Anticipating tuberculosis vaccine acceptability in Kenya and South Africa: a narrative review of behavioral and social drivers and strategies to optimize acceptability

Tuberculosis (TB) remains the leading infectious cause of death worldwide, yet the only vaccine currently available is the pediatric BCG, which has poor effectiveness in preventing TB in adolescents and adults. A TB vaccine for this older age group is projected to prevent 4.6-8.5 million deaths by 2050 and increase gross domestic product by US$1.6 trillion by 2080, making this a priority investment for global stakeholders. In response to the World Health Organization's End TB Strategy, several TB vaccine candidates are now in phase III clinical trials, many of which target adolescents and adults. However, research on attitudes towards a TB vaccine is limited and urgently needed among these key populations to inform vaccine demand creation, scale up needs, and implementation strategies, particularly given global trends of increased vaccine hesitancy following the introduction of novel COVID-19 vaccines. To address this gap, a literature search was conducted for published studies evaluating socio-behavioral predictors of acceptability of HPV, COVID, and childhood immunizations as proxy indicators since there is a lack of published data on TB vaccine acceptability. We focused our search within Kenya and South Africa between January 2015 and July 2025 to represent high TB burden countries. Findings were supplemented with emerging data from unpublished conference abstracts on TB vaccine attitudes. Significant predictors of vaccine acceptability included higher perceived risk of disease, older age, a sense of collective responsibility, accurate and sufficient knowledge of the vaccine, trust in government or health authorities, and confidence in vaccine safety, side effects, and efficacy. Corresponding strategies to improve TB vaccine acceptability included early and accurate public communication, engagement of community influencers and youth, and use of diverse communication platforms.