Beyond the 28 November 2021 vote: a paradigm shift with public health to counteract the pandemic and fifth wave of COVID-19 in Switzerland?

Cyril Pervilhac, Tina Draser

The vote of 28 November 2021 on modification of the law and the COVID certificate in Switz erland, far from ending the debate, reopens it as to the measures to be pursued. The rate of infection has risen dramatically in recent weeks (doubling of cases every two weeks), whereas the vaccination rate (66%) is only slowly increasing. The measures taken at present are accompanied by a certain scepticism of experts, with containment seeming over the horizon as a possible consequence. But what are the solutions and avenues offered by public health and prevention to overcome the fifth wave and also this pandemic in 2022 and beyond? Are they fully exploited?

The background to these figures in Switzerland has already been well documented in recent weeks:

1. Austria has shown trends similar to Switzerland, but a few days ahead, as reported by members of the COVID-19 task force: similar, insufficient vaccination rates in the two countries, infection curves with identical trends, recent high incidence of the virus in the three cantons bordering Austria.
2. The German-speaking cantons suffer from a tighter situation and lower vaccination coverage than the French-speaking cantons; to recall that in addition to vaccination, the Federal Council will not be able to avoid seriously considering a new set of measures in the coming weeks.
3. With only a little over two thirds of the population fully vaccinated as of a few days ago and the failure of the recent National Immunisation Week in November accompanied by underestimation of popular anger, the situation is serious.
4. The causes and degree of rejection of vaccination are complex. A recent analysis grouped them into six social categories: "natural medicine followers, primitive Swiss, conspiracists, politicians, moderates, and populists".
5. Vaccine refusal or hesitancy is a well-known and long-standing phenomenon throughout the world, with an average of 13% of the population expressing some degree of scepticism [1].

Faced with this situation, there is no reason to despair, however: public health measures offer us clear paths to overcome this pandemic in the weeks and months to come.

Lessons learned from other countries with high vaccination rates (e.g., Portugal, Italy, Spain) with a Latin culture of collective responsibility (vs individual responsibility for German-speaking countries) indicate how culturally adapted communication played a key role. These campaigns took place weeks before and during the launch of the vaccination programmes so that the population would adhere to them. The "seven good reasons to get vaccinated" for Switzerland are a good example:

1. You protect yourself from catching COVID-19 and getting very sick.
2. You get immunity the safe way.
3. You help reduce the number of cases.
4. You help combat the effects of the pandemic.
5. You prevent potential long-term debilitating effects of COVID-19 (long-term effects of COVID-19).
6. You help relieve pressure on the healthcare system.
7. You help us get our everyday freedom back.

But these remain very general and insufficiently convincing in terms of their formulation and simplified messages, which need to be regularly updated and targeted to different populations and ages using the wide range of multimedia available.

In Spain, the cultural context, the importance of intergenerational family ties and solidarity, played a fundamental role. They are accompanied by close social contacts with consequent mutual responsibility to be vaccinated. At the same time, in Switzerland, the Christmas and New Year's holidays encourage the population to protect close family members. This could be an opportunity to launch a sustained and massive media campaign on family solidarity and thus convince a few hesitant people.

In addition, there is now an urgent need to use tailored communication campaigns targeting some of the six groups identified above as hesitant with education and training interventions. This will help to gain a few more critical percentages. Exploitation of all communication channels to disseminate the vaccination and barrier messages with posters and pamphlets, audio-visuals and social media is needed. The vaccinated can in turn use them in their own communities when counter-campaigns take place. Prior to the referendum, anti-vaccination materials flourished and were already being massively distributed in many public places such as hotel entrances, small shops, weekly markets, entertainment sites, or in mailboxes with sophisticated anti-vaccination newspapers and messages. Future targeted communication campaigns should be based on detailed mapping of current immunisation coverage and incidences of new infections and their diverse populations.

At the local level, the involvement of the community and their local medical doctors' offices is crucial. Confidence in local doctors and the public health system are key factors in the willingness to be vaccinated. They should therefore be equipped accordingly. We can also take advantage of the situation to offer messages for the whole family, for example on the measles vaccine for children, which is also meeting resistance.

Communication is essential in prevention, but accessibility to services is another challenge. It is ironic that for both, and from our international professional experience, we have much to learn from public health programmes in Africa that, over the years, have achieved sustained rates of immunisation coverage of 80–90% or higher,  achieving herd immunity. Social decision-making is an open and complex process, but immediate investment can pay off in the short term and will be beneficial from a long-term public health perspective. Facilitating access for different populations is essential, especially in sites that are not easily accessible by mobile facilities or services offered in public places (e.g., schools, supermarkets). Access to the third dose for the elderly should be aided with nearby sites, mobile facilities or walk-in centres. Other age cohorts will follow and will also require easier access.

It is encouraging to know that cantons are currently launching initiatives to evaluate their own strategies since the beginning of the pandemic. However, will this opportunity be fully exploited with sufficient financial support and multidisciplinary expertise to fully assess the impact of the various measures and factors of resistance to vaccination, or will it be a simple exercise of a few days by one or two epidemiological experts to study statistical data already known? For example, an international panel of experts on pandemic preparedness points out that systemic, behavioural, environmental and social interventions also need to be better understood. These interventions, beyond the strict biomedical ones that are currently the focus of debate and strategy, are too few in number and insufficiently financed.

Based on the lessons learned from failures and successes, an innovative platform for exchange between the cantons could stimulate more appropriate strategies for rapid and dynamic adaptations according to local situations.

Consequently, in order to get out of the paradigm that favours only the biomedical interventions, it is necessary to counteract this pandemic that will leave COVID-19 endemic in the years to come: it is therefore necessary to give a central role to public health and prevention strategies. These must be adapted to each canton, with support at the federal level, and focused on reducing the circulation of the virus through the rapid achievement of high vaccination rates combined with the continuation of proven effective barrier measures such as hand hygiene, wearing masks, and physical distancing and ventilation.

 

Cyril Pervilhac, Retiree, WHO HQ Geneva, pervilhacc[at]gmail.com

Tina Draser, Retiree, The Global Fund to fight AIDS, TB and Malaria, Geneva

 

Reference

1. Larson , et al. in Hans Rosling et al, Factfulness, 2018