The Person Reluctant to Vaccination: Some Approaches

William Buchholz, MD

The Person Reluctant to Vaccination:

Some Approaches

Updated 2/15/21

The strategy of changing minds

There are many reasons given for declining vaccination: misinformation, lack of knowledge of facts; negative cultural experiences with medicine; deeply held ideas and convictions; fear and underlying suspicion. To address a person’s reluctance start with two principles: be curious why the person is reluctant and allow the person to feel heard and their beliefs understood. Different reasons require different approaches.

Misinformation and lack of knowledge may be addressed by providing TRUSTWORTHY true information. Explaining the foundation for misinformation which may have some distorted truth can replace the doubts about vaccination. Providing the scientific source of facts, possibly with a reference website or source of the information (like the CDC or county public health department) makes shifting ideas easier. Acknowledging outright that certain events do occur and adding the frequency—often far lower than the person believes—can create a tolerable sense of risk and benefit.

Some persons may recognize only some sources of information as trustworthy. If science is not one of them then the words and experience of friends or other individuals like clergy—for example a parish priest--or even celebrities, may allow them to accept information.

Negative cultural experiences like the Tuskegee experiment to deny Blacks effective treatment for syphilis to understand the natural history of the disease can create deep suspicion of the medical system in general. Persons of color or underserved populations likewise may have unpleasant and disappointing experiences with the medical system and not understand that it can work well for them. This type of hesitancy may not be refusal but a wait and see attitude. If they can gathering more real time positive information on vaccination that may allow them to accept the shots.

Deeply held beliefs, often arising from mistrust and fear, require a different approach.

Until you discover what that person believes or fears you can’t have a logical conversation with them. Mark Twain once remarked You can’t reason someone out of something they weren’t reasoned into. The best thing to do is listen without judgement

to what beliefs that person holds. Expressing their fears and having someone actually listen to them can be healing. Even if the person sticks to their position after being heard and given accurate information about the risks of vaccination or not being vaccination there is still an opportunity to change the context of the subject.

Most people hold ethical values for treating friends and loved ones. These include the wish to help them or at least not harm them. Determine what the person’s values are is a place to start. Posing What if…? questions like What would happen if you did get Covid and infected your parents, grandparents, partner, children? Finding out what is more important to them than their current belief changes the calculus for deciding on vaccination. If they seem open to that then ask what would get in the way of being vaccinated and helping them problem solve.

Finally, the most critical element of a successful strategy is timing. Maintaining connection with that person, listening to them without judgment, having conversations that don’t focus on vaccination but shared experiences—grandchildren, golf, go-carting—does establish a relationship that is removed from conflictual positions. That can create the trust needed to feel safe to change minds.

Reasons for reluctance and possible responses

Many reasons may be given for their reluctance.

Common ones include:

1 We don’t know the long-term side effects. 2. What about the side effects now; I heard there some people have anaphylactic shock or even die after getting vaccinated. 3. I might spread Covid from the vaccine. 4. How do I know I won’t give someone Covid even if I get the vaccine?

5. I don’t trust anything/any medicine that was produced in that short a time. 6. They put nanoparticles in the vaccine that will track your body or change your DNA 7. Vaccination is a conspiracy for … 8. What if…?

Possible responses could include:

1. It’s true that we don’t know the long-term side effects yet. We do know the short-term side effects of NOT being vaccinated, however. Infecting someone else, maybe someone you love; Getting severely sick and being in the ICU for a month; Having a long recovery with many complications like chronic fatigue, impaired cognition and memory, chronic pain, shortness of breath; and others. 2. Statistics show only 0.2% of people have adverse effects. Of 11,000,000 injections 21 persons had very severe reactions (0.002%). 17 of this group of 21 persons had previous severe allergic reactions to medicines, foods, insect stings. No one died from their reaction. IF YOU HAVE HAD A SEVERE ALLERGIC REACTION BEFORE TELL THE PERSON ADMINISTERING THE VACCINE. THEY WILL OBSERVE YOU FOR AT LEAST 30 MIN. AND BE PREPARED WITH APPROPRIATE MEDICINES IF NEEDED. 3. The current vaccines (Moderna and Pfizer) do not have any virus in them and cannot give anyone Covid. 4. It’s true that at this time we don’t have robust data that proves you can’t infect someone after you’ve been vaccinated. There are some reports that persons who have been vaccinated can later be found to have a positive Covid 19 throat swab. It is not clear whether they can transmit this to anyone else since there may not be enough viral particles—though they can be detected with very sensitive PCR tests—to infect someone else. The sporadic reports, however, show that the number of persons to have a positive test either after vaccinated or recovered from active infection are only a fraction of a percent. 5. Generally fear is the basis for not trusting any medicine that has been produced quickly and verified by impartial doctors. Yet some people with the threat of a seriou disease that could kill them like cancer seek out new medicines that have not even been approved. Since there is a risk of dying from Covid, you need to look at the alternatives. 6. There are tracking numbers on the boxes of vaccine to make sure there is proper distribution. There isn’t any tracking device in the actual vaccine. The vaccine has bits of RNA, not DNA which is different. It cannot affect huma genetics which is based on DNA. 7. Conspiracy theories are unfortunately common these days. It’s impossible to track down the basic information that ha been misunderstood or simply perpetuates fear. Changin the mindset of individuals unwilling to change their mind will take a lot of time; be patient. 8. It is true that the future is unknown, yet we keep on living as best we can with what we have. Overcoming fear and mistrust is the job now.

Information Behind The Information

Recent articles highlight healthcare workers who decline vaccination or take a wait-and-see position. This may lead to the conclusion that since they work in health care they must know something that makes them hesitant.

The information behind this belief is that many health care workers are African-American or Latinex. They may have legitimate reasons to be suspicious of medicine because of racial discrimination or generally poor healthcare. Think of the Tuskegee experiment withholding treatment for syphilis in Blacks or the way that people of color may not have access to medical care at all.

Anti-vaxxers, groups who purposely promote misinformation, have 59.2m followers on social media according to an article in a British publication, The Economist. The majority of them (80%) have financial interests like selling alternative therapies or creating advertising revenue for their commercial sites. Their strategies include sowing doubt about the seriousness of the threat, spread concern about the safety of the vaccines; and stress the untrustworthiness of experts. (http://econ.st/3savYM0)

Interesting Statistics and Data

Mark Twain once said There are lies, there are damn lies, and then there are statistics. In this time of lies, misinformation and the global pandemic of fear and mistrust, we still have to deal with reality and data. Most of the following information I’ve gathered from articles published in the New England Journal of Medicine, from Santa Clara County Public Health department and the Centers for Disease Control (CDC). Some comes from citations from reputable journals (like Nature) and reports from other sources I trust.

Incidence and Mortality from SARS-CoV-2 Virus and COVID 19 disease

Both Moderna and Pfizer vaccines are used in this area and have similar benefits (95% protection) and side effect profiles. The data does not specify which vaccine was used.

The risk of death in Santa Clara County from a new case of Covid has varied from 1% to 3% from Oct. 1 thru Jan. 15.

Infections and deaths vary with age. Infections are highest in ages 20-29, 7000/100,000 or 7% though mortality rate is low, 2.5/100,000. For Seniors age 70-79 infection rate is 3300/100,000 (3.3%) and for 80+ the infection rate is 5100/100,000 (5.1%). This is generally lower than for younger groups. The mortality rate is greater, 207/100,000 (0.2%) for 70-79 and 5100/100000 (0.5%) for those 80+. Seniors have more chronic illnesses and co-morbidities that make them less able to survive an additional illness, especially if they have moderate or severe Covid.

Risk of Side Effects from Vaccine

About 80% of persons getting vaccinated have one or more side effects, mainly pain or soreness at the injection site after the second shot. In general, older (>55) persons had fewer side effects. Local side effects include pain (50-60%), swelling (20%), achy joints or muscles (20% first shot, 60% second shot). Some people experience a fever or chills, fatigue and headache. All these symptoms were rated mild or moderate and lasted for less than 7 days.

There have been some allergic reactions including serious ones. Statistics show only 0.2% of people have adverse effects. Of 11,000,000 injections 21 persons had very severe reactions (0.002%). 17 of this group of 21 persons had previous severe allergic reactions to medicines, foods, insect stings. No one died from their reaction.

Data from the Astra-Zeneca vaccine shows 50% have injection site pain, headache or fatigue though the second shot side effects are milder than the first.

There have been no deaths linked to any of the vaccines.

Vaccination Beneficial Effects

Immune response is nearly equal in younger (18-55yo) and older (65-85) persons and is measurable 14 days after the first shot. The second shot is given on day 21 (Pfizer vaccine) and improves dramatically one week later, by day 28. People who have had Covid 19 have antibody levels slightly lower than those vaccinated. The current recommendation is to be vaccinated even if you have had Covid 19 infection.

The graph below shows the incidence of symptomatic Covid 19 with vaccination vs. placebo. Open circles are cases of Covid 19 and dark circles are severe cases. The two lines are superimposed up to d 12-15, before any immune response occurred in the vaccinated population. The rising line (Placebo) shows continuous rise in cases; the horizontal like shows far fewer cases (94.8% fewer) and only one serious case. This dramatically illustrates that the vaccine prevents total cases as well as serious ones and protection continues for at least 98 days.

Update 2/28/21

Mutations in SARS-CoV-2

All viruses mutate as they multiply and several new strains have been detected. In Great Britain the mutation B.117 is now predominant and is also widespread in the US. The mutant virus predominant in California is different from B.117 and known as CAL.20C, or B.1429.

Mutations continue to evolve and each new virus that is shown to be widespread in a country raises concern about its behavior and whether they will be sensitive to the existing vaccinations. There are new vaccines being released by different companies that are known to be effective on new variants. Existing Moderna and Pfizer vaccines remain effective at neutralizing the variants though at a lower titer than for the original virus.

Johnson and Johnson vaccine is now available. It is different from Moderna and Pfizer vaccines in several aspects. It works like other vaccines that rely on the immune system responding to the viral spike protein, not the RNA. It only requires a single jab and doesn’t need special refrigeration. It is effective against some of the variants; 80-85% protection against severe illness and overall including less severe illness, 66% protective. It was 100% effective in preventing hospitalization and deaths in the US as well as South Africa (B.1351) and Brazil (B.11248).

There is a pattern in the reports of new variants. Initially they raise concern about the variants in the first two paragraphs and further down in the article it notes that there is insufficient data to know what it will actually do. I update information from reliable resources as it is available.

Earlier reports on B.117 suggested it was transmitted 35-45% more easily than the original virus and more likely to cause death. The answer why some variants (like B.117) are more infective than other strains is believed to be that they last longer in the person. B117 lasts 13.3 days in the body while other variants last 8.2 days. (S. M. Kissler et al. Preprint at http://bit.ly/3lF3rLT; 2021, not yet peer reviewed data).

The increase in death rate is small and not yet understood. For men from 55 to 69 years old, that raised the overall risk of death from 0.6 percent to 0.9 percent. For women in that age group, it raised the overall risk of death from 0.2 percent to 0.3 percent.

On Feb. 2, 2021 there was a webinar by the New York Academy of Science that reported a Covid 19 producing virus that had combined RNA from both the British (B117) and California (B.1249) variants. The implications of the finding aren’t yet clear because very little is known about the recombinant’s biology. The concern is that the mutation from B117 making it more transmissible and from B1.429 which could confer resistance to antibodies. http://bit.ly/3c9H9yQ and

http://bit.ly/3eYSXG2

QUESTIONS ON VACCINES

Update 2/28/21

Does vaccination prevent getting infected from SARSCoV-2 or from spreading SARS-CoV-2 to others?

The current hypothesis is that the immunity from vaccination prevents the virus from getting concentrated enough to cause symptoms. Vaccinated persons can have a positive Covid test and remain asymptomatic even when they have antibodies. The viral load (amount of virus present in the person is too low for them to be infectious and spread the virus.

Marks, M. et al. Lancet Infect. Dis. https://doi.org/10.1016/ S1473-3099(20)30985-3 (2021). Levine-Tiefenbrun, M. et al. Preprint at medRxiv https://bit.ly/3sgqxLq

Update 2/25/21

Nature is a well-respected international journal of the sciences. The following information comes from this website: https://go.nature.com/3vKKWKV are currently licensed vaccines (Moderna, Pfizer, Astra-Zeneca, Johnson and Johnson) protective against emerging variants?

When serum from persons vaccinated with Pfizer was tested against the South African variant B.1351 was effective but at 1/3 the titer as against the original virus. (Y. Liu et al. N. Engl. J. Med. https://doi.org/fwsc; 2021)

The efficacy of the Astra-Zeneca/Oxford vaccine was even higher if there was a longer interval between the first and second shots. It was 55% effective in those who received their second dose less than 6 weeks after their first, and 81% effective in those whose second dose was more than 12 weeks after their first. A single dose was 76% effective (compared to placebo) for at least 90 days.

2020 YEAR IN REVIEW

2020 was unlike any other year in CMA’s 164-year history. As an association largely founded during a cholera outbreak, we quickly rose to the challenge and shifted all gears to help physician members, elected officials and policymakers navigate the COVID-19 crisis. This year’s achievements include:

Advised the state’s development of executive orders and laws to ensure physicians

could respond to the pandemic, including on telehealth policy, regulatory waivers and public health officer safety.

Distributed more than 60 million pieces of personal protective equipment (PPE) to more than 8,000 physician practices statewide.

Secured more than $100 billion in financial

assistance to physician practices in Coronavirus Aid, Relief, and Economic Security (CARES) Act and an additional $75 billion to the HHS Provider Relief Fund in the COVID-19 “Interim Economic Relief” bill.

Created a new COVID-19

website with daily updates, toolkits, webinars and other resources for physicians.

Convened virtual grand

rounds on COVID-19 topics, including transmission, schools re-opening, testing and vaccines. Protected Proposition 56 funding (tobacco tax revenues) in the state budget, including $57 million for physician loan repayment and $38 million for graduate medical education programs.

Sponsored a new ban on flavored

tobacco products that will save lives, as well as limit Big Tobacco’s ability to target children and communities of color. Amended CMA’s mission statement to include health equity.

Continued our court fight to protect the Affordable Care Act.

Helped shape a federal surprise

billing ban that includes baseball-style arbitration to resolve disputes between physicians and payors.

Visit cmadocs.org for more information.

CMA Launches Free PPE Direct Shipment for California Physicians and Medical Groups

https://www.cmadocs.org/newsroom/news/view/ArticleId/49253/CMA-launches-free-PPE-direct-shipmentsfor-California-physicians-and-medical-groups

The California Medical Association (CMA) is extending its distribution of free personal protective equipment (PPE) with direct shipment of supplies to California physicians.

The new online portal offers California physicians the ability to register for specific types of PPE including coveralls, face shields, goggles, hand sanitizer, sanitizing wipes, isolation gowns, N95 masks, surgical masks and vinyl gloves. The PPE is free, and the medical practice pays a nominal cost for shipping and handling.

CMA distributed over 100 million pieces of PPE to physicians and medical groups from August 1 to December 31, 2020. The donations supported approximately 100,000 California physicians and their staff, which represented a total value of more than $200 million.

“Lack of PPE throughout the COVID-19 pandemic has compounded hardships for medical practices and hindered physicians’ ability to serve patients,” said CMA President Peter N. Bretan, Jr., M.D. “We knew we had to act – and fast – to help physicians keep their practices open. What resulted was an unprecedented effort in the organization’s 165-year history. CMA is grateful to our partners for their collaboration and support, which ultimately helped so many Californians continue to receive health care.”

Last summer, CMA partnered with local county medical societies to develop an entirely new statewide distribution system for essential medical equipment, which included PPE donations from the Office of Emergency Services (OES).

Within weeks, PPE was being moved from state warehouses, repackaged into individual kits and loaded on trucks to be handed out at drive-through events across the state. Physicians and medical practices also accessed PPE through their local county medical society or CMA’s online request portal.

As of December 31, 2020, the effort had distributed a combination of 35 million masks, 35 million sets of gloves, 2.3 million isolation gowns, 2.5 million face shields, 400,000 hooded coveralls, 21 million N95 respirators, 3 million sanitizing wipes and 700,000 sanitizer bottles.

“I’m really impressed with the distribution operations to small- and medium-sized practices,” said Richard Siedman, M.D., Chief Medical Officer of the LA Care Health Plan. “These medical practices are critical to the overall health care delivery system in our state and enables physicians and their staff to more safely provide the care that their patients need.”

“These free PPE kits were a lifeline during a very challenging year,” said Elk Grove cardiologist Rajan Hundal, M.D. “Without the donations, we would have had to limit hours or close our practice completely. The PPE helped our patient care team stay healthy and enabled us to continue serving our patients – our community is healthier because of this program.”

The lessons learned during the PPE distribution effort will be applied to helping the state build its vaccination network.

“The administration of COVID-19 vaccines brings hope into focus, but the global pandemic remains challenging,” said Dr. Bretan. “Equity and speed remain vital components of any successful vaccination strategy, and we cannot compromise one for the other. The lessons learned distributing PPE will guide CMA as we help the state build out their robust vaccination network connected to community physicians that millions of Californians already rely on for flu shots and routine vaccinations.”

Download:

Watch:

See also:

Program infographic

https://www.cmadocs.org/ Portals/CMA/files/public/ PPE%2520Relief%2520Infographic%2520(2020).

CMA PPE Relief Documentary (October 2020)

https://www.youtube.com/ watch?v=Mgs7108h5f8

CMA distributes two-month supply of free PPE to more than 40k California physicians (September 2020)

https://www.cmadocs.org/newsroom/news/ view/ArticleID/49021/t/CMA-distributes-twomonth-supply-of-free-PPE-to-more-than-40kCalifornia-physicians