Reaching Immunity – Barriers to adult vaccine in APAC

The global pandemic has brought adult vaccination into the spotlight, emphasizing the importance of preventive medicine as a core pillar of health policy agendas worldwide. While the world has declared the COVID-19 pandemic to be over, we see an increasing incidence of devastating influenza and respiratory viruses, emphasizing the need for preventative medicine to stop outbreaks before they reach catastrophic scales. As public health initiatives increasingly target adults with vaccines for a wide range of diseases, from respiratory illnesses to malaria and shingles, it’s crucial to address the barriers that might limit vaccine uptake.

Excluding COVID-19, the global vaccine market has continued to grow over the past four years, driven by the increased use of high-priced adult vaccines such as the pneumococcal conjugate vaccine and shingles vaccine. Significant growth in China, particularly in the private market demand for the human papillomavirus vaccine, has also contributed to this trend. However, despite the increase in market value, overall vaccination rates among adults—especially the elderly—remain low, with significant variation across Asia-Pacific (APAC) countries. Vaccine hesitancy, characterized by the delayed or refused acceptance of vaccines, stems from a complex interplay of social, economic, and physical factors. Understanding these barriers is essential to improving adult vaccine uptake and enhancing health outcomes through preventive medicine in the APAC region.

Barriers to Adult Vaccine Uptake

1. Accessibility Issues
   Accessibility remains a significant barrier to adult vaccine uptake. Limited access to vaccination sites is a major challenge, particularly in areas where hospitals and clinics are scarce. For example, in Bangkok, regions with fewer vaccination sites exhibit lower vaccination rates.  This challenge is compounded by transportation issues and lack of mobility, especially among the elderly and homebound individuals.

1. Education & Awareness
   A lack of education and awareness also hampers vaccine uptake. Concerns about vaccine efficacy and safety, fuelled by misinformation, create uncertainty and fear among the public. Additionally, a general lack of awareness about the availability and benefits of adult vaccines contributes to low vaccination rates.

1. Social & Cultural Barriers
   Social and cultural factors play a crucial role in vaccine hesitancy. Health literacy, or the ability to obtain, process, and understand basic health information, is often lacking, particularly in elderly and marginalized communities. During the COVID-19 pandemic, the failure to address the needs of ethnic minorities highlighted the importance of tailored communication strategies. Mistrust in public health institutions, often exacerbated by misinformation, further discourages vaccine uptake.

1. Economic Factors
   Economic factors also contribute to vaccine hesitancy. There is a clear correlation between lower economic growth, lower household income, and reduced immunization rates. For many, the cost of vaccines—whether direct or indirect—can be prohibitive, limiting access to essential preventive care.

Funding for Adult Vaccines in National Immunization Programs

National Immunization Programs (NIPs) in many countries provide limited coverage for adult vaccines. For instance, tetanus vaccines are often covered only for pregnant women or specific age groups, while influenza vaccines are extended to risk groups such as the elderly, pregnant women, healthcare workers, and individuals with chronic medical conditions. Available vaccines for adults to prevent, for example, pneumococcal, shingles or malaria are generally not covered within NIPs. In the Philippines, pneumococcal vaccines are covered for the elderly, as one of the few cases of adult vaccine coverage in emerging markets.

Cost of Adult Vaccines: NIP versus Out-of-Pocket (OOP)
The cost of adult vaccines poses a significant challenge, particularly when NIP funding is insufficient. A majority of APAC countries rely on full or partial out-of-pocket contributions, which limits the adoption especially amongst the elderly population. From a government perspective, the financial strain imposed by the COVID-19 pandemic has further exacerbated this issue. Many APAC countries have relied on external assistance to manage the unexpected expenses associated with COVID-19 vaccination, which in some cases, has accounted for more than 60% of vaccination program costs in 34 APAC markets.

Impact of COVID-19 Vaccination on Adult Vaccination Programs

During the pandemic, COVID-19 vaccination costs dominated the budget allocations for vaccination programs. As the world moves forward, changes in recommendations for COVID-19 boosters could impact future vaccination budgets, potentially affecting the availability and affordability of other adult vaccines.

Initiatives to Overcome Vaccine Hesitancy

The World Health Organization (WHO) has emphasized the need for community engagement and effective communication strategies to ensure the acceptance of new vaccination programs. Examples from African countries during the pandemic have demonstrated that social support and clear communication from health professionals are vital in increasing vaccine acceptance. Public awareness campaigns that disseminate accurate information about vaccines are essential to counteract misinformation and build trust among the population.

Overcoming Funding Problems

Strategies to make vaccines more affordable could significantly reduce the overall costs of vaccinating adults. Organizations such as Gavi and the Global Fund have established market-shaping initiatives that have made vaccines more affordable for the countries they support. These strategies could serve as models for other regions, helping to bridge the funding gaps in adult vaccination programs. Additionally, initiatives such as the pay-it-forward intervention in China was successful in increasing influenza vaccination rates at lower cost than standard programs. This Pay-it-forward is a community-focused initiative running in 2020/2021 where participants received a free influenza vaccine and were then invited to contribute a donation or write a message to support future vaccinations.

Conclusion

Addressing adult vaccination hesitancy is critical to improving public health outcomes, particularly in the APAC region. By understanding and overcoming the barriers to vaccine uptake—whether they be accessibility, education, cultural, or economic—policymakers can develop more effective vaccination strategies. Integrating adult vaccines into National Immunization Programs, improving funding mechanisms, and fostering trust through clear communication and community engagement are essential steps in this process. As the world continues to recover from the COVID-19 pandemic, these efforts will be crucial in ensuring that preventative medicine become more accessible.