After a slow start, Australia now has one of the highest vaccination rates in the world. But despite the country's success, 902,834 people over the age of 16 are yet to receive a first dose of any COVID-19 vaccine.
In only a minority of cases, access to vaccines remains a hurdle. So why do almost a million Australians remain completely unvaccinated?
On January 16, NSW Health Minister Brad Hazzard spoke directly to this group, as hospitals in the state sounded warnings that the Omicron outbreak was proving overwhelming.
"I will say this to the disbelievers, the disbelievers that we still have in New South Wales — wake up to yourselves ... forget your silly messages and let people just have their vaccines."
Just over two weeks earlier, he had a similar message for those that remained unvaccinated:
The suggestion from Hazzard — as well as from many others in politics and the media — is that the bulk of the remaining unvaccinated are "anti-vaxxers".
By that, they mean those who have been convinced by conspiracy theories and misinformation not to get vaccinated.
Brad Hazzard has in the past labelled these groups "selfish and self-entitled".
But while there's little doubt anti-vaxxers are a concerning and growing minority, there are many reasons why more than 900,000 adults in Australia remain unvaccinated.
Resistance versus hesitancy
Novak Djokovic's recent entry into Australia — and exit — pushed the country's medical exemption system into the spotlight.
The men's world number one tennis player listed a prior COVID-19 infection as the reason why he should be granted a temporary exemption from vaccination.
While Professor Allen Cheng from the Australian Technical Advisory Group on Immunisation has said that particular exemption never applied to overseas travellers, there are some Australians who, through consultation with their GP, decide that they can't be vaccinated for medical reasons.
This is, however, incredibly rare. According to Department of Health data provided to The Drum, the number of medical exemptions granted is less than 0.153 per cent of the more than 21 million people who have been vaccinated in Australia. That's about 32,000 people.
And of those, most have only been given temporary exemptions. Only around 1,200 people have been granted permanent medical exemptions from a COVID vaccine.
Professor Graeme Stewart is the director of clinical immunology & allergy at Westmead Hospital.
"The only people who should be exempted are those with genuine allergies and a risk of anaphylaxis. But those who have that risk from all COVID vaccines are vanishingly rare," he said"
According to Professor Stewart, we need to separate the "vaccine hesitant" from the "vaccine resistant" — because these are two very different groups.
Among the hesitant are those that may have had bad reactions to vaccines or medications in the past. Some may have underlying health issues or be undergoing treatment for other conditions and be worried about any side effects that a COVID vaccine might cause.
"I've fielded calls from patients and GPs who feel there is a genuine medical reason for them not to be vaccinated," he said.
In the vast majority of cases, doctors say their fears are unfounded.
"It's reasonable to be hesitant if you've had a severe allergic reaction to vaccines or other drugs in the past," Professor Stewart said.
"My job has been to tell those that contact me that it is extremely unlikely that a bad reaction to a drug in the past will mean a patient would have a bad reaction to one of the COVID vaccines on offer."
Room for improvement in younger cohorts
Another large proportion of the remaining unvaccinated can be broadly — and crudely — separated out into a category we might call "the young".
Ninety-three point five per cent of Australia's over-16 population is fully vaccinated. In older cohorts, the proportion is even higher: 98 per cent of the country's over-50s have received at least two doses of a COVID vaccine.
But this rate is noticeably smaller in younger age groups. Currently, 85.2 per cent of 20 to 24-year-olds are fully vaccinated, and 87 per cent of 25 to 29-year-olds.
It's here that some context is important. This level of vaccination coverage, while lower than other age groups in Australia, is still far higher than most countries in the world.
It's also a far greater proportion vaccinated than many experts were predicting when the rollout first began.
However, Professor Stewart thinks that we can do better.
"I don't think an 84 to 86 per cent vaccination rate is high because it means that about one in seven are unvaccinated in that age group," he said.
"These are the people that have been overwhelmingly the conduit for Omicron. Their potential to spread the virus is huge."
When it comes to why up to 15 per cent of this age group remains unvaccinated, Professor Stewart would have us look at apathy, before conspiracy.
"Young people know that they're less likely to get seriously ill or die from COVID. Many think they're bulletproof, or they're too busy, or it's just been too hard to get an appointment and [it] so hasn't been a priority."
Concerns up to a third of pregnant women could be unvaccinated
High levels of vaccine hesitancy have also been reported in pregnant women.
President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Dr Benjamin Bopp, says that while no official data has been gathered, "our best guess is that a third of pregnant women are fully vaccinated, a third have had one dose and a third have had no doses whatsoever".
He points to misinformation largely circulated through social media that claims there has not been enough research done on the effects on pregnant women. He says this is understandable but ill-founded.
A recent study from Scotland, published in Nature Magazine, gives us perhaps the clearest view of the scale of hesitancy among pregnant women.
Researchers working with Public Health Scotland analysed data relating to more than 87,000 women between the start of vaccination uptake in December 2020 and October 2021.
They found that just 32 per cent of women who gave birth in October 2021 were fully vaccinated, compared with 77 per cent of the general female population aged 18 to 44.
That's despite data from the UK Department of Health that showed 98 per cent of pregnant women critically ill in hospital with COVID were unvaccinated.
Activists a tiny but vocal minority
Finally, there are those who do hold "anti-vax" views that have been fomented online through conspiracy theories and misinformation.
It's impossible to tell how many people fall into this group, but according to some experts, lumping all unvaccinated people into this category is unhelpful.
Professor Julie Leask from the University of Sydney Institute for Infectious Diseases is a leading authority on why people choose not to get vaccinated.
She says it's not useful to label and stigmatise the practice of vaccine rejection.
"It does a lot more harm than good. The anti-vax activists are a tiny but vocal minority. Those who remain unvaccinated are strong in their views but diverse in their reasoning."
Professor Leask says it will be hard to shift many of those who still haven't received their first doses, but stern words from politicians or media pundits are unlikely to help.
"When you have politicians getting up and remonstrating with the unvaccinated, that concerns me. Because it doesn't confront the problem."
"We need leaders to look at why people aren't vaccinating and say, 'We know there's a problem and we're doing something about it.'"
Hear more on this topic in The Drum's full episode, here.
