Vaccine Hesitancy

The COVID-19 vaccine development started in January 2020, as soon as the genome sequence of the virus became available. The development of this vaccine has been extraordinarily quick, with phase I trials beginning in March 2020. Many groups of researchers around the world have taken the initiative, and although there are around 180 vaccines getting developed, the Pfizer vaccine has already been administered to people in Great Britain (Bailey, 2020). This paper will examine some of the reasons for vaccine hesitancy during the COVID-19 pandemic through the lens of past research on vaccine hesitancy, and provide some solutions for addressing the skepticism. Although looking at the sources reveals some consistency in reasons for vaccine hesitancy over time, there are new issues arising specifically with COVID-19 vaccines. Since this review is not an exhaustive account of all the literature on vaccine skepticism, only a few important points on COVID-19 vaccine hesitancy will be covered.

Despite the arrival of an allegedly safe vaccine, vaccine hesitancy is high and continues to grow in the US. Recent polling shows that only about half of all Americans are sure they will get a COVID-19 vaccine when one is available (Neergaard & Fingerhut, 2020). Globally, vaccine acceptance is higher but decreasing with 73% saying “if a vaccine for COVID-19 were available - [they] would get it” when three months ago that statistic was at 77% (Boyon, 2020). There is a global trend downward in vaccine acceptance, which one would expect to be unusual in times of a pandemic, but as this paper will explore, there are reasons for this skepticism.

Understanding those reasons will help policy makers and health professionals address the growing vaccine hesitancy surrounding this pandemic. First, a bit of history about the anti-vaccine movement is required to understand how it came to be. There has always been opposition to vaccinations since they were first developed but the anti-vaccine movement garnered major support when Andrew Wakefield released his study in 1998 that detailed how the measles, mumps, and rubella (MMR) vaccine caused autism in children (Hussain et al., 2018). The study has been redacted and refuted multiple times, but support for it still remains. This study is used as one of the pillars of the anti-vaccine movement and popularity has only grown as the media has continued to give it attention.

Apart from the anti-vaccine movement, there are contextual influences that impact vaccine acceptance. Communication is one of these. Vaccine acceptance can be negatively affected in situations where communication is poor or misinformed about vaccination efforts (MacDonald, 2015). For example, in 1999 there was a decision to remove the preservative thimerosal from some vaccines in the US, but the reason why was poorly communicated to the public (MacDonald, 2015). This undermined public confidence in vaccines and resulted in increased hesitancy and refusal. Similarly, with COVID-19 there has been rapid progress in the development of a novel vaccine. Poor communication and the spread of misinformation on social media has resulted in increased vaccine hesitancy (Chou & Budenz, 2020).

Fig 1: Table of factors influencing people’s decisions about vaccination. (WHO, 2017)

Another contextual influence is that of race and socioeconomic status. In the US there has been a long history of treating minority groups unfairly, this includes health institutions (Wilder, 2020). The outcome of this treatment is that the majority of minority communities have poor access to health treatment and information, and as a result, poor health outcomes (Tai et al., 2020). Similarly, the socioeconomic status of most of these minority groups is lower than white Americans. Poverty rates before the pandemic were high, around 24% for Native Americans, 22% for African Americans 19% for Hispanics compared to 9% for white Americans (Tai et al., 2020). Also, minority groups compromise a disproportionate percentage of workers in essential industries and they are more likely to live in higher density housing and neighborhoods (Tai et al., 2020). During this pandemic all of these factors have resulted in a disproportionate effect of COVID-19 on minority groups (see figure 2) (WHO, 2020).

Fig 2: Table displaying the rate ratios of cases, hospitalizations, and deaths by race/ethnicity compared to White, Non-Hispanic persons (CDC, 2020).

The individual and group factors influencing people’s decisions about vaccination include 1) knowledge and awareness about the vaccination and vaccine development processes, 2) the quality of personal, family and/or community members’ prior experiences with vaccination, as well as 3) trust and personal experience with healthcare providers. It is important to note that higher levels of education do not correlate with higher vaccine acceptance rates (MacDonald, 2015). Rather, high levels of awareness about the process of vaccine development, manufacturing, and approval are associated with lower vaccine hesitancy rates. The biggest positive predictor for COVID-19 vaccine acceptance is current vaccination against seasonal influenza, as such people have the knowledge about the vaccination process, have had high quality experiences with vaccination and possibly with health providers in general (Dror et al., 2020). It is also noteworthy that males are more likely to be vaccine-accepting, whereas being a parent is a negative predictor for accepting the future COVID-19 vaccine (Dror et al., 2020). One interpretation for this is that parents are more worried about their own well-being, because the vaccination consequences could jeopardise their ability to take care of their kids (Dror et al., 2020).

Given the systemic racism that has plagued the national healthcare system and the recent political turmoil and division in the United States, there remains underlying doubt surrounding the effectiveness of vaccines across the country. So much so that vaccine skepticism in and of itself may prevent the impact of new COVID-19 vaccines towards national immunity. Beyond contextual and individual factors, there are looming concerns regarding the COVID-19 vaccine itself, both for its expedited development schedule and the employment of a new vaccination technique. Vaccine development is a long and strenuous process, taking up to fifteen years to achieve official approval and licensure, after undergoing thorough prototyping, clinical testing, and post-market surveillance (Stanberry & Barrett, 2009). However, the recently approved Pfizer BioNTech COVID-19 vaccine only began Phase I trials in March, due in part to the U.S. partnership with the Operation Warp Speed Vaccine Initiative, specifically designed to advance COVID-19 vaccine development and testing (Van Norman, 2020). As such, there is significant concern that the COVID-19 vaccine may be unsafe or will present dangerous and unexpected side effects with a combined 51% of Americans saying that they are either unsure or will definitively not get the COVID-19 vaccine (Neergaard & Fingerhut, 2020).

Combined with an accelerated development timeline, concern may be further heightened when tried and tested strategies are replaced with new technologies. On the molecular level, Pfizer’s COVID-19 vaccine is using the newest technique on the vaccine market, attempting to instruct coronavirus protein production through mRNA to activate the immune system, instead of injecting a deactivated form of the virus (Reynolds et al., 2020). Physicians and the public alike are expressing concerns about the safety of the vaccine, including side effects and the potential for contracting the virus itself (Dror et al., 2020). While it is important to acknowledge that polls are not always an accurate representation of public opinion, nor can they truly represent the entirety of a population, it is evident that there is enough doubt surrounding the Pfizer vaccine, and those to follow, that progression towards immunization may be short lived.

Our proposals on how to address the population’s vaccine hesitancy are mostly based on the World Health Organization’s 2017 training module for health workers and recommendations of a Communications Specialist for the King County (Washington) Department of Public Health, Lily Alexander.

Most importantly, we need to have trusted communicators targeting small communities based on faith, languages spoken, ethnic minorities, and etc. This helps to make the information much more relevant to people, adapting the communication to the particular setting in order to be sensitive to cultural and social norms, religion, and level of education (WHO, 2017). Moreover, since a lot of people are vaccine hesitant merely because they do not understand the processes behind vaccine development, manufacturing, and approval, sharing details about those processes will help reduce fears people might have (WHO, 2017). In order to build trust with people, communicators must provide information about the risks and safety of vaccination and explain why vaccines are recommended. Validating people’s concerns and fears and being very transparent, even if the answer is “I do not know” is vital (WHO, 2017).

As mentioned before, one of the reasons people are hesitant to get vaccinated is the lack of an adequate amount of information for them to make an informed decision. Having a call center and an FAQ webpage designated just for COVID-19 vaccine-related concerns would make an appropriate amount of information available to the general public (Kaufman & Danchin, 2020).

Furthermore, immunization program managers must remember that vaccine acceptance does not mean hesitancy is not present. Therefore, paying attention to the vaccine accepting group of people, and supporting them in their resiliency in the face of anti-vaccine messages is extremely important in order to not lose the vaccine-trusting majority. Having them help the pro-vaccine movement will provide us with strong immunization program associates promoting its importance for the community, pushing for community-wide vaccine acceptance (MacDonald et al., 2017).

Image Credits

Header. Coronavirus: Facebook, Twitter and YouTube 'fail to tackle anti-vaccination posts'

Figure 1. Table of factors influencing people’s decisions about vaccination

Figure 2. Table displaying the rate ratios of cases, hospitalizations, and deaths by race/ethnicity compared to White, Non-Hispanic persons

Figure 3. A graph of the distribution of different factors into avoidance/acceptance predictors for COVID-19 vaccines

Figure 4. American vaccine poll

Figure 5. Expectations for a COVID-19 Vaccine