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Prospective recipients of a vaccine against COVID-19 waited to be called from under a shed at a public vaccination site in Nigeria’s southwest city of Ibadan. Credit: Paul Adepoju / Nature Medicine Africa is waging a war on COVID anti-vaxxers Misinformation about COVID-19 vaccines often starts life in Europe or the United States but has found fertile ground in Africa, which poses a challenge for local health leaders. Paul Adepoju

hade is a 58-year-old Nigerian So many uncertainties made me doubt expressed doubt about the vaccination,” frontline health worker living with whether I really need the vaccine,” she tells says Roger Tatoud, deputy director for Sosteoarthritis. She is also overweight, Nature Medicine. HIV Programmes at the International diabetic and hypertensive, all of which Shade is not the only frontline health AIDS Society. made her first in line for a vaccine against worker to refuse a vaccine against Whether or not to receive a vaccine is COVID-19 when it finally became available COVID-19, despite its availability. a person’s individual decision, but vaccine in Nigeria. Her eldest daughter booked an hesitancy may prevent herd immunity from appointment for her at their local primary Africa’s anti-vaxxers being reached, especially in sub-Saharan healthcare center, but when the day came to Vaccine hesitancy is a phenomenon that Africa, where vaccine doses are sparingly receive her first dose of the vaccine against predates COVID-19. A 2015 report by the available and the anti-vaccine campaign has COVID-19, she changed her mind. Shade European Centre for Disease Prevention influential mouthpieces. instead chose to take her chance with the and Control noted that vaccine-hesitant In January 2021, former Tanzanian virus instead of getting vaccinated. healthcare workers might spread unfounded President cast doubt on the “It isn’t about my trypanophobia [fear of concerns about vaccines to the general effectiveness of vaccines against COVID-19, needles], it’s the aftermath of a constellation population, recommend vaccines less and even denied the existence of of conflicting, confusing and scary frequently to their patients, and reduce SARS-CoV-2 in his country. After his death, messaging and reports on the safety and vaccine confidence and uptake. Vaccine his successor, , decided politics of the vaccine. I saw videos of people hesitancy is therefore a major concern in the to take a different approach when she getting dizzy and fainting after receiving global fight against the COVID-19 pandemic. said the country “cannot isolate ourselves the vaccine. We also heard of people that “We should be worried that up to 40% of as an island while the world is moving developed blood clots and died afterwards. medical staff in a number of countries have in a different direction.” Even though a

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of social media. We’re working on aggressively supporting countries on how to provide the right information to educate the people,” Mihigo adds.

Nothing like Ebola Africa has vast experience with vaccinations, so much so that countries like Ethiopia have been able to continue routine immunization exercises for measles, reaching millions of children in the middle of the pandemic. The WHO and the Africa Centres for Disease Control and Prevention were keen to report that several African countries, including Rwanda and Ghana, quickly rolled out doses of vaccines against COVID-19 from COVAX and other donors. But not all African countries have performed as well. Formerly known as Zaire, the Democratic Republic of Congo (DRC) A primary healthcare officer fills out a COVID-19 vaccine card for a frontline health worker after is located in Central Africa, and by area, it registration online as required by the health authorities. Credit: Paul Adepoju / Nature Medicine is the largest country in sub-Saharan Africa, the second largest in all of Africa and the eleventh largest in the world. The DRC has committee to advise the government on in Western countries, especially the United a battered health system that leaves children COVID-19 has been set up and its members States and Europe, and these were fueling at the mercy of killer diseases, including are public-health and medical experts, and vaccine hesitancy in Africa. malaria, cholera and measles. The DRC has strict COVID-19-prevention measures “Building vaccine confidence is an reported more Ebola outbreaks than any have been reintroduced, is yet issue across the globe. What we’re really other country in the world and continues to to announce any vaccination plans. There concerned about is that these pieces of face a complex humanitarian crisis. remains formidable opposition to vaccines misinformation that are created in the USA Since the COVID-19 pandemic began against COVID-19 in Tanzania, even by or in the UK, they’re traveling and finding in the DRC in 2020, misinformation has some key players in the country’s science some fertile ground in Africa as well,” been a major force slowing down progress, ecosystem. Fleming says. according to warnings from Doctors In early April 2021, Wilcox Richard Mihigo, coordinator of the Without Borders. Misinformation is further Onyemekeihia, Secretary of Programmes to Immunization and Vaccine Development complicated by skepticism about the the Senior Special Adviser on Youth Affairs Programme of the World Health seriousness of COVID-19 relative to that of in Nigeria’s Cross River state, was on a Organization (WHO) Regional Office for Ebola and other leading causes of death in panel that discussed the myths and realities Africa, says vaccine hesitancy in Africa is the DRC. The vaccine rollout in DRC was of vaccine hesitancy for COVID-19 and not being driven by people’s fears alone. paused following news of vaccine-linked other vaccine-preventable diseases. To the According to Mihigo, international groups complications in Europe. This suspension alarm of some on the panel, Onyemekeihia are fueling anti-vaccine tendencies that had was subsequently lifted but may have queried the vaccine’s quick development not been seen in Africa before COVID-19. further damaged vaccine acceptance, as seen process, overhyped the side effects of the “Anti-vaxxers in some Western countries when the DRC returned 1.3 million doses vaccines and questioned the true status of are taking advantage of all the concerns of vaccines against COVID-19, supplied the pandemic in Africa—implying vaccines about the adverse effects of vaccines. We by COVAX, for redistribution to other were unnecessary, given the associated risks. need to address the spread of vaccine countries. All of these talking points were straight from misinformation in Africa,” says Mihigo. the anti-vaccine playbook. When the first case of COVID-19 Do as I do Onyemekeihia continues to share was confirmed in Nigeria, officials at the Some of the health infrastructure used to vaccine-hesitancy sentiments on social Nigeria Centre for Disease Control, led by combat COVID-19 was acquired in the media, views that may be influenced by one the director general, Chikwe Ihekweazu, fight against human immunodeficiency of Nigeria’s top pastors, who connected 5G described a miscommunication menace, virus (HIV) and AIDS. At the first to COVID-19 and spread other enabled by social media, as a major threat to virtual HIVR4P conference in January vaccine myths. the country. COVID-19 is the first pandemic 2021, Anthony Fauci, director of the US since mobile, internet and broadband National Institute of Allergy and Infectious Spread from the West use expanded in Africa. The number of Diseases, described how decades of HIV In early December 2020, before doses people in sub-Saharan Africa with access research influenced the development of of vaccines against COVID-19 became to a mobile broadband network more than vaccines against COVID-19 and attributed available in Africa, vaccine hesitancy was doubled from 120 million people (13%) in reluctance and vaccine hesitancy among already gaining momentum globally. Melissa 2014 to 270 million (26%) in 2019. African Americans to the strained Fleming, chief spokesperson for the United “In terms of vaccine hesitancy, we’ve seen history the community has had with High Commissioner for Refugees notes that a surge in misinformation, particularly in government-funded research, including miscommunications probably originated urban areas where there’s high penetration the infamous Tuskegee Study of Untreated

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poliomyelitis. This was in part because of a Matshidiso Moeti, WHO Regional polio-vaccine boycott that began in August Director for Africa, notes that African 2003 in three Nigerian states where rumors countries now have another chance to get started that the oral polio vaccine was laced their logistics and communication plans in with antifertility drugs in order to sterilize order, due to the delay in the shipment of young Muslim girls. doses of vaccines against COVID-19 from “The vaccine boycott in Nigeria was COVAX. Moeti says that vaccine hesitancy influenced by a complex interplay of in Africa can be preempted, identified and factors—lack of trust in modern medicine, tackled by carrying out simulation exercises, political and religious motives; a long history listing priority groups and communicating of perceived betrayal by the political class, early with communities. the educated elite and big business; and the spread of false information,” Tomori says. Pause and rewind The suspension of vaccination against When countries in Europe decided to pause polio in Nigeria sparked a global polio the rollout of the ChAdOx1 vaccine from outbreak that quickly spread to 20 countries Oxford–AstraZeneca following reports of in Africa, the Middle East and Southeast very rare side effects, John Nkengasong, A Nigerian medical practitioner draws diazepam Asia, causing 80% of the world’s cases of director of the Africa Centres for Disease into a syringe for a patient booked for an paralytic poliomyelitis. Beyond delaying Control and Prevention, was concerned emergency cesarean section procedure during the eradication of polio, the outbreak that that the pause would damage trust in the COVID-19 lockdown. Credit: Paul Adepoju / started in Nigeria also resulted in a cost this particular vaccine. This is especially Nature Medicine of over US$500 million for immunization worrying because ChAdOx1 is the main campaigns and public-awareness initiatives. vaccine being distributed to African “[In Nigeria], there is a general distrust countries through COVAX. Syphilis that targeted Black males in the of the aggressive, door-to-door mass For Tomori, African leaders should not United States. immunization campaigns due to poor access pause vaccine rollout whenever they suspect Fauci described how church groups to basic health care. There is no medicine a possible side effect, as most African were engaged to drive support for the for children dying of measles and diarrhoea; countries have only a single vaccine on vaccine against COVID-19 among but you bring polio vaccine for free offer, with no other vaccines as possible African American populations. This was house-to-house,” Tomori says. replacements. “In my discussion with complemented by respected members of “The [vaccine] rollout has to be an all-out people I say ‘Europeans have a choice of the Black community, including Reverend effort, not just the federal government. vaccines, Africans don’t have a choice and Jesse Jackson, publicly receiving the vaccine Some states, two weeks after the vaccine the WHO still says the vaccine is safe. There against COVID-19 to show that it is safe. came, were not even ready. Some of the state is no vaccine that doesn’t have side effects. Similar public actions were taken by governments were stalling probably because [ChAdOx1] is what we have for now,’” says several African heads of state, who received they did not have confidence in the vaccine Tomori. “’If you have a half loaf of bread and their vaccines against COVID-19 on live TV. and were delaying. In one state, they said you’re hungry, will you say no [until] you However, even this publicity can backfire. they had not trained health workers, while have a full loaf to eat? If your neighbor has In Nigeria, several politicians and their another said they were testing the vaccine ten loaves and decides not to eat one, how is family members, including Atiku Abubakar, for sterility,” says Tomori. that your concern?’” a former vice president and presidential Nkengasong notes that the COVID-19 candidate, flew to Dubai to be vaccinated, Different strokes pandemic has raised the need for Africa to while a governor’s wife received her vaccine A single approach may not be effective in focus more on continuous vaccine literacy in Houston, Texas. tackling vaccine hesitancy across Africa, in order to build the confidence of the Oyewale Tomori, a Nigerian professor says Mihigo, due to differences between people. Nkengasong describes trust as the of virology and chairman of Nigeria’s countries. Even within countries, vaccine foundation of good public-health practice— Ministerial Expert Advisory Committee concerns vary from one place to another. building trust with the community and on COVID-19, says that politicians “There are countries where up to 50 or with public-health agencies. “We should receiving the vaccine overseas allowed even 60% of people are not keen to be work consistently to make sure that the distrust to germinate among citizens. Some vaccinated and others where most of the right message and information are shared, were concerned that the vaccine being population are willing to be vaccinated. This and that the right education, what is called administered in Nigeria might not be the is something that needs to be addressed very vaccine literacy, is actually promoted,” says same vaccine that politicians flew abroad to comprehensively and very strategically,” Nkengasong. receive. “There is distrust and mistrust all Mihigo says. Efforts should be geared toward over. Even when the president receives the effective communication and should be Vaccines work vaccine publicly, some people will ask if the driven by an understanding of what people Public-health authorities in Africa are keen syringe is the same, and whether it is also the are believing, thinking and fearing. “It’s one to share positive stories from places where same content. We will never achieve herd thing to have political leaders speaking on the rollout is going well, such as Morocco, immunity if this continues,” Tomori says. the television telling people broadly what Rwanda and Angola. Another such positive Tomori argues that several developments needs to be done, it’s quite another to have story comes from Ghana, the first country spanning decades have contributed to somebody understand as a person and an in Africa to receive the vaccine against vaccine hesitancy in Nigeria. Nigeria was individual in a particular context why the COVID-19 through COVAX. the last country in Africa, and one of the story that they’ve been told is not true,” Christian Owoo, Ghana’s National last countries in the world, to eradicate Mihigo tells Nature Medicine. COVID-19 Case Management Coordinator

1124 Nature Medicine | VOL 27 | July 2021 | 1122–1125 | www.nature.com/naturemedicine news feature for Severe and Critical Diseases, explains African countries. Research and sharing of vaccination campaigns for years, and we’re that the vaccine is already having a knowledge are going to be a massive part always faced with the same situation every substantial positive impact in reducing of reducing vaccine hesitancy; working time there’s a new vaccination campaign. COVID-19 mortality among people who collaboratively with other African countries We need to stop this disinformation and have been vaccinated. Owoo says that and making sure that this evidence is put out fight back.” In the end, says Fall, Africa the successes in Ghana should be a key there to encourage an efficient distribution can win the war against vaccine hesitancy message used to encourage more Africans of vaccines,” Owoo adds. by focusing on what truly matters: how to receive the vaccine. “One of the lessons Mohamed Moustapha Malick Fall, vaccination has saved millions of lives on the we’ve learned from critical care is that since UNICEF’s Regional Director for Eastern and continent. ❐ Ghana started vaccinating, the proportion Southern Africa, argues that partnerships of patients who have presented to ICU with key people in the region, such as Paul Adepoju with severe critical diseases, and that had social-media influencers, are needed to Freelance journalist, Ibadan, Nigeria. been vaccinated, is much lower than those tackle vaccine hesitancy. “These people can who have not been vaccinated,” Owoo says. relay the message that vaccination is nothing Published online: 5 July 2021 “Sharing this knowledge is important in new in Africa. Africa has been doing https://doi.org/10.1038/s41591-021-01426-2

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