“A national month of action did little to arrest the Great Vaccine Decline. Now a national month of pain and suffering is all we have left.” - Daniel Engber, senior editor, The Atlantic
“I hug their family members and I tell them the best way to honor their loved one is to go get vaccinated and encourage everyone they know to do the same.”
- Dr. Brytney Cobia, Physician in Alabama (lowest vaccination rate in U.S.)
The COVID-19 pandemic has been full of surprises. To me, the two biggest relate to the vaccines. On the positive side is the extraordinary feat of having of three highly effective and safe vaccines deployed in our country within one year of the discovery of SARS-CoV-2, the cause of COVID-19. On the negative is the solid reluctance of a large number of Americans to get vaccinated.
This past week the SARS-CoV-2 Delta variant, a mutation that is estimated by some to be 1,000 times more contagious than any of the others, swept through the U.S. causing 83% of new infections and overwhelming hospitals once again. This development plus the striking fact that now nearly all (approaching 99.5%) COVID-19 deaths in the U.S. are in the unvaccinated make vaccine hesitancy not just baffling, but a national tragedy. In this Germ Gems post, I’ll provide my understanding of the basis for vaccine hesitancy and discuss some of the strategies being taken to thwart it.
The roots of evil in America’s COVID-19 pandemic. Vaccine hesitancy and the Delta variant are two evils that are foiling our efforts to end this pandemic. (I have discussed both subjects in prior Germ Gems posts: June 23, 2021 “Vaccine Advocates and Vaccine Antagonists: What’s Driving Them?” and July 7, 2021 “What’s the Deal with the Delta Variant?”) Despite considerable efforts to stop these two evils, both continue to thrive. Thus, they are again in the spotlight as root causes of what’s become referred to as “America’s Great Vaccine Decline.”
The “unvaccinated” are the problem. Fortunately, a large percentage of Americans are “vaccine enthusiasts.” Some drove hundreds of miles to get jabbed as soon as the COVID-19 vaccines became available. They, and everyone else who has been vaccinated, should be commended.
There is, however, a large group of people in the U.S. who still are not vaccinated and therefore universally share a vulnerability to COVID-19. Nonetheless, they are a heterogeneous group. Some are hard core “anti-vaxxers” or “vaccine hostiles,” people who refuse to be jabbed. It has become increasingly clear that it’s a complete waste of time to try to change the minds of these people. The main worry about these folks is that they’re often very vocal and willing to spread all kinds of misinformation via social media about the dangers and lack of efficacy of vaccines.
But not all unvaccinated people fall into the anti-vaxxer camp. Some people are merely reluctant to be jabbed claiming either that they need more information or that they are waiting for full approval of the vaccines by the Federal Drug Administration (FDA). They fall into the camp of “vaccine hesitaters.” It is this group of people that we have to convince to get vaccinated.
The message and the messenger. In 2019, in the months before COVID-19 emerged, the World Health Organization included vaccine hesitancy—“the reluctance or refusal to vaccinate despite the availability of vaccines”—in its list of “Ten Threats to Global Health.” All public health organizations recognize as a high priority the need to counter vaccine misinformation in order to overcome vaccine hesitancy. In his recent report “Confronting Health Misinformation: Building a Healthy Information Environment,” Dr. Vivek Murthy, the U.S. Surgeon General, underscores the role that vaccine misinformation plays in vaccine hesitancy in the era of COVID-19. Moreover, in an effort to quash such misinformation, the Center for Countering Digital Hate, a non-profit organization, launched a new website aimed at disrupting the spread of digital hate and vaccine misinformation (http://www.counterhate.com/disinforrmationdozen). Let us all hope it is successful.
For all of us, the message we should be looking for is the scientific evidence on safety and efficacy of the vaccines. It is not, however, just the veracity of the “message” that will persuade people to get vaccinated; it is the “messenger” who is equally, if not more, important. And, in my opinion, the messengers we can most rely on are not only scientists and respected public health authorities but also our own physicians.
It’s all about trust. The messengers that vaccine hesitaters should find most trustworthy are their personal healthcare providers (in particular, nurses and doctors). A number of surveys have shown that these health professionals rank no. 1 and no. 2 by the public for honesty and ethical standards (a March 2021 poll listed members of Congress as no. 15 of 15, right after car sales people at no. 14; members of the clergy ranked no. 7).
In recent months, I’ve been delighted to see increased recognition nationally of the pivotal role that primary care doctors can play as vaccine messengers. In my experience, doctors and nurses are particularly good at patient education. Recent surveys have demonstrated that half of unvaccinated Americans aren’t concerned about the Delta variant; these health care professionals can warn their patients of this dangerous variant and of the urgent need to get vaccinated as soon as possible.
The FDA also looms large as an important messenger regarding vaccine safety and efficacy. Their assessments of the three COVID-19 vaccines that are currently available in the U.S., all under “Emergency Use Authorization,” were critical in the vaccines gaining acceptance and implementation in America. Because some vaccine hesitaters are waiting for the FDA to give its full approval, this is now a priority item. (According to the Biden Administration, this is expected to happen in September.)
Sadly, some Americans, including many of the vaccine hesitaters, do not trust the message and messengers on which my medical colleagues and I rely. Instead, an unprecedented politicization of vaccine acceptance has beset our country. The lowest vaccination rates are found in Republican (or red) states, where sentiments against big government run high. Government-related institutions, like the Center for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), aren’t trusted by hesitaters in these regions of the U.S. It’s important to recognize, however, that minority groups like Black and Hispanic Americans, are heavily represented in these states, and they’re not only among the least vaccinated but have deep-seated historical reasons for their distrust of some government agencies.
On a related note, politicians and news media experts (“talking heads”) don’t get high marks on the trust scale of many Americans. Although several prominent leaders of the GOP recently endorsed the urgency of getting vaccinated against COVID-19 (see Susan Glasser’s July 22, 2021 New Yorker article, “Suddenly, [Some] Republicans Are All In on the Vaccine”), many Republican leaders are still not on board. But as Glasser suggested in her article the “grim new math of the pandemic for Red America” is catching on. Indeed, last week, Representative Steve Scalise, R-La, stated, “There shouldn’t be any hesitancy over whether or not it’s safe and effective.” And, Kay Ivey, Republican governor of Alabama, provided this unvarnished opinion, “It’s time to start blaming the unvaccinated. … It’s the unvaccinated folks that are letting us down.”
It’s all hands (and arms) on deck. Most public health experts agree that a variety of strategies are needed to reverse America’s Great Vaccine Decline. Making vaccines more accessible is an important and achievable goal, especially for communities with limited access to health care. I’m not sure if positive incentives (“carrots”) such as free lottery tickets have been very successful. Nonetheless, they haven’t hurt and should continue. To me, punitive incentives (“sticks”) like vaccine mandates for healthcare workers and for college and university students and faculty members, are sensible and should be encouraged. Also, in some work environments, “no jab, no job” policies seen reasonable. But admittedly, these are complex issues that require thoughtful discussion with public health experts before implementation.
What we do and don’t know. Dealing with SARS-CoV-2 has been a steep learning curve for all of us in science and medicine. There is a lot we still do not know about COVID-19. For that, we need a large dose of humility.
That said, there is a lot that we do know about this virus, for example, its structure and how it causes disease, that is its pathogenesis. More important, we do know that the vaccines we use in America are amazingly safe and effective (but, of course, not 100%...no vaccine is). Therefore, the decision to be vaccinated should be based on the evidence of risks versus benefits. As I mentioned above, doctors and nurses are trusted sources for this information. In my opinion, we also know that the CDC, NIH, and FDA can be trusted to provide accurate and up-to-date information on almost all aspects of COVID-19 vaccines.
When I was a practicing infectious diseases specialist, it often seemed that there were as many opinions about treatments as there were infectious diseases consultants in our group of seven. It was the job (responsibility) of the primary consultant, however, to get and weigh the facts. Based on these facts, the primary consultant was tasked with providing the referring physicians or patients the best advice possible in language that was easy to understand. Applying this process to the Great Vaccine Decline that we’re facing as a nation, here’s a message on which there’s uniform agreement for vaccine hesitaters: Get vaccinated as soon as possible! Your life may depend on it!