Vaccine Hesitancy By Diane Simpson, MD

Vaccine Hesitancy

By Diane Simpson, MD

People who remain hesitant to receive a COVID-19 vaccine are receiving a great deal of attention in print and broadcast media. They are in effect the ‘swing votes’ on whether or when the United States can achieve herd immunity through vaccination and prevent the introduction and spread of new variants.

Not all eligible persons who remain unvaccinated in July 2021 are “vaccine hesitant.” Some are “vaccine opposed” and refuse or resist most or all immunizations and laws that mandate vaccines. Others are “vaccine challenged.” These are vaccine eligible persons who will take the vaccine when they can, but currently face barriers in time, transportation or other logistical factors. The “vaccine hesitant” are those with unanswered concerns and questions that keep them from receiving the vaccine. Understanding the who and why of vaccine hesitancy can help inform the public health and medical provider on what to do.

THE WHO National Information

Through a series of surveys and focus groups, the Kaiser Family Foundation monitors COVID-19 vaccination attitudes and experiences in the United States. Their latest results obtained in late May provide a national snapshot of the percent who are either receptive, hesitant, resistant or adamantly Figure 1: Kaiser Family Foundation COVID-19 Vaccination Attitudes

Figure 2: Vaccine Attitude by Class

against receiving the COVID vaccine (Figure 1).1

The media has focused on the Republican vs. Democratic divide evidenced in these surveys. However, a recent article published in the May 24, 2021 New York Times, “The Morning” online newsletter argues that the vaccination rate differences are more of a class divide between those with college degrees and those without, rather than politics or race.3

The data in Figure 2 shows a random survey of 2,097 adults conducted from April 15 to April 29, 2021. Not all rows total 100 percent. Some participants did not give an answer.

In Bexar County, results from focus groups conducted by the NIH-funded Project, Community Engagement Alliance (CEAL), concluded that vaccine hesitancy was high in the county’s communities of color. (CEALing the COVID19 Loopholes Project CEAL (Bexar County). The work was completed as part of the Community Assessment Methods course offered at the UT Health School of Public Health and overseen by Drs. Valerio and Whigham and Teaching Assistant Dennis O. Nyachoti. All work was completed during the Spring 2021 term. This conclusion is supported by recent county data collected from the state’s immunization registry, although ‘vaccine challenges’ remain another reason for lower vaccination rates. THE WHY

The vaccine challenged remain unvaccinated, but for reasons other than choice. At first, changing eligibility guidelines and the need for an appointment were confusing, time consuming and difficult to navigate. In addition, work, child care and transportation for either the vaccinee or the person transporting them can be barriers. These numbers should decrease as the vaccines are more equitably distributed and vaccination sites are becoming more available around the county.

The vaccine hesitant, who include some health care providers, have chosen not to be vaccinated right now. Prior COVID infections, concerns over vaccine side effects, previous bad experiences with vaccines, as well as historical vaccine abuses by governments are reasons why some choose to wait. Other reasons include misinformation on factors such as costs, citizenship status requirements and medical risks associated with the vaccine. Figure 3: Vaccinations of Bexar County Residents by Race/Ethnicity VA data included; DOD data not included Data provided by the San Antonio Metropolitan Health District, Division of Epidemiology Figure 4: Vaccine Attitudes By New York Times author Sema K. Sgaier of the Surgo Foundation, adjunct assistant professor at the T.H. Chan School of Public Health, Harvard Studies on the effect of personal attitudes toward COVID vaccine uptake are taking place, although results must be viewed with caution. Much of our information on public perception comes from online and telephone surveys or focus groups which, while rapid, face challenges obtaining representative samples that allow scientists to quantify and understand with any certainty the extent of COVID-19 vaccine hesitancy. In an opinion article published by the New York Times author Sema K. Sgaier of the Surgo Foundation and an adjunct assistant professor at the T.H. Chan School of Public Health, Harvard suggested that, based on telephone and online surveys of over 4,400 adults conducted in late 2020/early 2021 and again in March 2021, those who were vaccine hesitant could be placed in one of four types (Figure 4): • Watchful – They are waiting to see what happens next. • Cost Anxious – They want the vaccine but can’t afford the time or cost. • System Distrusters – They feel the health care system does not treat them fairly. • COVID Skeptics – They don’t believe the threat. The remaining persons are “Enthusiasts.”4

A third survey of 18,000 people conducted in English via Facebook in February through April 2021 developed state specific data.

Understanding these categories, the author argues, allows public health officials and medical providers to understand where they face the most challenges and respond more specifically to the concerns of the vaccine hesitant.

WHAT THE PROVIDER CAN DO

There is no one answer or technique to convince every vaccine hesitant person to accept the COVID-19 vaccine. But providers should know the facts and encourage vaccine uptake among eligible patients. Earlier this year in a national poll, more people responded that they listen to their medical providers more than other sources for vaccine information.

DO • Ask why vaccine hesitant patients are concerned about the

COVID-19 vaccine. Be respectful of their reasons. • Explain your views. • Offer to answer their questions. The BCMS has information on

COVID vaccines available through The Physicians Link. • Be honest about the limitations and side effects of COVID-19 vaccines. • Recommend the vaccine to eligible unvaccinated patients. • Have on hand and make available the most recent information on the site and time of COVID-19 vaccination clinics and nearby pharmacies that offer the COVID vaccine. If possible, post information in the waiting room.

DON’T • Jump into an argument without thinking. • Argue, become angry and/or respond only with, “You are wrong.”

References 1. KFF COVID-19 Vaccine Monitor Dashboard. kff.org. (n.d.). https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid19-vaccine-monitor-dashboard/?gclid=Cj0KCQjwhr2FBhDbARIsACjwLo0LjHeLEbqaRCX0vz_sIb3hwuceWCsM5ZHyt_ 8pwhCXYgqUXY_lwt4aAimAEALw_wcB. 2. KFF COVID-19 Vaccine Monitor Dashboard. kff.org. (n.d.). https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-

19-vaccine-monitor-dashboard/messages/messages/information#messengers. 3. Leonhardt, D. (2021, May 24). The Vaccine Class Gap. The New

York Times. https://www.nytimes.com/2021/05/24/briefing/ vaccination-class-gap-us.html. 4. Sgaier, S. K. (2021, May 18). Meet the Four Kinds of People

Holding Us Back From Full Vaccination. The New York Times. https://www.nytimes.com/interactive/2021/05/18/opinion/cov id-19-vaccine-hesitancy.html.

Figure 5: Percentage who says they are likely to turn to each of the following when deciding whether to get a COVID-19 vaccine2

Diane Simpson, MD is a retired physician who is a member of the Public Health and Patient Advocacy Committee and the COVID-19 Taskforce of the BCMS.