By Theebika Shanmugarasa
News of the devastating impact of India’s second wave of COVID-19 are sobering. As of May 14th, the official death toll from coronavirus passed 260,000. The unrecorded numbers are said to be much higher. Globally, India now accounts for over 40% of recorded infections.
How is India dealing with the crisis?
Overwhelmed hospitals, a shortage of oxygen supplies, and need for makeshift funeral pyres all highlight the country’s struggle to contain the health crisis. While previously struggling countries, like the UK and US, now showcase their vaccine rollouts as proof of their successful handling of the pandemic, India is struggling with a shortage of COVID-19 vaccines. Officials blame the drastic rise in COVID-19 cases, but in a country that boasts the world’s largest vaccine manufacturer, a closer look suggests that India may be grappling with other issues; such as increased vaccine hesitancy and disinformation.
Is vaccine hesitancy an issue in India?
Vaccine hesitancy is defined by the World Health Organisation, as ‘the reluctance or refusal to vaccinate despite the availability of vaccines’. Prior to the pandemic, vaccine studies conducted by ORB International, in collaboration with the London School of Hygiene and Tropical Medicine, revealed high vaccine confidence in India, i.e. citizens reported high vaccine uptake levels, and positive attitudes towards the importance, safety and effectiveness of vaccines. This held true for the general public, as well as slightly more vaccine hesitant groups such as pregnant women and new mothers. As the coronavirus pandemic unfolded, this trend continued. ORB polling, conducted between June and July 2020, showed the vast majority of Indian respondents (91%) claimed they would take a COVID-19 vaccine if it became available – ranking second (behind Ethiopia) among the 17 countries surveyed worldwide.
Almost a year on, a survey conducted by CVoter, a polling agency in India, suggests a significant drop in those feeling absolutely certain about taking a COVID-19 vaccine (May 2021). Although overall figures remain high, with around 8 in 10 (82%) agreeing that they would take a COVID-19 vaccine, this marks a roughly ten-percentage-point drop since ORB’s survey last summer.
A closer look at public perceptions towards the importance, safety, and effectiveness of COVID-19 vaccines points to a link between declining positive attitudes across these vaccine measures and lower reported acceptance of COVID-19 vaccines. The shift indicates increased uncertainty since last summer, with respondents moving from ‘Strongly Agree’ to ‘Agree’ responses, and showing higher propensity to give ‘Don’t Know’ responses.
Low reported cases in early 2021 may have given the sense that India had overcome the pandemic and acquired herd immunity – an opinion gaining ground among policy makers, some of the media, and the public, according to Srinath Reddy, president of the Public Health Foundation of India. This could explain the lax approach to large political rallies and religious gatherings since March this year, where unrestrained crowding and large-scale travel were allowed.
The quick approval in January for three different jabs, i.e. British AstraZeneca; Indian-made Covaxin; and Russian-made Sputnik V vaccine. Coupled with the assumption that vaccines will be easily accessible due to its large vaccine manufacturing capacity this may have encouraged a laid-back approach to engaging the public in conversations around COVID-19 vaccines. This in turn may have exacerbated existing suspicions, and concerns around vaccines and fed into rising hesitancy in an otherwise vaccine confident country.
The interlinking nature of the reasons behind vaccine hesitancy (outlined below) suggest a clear need for a vaccine strategy that engages all segments of society:
1. Personal experience of COVID-19. Despite the high reported number of cases and deaths in India, the majority of CVoter survey respondents claimed in May 2021 that no one in their family or surrounding had been infected or affected by COVID-19. ORB polling in other countries suggests that the lack of personal experience of the virus may lead citizens to believe that a vaccine against said disease may not be necessary.
2. Type and origin of vaccine. This appears to matter to citizens. ORB’s survey last summer suggested that Indian respondents believed the type and origin of a COVID-19 vaccine would impact uptake. A view held by an even higher proportion currently, as the survey in May suggests. This may be linked to highly publicised concerns around certain types of vaccines. India’s approval of Covavaxin, developed by Bharat Biotech alongside government-backed research groups, was met with widespread criticism from scientists because of the perceived lack of complete data. 
3. Impact of healthcare professionals’ views on the public. India’s vaccine rollout strategy involved prioritising healthcare professionals (HCPs) as one of the first target groups for vaccination. Failure to get this audience onboard seems to be a critical miscalculation of the Indian government and public health bodies. HCPs have shown resistance due to concerns around safety and effectiveness around specific vaccines.
In a country, where women in particular, place much faith in vaccine recommendations given by doctors and nurses, engaging HCPs in transparent and evidence-driven conversations around vaccine safety and effectiveness is crucial. Not only to ensure that HCPs are willing to take the vaccine themselves but given that their views are widely disseminated in the media to foster public trust.
“Many in our institute aren’t comfortable with Covaxin because we don’t know how effective it is,” said Adarsh Pratap Singh, a member of the Resident Doctors Association at the All India Institute of Medical Sciences in New Delhi. “To build trust among people the government must come out with the data, evidence of the trials, and encourage free and fair discussions. […] At least 40% of doctors here are unsure and want to wait,” said Vinod Kumar, a resident doctor at the All India Institute of Medical Sciences of Patna, in the eastern state of Bihar.” (Business Standard, January 2021)
4. Rushed and incomplete vaccine trials. While ORB’s global studies suggest that countries tend to view foreign vaccine trials with suspicion, in India, its very own trials are met with public criticism. The perceived lack of transparency and hurried approval of Covaxin, India’s first home produced vaccine, is seen to threaten domestic trust[1o].
“The All India People’s Science Network, representing multiple scientists’ organisations, has described the approval of Covaxin as hasty. “This achievement will be hailed as a major Indian scientific achievement once efficacy data are released—but by this hasty approval, the government has shot itself in the foot,” the network said in a statement.” (British Medical Journal, January 2021)
In addition to hurried approval, critics are also questioning the way in which Covaxin’s phase III clinical trials have been conducted. For one, some argue that phase III had not been fully completed. There has also been widespread criticism of these trials for allegedly failing to obtain informed consent and ensuring participants understood what the trials entailed.
“Many did not understand that they were participants in a trial. They thought the jab was protection against Covid-19.” Follow-up on their symptoms was inadequate and further hindered by the fact that they could not make a written record of their reactions to the vaccine. Many family members shared one phone and not everyone was available for such monitoring.” (British Medical Journal, January 2021)
Controversies such as these have been widely covered in the Indian media and may be influencing decision-making regarding COVID-19 vaccine uptake.
5. Disinformation. This leads to another potential driver of increased vaccine hesitancy, i.e. exposure to negative COVID-19 vaccine related media stories, particularly untrue ones . In India, the proportion of Internet users is on the rise. A recent survey found that social media usage in India increased 75% during the pandemic. As observed in other countries around the world, COVID-19 related disinformation is rife on social media. In a country, where increased use of digital platforms does not translate into increased digital literacy , this is an issue.
“People get cheap internet-based tech on their smartphones, but they don’t have the necessary education on how to assess the veracity of claims made in the messages,” said Rajneil Kamath a publisher at the Indian fact-checking portal NewscheckerIn .
A study carried out in March 2020 found widespread health-related fake news in India. This includes topics such as fake medicine (e.g., “Alcohol or weed cure coronavirus infection”), fake information regarding medical and healthcare facilities (e.g., “Medicine will be sprayed in the air to kill coronavirus”). Religiopolitical fake news, such as “Muslim vendors are spreading coronavirus in Surat”, are also prominent in India
A lot of these rumours are reportedly spread on WhatsApp, which is difficult to monitor and cannot easily be flagged for fact-checking. The ORB study last summer shows that although only 14% cite WhatsApp as a trusted source for news on Coronavirus in India, it is still higher compared to other countries surveyed (6% overall). Even popular traditional media sources leave room for ambiguous interpretation and facilitate scaremongering 
For the Indian government, Dispelling rumours on social media has proved to be a double-edged sword of the Indian government, with widespread criticisms of curbing freedom of speech. Getting the balance right is crucial for targeting disinformation and reassuring the public of vaccine safety and hesitancy.
Is there hope?
Vaccine confidence has been relatively high in India, pre-COVID-19. Yet, the path to increased vaccine confidence was not plain sailing. Concerns around polio vaccination prevailed initially; to tackle this, India carried out a successful immunisation programme, by launching a large campaign involving children, mothers, and opinion leaders to help dispel vaccine fears. A similar approach, involving healthcare professionals, can help dispel initial apprehension around COVID-19 vaccines.
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1 Worldometer. 21 May 2021. https://www.worldometers.info/coronavirus/country/india/
2 The Straits Times. Doubts surround India’s official COVID-19 death toll. 12 May 2021. https://www.straitstimes.com/asia/south-asia/doubts-surround-indias-official-covid-19-death-toll
3 CVoter Poll. COVID 19 Tracker 2020. 5 May 2021. https://cvoterindia.com/wp-content/uploads/2020/COVID%2019%20Tracker_May_5_2021.pdf
4 Anoo Bhuyan. Lancet. Experts criticise India’s complacency over COVID-19. 1 May 2021. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00993-4/fulltext
5 BBC News. India coronavirus: Over-18s vaccination drive hit by shortages. 1 May 2021. https://www.bbc.co.uk/news/world-asia-india-56345591
6 Bibhudatta Pradhan & Sudhi Ranjan Sen. Bloomberg. India Has Plenty of Coronavirus Vaccines But Few Takers. 26 January 2021. https://www.bloomberg.com/news/articles/2021-01-26/india-s-unusual-vaccine-problem-plenty-of-shots-but-few-takers
7 BBC News. India coronavirus: Over-18s vaccination drive hit by shortages. 1 May 2021. https://www.bbc.co.uk/news/world-asia-india-56345591
8 Lance Stevens & RJ Reinhart. Gallup. India’s COVID-19 Lockdown Depends on Trust in Institutions. 1 April 2020. https://news.gallup.com/opinion/gallup/305816/india-covid-lockdown-depends-trust-institutions.aspx
9 Bibhudatta Pradhan & Sudhi Ranjan Sen. Business Standards. India’s unusual Covid vaccine problem: Plenty of shots, but few takers. 27 January 2021. https://www.business-standard.com/article/current-affairs/india-s-unusual-covid-vaccine-problem-plenty-of-shots-but-few-takers-121012700129_1.html
10 Kamala Thiagarajan. The BMJ. Covid-19: India is at centre of global vaccine manufacturing, but opacity threatens public trust. 28 January 2021. https://www.bmj.com/content/372/bmj.n196
11 Bibhudatta Pradhan & Sudhi Ranjan Sen. Business Standards. India’s unusual Covid vaccine problem: Plenty of shots, but few takers. 27 January 2021. https://www.business-standard.com/article/current-affairs/india-s-unusual-covid-vaccine-problem-plenty-of-shots-but-few-takers-121012700129_1.html
12 Kamala Thiagarajan. The BMJ. Covid-19: India is at centre of global vaccine manufacturing, but opacity threatens public trust. 28 January 2021. https://www.bmj.com/content/372/bmj.n196
13 Md. Sayeed Al-Zaman. MDPI. COVID-19 related Social Media Fake News in India. 3 March 2021. https://www.mdpi.com/2673-5172/2/1/7
14 DW. India fake news problem fueled by digital illiteracy. 2 March 2021. https://www.dw.com/en/india-fake-news-problem-fueled-by-digital-illiteracy/a-56746776
16 Md. Sayeed Al-Zaman. MDPI. COVID-19 related Social Media Fake News in India. 3 March 2021. https://www.mdpi.com/2673-5172/2/1/7
17 Rema Nagarajan. India News – Times of India. Covid 19 vaccine: 180 deaths after jabs till March 31, 75% within 3 days. 12 April 2021. https://timesofindia.indiatimes.com/india/180-deaths-after-jabs-till-mar-31-75-within-3-days/articleshow/81978526.cms