COVID-19 vaccines were developed in record time and vaccination exercise is of course ongoing in most countries. Everyone is anxious to see the pandemic come to an end for things to return to normal. As of 23rd April 2021, more than 966 million doses have been administered worldwide , however, we have to remember that we do not live in a world where everyone is going to be vaccinated. Two questions are of importance here: Are the current strategies and measures in place adequate to contain the virus fast enough, and are there things that could be done differently for a faster sustainable outcome? To this effect, I state a couple of opinions that I believe are quite essential.
Are there other effective strategies for the COVID-19 vaccination campaign that programme managers can adopt for better vaccination coverage?
We have vaccines that are up to 95% efficacious, but more than that is requires for a well-planned campaign to bring the pandemic to an end. When a campaign is well planned and a good approach is adopted, it helps a lot in yielding an expected outcome. These approaches stated below have not yet been well-practised in the course of this pandemic. I believe it will be beneficial for the vaccination programme managers to adopt them accordingly.
This is a rapid assessment tool that project implementers can use to identify behavioural determinants to know why a promoted behaviour has not been absorbed or adopted. This approach was developed in 1990 by Tom Davis who found it very useful in behaviour change projects . Barrier analysis is necessary considering the context of different countries. Until today, some health organizations have used this approach to have successful and impactful projects [3,4]. This approach involves the use of a structured tool to understand why a particular behaviour has not changed even though a reasonable amount of effort has been put into it. It helps you to know the behavioural determinants of a particular behaviour and what needs to be improved for a better outcome. With this, vaccine uptake can be promoted for better vaccination coverage.
Needs Assessment is the collection and analysis of information that relates to the needs of affected populations which will help determine gaps between an agreed standard and the current situation. It helps to determine the key activities for intervention. After the designed questionnaires have been administered, retrieved and analysed, the actual area of focus will be more evident before project implementation. This can help prioritise or improve the services offered to a patient for better acceptability. We have used this approach to implement a health care worker vaccination programme in 2016 and it was very successful and impactful . It helped to determine specific behaviours, activities and actual high-risk areas (apart from the normal official statistics) before implementation.
Health behaviour theories that can also be adopted during implementation
Health Belief Model was developed in the 1950s by a group of U.S. Public Health Service social psychologists who tried to know why some disease detection and prevention programmes had few participants [6,7]. It is based on the construct that people are willing to change if they:
- believe their susceptibility to a particular condition (perceived susceptibility),
- believe that the condition may have serious effects (perceived severity),
- believe the need to take action to reduce any negative effect or its severity (perceived benefits),
- believe they can practice the behaviour without anything stopping them (perceived barriers),
- are exposed to the things that make them remember to do the behaviour (e.g., posters, television advertisements, setting a reminder) (cue to action), or
- believe in their ability to practise the behaviour (self-efficacy)
Theory of Planned behaviour assumes that behavioural intention is the most important determinant of behaviour. It says that behavioural intention is influenced by a person’s attitude towards performing a behaviour and by beliefs about whether individuals who are important to the person approve or disapprove of the behaviour (subjective norm) .
I do encourage vaccination project managers to employ any of these models for a fast and better outcome since pieces of evidence have shown the effectiveness on vaccine uptake .
How have vaccines been distributed?
As of 23rd April 2021, 01:25 CEST, more than 966 million doses have been administered across 172 countries in the world with the rate of 16.4 million doses daily. This is adequate to vaccinate only 6.3% of the global population . More than 20 countries have not started vaccination at all, and they do not have the vaccines. The vaccine distribution has been so uneven when comparing the high-income and low-income countries. A considerable quantity of vaccines has been administered in the high-income countries and they have also booked more vaccines. As of 19th March 2021, high- and upper-middle-income countries have secured more than 6 million doses out of 8.6 billion expected to be produced. There is a very large margin between these two, high-income countries vaccinate 25 times faster than the low-income countries (ones that have been able to procure few vaccines). In Africa, the majority of the countries have doses that can only be enough for <1% of their total population. For example, Nigeria plans to vaccinate at least 70% of the eligible people aged 18 years and above in four phases within the next two years, but this is impossible with the rate they are going . India (the world’s biggest maker of vaccines) usually supplies vaccines to low-income countries that cannot afford very expensive vaccines . Now, India is experiencing a large COVID-19 surge (since April 2021), and they will have to stop some external supply for their use which will cause more shortage in all these low-income countries. This even makes it more difficult to quell the outbreak globally. It is understandable to prioritise one’s country, but we must remember that eradicating a disease is more than that, it is just “a flight away” and the virus will come back to one’s own country—if not a new variant. The fewer coronavirus cases we have globally, the less likely that new variants will emerge.
How do we maintain protection?
All the approved COVID-19 vaccines will protect you from severe infection, hospitalisation and death irrespective of the efficacy rate. From research, when one is infected with COVID-19 and recovered, the person will gain at least a 6-month protection—it varies from person to person [11–13]. New variants will keep emerging, but I believe that at some point, the variants will not be very strong anymore as vaccination continues. This is why we need to have a running immunization programme at regular intervals. Since we are not yet certain about how long the immunity offered by the vaccine will last and as new variants keep emerging, it will be nice for countries to establish Supplementary Immunization Activities (SIAs), especially for COVID-19.
SIAs is a programme put in place to complement vaccination and get more people vaccinated. It does not replace routine immunization. This is done to boost immunity and prevent emerging variants. In the case of COVID-19, I think it should be carried out annually or on an even shorter schedule.
How do we get more people vaccinated with COVID-19 vaccines?
The best way to reach herd immunity is through vaccination. Vaccination is always considered effective and successful when people are willing to receive the vaccines. You can manufacture the most efficacious vaccine, but when people have disinformation or contrary opinion in getting vaccinated, it is a wasted effort.
Religious and traditional leaders are vital for a successful roll-out of COVID-19 vaccines mostly in the developing world. Generally, these trusted leaders should be involved .
Also, mainly in the developed world, one of the major setbacks in vaccination is that people do not want to be told what to do, they see it as a form of violation to their freedom. Adopting the theories mentioned above can help deal with the major determinants of such behaviour.
Incentivising vaccination at this point is important—giving people a quality shirt (for example, with an imprint of their favourite leader) or likes, which they can proudly wear outside, can help spread awareness. When others see that this person has been vaccinated and “did not die”, they can re-consider getting vaccinated.
Other prevention strategies that need to be encouraged other than masking, hand-washing, and social distancing:
In disease prevention, it is always encouraged to observe any safe and effective measures first before thinking of medications or treatments, in order to protect yourself. It is not yet peer-reviewed or strongly proven that the vaccines protect you from spreading or contracting the virus—most especially the new variants—, and that is the reason you are always encouraged to employing masks and social distance. I must encourage these other preventive measures as well.
Nasal irrigation and gargling: Nasal irrigation- is simply the practice of washing your nasal cavity to reduce mucus and germs. There may be a shred of limited clinical evidence on this for SARS-CoV-2 infection, nevertheless, other studies support this, and I agree with them [14,15]. This is usually performed by mixing salt and baking soda in lukewarm water, using it to flush your nostril. Please do keep any device you are using sterile and clean, anyway. A lot of people forget that it is important to wash your nose just as you wash your body mostly to prevent respiratory tract infections. Whenever I take a shower, I wash my nose and expel, it has drastically reduced my chances of getting an allergic reaction.
Figure 1: A person performing nasal irrigation.
The study conducted in 1999 to ascertain the use of isotonic saline nasal irrigation among woodworkers, who face challenges due to the inhalation of dust particles, indicates that it significantly improves nasal symptoms. Also, more than half of the subjects continued to practise it after one year .
Gargling with warm saltwater can also help reduce the accumulation of mucus and germs in the upper respiratory tract [17,18].
Eating habit: Poor diet behaviour plays a vital role in disease prevention and management. You may wish to cook more often and stop eating junks or unhealthy food. I believe that eating food enriched with vitamins will help reduce the severity of illness. A well-nourished and hydrated (drink enough water) person is more likely to have a stronger immune response to fight infections.
Figure 2: Unhealthy diets.
Elevator: People must be aware that elevators are not well ventilated. Viral droplets sneezed out can spread fast in there. You may wish to reduce the number of times you use elevators and always wear your masks inside the elevator.
Good strategies and planning are key to a successful vaccination programme, which is very important in tackling the ongoing pandemic. Some of the above-mentioned theories are worth considering for better vaccine uptake. Focusing on your country will not end the pandemic, and it will even affect the low-income countries negatively as they will find it more difficult to recover economically not just from the virus. There may be new variants of SARS-CoV-2 every year or more, but after a while, the variants will be less of a problem to deal with, as people get booster shots yearly for the next two or three years. Only one human virus (smallpox) has been eradicated in history using vaccination [19,20]. Hence, SARS-CoV-2 can be controlled to the point that it will not cause major disruption to our lives, and things will return to normal. Government and policymakers around the world should put in more effort to ensure that vaccines are supplied quickly across the globe.
 Bloomberg. More Than 966 Million Shots Given: Covid-19 Tracker. Bloomberg.com [Internet]. [cited 2021 Apr 23]; Available from: https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/
 A Practical Guide to Conducting a Barrier Analysis [Internet]. [cited 2021 Apr 20]. Available from: https://pdf.usaid.gov/pdf_docs/PA00JMZW.pdf
 World Vision. BA Tabulation Tables and Results Summaries (by country). [Internet]. [cited 2021 May 25]. Available from: https://drive.google.com/drive/folders/1uUb_IWgw6Kk8wgWHFb3Yxr5kpyEDJaMk?usp=sharing
 Harris N. Faith leaders must play key role in COVID-19 vaccine roll-out [Internet]. World Vision. [cited 2021 Apr 20]. Available from: https://www.worldvision.org/about-us/media-center/faith-leaders-must-play-key-role-in-covid-19-vaccine-roll-out
 Arogundade L, Akinwumi T, Molemodile S, Nwaononiwu E, Ezika J, Yau I, et al. Lessons from a training needs assessment to strengthen the capacity of routine immunization service providers in Nigeria. BMC Health Serv Res. 2019 Sep 14;19(1):664.
 Wong MCS, Wong ELY, Huang J, Cheung AWL, Law K, Chong MKC, et al. Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong. Vaccine. 2021 Feb 12;39(7):1148–56.
 National Cancer Institute- Theory at a Glance [Internet]. [cited 2021 Apr 26]. Available from: https://cancercontrol.cancer.gov/sites/default/files/2020-06/theory.pdf
 Chu H, Liu S. Integrating health behavior theories to predict American’s intention to receive a COVID-19 vaccine. Patient Educ Couns [Internet]. 2021 Feb 17 [cited 2021 May 4]; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889032/
 Joint press statement by NPHCDA, WHO and UNICEF on the arrival of COVID-19 vaccine in Nigeria [Internet]. [cited 2021 May 26]. Available from: https://www.unicef.org/nigeria/press-releases/joint-press-statement-nphcda-who-and-unicef-arrival-covid-19-vaccine-nigeria
 Serum Institute of India. About Serum Institute Of India Pvt. Ltd. [Internet]. [cited 2021 May 8]. Available from: https://www.seruminstitute.com/about_us.php
 Hall V, Foulkes S, Charlett A, Atti A, Monk EJM, Simmons R, et al. Do antibody positive healthcare workers have lower SARS-CoV-2 infection rates than antibody negative healthcare workers? Large multi-centre prospective cohort study (the SIREN study), England: June to November 2020. medRxiv. 2021 Jan 15;2021.01.13.21249642.
 Dan JM, Mateus J, Kato Y, Hastie KM, Yu ED, Faliti CE, et al. Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection. Science [Internet]. 2021 Feb 5 [cited 2021 Apr 26];371(6529). Available from: https://science.sciencemag.org/content/371/6529/eabf4063
 Abu Raddad LJ, Chemaitelly H, Malek JA, Ahmed AA, Mohamoud YA, Younuskunju S, et al. Assessment of the risk of SARS-CoV-2 reinfection in an intense re-exposure setting [Internet]. Epidemiology; 2020 Aug [cited 2021 May 26]. Available from: http://medrxiv.org/lookup/doi/10.1101/2020.08.24.20179457
 King D, Mitchell B, Williams CP, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database of Systematic Reviews [Internet]. 2015 [cited 2021 Apr 26];(4). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006821.pub3/full
 Panta P, Chatti K, Andhavarapu A. Do saline water gargling and nasal irrigation confer protection against COVID-19? Explore (NY). 2021;17(2):127–9.
 Rabone SJ, Saraswati SB. Acceptance and effects of nasal lavage in volunteer woodworkers. Occup Med (Lond). 1999 Aug;49(6):365–9.
 Ramalingam S, Graham C, Dove J, Morrice L, Sheikh A. Hypertonic saline nasal irrigation and gargling should be considered as a treatment option for COVID-19. J Glob Health [Internet]. [cited 2021 Apr 26];10(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193539/
 Satomura K, Kitamura T, Kawamura T, Shimbo T, Watanabe M, Kamei M, et al. Prevention of upper respiratory tract infections by gargling: a randomized trial. Am J Prev Med. 2005 Nov;29(4):302–7.
 Greenwood B. The contribution of vaccination to global health: past, present and future. Philos Trans R Soc Lond B Biol Sci [Internet]. 2014 Jun 19 [cited 2021 Apr 26];369(1645). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4024226/
 World Health Organization. Smallpox [Internet]. [cited 2021 Apr 26]. Available from: https://www.who.int/health-topics/smallpox#tab=tab_1[