledge, or health behaviours were not tagged as barriers. Pregnant women were more likely to give protection of their baby, knowledge about flu, vaccination policy and past experiences as reasons for taking vaccines.

The report does warn that three of the nine reviews included in the study of factors affecting uptake were of low quality, and that due to inherent biases and issues around their transferability to the current situation in Ireland, their findings need to be “interpreted with caution”.

The second review, focused on interventions to drive uptake, included 21 reviews, seven of which were of high quality. It found moderate to high certainty that personalised and targeted interventions were effective among older adults - these included low intensity interventions like postcards, through to more intensive interventions like personalised phone calls or home visits.

Personalised approaches such as postcards or telephone calls also seemed to be more effective among those with underlying conditions, and pregnant women. Among healthcare workers, it found low to very low certainty that what is described as “multicomponent interventions” were effective - these combine education, incentives and requirements to write statements detailing the reason for refusal. It found that mandatory vaccine was most effective at driving uptake among healthcare workers, but that there are “concerns regarding individuals’ autonomy”. It said that some interventions could also negatively impact staff morale.

There was moderate certainty in papers reviewed that patient reminded and recall systems “probably” improve vaccine uptake in adult and child populations.

However, Hiqa warned that because Covid and seasonal flu are “very different diseases” the applicability of the evidence gleaned from the review is “likely to be limited”.

“The huge amount of attention to Covid-19… will be an important influencing factor,” the review found, arguing that motivations will be driven by different factors in different groups - for example among younger people, it may be driven by social responsibility rather than the perceived risk of the disease. It found that the most relevant evidence for the Covid vaccination will be directly related to the immunisation programme itself “and that it will be important for reliable evidence in relation to effectiveness and safety” to be made available.

Community leaders

During a discussion of the findings by the Expert Advisory Group (EAG) on Covid, there were concerns raised about misconceptions in relation to how mRNA (messenger RNA) vaccines work - this is the new technology which some of the candidate vaccines likely to be administered are based. There were also concerns expressed about the potential for misconceptions around the rigour of the authorisation process for the Covid-19 vaccines, which have been developed and approved in record time.

The EAG agreed that policies to maximise the uptake “need to focus on trust, communication and knowledge”, and emphasise that while timelines have been shortened, the new vaccines “undergo the same rigorous evaluation process by regulatory authorities”. Community leaders, including religious leaders and other influencers, were also identified as important drivers.

The EAG also discussed differences between established vaccines and new ones like Covid in the context of older people in long term care facilities like nursing homes, and that vaccination of this population will only occur based on informed consent - which will also apply to other long-term residential facilities and vulnerable individuals. The group also discussed the fact that mandating vaccination was practiced in some instances, such as yellow fever vaccination for entry into some countries and childhood immunisation for school entry elsewhere.

However, it noted that “significant ethical and organisational issues” surround mandatory vaccination policy for a workforce.

Dr Máirín Ryan, Hiqa’s deputy chief executive, said it was important to continue to monitor and review evidence on the effectiveness of the vaccine once the campaign begins.

“As the Covid-19 vaccine is rolled out in Ireland and across the world, updated evidence in relation to effectiveness and safety must be made available in an open and accountable manner, so trust can be maintained.”