Vaccination against SARS-CoV-2, the most anticipated scientific development of the last year, is finally here. “COVID vaccine has emerged, and it's emerging rapidly. In just the past week, we've had several important regulatory and clinical use deliberations that have occurred,” said Ryan D. Mire, MD, FACP, an ACP Regent and assistant professor of clinical medical education at the University of Tennessee Health Science Center College of Medicine in Memphis, who moderated the Dec. 16 “ACP and Annals of Internal Medicine COVID-19 Vaccine Forum II, Promoting COVID-19 Vaccination: What Physicians Need to Know.”
But the next step of widespread vaccination will involve numerous challenges, most of which, such as production and shipping, are outside of internists' control. Experts believe practicing physicians are well positioned to take a lead role combating one of the biggest anticipated obstacles, however: patients' hesitancy to be vaccinated.
“Polls still show considerable reluctance about getting the vaccine, particularly in populations where the pandemic has had a great impact,” said Helene D. Gayle, MD, MPH, a specialist in preventive medicine, CEO of The Chicago Community Trust, and a co-chair of the National Academies of Sciences, Engineering, and Medicine's framework for equitable allocation of COVID-19 vaccines.
She and other experts discussed the causes of this reluctance and internists' potential responses during the virtual forum, which is available for replay online and is described in an accompanying article in Annals of Internal Medicine.
Causes of hesitation
Leeriness about vaccines is neither new nor uniquely American, explained Heidi J. Larson, MA, PhD, an anthropologist, clinical professor of health metrics sciences at the University of Washington in Seattle, and founding director of the Vaccine Confidence Project.
“I started the Vaccine Confidence Project a decade ago, after having seen in the previous decade what looked to me like a growing epidemic of questioning and refusing vaccines in different parts of the world,” she said. “We always see heightened anxiety around anything new. In the H1N1 pandemic, that was one of the key anxieties: the late addition of an H1N1-specific vaccine after the seasonal flu vaccine had already been made. That was the number-one biggest reason that people were saying they wouldn't take it—‘It's too new too fast.’”
The vaccines against COVID-19 also arrive in the midst of organized opposition to even long-established vaccines, added Peter J. Hotez, MD, PhD, a professor of pediatrics and molecular virology and microbiology at Baylor College of Medicine in Houston. “We have to acknowledge a pretty aggressive and globalizing anti-vaccine movement that has really accelerated since 2015,” he said.
Dr. Larson noted that trends in anti-vaccine sentiment vary by country, as she and colleagues found in a study published by The Lancet on Sept. 10, 2020. “Some countries have gotten better in the last five years,” she said. “On the other hand, the more extreme groups have dug deeper and are more insidious, and also the whole social media environment has amplified it beyond belief.”
Public messaging about the vaccine development effort has not done much to alleviate this problem, the experts said. “While the Operation Warp Speed program was great scientifically, it never launched the communication strategy to go along with it,” said Dr. Hotez.
Dr. Larson agreed. “We've heard a lot of … ‘Great for politicians, even scientists. It's get our flag to the moon first.’ But there's been almost no celebration, really, of the fact that it's faster because of the new technologies. We had funding mechanisms that allowed for it to move faster,” she said.
Close media focus on the vaccine trials has also shaped the public's perceptions. “You're seeing lots of ups and downs with news cycles, so that if you take surveys on days when, for instance, you had the two NHS workers in the U.K. develop allergic reactions, you'll get a different result than you would a couple of days later,” said Dr. Hotez.
Even people who look beyond the day's headlines to the scientific evidence may find reason for concern, said Ada Adimora, MD, MPH, FACP, a professor of infectious diseases and epidemiology at the University of North Carolina at Chapel Hill. “The main issues that I've been hearing are generally pretty reasonable ones, concerns about the paucity of long-term safety data. We only have about two and a half months' worth of data right now,” she said.
How to respond
A good first step in responding to vaccine concerns is to acknowledge that they may be reasonable, according to Dr. Larson. Parents questioning childhood vaccinations have specifically asked her to pass a message to physicians: “Because they'll listen to you, and they're not going to listen to me, tell them to speak nicely. We get told we're ignorant, we get told we're this, we're get told we're that, and we really just have some questions.”
She recommends offering empathy and finding at least some small point of agreement with the patient. “They'll say, ‘These are not 100% safe.’ And just by saying, ‘You're right, they're not 100% safe’ … I think that you can buy a lot of trust with openness,” Dr. Larson said.
William Schaffner, MD, MACP, a moderator of the forum, agreed. “I've always been taught, and I teach, that the first thing you do is mirror back to the patient what they've just told you: ‘Ah, Mr. Jones, so you're concerned about the vaccine. I understand that, of course. That's a perfectly reasonable thing,’” he said.
The next step is to ask patients about the nature of their concerns. “The patient knows that you've heard them, and you validate them,” said Dr. Schaffner, who is a professor of preventive medicine and infectious diseases at Vanderbilt University in Nashville, Tenn.
If the patient's worry is the speed of vaccine development, Dr. Hotez has a ready response. “I point out that actually these vaccines are not really being rushed,” he said. “Identifying that the spike protein is the target of the coronavirus, and making vaccines with spike proteins—that began in 2003 after the first SARS, so, this was actually a 17-year vaccine development program, supported by the NIH initially.”
It may also be helpful to point out that the clinical trials of SARS-CoV-2 vaccines were very large. “Really well-powered, massive studies—44,000 individuals in the case of the Pfizer vaccine,” Dr. Hotez said.
“The trial composition is another important part. People want to know that people like them were in the trials,” added Dr. Gayle, noting that there has been a concerted effort to have racially diverse patients get the vaccine.
Spokespeople for vaccine promotion should be similarly diverse, she said. “Have the right messengers. People are going to believe people who look like them, or have shared their life experiences more,” said Dr. Gayle.
They'll also believe people they know, the experts said. “With drop in trust in central government, local, local, local is going to be key,” said Dr. Larson. “The first question everyone's going to get, as a doctor, as a health provider, is, ‘Well, did you take it?’”
Dr. Schaffner is ready for that question. “I'd like to roll up my sleeves right now and get it,” he said. By the time the vaccine is available to patients, he plans to be able to say, “‘I got the vaccine, and so did my wife.’ You immediately personalize it, and you begin to provide some reassurance.”
His next step in these conversations will be to gently address the patients' concerns. “Don't bludgeon them with [arguments for vaccines], and let them ask further questions,” he said.
A laid-back approach is important, agreed Dr. Larson. “Anything that sort of suggests promotion or propaganda—there's antibodies to that in the public these days,” she said. “Go with inform, encourage, and support, rather than promote.”
That doesn't mean telling patients vaccination is their own decision and leaving it at that, however. “We've also seen that's not a good way either. … People want guidance. People want some encouragement for their decision, even though they want to make it themselves,” Dr. Larson said.
It might be more challenging to maintain this approach when faced with the less reasonable concerns about vaccination. “It's become a bit like a whack-a-mole game,” said Dr. Hotez. “It started out, you know, with vaccines causing autism at first … then pervasive developmental disorder … then no, we didn't mean the MMR vaccine, we meant the thimerosal preservative, and then it pivoted again to vaccines too close together, and then it was aluminum.”
With the COVID-19 vaccines, the equivalent trendy worry is “It's going to mess with my DNA,” said Dr. Larson. “Be ready for the RNA/DNA question.” Other experts mentioned other claims, such as the vaccine causing sterility in women. Such ideas may spring from both the existential nature of reproduction and historical examples of forced sterilization, the experts said.
Another common argument for skipping the vaccine is likely to be that only older patients are at risk from COVID-19. “To a certain point, that's true in terms of more serious illness and mortality,” Dr. Larson said.
However, there are a number of other factors that put patients at high risk, pointed out Dr. Adimora. “A lot of internal medicine patients, in fact, do have a fair amount of comorbidities and coexisting conditions, from obesity to cardiovascular disease, etc.,” she said. Such patients should be made to “understand that if they are hospitalized due to COVID, their risk of dying or having a pretty bad outcome is probably substantially higher than the long-term risks of this vaccine.”
Public advertising campaigns, which multiple experts recommended as a key component of the vaccination effort, can show how COVID-19 has caused morbidity and mortality in a wide range of people. “I worked in AIDS for about a decade, and one of the most powerful communication campaigns was a series of posters that were all ages, shapes, sizes of people: Does this look like AIDS?” said Dr. Larson. “It really created a sense of ‘Everyone's at risk.’”
Clinicians can also appeal to altruism as a reason to vaccinate. “We did also see in a lot of our surveys, and it was heartening to see, that people were more likely to accept the vaccine if it was to protect other people than just to protect themselves,” she added.
The viral spread of ideas, as well as COVID-19, is important to remember in these efforts, Dr. Schaffner said. “Physicians will have the opportunity, many of them, to actually administer this vaccine in their offices, or will be speaking with their patients,” he said. “Remember, if you've encouraged them and convinced them, they're going to tell their neighbors. They will be accelerators of the reassurance in their families and communities.”