Why is there vaccine hesitancy in Nepal?

Nepal was one of the first countries in the region to start a mass Covid-19 vaccination drive two weeks ago, but less than half of the frontline workers and high-risk individuals prioritised by the government have chosen to inoculate themselves.

Officials figures show that only 184,000 of the 430,000 people on the government’s list for the first phase opted for the jabs. India had donated 1 million doses of the Astra Zeneca Covishield vaccine made by Serum Institute of India.

This means that the vaccines which were manufactured in October 2020 will expire by April, and the Nepal government is running out of time to use up the doses before another batch of 2.25 million Covishield doses under the WHO’s COVAX initiative arrive in Nepal.

“It’s a new vaccine against a new disease, people are naturally concerned about taking it,” says Sher Bahadur Pun of the Sukraraj Tropical and Infectious Disease Hospital. “We should have promptly addressed safety concerns and about its minor side effects to curb any doubts.”

Pun said even some of his doctors and nurse colleagues refused to take the vaccines, doubting their efficacy. The first phase of inoculations was being administered through 201 booths across 77 districts.

Possibly because there are still so many doses left, the Ministry of Health has decided to ignore its own vaccination strategy and expand the first phase to also include civil servants, diplomats and journalists.

“The first phase showed us that the vaccine is safe, there were no major side effects or deaths but our coverage was much lower than targeted,” admits Shyam Raj Upreti, head of government’s Covid Vaccine Strategy. “The vaccination campaign wasn’t as decentralised as we would have liked and weren’t able to reach as many people. We need to take vaccination booths to areas closed to the public, especially as we prepare to jab the elderly and those with morbidities in the second phase.”

Quick, successive vaccine development also made many wary. Others in the priority list such as cleaners and security guards were suspicious of being turned into guinea pigs.

“The government was unsuccessful in properly communicating the significance and efficacy of the vaccine and explain why certain groups of people are being prioritised for the vaccination,” says Ramesh Kant Adhikari of the National Immunisation Committee which oversees other vaccination programs in Nepal besides Covid-19.

To be sure, vaccine hesitancy is not unique to Nepal. Several countries have deployed methods to increase vaccine acceptance among the masses: national leaders, politicians and celebrities were televised live being inoculated. Many influencers took to social media to share their experience of being vaccinated.

India’s donation of 1 million Covishield vaccines to Nepal on 20 January has prompted China to now offer 500,000 doses of its own Sinopharm vaccines to Nepal even though it has not yet been certified by WHO. The Nepal government is reported to be reluctant to accept this gift because there might be even more public scepticism about it.

Nepal is receiving 2.25 million more Covishield vaccines with a £550 million UK government support under the World Health Organisation (WHO) and the Global Vaccine Alliance (GAVI) COVAX initiative by early March. Nepal will receive the rest of the vaccine it applied for 20% population later.

But excluding people under 18 years of age, Nepal needs vaccines for 72% of its population. So in the meantime, the government is in talks with India to purchase another 2 million doses of Covidshield, which will arrive in a month.

China’s promise of 500,000 doses of Sinopharm vaccine in March is up from 300,000 previously promised. India’s Bharat Biotech-manufactured Covaxin and Russian Sputnik V are in a race to supply additional jabs for Nepalis.

Earlier doubts about Russian and Chinese vaccines have been quelled with new findings and due to the limited manufacturing capacity of Covidshield, Moderna and Pfizer.

A recent research paper on the medical journal Lancet called Russian Sputnik V safe and effective (91.6%) based on interim results from its phase three trials. Sinopharm has had efficacy ranging from 86% to 79%.

An op-ed in the New York Times last week explained that another Chinese vaccine Sinovac performed poorly (50.4%) in Brazil compared to Turkey (91%) because it was conducted exclusively among health workers in São Paulo who were at the highest risk, leading to much lower efficacy.

But so far Covidsheild is the only Covid-19 vaccine registered at Nepal’s Drug Development Administration, even though South Africa has discontinued its use because it was found not to be effective against a new strain of coronavirus found there.

“For us to administer Sinopharm and others, we need a different strategy, get an approval from a health authority in the manufacturing company and a study of its side effects in similar populations,” explains Adhikari.

There is also an on-going debate about the use of different vaccines for the same individual. While experts agree on using the same vaccine for both the first and second dose as far as possible, a mix of two different shots is also being advocated given there is a limited stock of vaccines of one kind.

Vaccines are here at a time when positivity and fatality rates are going down in Nepal and the region. Multiple factors have been credited to this: fewer tests and contact tracing, large chunks of the population developing immunity against SARS-CoV-2 after contracting it and the natural peak and fall cycle of infectious diseases.

But one cannot ignore the possibility of another wave as seen frequently in the US and Europe and continue to wear masks, maintain physical distance and practice handwashing.

Says Sher Bahadur Pun: “This is the right time to vaccinate and be better prepared for possible next wave by strengthening our health infrastructure and human resource while continuing to follow safety measures, we must use this period to the fullest.”