On January 16, 2021, India began Phase-I of what may be the world’s largest vaccination drive, aiming to vaccinate nearly 300 million frontline workers against Covid-19. This rollout featured India’s indigenously developed Covaxin (Bharat Biotech/Indian Council of Medical Research) and indigenously produced Covishield (Serum Institute of India/Oxford-AstraZeneca), marking the beginning of a potential end to the pandemic’s eleven-month siege.
Over the last year, the pandemic has served as a litmus test for functional public health policy and preparedness at global and national levels. Around the world, the sustained loss of lives and livelihoods consequent to fragmented and sometimes inconsistent public health responses, combined with increasing pandemic fatigue and resistance to restrictions, highlights the importance of disseminating unified risk communication and messaging in the face of a public health emergency.
While high-income countries such as the US focussed their initial efforts on expanding critical care services, low-to-middle-income countries such as India instead turned their attention toward launching widespread Covid-19 surveillance and risk communication campaigns, recognising that their margins of tolerance for increased demands on their health systems were considerably lower.
Strategies for risk communication are neither new to public health nor to India. With decades of training in responding to regional epidemics, India’s public health arsenal includes the use of communication strategies aimed at widespread social and behavioural change. For instance, a key component of the 2018 POSHAN Abhiyaan (National Nutrition Mission) is Jan Andolan (mass mobilisation). Now being adapted into Covid-19 communication, this consists of community dissemination of messages through existing platforms and unified trans-media narratives engaging all stakeholders. Of note, over two million Accredited Social Health Activists (ASHAs) and Anganwadi workers, already embedded into rural primary healthcare infrastructure, expanded their roles in maternal and child health to educate communities on Covid-19.
In April, the Ministry of Health and Family Welfare (MoHFW) released a containment plan for large outbreaks directing inter-ministerial collaboration and the alignment of national and state-level responses. Built on the National Risk Communication Plan, it included directives for information dissemination through interpersonal communication (e.g., health workers), mass communication (public announcements, SMS, social media, radio, television), collaboration with existing partners (e.g., UNICEF), dedicated helplines, and regular press briefings.
Between March and April, a total of 36 videos were telecast in Hindi and English on India’s national television channel, Doordarshan, even as more regional content continued to be developed in alignment with the trajectory of the pandemic. The first campaigns emphasised symptoms, travel warnings, and screenings; subsequent messaging highlighted face-coverings and distancing, followed by tips for social and mental well-being, and finally on vaccines.
Use of social media
As the government released updates, journalists across the country played a crucial role in translating evolving scientific findings and guidelines for a largely health-illiterate public. The widespread use of social media in Indian cities, towns, and villages of all sizes also meant real-time transmission of both Covid-19 information and misinformation. Various stakeholders leveraged their presence on social media platforms to provide credible information (e.g., Ministry of Information and Broadcasting, Government of India Chatbot).
In an effort to generate public demand and inspire confidence in potential vaccines, alongside the historic development of some of the first Covid-19 vaccine candidates, public health departments, health journalists, scientific experts, and pharmaceutical industry veterans offered descriptions of vaccine candidates, overviews on vaccine types and their mechanisms, clinical trials and vaccine approval, and the all-important metrics of safety and efficacy.
A national Covid-19 Vaccine Communication Strategy identified approaches to transparently disseminate information on new Covid-19 vaccines, address vaccine hesitancy, build vaccine trust, and communicate the basis of a staggered vaccine rollout. Previously engaged stakeholders now refocussed their efforts towards partnerships with community influencers and leaders to circulate accurate vaccine information, produce evidence-based social and traditional media content on vaccine benefits, monitor digital media to curb misinformation, and identify and work with vaccine-resistant groups to improve trust .
India’s experience with mass-vaccination campaigns is marked by the successful implementation of the Universal Immunization Programme that uses evolving mass-communication and social media strategies to build vaccine trust and confidence. This trust is reflected in a November 2020 survey showing that 87 per cent of Indians were willing to receive a Covid-19 vaccine when available. However, we should be wary of taking this hard-won trust for granted.
On January 3, 2021, in an unexpected move that took vaccine experts and the public by surprise, India’s Central Drugs Standard Control Organization (CDSCO) announced the approval of Covaxin, Bharat Biotech’s attenuated coronavirus vaccine candidate for “restricted use in emergency situations in public interest as an abundant precaution, in clinical trial mode, especially in the context of infection by mutant strains.”
Across the scientific community, experts raised doubts and concerns over the absence of Phase-III clinical trial data demonstrating vaccine efficacy, and the lack of publicly available Phase-II data on the vaccine’s demonstrated immune response in trial participants. More confusing is the language of the approval that refers to a “clinical trial mode” ostensibly requiring volunteers and a placebo arm; the current rollout does not meet either requirement and, instead, vaccinates individuals at centers marked for Covaxin, with follow-ups for adverse reactions.
As news of the approval and subsequent concerns spread, non-governmental communication about India’s latest vaccine candidates, including the less contentiously-approved Covishield, has been mixed, inspiring sentiments from optimism to confusion and mistrust. Daily media debates surrounding the opacity of the vaccine development and approval processes were being absorbed en masse by audiences now primed to comprehend, even if at a high-level, important concepts behind vaccine science.
To further muddy the waters, the CEO of Serum Institute of India and Chairman of Bharat Biotech engaged in a heated back-and-forth exchange through public comments casting doubt on the safety, efficacy, and integrity of clinical trial data for either vaccine, before finally issuing a joint statement demonstrating their shared commitment to supplying safe and effective vaccines. Despite months of largely unified Covid-19 messaging, this uncoordinated and chaotic introduction of India’s vaccine candidates may have put at risk, at the least, initial trust and public vaccine uptake.
Potential for mistrust
This potential for erosion of vaccine confidence is further compounded by the ongoing Covid-19 infodemic. In India, myths surrounding the Covid-19 vaccine have resurfaced and mutated from those that accompanied prior vaccine rollouts, frequently capitalising on religious sentiment (example, alleged use of pig-gelatin in vaccines), science illiteracy (ex. allegations that vaccines alter DNA), and mistrust of authorities (ex. allegations that vaccines contain trackers). These, in combination with the historically-paced development and expedited approvals of Covid-19 vaccines around the world, and fear of potential corruption and political incentives in our own institutions, may be fertile grounds for the Indian public’s decline in vaccine confidence.
Mistrust in vaccines and vaccine hesitancy have arisen in India in the past. The 2008 Human Papillomavirus vaccine trials were mired in controversy from a lack of transparency, poor initial communication, and scientific illiteracy among target communities. Misinformation about the Polio vaccine led some communities to believe that vaccinations cause sterility. Despite these roadblocks, childhood vaccination rates in India have continued to rise, owing in large part to the consistent communication of vaccine benefits and fear-reducing information. India’s successful eradication of Polio in 2014 is still recent in our collective memory, and the nation has historically trusted vaccines that have demonstrably protected its children.
We rest now at a pivotal point in our efforts against Covid-19, a time in which public vaccine trust and confidence can yet be re-won by transparency, integrity, and accessible public health communication. As frontline and high-risk communities begin to receive vaccines across the world and in India under public scrutiny, governments, experts, and media must prioritise real-time translation of scientific jargon into their most relevant and easily understood forms.
They must reiterate at every step the facts we know, the facts we do not, and in every instance, how individuals and institutions can best protect themselves. The rise of fact-checking services (ex. WhatsApp chatbots) is promising and replicable. Health literacy in journalism can be complemented by media communication training among scientists and academic experts to facilitate greater capacity for evidence-based public health reporting, and subsequently, greater public engagement with science and health.
As India deploys what is hopefully a final means toward the end of the Covid-19 pandemic, we must continue to be both mindful and consistent with our messaging on vaccines and Covid-19 precautions, and not slide backwards on this last leg.
Pinnamaneni is a Research Fellow at the Harvard TH Chan School of Public Health and a physician working on projects focussing on health communication and maternal and child health in India. Seshasayee is a Research Analyst at MaineHealth, and has experience practising as a Dentist in India. This article is by special arrangement with the Centre for the Advanced Study of India, University of Pennsylvania.