Vaccine Hesitancy and the Race to Get Everyone Vaccinated.

​The World Health Organization has identified vaccine hesitancy as a leading global health threat, which left unchecked could lengthen the duration of the COVID-19 pandemic. The United States is far ahead of most nations in vaccinating its population. But even the Centers for Disease Control and Prevention recognizes that reaching herd immunity is no longer a realistic goal. The best hope to mitigate the consequences of the pandemic is to get as many people as possible vaccinated, within the shortest period of time.

​President Biden has a goal of getting at least 70% of the adults in the U.S. vaccinated with at least one shot by the 4th of July. This should be achievable, but it won’t be easy. To date about 64% of adults have received at least one COVID shot. But the pool of adults willing and able to get vaccinated is shrinking. Lack of access and misinformation are leading to vaccine hesitancy and outright refusal to get the shot. Lack of access to the vaccine in certain populations is a big challenge, but one that can be overcome with time and resources. Reaching the homeless, migrant workers, shut-ins, and isolated rural communities present logistical challenges. The more difficult challenge will be to overcome all the misinformation out there and get through to those refusing to get vaccinated.

​Who is Hesitant about Getting Vaccinated: The Kaiser Family Foundation COVID-19 vaccine tracking poll tracks vaccination rates and behavioral attitudes towards vaccinations among various demographic groups,  https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/?gclid=EAIaIQobChMI_qiK1aGI8QIVIPHjBx2Ejw5SEAAYAiAAEgJt2fD_BwE. Here is some of the latest data on adult vaccination rates in the U.S.:

• Already Vaccinated                                  64%
• Plan to Get Vaccinated Soon                    4%
• No Hurry, Will Wait and See                 12%
• Will Get Vaccine Only if Required         7%
• Definitely Will Not Get Vaccine            13%

The people in the last two groups, making up 20% of the adult population in the U.S., are considered “hesitant” about getting the vaccine. This hesitant group tends to be younger, Republican, and from rural communities. Here is the breakdown for these groups:

                                Group                                   Hesitant or Outright Skeptical
                                Ages 30-49                                           28%
                                Republicans                                        36%
                                From Rural Areas                              27%

The most significant determinant among all groups, including race and gender, was the level of education. Working class members of every demographic group are less likely to be vaccinated and are hesitant to do so. People with a college degree are twice as likely to be vaccinated than those without a degree. Nearly 25% of all adults without a college degree fall into the vaccine hesitancy group. People in the “wait and see” group tend to be the young and people of color. 

​Reasons for Vaccine Hesitancy: To overcome vaccine hesitancy it is important to understand the root causes. The predominate cause is misinformation, but here is a partial list of other reasons.

• Lack of information
• Fear of side effects. Blood clots associated with the J+J vaccine only added to this fear.
• Long term effects of the vaccine are unknown.
• Mistrust of the government.
• Mistrust of the health care system. This is particularly true among Blacks and Hispanics.
• Fear of needles.
• Mixed messaging from the government and the CDC.
• Consider the vaccine experimental.
• Belief that the vaccine was rushed. Calling the vaccine program “Operation Warp Speed” didn’t help.
• Fear of unexpected medical bills, even though the government is picking up the bill.
• The seriousness of COVID-19 is exaggerated and the risk from getting the vaccine is greater than the risk from the infection. 

                                                   ​Overcoming Vaccine Hesitancy

• Combating Misinformation: Of all the reasons that people give for delaying or refusing to get vaccinated, most come down to misinformation. According to the Kaiser Family Foundation, 54% of Americans believe common misinformation about the COVID-19 vaccine. Vaccine myths have spread like wildfire on social media. Some common myths include, the vaccines cause infertility, they can spread the disease, and the vaccines contain tracking devices. 

 

• Effective Messaging: Various focus groups, https://debeaumont.org/wp-content/uploads/2021/03/GOP-focus-group-summary.pdf, and polls, https://consumer.healthday.com/b-4-29-poll-reveals-whos-most-vaccine-hesitant-in-america-and-why-2652810397.html, have shown that misinformation can be overcome with effective messaging from trusted leaders, not politicians or celebrities. Trusted members of the community such as personal physicians, clergy members, and local leaders, have the best chance of delivering effective messaging about the benefits of vaccination and dispelling misinformation. Key messages about the vaccines must include vaccine safety and the positive benefits of getting vaccinated. These benefits include protection of your health and those around you, the ability to see family and friends again, getting kids back in school, the ability to travel, and for the businesses in your community to reopen.      

​Here are some other messaging points put together by Sherita Hill Golden, MD, Professor of Medicine at Johns Hopkins, to assist in overcoming vaccine misinformation:

• It can prevent you from getting sick.
• People of color are especially vulnerable to severe COVID-19.
• Getting vaccinated helps others in your community.
• The more people that get vaccinated, the quicker society can get back to normal.
• Vaccines were developed quickly, but the trials involved large numbers of people from diverse backgrounds.
• The vaccines are safe and effective.
• Side effects are temporary and do not indicate you have COVID.
• Even people with allergies should get the vaccine.
• The vaccine has no impact on a woman’s fertility.
• The vaccine is generally safe in pregnant women. Discuss any concerns with your doctor.
• Even if you have had COVID, get the vaccine.
• Time is of the essence.
• Vaccines save lives.

• ​Improving Vaccine Access: Removing barriers and making it convenient to get a vaccine is another critical step in reaching those who are ambivalent or hesitant about getting the vaccine. This includes making the vaccines available in clinics and pharmacies without appointments, and extending hours to include evenings and weekends. Bringing the vaccine to where people live, work, worship, and gather is important to improve access. This is already happening, but needs to be accelerated. Another barrier for working people is time away from the job. According to the Kaiser Family Foundation, 20% of unvaccinated workers are more likely to get a vaccine if they receive paid time off to get it, and paid time off to recover from any side effects. 

•  ​​Incentives: Many states are now incentivizing people to get vaccinated with prizes, giveaways, and lotteries. Vaccine administrations jumped 49% in the first two weeks after Ohio launched its weekly “Vax-a-Million”, giving every vaccinated Ohioan a chance to win a $1 million. California launched its own multi-million dollar lottery for the vaccinated and also provides gift cards to the newly vaccinated. Companies such as Budweiser and Krispy Kreme Donuts are also getting into the game with free giveaways with proof of vaccination. Surveys from the Kaiser Family Foundation have found that 15% of unvaccinated adults would reconsider getting vaccinated if induced by a $100 cash payment.  Some consider it unethical to pay (bride?) people to get vaccinated, when much of the world is begging for the vaccine. But I feel that the sooner we get the U.S. population vaccinated, the quicker we can help the rest of the world.  

• ​Full FDA Approval of Vaccines: The COVID vaccines in use in the U.S. are being used under an FDA “Emergency Use Authorization”. This has led many vaccine skeptics to view them as experimental, and therefore unsafe. About half of the unvaccinated group who are taking a “wait and see” approach said that they would be more likely to get a vaccine that had received full FDA approval. Pfizer and Moderna have both submitted paperwork for full FDA authorization. I think that most people will feel better about taking a vaccine that has received full FDA approval.

                        ​Consequences of Not Getting Vaccinated 

• ​​High Risk from New Variants: Overtime, new highly contagious variants of the virus will develop in the unvaccinated population. New outbreaks around the world are from highly contagious new variants that have emerged since the introduction of the COVID vaccines. The highly infectious “Delta” variant that is a major concern in Britain, was first detected in India, and has recently been detected in the U.S. The longer COVID-19 persists in the human population, the more likely a variant resistant to our current vaccines will emerge. 

• ​Hospitalization Rates: Even though the vaccines have brought the overall infection and hospitalization rates down, the picture is not as rosy in the unvaccinated population. Maine, Colorado, Rhode Island, and Washington state are experiencing COVID-19 spikes among the unvaccinated, at rates not seen since the winter surge,  https://www.washingtonpost.com/health/interactive/2021/covid-rates-unvaccinated-people/. Highly contagious variants, such as B.1.1.7, have made the problem worse with the easing of restrictions on social gatherings and the lessening of mask mandates. In Maryland, unvaccinated young adults have the same infection rate as they had during the January surge, but their hospitalization rates have doubled.

• Putting the Vulnerable at Risk: There are millions of Americans, both vaccinated and unvaccinated, who are risk from COVID-19 due to underlying medical conditions. An estimated 6 million Americans are on immunosuppressant drugs that could diminish the effect of the COVID-19 vaccine, leaving them vulnerable, https://www.cnn.com/2021/06/04/health/covid-19-vaccine-immunosuppressants/index.html. Unvaccinated children are less likely to get seriously ill from COVID-19, but let’s not forget that since the start of the pandemic over 4 million children have tested positive, 16,500 have been hospitalized, and over 322 have died. 

​Getting a COVID-19 vaccine is a very personal choice, and although I believe that most adults should get vaccinated, it should not be forced upon them. There are some very legitimate reasons for some people not to get vaccinated, such as deeply held religious beliefs and some underlying medical conditions. For the benefit of the community, the country and the world, all people eligible to receive the vaccine should, for the common good. 

There was a strong consistent message when the polio vaccine was introduced in the 1950s. It gained widespread acceptance under the banner “we’re all in this together”. Will this message resonate in our polarized world? Let’s hope and pray that it does.

Update July 13,2021: The pandemic is far from over, but you wouldn’t know it by walking down the streets of most American cities. The world recently surpassed the grim milestone of 4,000,000 deaths due to COVID-19. This was the official death toll, but the actual death toll is certainly much higher. Approximately 25% of the world’s adult population has received at least one shot of COVID-19 vaccine, mostly in the rich countries. Less than 1% of the adults in low- income countries (Africa, Asia, South America, Central America) have received a single shot of the vaccine.

On June 15th the U.S. surpassed 600,000 deaths due to COVID-19, and the death rate continues to climb, mainly among those who have been unvaccinated. President Biden missed his July 4th goal of getting 70% of eligible adults vaccinated with at least one shot. As of this writing just under 68% of adults have received at least one shot. COVID-19 cases have come down significantly in the U.S. over the past few months due to the highly effective vaccines. As a result, most areas of the country have dropped all COVID-19 related restrictions. Mask mandates, social gathering restrictions, and indoor business restrictions have disappeared, and domestic travel has returned with a vengeance. But this rosy picture hides vast geographic disparities which show a significant rise in hospitalization rates and deaths due to COVID-19 in regions with low vaccination rates. Rural areas, which tend to be conservative, have seen a recent rise in COVID-19 cases. Low vaccination rates make these populations vulnerable to the highly contagious Delta variant. Arkansas and Missouri are seeing the worst outbreaks, followed by Florida, Nevada, Wyoming, and Utah.

But unvaccinated people are driving increases in COVID-19 cases even in areas with high vaccination rates. This corresponds with the lowering (or elimination) of COVID restrictions and the emergence of the Delta variant.  I live in a county north of San Francisco, where 68% of eligible people are fully vaccinated and another 8% are partially vaccinated. But there has been a troubling uptick in COVID-19 cases and hospitalizations, even before the full effects of 4th of July gatherings are felt. The vast majority of the hospitalized COVID-19 patients are unvaccinated. Contact tracing has shown that most of the current COVID-19 cases in my county are being fueled by social gatherings and leisure time activities, with the highest rates in the 18-32 age group.

Vaccine hesitancy continues to align significantly with party affiliation. According to a recent Washington Post-ABC News poll, 6% of Democrats said they are not likely to get vaccinated, compared with 47% of Republicans, including 38% of Republicans who said they definitely will not get the vaccine    https://www.washingtonpost.com/politics/post-abc-poll-biden/2021/07/03/54e95b6e-db43-11eb-8fb8-aea56b785b00_story.html.

First detected in India, the Delta variant is estimated to be 60% more transmissible than earlier variants. The Delta variant has rapidly spread around the globe and is currently driving COVID-19 outbreaks in African, Asia, Australia and South America. The CDC has determined that the Delta variant is now dominant in the U.S. and is spreading rapidly in unvaccinated populations. Researchers in France, Israel and Britain have shown that a single dose of the Pfizer or AstraZeneca vaccine is largely ineffective against the Delta variant. Therefore, delaying the second shot in order to vaccinate more people is no longer an effective option. New variants, like the Lambda variant spreading rapidly in South America, provide more reason to quicken the pace of vaccination around the world. The unvaccinated population provides a breeding ground for new variants, and short of shutting down the world, vaccines are our only real defense. 

Pfizer made news last week by announcing that it would seek FDA approval for a COVID-19 booster vaccine. The CDC and NIH strongly rejected the need for vaccine boosters at this time, refuting the claims made by Pfizer. But many in the scientific community acknowledge that it is not a matter of if, but when booster shots will be needed. Preliminary research out of Israel suggests that the Pfizer vaccine is less effective against the Delta variant and there is a decline in antibody levels against the virus over time. I think that we should be prepared for the eventuality of booster shots, but we need to think through the ethical issues involved. Is it ethical to provide booster shots to fully vaccinated people in wealthy countries when the vast majority of people in poorer countries remain unvaccinated? Israel plans to offer booster shots of the Pfizer vaccine to adults with weakened immune systems, and Britain has announced plans to provide booster shots to its vulnerable populations and front-line workers.  It makes sense to protect our most vulnerable, but it seems premature to do so when there is a limited supply of vaccines.

The FDA warned this week that the Johnson & Johnson COVID-19 vaccine can lead to an increased risk of Guillain-Barré syndrome, a rare neurological condition. The incidence is very rare, and the benefits of this highly effective vaccine outweigh the risks. But I fear that this warning from the FDA will further diminish the acceptance of this much needed vaccine.

The vast majority of hospitalizations and deaths due to COVID-19 are occurring in unvaccinated people. The evidence is overwhelming. Unvaccinated people pose a risk to themselves and to vulnerable populations who have been vaccinated. No vaccine is 100% effective and breakthrough infections do occur. The incidence of COVID-19 is eleven times higher in unvaccinated people than vaccinated ones. If that isn’t an incentive to get vaccinated, I don’t know what is. Encourage everyone you know to get vaccinated. Regarding the use of face masks, do like I do, don’t leave home without one.  

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Thanks,
Armchair American