Confronting Vaccine Hesitancy: An Update

I just reread my editorial from 18 months ago, “Confronting Vaccine Hesitancy.” Was it only 18 months ago? Enough time has elapsed to look back, compare the state of our knowledge then and now and perhaps be better prepared for the coming year.

In February 2021, fear was much more pervasive than I appreciated at the time. (Perhaps that is just as well—when in acute stressful situations, full appreciation of the extent of danger and fear could be immobilizing!) I was volunteering, vaccinating lines of people-at-risk at the convention center while my inpatient colleagues were doing their best to save patients dying from COVID-19 without fully understanding the risks of this powerful, novel virus. Many people were dying. So little was known about the new virus—remember washing off groceries before bringing them into the house, and the shortage of antiseptic wipes? Advice was conflicting, even from scientific and public health authorities. Fear plus uncertainty plus incomplete knowledge provided fertile ground for even more frightening theories.

When I wrote “Confronting Vaccine Hesitancy,” I assumed this virus and its vaccine would follow a more standard, predictable course followed by previous pestilences. There were high hopes that, if enough people were vaccinated (was that critical number 70% or 90%?) and variant forms could be avoided, life would go back to normal in maybe a year, and COVID-19 would retreat.

If I had a crystal ball and saw how COVID-19 would progress, I would be underwhelmed and shocked at the same time. Underwhelmed because the vaccine was not the complete “get out of jail free” card. Instead, practical strategies like masking and isolation proved to mitigate some COVID-19 morbidity and mortality. Antiviral options for treatment of infection that is more serious, quarantining and face-masking, and more available testing all contributed to make the pandemic more manageable, from a medical point of view. However, the shock of losing 1 million people (I had to check—was it really one million?) over the ensuing year validated all the ominous fears of early 2021.

We have painstakingly learned so much more about COVID-19 over these past 18 months, while trying to anticipate and minimize its effect upon our economy, including:

• the virus’ transmission;
• the rapid development of variants which quickly sweep through populations worldwide;
• the modest impact of public health measures to reduce spread (what ever happened to contact tracing?);
• how global disruption can impact supply-chain operations (a factor about which many of us had been blissfully unaware);
• how uncertainty can fire up conspiracy theories and political discord;
• the consequences of underfunding the public health system in our country; and
• the severity and pervasiveness of our socioeconomic and health care disparities (Kaminski M, Skoufalos A. The pandemic exposes clear opportunities for population health in the United States. Popul Health Manag 2020;23(3). doi:10.1089/pop.2020.0071)

In rereading the February editorial, I would have modified this one key takeaway about confronting vaccine hesitancy:

“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, coworker, or friend.”

Since then, I have learned a brief conversation is unlikely to change the views of a patient who has decided not to be vaccinated, inviting a conversation is less likely to be productive. For the greater number of patients who are “on the fence,” research shows expecting the patient to get the vaccine, or that the vaccine is the default approach, is more likely to achieve greater vaccination rates. This includes aligning the office staff, such as the medical assistant or nurse who can advise the patient when they enter the exam room of the preventive measures for which they are due, including vaccines.

Dr Marie T. Brown, MD, the American Medical Association's (AMA) director of practice redesign, noted in the article, “Vaccine Hesitancy: 10 Tips for Talking to Patients,” published by the AMA in 2021: “Adult patients say the second biggest reason they don't get an immunization is that a ‘doctor hasn't told me I need it,’ according to a 2008 study in the American Journal of Medicine, ‘Barriers to Adult Immunization.’ Saying nothing is saying something.”

This default approach is supported in an article from the Canadian Family Physician:

"Decision making around vaccination is complex. As the most trusted source of information on vaccination, physicians are uniquely positioned to sway parents from vaccine hesitancy to acceptance. Facts are not enough to change the views of vaccine-hesitant parents. Present vaccination as the default approach early on; be honest about side effects; maintain trust; focus on protection; and address pain. Be prepared to answer commonly asked questions and know where to find answers to unfamiliar questions. Provide credible resources to parents, especially if they ask."

What can we expect in the coming year?

Today, it looks like COVID-19 will simmer to a slow boil instead of disappearing. As social restrictions are relaxed, and life returns to a closer semblance of what it was pre-pandemic, the monitoring for evolving strains of the virus, and reinstitution of protections in areas with spikes of infections, will become the norm. Our experience in the last 18 months has at least provided us with greater evidence and understanding of COVID-19. Health care professionals can be more confident as they guide their patients through this “new normal.”

Projections using the latest tracking data show that we can expect COVID-19 deaths to be at least three times higher than deaths from influenza. Today, the CDC is reporting a decline in COVID-19 deaths, with an average of 353 deaths/day.

That would project to about 150,000 annual deaths, but does not account for potential surges or new variants this coming year. In comparison, the estimated annual burden of influenza death from 2010-2020 is 12,000-50,000.

Health care is moving towards an annual COVID-19 booster, although debate continues about whether data will support its efficacy.

Vaccine hesitancy will continue to challenge us to provide our patients with optimal protection.