Patralekha Chatterjee | Vaccines and trust: Need for nuanced conversation

Soon after Anglo-Swedish drugmaker AstraZeneca acknowledged in a British court that its Covid-19 vaccine can, “in very rare cases, cause TTS”, there has been utter panic among sections of the Indian public. TTS, or Thrombosis with Thrombocytopenia Syndrome, causes people to have blood clots and a low blood platelet count.

Back in April 2021, a statement by the World Health Organisation had noted: “Based on latest available data, the risk of TTS with Vaxzervria and Covishield vaccines appears to be very low. Data from the UK suggest the risk is approximately four cases per million adults (1 case per 250,000) who receive the vaccine, while the rate is estimated to be approximately one per 100,000 in the European Union. Countries assessing the risk of TTS following the Covid-19 vaccination should perform a benefit-risk analysis that considers local epidemiology (including incidence and mortality from Covid-19 disease), age groups targeted for vaccination and the availability of alternative vaccines.”

The statement, following a review by WHO’s Global Advisory Committee on Vaccine Safety, flagged the possibility of “a geographic variation in the risk of these rare adverse events” and urged evaluation of potential cases of TTS in all countries.

At the time of writing, AstraZeneca has begun worldwide withdrawal of its Covid-19 vaccine. The pharma major says the vaccine was being removed from markets for commercial reasons; it was no longer being manufactured or supplied, having been superseded by updated vaccines that tackle new variants.

In India, it is election time and the Oxford-AstraZeneca vaccine, manufactured and marketed by the Pune-based Serum Institute of India (SII), is troublingly at the centre of a fierce political row between the ruling Bharatiya Janata party and the Opposition.

Scientists must investigate the side effects of all vaccines, rare or not. Questions must be asked about Covishield or any other vaccine or drug in public interest. But how it is done, and by whom is critical. Sweeping generalisations can do immense damage. In India, nearly one out of every four children still miss out on essential vaccines.

Fear of vaccines is the last thing that one wants.

How did we get to this messy state?

India’s effort to vaccinate its vast population against Covid-19 was widely lauded, critiques about overall management of the pandemic notwithstanding. But the vaccination campaign, like so many other campaigns in recent years, pivoted around Prime Minister Narendra Modi. Until recently, Covid-19 vaccination certificates had the Prime Minister’s photo. Mr Modi's photo was removed from CoWIN certificates after an Election Commission directive. “Vote for Modi as he got us Covid-19 vaccines”, said a BJP leader last month.

Now, several politicians opposed to Mr Modi have latched on to AstraZeneca’s statement about rare side effects in a British court; all too predictably, BJP sympathisers see a grand conspiracy about AstraZeneca admitting to side effects in its Covishield vaccine during the ongoing election season.

What is being muted in all the noisy paranoia about blood clots and heart attacks in relation to Covishield are three key words -- a “rare side effect”. They may happen within a few days or a few weeks of taking the vaccine, but not several years after the vaccination.

What has contributed to the mess is the insufficient emphasis on possible rare adverse effects during earlier awareness campaigns when the priority was to get every eligible person vaccinated.

As Dr Anant Bhan, a researcher on global health and bioethics, puts it: “Every vaccine, including the long established and used oral polio vaccine, has some risk. But serious adverse effects are rare and the benefits of vaccines, whether old or new ones, far outweigh the risks. The hysteria in the social media over the recent disclosure by AstraZeneca (about rare adverse effects of their Covid vaccine, used as Covishield in India) is unfortunate”.

Dr Bhan points out there was always a large active online community of “anti-vaxxers” globally. Now there is a risk of the recent developments feeding local discourses over vaccines negatively. “Disclosure about risks of clotting (TTS) are not new findings. These were not hidden. They have been known and written about in medical journals since 2021. The problem is that in an election season, the whole issue about known adverse effects as discussed in the context of a UK court case has got politicised. And there is a danger of sections of the public thinking that vaccines mean risk. This is dangerous,” says Dr Bhan.

Health advocates are stressing that it is crucial to remember that the benefits of vaccination far outweigh the risks. “To put it into perspective, let us consider cancer treatment. Some cancer drugs can have serious side effects, like lowering blood counts or harming the heart, liver, and kidneys, or even increasing the risk of severe infections. Despite these risks, we still use chemotherapy because the benefits are clear. Similarly, in treatment for heart attacks, thrombolytic drugs can be life-saving, but they also carry the risk of causing bleeding in the brain, which can be fatal. Yet, we still administer them because the benefits outweigh the risks. So, it is not fair to blame the vaccine for these adverse events and blow them out of proportion. Yes, there have been cases of myocarditis, especially in younger people, but at the time, we did not fully understand the extent of the risk. However, it is worth noting that the anti-vaccine movement might do more harm than good by spreading fear and panic. If people become too scared to get vaccinated, it could have serious consequences for public health,” says Dr S.P. Kalantari, professor of medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra.

Which brings me to trust: the bedrock of immunisation programmes.

Trust remains vital in the age of polycrisis, uncertainty and shifting truths. How one communicates messages about vaccines is the key to building trust. There is a real need for a nuanced conversation, openness, and transparency in the vaccine conversation.

“Health policy messaging must convey that vaccines have significant benefits and acknowledge the rare risks. This calls for responsible behaviour on the part of everyone and there is an urgent need to build trust in the system. A person being vaccinated must believe that the health system will come to her/his aid if anything were to go wrong, even if that probability is rare. We cannot whitewash concern whenever and wherever it arises,” says Dr Bhan.

The system cannot be opaque.