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BackgroundWidespread uptake of COVID-19 vaccines will be essential to extinguishing the COVID-19 pandemic. Vaccines have been developed in unprecedented time and hesitancy towards vaccination among the general population is unclear.MethodsSystematic review and meta-analysis of studies using large nationally representative samples (n≥1000) to examine the percentage of the population intending to vaccinate, unsure, or intending to refuse a COVID-19 vaccine when available. Generic inverse meta-analysis and meta-regression were used to pool estimates and examine time trends. PubMed, Scopus and pre-printer servers were searched from January-November, 2020. Registered on PROSPERO (CRD42020223132).FindingsTwenty-eight nationally representative samples (n = 58,656) from 13 countries indicate that as the pandemic has progressed, the percentage of people intending to vaccinate and refuse vaccination have been decreasing and increasing respectively. Pooled data from surveys conducted during June-October suggest that 60% (95% CI: 49% to 69%) intend to vaccinate and 20% (95% CI: 13% to 29%) intend to refuse vaccination, although intentions vary substantially between samples and countries (I2 > 90%). Being female, younger, of lower income or education level and belonging to an ethnic minority group were consistently associated with being less likely to intend to vaccinate. Findings were consistent across higher vs. lower quality studies.InterpretationIntentions to be vaccinated when a COVID-19 vaccine becomes available have been declining globally and there is an urgent need to address social inequalities in vaccine hesitancy and promote widespread uptake of vaccines as they become available.FundingN/AResearch in contextEvidence before this studyWe searched PubMed, Scopus and pre-print servers for manuscripts from January to November, 2020, reporting on studies examining intentions to be vaccinated against COVID-19 in large nationally representative samples (N≥1000). No language restrictions were applied. Search terms were [(COVID OR coronavirus OR SARS-COV-2) AND (Vaccine OR Vaccination) AND (Inten* OR willing* OR attitud* OR hypothetical)]. From 792 articles, we identified 20 eligible articles reporting on 28 nationally representative samples.Added value of this studyThis is the first systematic study and meta-analysis to estimate the proportion of the global population willing to be vaccinated against vs. intending to refuse a vaccine when COVID-19 vaccines become available and how this trend has changed over time, using large and nationally representative samples. Results indicate that COVID-19 vaccination intentions vary substantially across countries, the percentage of the population intending to be vaccinated has declined across countries as the pandemic has progressed (March-May estimate: 79%, June-October estimate: 60%) and a growing number report intending to refuse a vaccine, when available (March-May estimate: 12%, June-October estimate: 20%). There is consistent socio-demographic patterning of vaccination intentions; being female, younger, of lower income or education level and belonging to an ethnic minority group are associated with a reduced likelihood of intending to be vaccinated when a vaccine become available.Implications of all the available evidenceIntentions to vaccinate against COVID-19 among the general public when a vaccine becomes available have been declining and this will limit the effectiveness of COVID-19 vaccination programmes. Findings highlight the need to improve public acceptability, trust and concern over the safety and benefit of COVID-19 vaccines and target vaccine uptake in disadvantaged groups who have already been disproportionately affected by the pandemic.