Covid-19 vaccine hesitancy among ethnic minority groupsBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n513 (Published 26 February 2021) Cite this as: BMJ 2021;372:n513
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Vaccine hesitancy and resistance has been reported among people and healthcare staff from ethnic minorities (1). This is a serious concern given covid-19 is the largest global public health challenge in recent years. Covid-19 vaccination offers hope in preventing covid related morbidity and mortality and helps to build community immunity.
The month of fasting, Ramadan, globally this year spans April to May 2021. People from some ethnic minority backgrounds such as Pakistani, black, and Bangladeshi will commence fasting but these groups are hesitant to receive a covid-19 vaccine (1). They may be more hesitant because they don’t want to compromise their fast: often seen as a religious obligation. It is therefore important for these groups of people to know that having vaccines, especially one of the covid-19 vaccines at first or second dose, through the intramuscular route does not nullify one’s fast and vaccination should not be delayed (2).
It is crucial to reassure people and healthcare staff that receiving a covid-19 vaccine within fasting time (from dawn to dusk) does not break the fast, and the fast remains intact. Internationally healthcare advocates and leaders need to work with Muslim faith leaders to disseminate this. Fasters may also be concerned that potential side effects of covid-19 vaccination for example myalgia, headache, and tiredness may make it difficult to maintain their fast. Clinicians and covid-19 vaccinators can advise fasters to drink more clear fluid and take simple analgesia outside of fasting times to mitigate side effects if needed.
1) Razai MS, Osama T, McKechnie DGJ, et al. Covid-19 vaccine hesitancy among ethnic minority groups. BMJ 2021;372:n513
2) British Islamic Medical Association. Fasting and Covid Vaccinations. 2021.
Competing interests: No competing interests
Hesitancy in Uptake of Covid Vaccine by Certain Population Groups
A year ago, on 11th March 2020, the WHO declared COVID-19 as a pandemic; so far, the impact of COVID on people and economy worldwide has been devastating. Globally, this pandemic has already killed over 2.67 million people; the mortality rate has slowed down but the threat of second wave or the new variant of Coronavirus still continues. For instance, Italy has announced lockdown on 14th March 2021 to curb fast growing COVID new cases. On the other hand, the new vaccine (the very first successfully announced by Pfizer) has given hope to combat the virus effectively in future. The United Kingdom has completed 100 days of vaccination programme, setting priorities to offer vaccines initially to healthcare professionals and then to the elderly in residential care homes. The Office for National Statistics (ONS) death data reveals that about 85% of COVID-19 deaths were amongst people aged over 70; thus, obviously formed the next priority to receive vaccination from early January onwards. The UK government achieved this 70 plus target by the end of February. Now this has been extended to aged 60 and over as well as to people with long-term chronic conditions. By mid-March, the UK successfully covered 45% of adult population and has also started a second dose to those who were vaccinated 12 weeks ago. The aim is to cover all 50 plus population with two doses by mid-May.
Israel is the only country (though smaller in size) which has already vaccinated and protected their citizens. On the other spectrum, the most populated country affected the most by COVID is India where the vaccination programme is on-going at full-swing and has already achieved 24 million coverage by mid-March (the highest number of people vaccinated by any country in the world). However, in terms of percentage of population vaccinated India is still far behind many OECD countries including the UK (as it covered just 2% of population).
However, a real issue in terms of equity and hesitancy in uptake of vaccine by certain population groups has emerged. The UK has experienced the highest death rates among Black and South Asian population than the White majority (which was 3-4 times was higher in the former compared to the latter group). Also, it was noticed that people of Black, Asian and Minorities Ethnic (BAME) group who died due to COVID were at least 12-15 years younger than their White counterparts (mean age 51 vs. 65 years); they were mostly men in the working ages from BAME communities consequently, their BAME families have suffered a devastating impact on their livelihoods as they lost a main earning member in the COVID pandemic. Despite this fact, BAME people being in the highest risk group have not received priority in getting into vaccination drive. As the BAME population has a much younger age distribution than the White population, they just waited for their turn to come for vaccination. There were few instances of hesitancy to uptake vaccination in the BAME community specially by those who were in the 70+ age group and received invitation in the first slot in January. This could be partly due to the fact that no prior information regarding vaccination was available to them as UK continued to remain in full lockdown since 30th December 2020. All community and religious places which are the main centres for communication and engagement for BAME communities are not open. They relied for their healthcare needs and health information through their GPs which are also not accessible physically. Furthermore, for a vast majority of elderly people in BAME communities English is not their first language and thus remained completely aloof from the English Media about vaccination drive information. Finally, the vaccination drive started with Pfizer dose, which was not developed in the UK, whereas the UK-based AstraZeneca vaccine was in approval stage which in fact recruited BAME people during their Clinical Trial Phase. Thus, BAME community was not much aware of Pfizer effectiveness, but shown reliance on the one introduced by AstraZeneca in mid-February. I think over a period of time, these small cases of hesitancy would disappear in the UK with improvement in age-specific coverage.
India is also undergoing similar phase of hesitancy and inequity in vaccine uptake. I think both UK and Indian Governments have not designed the right approach to prioritise the vaccination drive. Instead of initially targeting the oldest age-group, the government should have used the cluster area approach. In the UK the highest mortality and incidence of COVID were observed in the larger cities of London, Birmingham, and Manchester where they had the highest population density as well as highest infection rate due to enormous daily commuting population from their hinterlands. Therefore, irrespective of age-specific targeting, these geographical localities should have been given the first priority to get vaccinated and then in the next phase this could be rolled-out nationally. In India also almost all major cities and metros and about 150 (out of 700) districts where with the infection rates as well as death rates were alarmingly high, should have been given priorities for vaccination. We have not missed the train yet in India, the ‘highest-risk’ geographical area approach can still be planned so as to prepare better and safeguard against the second wave or the new variant of Coronavirus in the future. At least, we know that the Indian Government has till now shouldered the free vaccination drive responsibilities and thus ensured the poor and underprivileged should not be left out from the mainstream vaccination programme.
Competing interests: No competing interests
Despite the massive challenges of the ongoing pandemic, the development and rollout
of COVID-19 vaccines are a major scientific achievement: moreover millions of
people in the UK have already received their first doses from the NHS. That said,
vaccines may sharpen the focus on other systemic inequalities: for example, lower
vaccine uptakes have been reported in populations of lower socio-economic status
and ethnic minorities (1). Contributing factors for this vaccine hesitancy include
historic mistrust with the establishment, misinformation and concerns of lack of long
term outcome data (1,2). Interventions using positive messages from role
models/leaders representing communities, outreach into places of worship/
community centres have been suggested to improve the uptake (3).
Healthcare workers (HCWs) are often looked up in communities as role models and
their views about the vaccine can be an important factor for the population uptake
A recent study (5) from a large NHS trust has suggested that there is a similar
level of uptake as a result of hesitancy in HCWs like that of in general population,
particularly from Black, Asian and Minority Ethnicity (BAME) communities. HCWs
have directly experienced the impact of COVID-19 on patients and communities, with
many thousands of people dying in the UK alone, and with disproportionate deaths
from ethnic minorities. NHS Employees are required to minimise risk of acquiring
infections in high risk areas (6) and transmitting to patients but the data for latter is
It is important that key aspects of good medical practice encompass the vaccine
debate: doing good, doing no harm, justice and autonomy. For the latter, as well as
ensuring HCWs have the available information and access to care, a culture where
colleagues don’t feel stigma and barriers to express their views or concerns is ideal.
This is a complex issue that, along with other areas of wellbeing, needs balanced
consideration in an empathetic way, particularly in those with comorbidities or other
dependents to think about, including those who don’t work in high risk patient-facing
areas. Conversely, older staff in such areas may have their own anxieties esp. given
the delayed dosing of the second vaccine strategy that was implemented without
clear evidence at the time. Advising a patient or careers, particularly when they want
to validate beliefs, the HCWs should follow GMC (7) guidance for this: ‘You must not
express your personal beliefs (including political, religious and moral beliefs) to
patients in ways that exploit their vulnerability or are likely to cause them distress.’
Vaccine hesitancy and resulting lesser uptakes amongst HCWs will certainly have a
corresponding effect on communities’ uptake, even when paradoxically these are
some of the higher risk groups that need it the most. We need to follow professional
guidance on communicating personal beliefs to those we serve using our
competences and knowledge on COVID-19 vaccination and empathy to hesitant
colleagues: our attitudes, behaviours and compassion will be key in working on
tackling the balance of benefits versus risks together.
2. Razai et al.; (2021) Covid-19 vaccine hesitancy among ethnic minority groups
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n513
3. Mills, M.C. et al., (2020) COVID-19 vaccine deployment: Behaviour, ethics, misinformation
and policy strategies [online]. London: The Royal Society. [Viewed 14/12/2020]. Available
4. Rosenbaum, L., (2021) Escaping Catch-22 — Overcoming Covid Vaccine Hesitancy. NEJM.
5. Martin, C.A. et al., (2021) Association of demographic and occupational factors with SARSCoV-
2 vaccine uptake in a multi-ethnic UK healthcare workforce: a rapid realworld analysis
(pre-print - doi: https://doi.org/10.1101/2021.02.11.21251548).
Competing interests: No competing interests
Thank you for this succinct editorial about vaccine hesitancy. I would just suggest that it is important to make people aware of the historical context within which these vaccines have been developed. Many people are suspicious of the speed with which the vaccines have been developed and do not realise that the foundations for the research were built around the study of other coronaviruses especially MERS (with regards to the Oxford vaccine) and this important work allowed scientists to move much more quickly than they would have done otherwise. Hopefully the fact that such previous research was hindered by funding issues will not be repeated in the future given what is at stake.
Competing interests: No competing interests