Planning high COVID-19 vaccination uptake among the aged population in Switzerland: how can social sciences make a difference?
Cyril Pervilhac, Tina Draser
The national strategy for Switzerland to confront the epidemic was based on three pillars: the increase of vaccination coverage, screening and nonpharmaceutical interventions. For vaccination, however, the Swiss National COVID-19 Science Task Force (NCS-TF) had signalled insufficient coverage (67.24%, December 2021). As of mid-February 2022, 70% of the Swiss population had been vaccinated at least once against SARS-CoV-2, and 41% with an additional dose. Last October 2021, while planning the new massive vaccination promotion campaign, the plan stated that “based on current knowledge, it is likely that the vaccination rate for the over-65s would have to be between 90 and 95% before measures could be lifted. At present, only 88.5% of this age group have received at least one vaccine.” The elderly population has been vaccinated as a first priority and remains the prime target for second and booster doses to maintain full immunisation. This is in synchrony with broader recent international recommendations as an ongoing post-omicron strategy for the global COVID-19 response to reach among aged population, typically older than 60 years of age (60+), high and full vaccination coverage beyond the first dose, including boosters (90–95% coverage including the most at risk population) next autumn/winter months 2022/23.
The NCS-TF expects seasonal waves during the upcoming winter months based on the past 24 months of data from Central Europe. At the European level, the European Centre for Disease Prevention and Control (ECDC) recommended the planning of future campaigns based on taking stock of earlier phases of the vaccination programme and behavioural insights. The NCS-TF clarified with “options for action” the strategies for the management of SARS-CoV-2 in the next 12 months in order to reach a high vaccination rate.
In this opinion paper, in addition to a few primary sources of key informants and journal news, we reviewed essentially secondary sources of data: COVID-19 Social Monitor, Corona Immunitas Research Programme, Swiss Corona Stress Study, scientific reports/publications based on those, sociodemographic/economic studies (Geneva).
Our findings and discussion are limited by the rapidly changing epidemiological evolution of the variants and the still ongoing data analysis with pending results, and we could not here report on social media evaluations or the Federal Office of Public Health (FOPH) communication package. Upcoming findings (second semester 2022) of external reviews and experiences at federal and cantonal levels may clarify further this first insight into existing gaps and solutions. For example, the evaluation from the Canton of Geneva could not yet be exploited due to the “political agenda” substantially delaying its dissemination (Aglaé Tardin, communication personnelle, 24 juin 2022).
For the end of the pandemic, the World Health Organization (WHO) highlighted the importance of using robust social science data for the preparedness plans. Early findings on the importance of public health but the oversight of social sciences were already reported for the pandemic in France, with a historical perspective in Switzerland, and various communications about Switzerland. Bio-medical experts are actively preparing their response for the next autumn/winter seasons with the development of new vaccines and logistics. In turn, social scientists need to contribute with the refinement of their already available tool kits and activities for an improved targeted community response at primary health care level. Given this context, how can we nevertheless take stock of the lessons learned over the past year and activities related to full coverage among the most impacted vulnerable and aged population with the lens of social sciences in order to better prepare the vaccination strategy in the autumn/winter 2022/23?Findings and discussion
Given the neglect of social sciences, we utilise therefore this lens to analyse in more depth the findings, limitations and potential solutions of two existing robust tools. This will allow an increase in vaccination coverage among the 60+ population for the preparatory weeks ahead in order to reach at least 90–95% coverage next autumn/winter. We then consider additional strategic views on the upcoming FOPH plan and its goal.
The "COVID-19 Social Monitor” is a longitudinal online panel of a random sample of the Swiss population (aged 18–79 years). It allows the monitoring of 15 topics of key societal level indicators (e.g., mental health, general health, adherence to COVID-19 measures, health services use and non-use). Using the Social Monitor data (March 2020 to Dec. 2021), a detailed analysis of COVID-19 vaccination uptake among the study population living largely in urban areas (80%) has shown that the elderly aged 60–79 years shared a “much earlier and faster uptake”. This study showed higher uptakes than the data from the official vaccination rates from the FOPH: a vaccination uptake of 93% among the 60–69-year-olds (vs 86%, FOPH figure), and 95% among the 70–79-year-olds (vs 91%, FOPH figure). These discrepancies are largely due to a more representative sample of the national population for the FOPH data. Following the first 12 months of the vaccination strategy, a separate analysis had already highlighted two main causes of vaccine hesitancy, with the need for special attention for future vaccination campaigns: the fears of unwanted vaccine effects and doubts regarding vaccine effectiveness (Heiniger S., op. cit., p. 1). This was also reported earlier in the results from the data in spring 2021 of the “COVID-19 MOSAiCH survey”. An additional analysis of the data specific to elderly people from the “COVID-19 Social Monitor” revealed the need to improve prevention and communication efforts between linguistic regions in Switzerland. The rural German-speaking cantons have the lowest COVID-19 vaccination coverage.
Yet, as acknowledged in the methodology, the study has several limitations which need to be addressed for a full picture of the aged population group: the “selectivity of the sample with on-line affinity and education to be addressed by statistical adjustment”, and the “possible under- or even non-representation of specific subpopulations (individuals with chronic diseases, lower education level, vulnerable groups, persons with serious health conditions)” (M. Höglinger, “Limitations”, op. cit., March 2022). The latter are two key factors of importance among the small proportions of the still hard-to-reach 60+ population who may have a lower full coverage (beyond the first dose). The study analysed self-reported vaccination uptake (first dose or a proxy for access to vaccination services). The data may largely underestimate the second dose or full vaccination status (second and booster dose).
Exploiting further the “COVID-19 Social Monitor”, the sampling should be adjusted by including the rural population (approximately one fourth of the total population in Switzerland); additional sampling can be provided by the Social and Market Research Institute at reasonable costs (Von Wyl, personal communication, June 2022). Other limitations mentioned above can be addressed by monitoring as well the additional doses beyond the first one, and by analysing additional retrospective data collected over the past 12 months, which the study offers at present.
The “Corona Immunitas – Digital Follow-up Cohort” is a study focusing on vaccination uptake with large samples of people aged 65–74 and 75+ who have been followed-up over time in 2021. At first sight, the “Vaccination Status stratified by Age and Gender” (op. cit., Fig. 3, p. 8) is encouraging, with more than 80% of those aged 65–74 and 75+ vaccinated. “Corona-Immunitas” has produced general seroprevalence data at the end of 2021. (NCS-TF, 15 Feb. 2022, p. 9) The “Corona Immunitas” network is pursuing some analysis relevant to the upcoming vaccination strategies, for example disaggregated data on vaccination coverage for the second and booster doses, in particular among aged population (Von Wyl, personal communication, 1 June and 4 July 2022). In the next phase in June/July 2022, the network will assess to what extent the immunity in the Swiss population reached high rates (90% or more) among those aged 65+ in several cantons (e.g., Vaud, Valais, Zurich, Ticino).
There are several limitations of the “Corona-Immunitas” study. The potential biases in the study sample signal that the population selected may be more adherent to recommendations and obligations during the COVID-19 pandemic than the general Swiss population (op. cit., p. 4). The disaggregation is not matching the more useful age breakdowns of the “COVID-19 Social Monitor”, and the “vaccinated” are limited to those who received at least one vaccine injection for SARS-CoV-2. The NCS-TF noted that in the general population, the additional information about the second dose reports a limited 41% coverage at national level (mid-February 2022); this shows that the population is neither fully protected against the evolution to a serious outcome (hospitalisation or death), nor taking stock of the importance of the second dose (NCS-TF, Rapport scientifique, 26 Oct. 2022 p. 2).
For the “Corona-Immunitas”, the general findings leave many interpretations still open to programmatic questions. It merits further exploration, particularly in terms of the existing interpretations of graphs and summary of findings, for example, in relation to vaccine hesitancy and vaccination campaign messages. Studies pushing their findings to recommendations are rare. A good example is the recent prospective cohort study that formulated the following sound “implications”: early planning of vaccination campaigns encompassing lower education levels and lower health literacy with the support of local/cantonal authorities with actors other than government agencies and scientists to overcome the low trust in government and science (Heineger S. et. al., op. cit., p. 8). Building up practical recommendations and translating them into operations is a challenge that the various levels of health authorities need to tackle.
Antoine Flahault suggested the need to engage the anthropologists’ perspective as a potential solution to improve the understanding behind the non-vaccinated and to boost the vaccination rates when these were stagnating at the end of 2021. “Corona Immunitas” was able to establish quickly a national cooperation with more than 40 studies related to immunity in the country; the Swiss School of Public Health (SSPH+) offers access to close to 400 doctoral students with 50 fellowships through its multidisciplinary academic structures. The “Corona Immunitas” network can further advance the understanding of COVID-19 (also combined with influenza) vaccination completeness and vaccine hesitancy with an improved commitment of the SSPH+ network (involving half a dozen universities across the country) with an anthropological research focus.
A socioeconomic position paper recommended that “Governments and health-care systems should address this pandemic of inequality by taking measures to reduce health inequities in response to the SARS-CoV-2 pandemic.” Triangulation with additional data sources is necessary. Along these lines, based on existing studies (e.g., the Swiss neighbourhood index of socioeconomic position, the Geneva neighbourhood socioeconomic vulnerability index), the strategic use of socioeconomic mapping would allow rapid identification of areas with lower coverage among disadvantaged social classes or neighbourhoods in order to increase vaccination coverage among these hard-to-reach populations. This research will include urban and rural populations using a mix of quantitative/qualitative study via well-known anthropological methods. The latter combine focus groups and semi-structured interviews (closed questionnaires with representative samples encompassing more vulnerable socioeconomic status pockets).
Several of these anthropological methods have been used in this pandemic by young researchers from Swiss universities. The engagement of social scientists (social epidemiologists, anthropologists, sociologists, psychologists and economists) is an opportunity to exploit the diverse research areas and bring in the expertise needed.
Complementary to these studies and findings, additional strategic considerations may further feed into the upcoming plan. The experiences gathered over more than one year suggest continuous and sustained communication campaigns for vaccination (i.e., several weeks vs one week) adapted to the vulnerable groups (including people aged 80+ years). The changing epidemiology of the pandemic will necessitate adjusting vaccination strategies from large campaigns through vaccination centres to ongoing health services. This builds on the lessons learnt from the review about “Mapping the Swiss Supply Chain”, which suggests targeting elderly patients with their family physicians and tailoring individual communication. In addition, it recommends collaborating with the cantonal public health authorities who are in charge of the vaccination campaign implementation. In this context, the bridge between chronic and infectious diseases at the primary healthcare level and their medical services (medical doctors’ offices) is more than ever necessary, particularly for the aged population. It is necessary to identify factors influencing individuals' clinical vulnerability, such as obesity or diabetes, which increase the risk of COVID and the need for booster shots. Weight excess inequities linked to socioeconomic vulnerabilities is more common among individuals with low educational status, low revenue and belonging to some professional categories. Primary healthcare attention on the connection between infectious and chronic diseases is an opportunity to extend the links and the impact of public health services both at community and at tertiary hospital service level to end the pandemic. Injecting both the influenza vaccine and the COVID-19 vaccine during the same visit for double protection is a sustainable strategy, which may allow future routine services to be better accepted among the aged population. Such granular research and considerations are an investment in the potential improvement of other vaccination strategies and antigens (e.g., measles) for present and future pandemics.
Finally, the NCS-TF noted that the National Research Programme (NPR) will support advanced research and improve the understanding of inequities with the “COVID-19 and society” call for research (January 2022). Yet the final recipients (approximately forty) for this call were still to be selected at mid-year (June 2022). Consequently, the research will only be implemented in 2023 with, at best, findings expected in 2024. The social science-based innovative approach proposed could in the next few weeks leverage fast-track funds of the NPR for a rapid and robust design. Preliminary findings could then be available during the autumn of 2022 allowing refinement of the strategies, interventions and targeted vaccination campaigns among those aged 60+ at federal and canton levels.Conclusion
Promoting the importance of studies that are social-science driven with the determinants of health (vs biomedical and mortality focused) is critical to advancing the understanding of preventive measures, including vaccination. Furthermore, equity and well-being have been recognised by the international community to be at the heart of the COVID-19 sustainable response, with better governance encompassing the interdependencies between health, social, environmental and economic systems. Benefiting from the well-rounded tools offered by social science is essential to achieve this goal.
Stimulating further partnerships between researchers in large networks (e.g., SSPH+) and local communities (cantons and “communes”/ local authorities), as well as advocating for financial support, are essential to making a difference for the upcoming unfinished vaccination agenda. This approach is a worthwhile and relatively low-cost investment in ending the pandemic, taking into account the personnel and material costs, which reached CHF 352 million for five university hospitals in 2020 and 2021.
We hope our additional specific options for action in Switzerland may better inform the upcoming strategy towards the end of the pandemic for the aged population with the COVID-19 vaccines and for applications to all non-pharmaceutical interventions. Although the focus here is on Switzerland, the findings are largely applicable to other countries in Europe, for the long term (e.g., new omicron variants BA.4 and BA.5, new waves, upcoming Moderna and Pfizer-BioNTech RNA vaccines), and for future pandemics. A broader perspective of the importance of social sciences focusing on various measures to improve the responses and to counteract inequities with examples from Switzerland, Italy and Germany has been presented at the European Society for Health and Medical Sociology (ESHMS) conference.
Special thanks to those in charge of the COVID-19 Social Monitor, and Corona Immunitas, the Taskforce BAG COVID-19, Social Media Communication (FOPH), as well as to Stephane Cullati for reviews.
(This paper is based on preliminary findings presented by Cyril Pervilhac, Tina Draser, “COVID-19 Vaccination Coverage in Switzerland: How can Social Sciences Make a Difference in an Agenda Yet to be Fully Accomplished?”, Conférence suisse de l’AMADES, Lausanne, «Covid-19 sous l’angle des sciences sociales en Suisse», 3 juin 2022)
Cyril Pervilhac, Retiree, WHO HQ Geneva, firstname.lastname@example.org
Tina Draser, Retiree, The Global Fund to fight AIDS, TB and Malaria, Geneva