With the supply of vaccines now outpacing vaccination rates in countries like the USA and Canada, achieving robust community (herd) immunity and reducing illness, hospitalizations and death will be dependent on achieving adequate uptake of the vaccine in the population. At time of writing, the Delta variant is the most important variant of concern, and it appears to be more transmissible and potentially capable of causing more severe disease. And while the currently-authorized vaccines still seem to be effective at reducing the severity of COVID-19 infections, hospitalization, and death, there is acknowledgement that as long as SARS-CoV-2 continues to circulate widely, the risk of more dangerous variants appearing will remain.
Many of those eligible for the vaccine have leapt at the chance to be vaccinated. Where I am in Ontario, Canada, the rollout has been a Hunger Games-like experience at times, with limited supply, overloaded booking systems and long queues at pop-up clinics. But despite the technical issues and delays, Canadians are embracing vaccination. Currently 78.2% of eligible Canadians (12 years and older) have receive their first dose, which is 68% of the entire Canadian population. These numbers now outpace the overall USA and compare favorably with some states (congratulations Vermont!) with even better uptake. But there are huge differences within regions and state-to-state. For all of New England’s success in vaccinating its population, there are states like Mississippi (one dose: 36.3%), Louisiana (38.7%) and Idaho (39.8%). Even in Canada, with its generally high uptake, a granular analysis of Toronto (75%+ first dose overall) shows the rate varies from 56%-83% (at time of writing) when you break down vaccination by neighborhood. The variation is even greater when looking at county-by-county vaccination rates in the USA, where even some “successful” states have regions with low uptake.
So what is driving the variation? The correlation with voting patterns, in the USA, is one factor that has been widely cited. But hesitancy and resistance is not new to vaccination, or even vaccination during a public health crisis. Smallpox spread through the city of Montreal in 1885, killing almost 2% of the population. This was 90 years after Edward Jenner had published his work on smallpox vaccination. While Montreal’s wealthier English-speaking population had embraced the vaccine and were largely untouched by this epidemic, the disease found 90% of its victims in the poorer French-speaking population. When the Board of Health eventually mandated smallpox vaccination, people rioted, attacking the police station and police. The Board of Health attributed the riots to lies told by vaccine opponents. And while smallpox was eventually eradicated from the earth, the same cannot be said for antivaccination sentiment.
Steven Novella has written several posts about vaccine hesitancy in the era of the COVID-19 pandemic. With the Delta variant expected to cause the most cases of COVID-19, and signs that it is already fueling another wave in regions with poor uptake, the summer and fall are shaping up to be a race between vaccination and Delta.
In one of Steve’s prior posts he discussed a survey which stratified the population into three groups:
- Enthusiasts – those who are already vaccinated or plan to get vaccinated
- Vaccine Hesitant – unsure, but persuadable, which were further sub-divided:
- watchful – waiting for now
- cost-anxious – those with resource barriers like time or money
- system distrusters – those that distrust the medical “establishment”, but not necessarily vaccines
- Anti-Vaxxers – those that believe one or more conspiracy theories about vaccines or COVID-19. This group is likely to be largely unreachable and have reasoned themselves into a position where they will not accept the vaccine.
With vaccination rates in the USA dropping week over week since their April peak, which are similar to what we’re starting to see in Canada (albeit with a higher overall uptake), the focus now needs to change, acknowledging that there will remain a hard-core group of anti-vaxxers that will continue to refuse the vaccine. No amount of persuasion is expected to have an effect on this group.
The vaccine hesitant group is where efforts need to be focused – identifying them, understanding the barriers, and addressing them. Some strategies employed have included lotteries like those trialed in Ohio, which offered randomly selected individuals that had received a vaccine up to $1 million. While this tactic might be expected to be persuasive to some of the vaccine hesitant, an analysis of vaccine uptake suggests that this strategy was ineffective.
If we want to shrink that proportion of the population that is unvaccinated, then tactics will need to focus on these people who are hesitant, but convincible. And that means that delivery probably needs to shift from large vaccination centres, designed for high volumes of willing recipients, to targeted approaches that, if necessary, bring the vaccine to the recipient.
Addressing barriers seems like an obvious solution, but those barriers may vary and be hard to pinpoint. Time to access the vaccine is critical. Some people may be willing, but may not have found the time to get vaccinated or are worried about possibly needing to take time off because of side effects. A recent US survey noted that when employers offered employees paid time off to get vaccinated or recover from side effects, that uptake was higher.
Another barrier that can be very real is trypanophobia – fear of needles. Up to 10% of adults have a fear of needles, and that fear may be driving vaccination hesitancy. In response, some vaccination clinics offer different forms of accommodation which can include privacy and even an area to lie down after the vaccine has been administered.
Other barriers may include language, technology or trust. Here is where primary care physicians and health professionals like pharmacists have the advantage of a trusted relationship that can be leveraged. Confirming the availability of the vaccine, starting conversations with patients, and offering to share knowledge have the potential to be highly influential. I know that the independent pharmacist in my neighborhood is highly respected by his customers. He is proactively reaching out to his clients, confirming their vaccination status when they have their prescriptions refilled, and offering to work around their schedule to get them vaccinated. The same approach can be used by family doctors who can reach out to their patients and also confirm vaccination status with any appointment. The advantage of this approach is the opportunity for the professional to provide tailored advice relevant to that patient’s circumstances and health concerns.
Targeted discussions don’t have to just come from health professionals. Tara Smith recently outlined some tactics that can be used in your personal relationships with those that express hesitation:
- Lead from a place of emotional connection – ensure they know you have their best interests at heart.
- Put empathy front and center – Listen. Don’t judge or argue – no matter how difficult it may be. Gather information.
- Use the “Four R’s” – Receive, Repeat, Respond, Refer.
- Avoid easy-to-make mistakes – Condescension or impatience will derail the dialogue.
- This is a marathon, not a sprint – a single conversation is unlikely to work. Success means a follow-up discussion.
If you want to try out your skills before your next awkward conversation with your vaccine-hesitant friend or family member, practice with the New York Times Chatbot.
Finally, some tactics may seem more like sticks than carrots, but they may also help prod the highly resistant into getting vaccinated. The extent to which employers and schools will require vaccination is only beginning to be be explored, now that vaccines have become more widely available. Not every employer will go as far as Houston Methodist’s approach, but workplaces are expected to grapple with this, especially for those returning to the traditional office. The same can be said for anyone that wants to travel – vaccine passports are coming and showing proof of vaccination when crossing an international border could be even more common than it already is.
Vaccines don’t work if they’re not administered. And while COVID-19 vaccines clearly provide personal protection to the recipient, we will all be safer if we can achieve robust vaccine uptake and reduce community spread of the disease. Closing the vaccine gap with the vaccine-hesitant is the challenge that is going to make or break the overall success of the COVID-19 vaccine campaign.