Confronting Vaccine Hesitancy

I experienced relief, as I hope many readers already have, as I got my first and second COVID-19 vaccination recently. When I asked if anyone could take a picture of my “vaccine moment,” a staff member became an iPhone photographer as efficiently as they put a band aid on my vaccine site. I wasn’t the first to ask for digital capture of the moment! But despite the remarkable development of this vaccine within a year of identifying the novel coronavirus, vaccine hesitancy threatens the miracle’s impact on population health. Vaccination programs must address the tension between “vaccine choice” and the needs of population health. And failure to immunize a significant percent of the population prevents the protective achievement of “herd immunity” (“population immunity” might be a better term.)

A week prior to my first COVID-19 vaccine, I had a jarring experience with a patient who embodied at least three co-morbidities along with sociodemographic factors that put him at great risk for serious COVID-19 complications and death. His medical record prompted me to point out that, given his diabetes, a pneumococcal vaccine was recommended.

 “What’s that for?” he asked.

“It reduces your chance of getting pneumonia, or a bad case of pneumonia, especially because you have diabetes.”

“I don’t do vaccines,” he stated with a mixture of certainty, discomfort and defensiveness. “I hear people are already falling out from that new COVID vaccine.”

Anger welled up within me as I replied, “Well a few cases of allergic reaction have been reported, but those people didn’t even have to be hospitalized. Compare that to over 3000 people dying every day from COVID.”

Since then, as millions of vaccinations proceed, more and more serious reactions have been reported, although no deaths from vaccination have been reported. Adverse reactions are seen in only 0.03% of vaccinations or 2.5 cases per million.¹

The patient rose up, looked me in the eye, and said “Well I’ll just take my chances on getting COVID.”

It was a jarring experience because I suspect that our interaction did nothing to change his beliefs against vaccination, and may have reinforced his distrust of the health care system that I represented. In fact, many of my patients who decline simple flu vaccination seem to meet the recommendation with similar defensiveness and distrust.

Anti-vaccine sentiment has existed since 1798 when the Smallpox vaccine was developed.² Any vaccine is accompanied with some risk, which is balanced with public health and individual patient benefits. In fact, when monitoring has revealed an unacceptable level of risk, the vaccine has been withdrawn. RotaShield, the first Rotavirus vaccine introduced in 1998, was poised to mitigate a diarrheal disease that sickened and killed many infants around the world. It was withdrawn in 1999 after an unacceptable number of cases of intussusception, a bowel twisting disorder that could be fatal, was reported in a small but significant number of immunized infants.³

Also in 1998, British physician Andrew Wakefield published his study of 12 patients with autism who had received measles-mumps-rubella vaccine.⁴ No causative connection was subsequently shown in further study, and Wakefield’s assertion was debunked. His study nonetheless crystallized an anti-vaccination movement, still very active today, which recognizes Dr. Wakefield as a champion for parents concerned about vaccinating their children. Who can argue against the claim that parents know what’s best for their children? But some parents are misinformed about the risk vs benefit of vaccination for childhood diseases. Measles, once considered eradicable decades ago, has resurged around the world due to vaccine hesitancy and declining vaccination rates.

The tension between “vaccine choice” and community benefit is not simply about the vaccine itself. Social movements, political and religious agendas, and feelings of disenfranchisement are intermixed with conflicting and often overwhelming amounts of information that influence individual decisions. Many patients adopt the beliefs of their group without a critical review and the reliable information that many of us take for granted.

Rumors, some supported by past history, fuel distrust and fear. Today social media spreads them, literally, at the speed of light.

After all, US physicians and scientists ran the government-funded Tuskegee study from 1932 until its halt in 1972 due to the now acknowledged unethical study of natural untreated syphilis infection in a group of Black men.⁵ That may still be a factor, even after 50 years, in my Black patient’s distrust of my recommendations!

“Spread the science!” is a rallying cry heard from the medical and scientific community used to promote accurate information. It may paradoxically feed into the paranoia of those against vaccination who may question what we may actually be spreading. Did my patient believe that US physicians could be falsely documenting COVID-19 infection for financial gain or political agenda?

The US is not alone, nor necessarily the country that experiences the deepest levels of vaccine hesitancy. Dr Heidi J. Larson, an anthropologist who studies global vaccine hesitancy, shares her expert knowledge in Stuck, a book published in 2020 just before the COVID-19 Pandemic hit.⁶ She describes, for example, how vaccination campaigns in third-world countries have been thwarted by rumors that the US or the World Health Organization may be promoting vaccination to render populations infertile. Dr. Larson also presages much of the misinformation and hesitancy that we’ve witnessed as the COVID-19 pandemic has evolved through 2020:

“It struck me that the biggest glaring cause of the tsunami of vaccine protests is the fact that the medical and public health community are so focused on the act of vaccination, of counting, of reaching numerical targets, that efforts to engage the web of society, culture, politics, and economics that surround the vaccination have been lost,” Stuck, page 71.

What could this suggest for each of us, as we advise our patients (and customers, employees, and family members) about vaccination? My key takeaways are:

• Be aware of the extent of misinformation, and the power of social media to spread rumors and foment distrust.
• Understand that vaccine hesitancy is about much more than just the vaccine.
• Recognize that each of us, even the vaccine hesitant, truly wants what is best for ourselves and our loved ones.
• Listen and encourage a patient to share their concerns about vaccination. If they feel heard and respected, they are more likely to trust information from their physician, family member, co-worker or friend.

Please share with me your thoughts about and experiences with vaccine hesitancy!

This article was published in partnership with the Jefferson College of Population Health

Disclaimer: The views and opinions expressed are those of the authors and do not necessarily reflect the official policy or position of Population Health Learning Network. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, organization, company, individual or anyone or anything.   

References:

1. Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Moderna COVID-19 Vaccine-United States, December 21, 2020-January 10, 2021. MMWR Morb Mortal Wkly Rep. ePub: 22January 2021. DOI: https://dx.doi.org/10.15585/mmwr.mm7004e1
2. US National Library of Medicine. Smallpox: A Great and Terrible Scourge. https://www.nlm.nih.gov/exhibition/smallpox/sp_resistance.html. July 30, 2013. 
3. Schwartz, JL. The First Rotavirus Vaccine and the Politics of Acceptable Risk. Milbank Q. 2012 Jun; 90(2): 278-310. Doi: 10.1111/j.1468-0009.2012.00664.x
4. Wakefield A, Murch S, Anthony A, Linnell J, Casson D, Malik M, Berelowitz M, Dhillon A, Thomson M, Harvey P, Valentine A, Davies S, Walker-Smith J. Ileal-Lymphoid-Nodular Hyperplasia, Non-specific Colitis, and Pervasive Developmental Disorder in Children. The Lancet. 1998;351(9103):637–41.
5. Centers for Disease Control and Prevention. U.S. Public Health Service Syphilis Study at Tuskegee. https://www.cdc.gov/tuskegee/index.html. 2020. 
6. Larson, Heidi J. (2020). Stuck: How Vaccine Rumors Start, and Why They Don’t Go Away. Oxford University Press.