The race to achieve herd immunity in the US is stumbling due to decreased demand to get vaccinated. As I discussed three months ago, we are at a precarious moment in this pandemic. While it feels like things are returning somewhat back to normal, especially with the relaxation of the mask wearing and social distancing recommendations from the CDC, worldwide we are still in the middle of a large wave of cases. Cases in the US have dropped sharply from our recent large wave, but are still at numbers similar to last Spring.
But there are still locations in the world, such as India, being overwhelmed by new cases. This creates the opportunity for new variants of SARS-CoV 2 to emerge. If a variant emerges that is resistant to the current vaccines, then the vaccine program may essentially be reset. The best way to avoid this outcome is to achieve herd immunity, when enough people are resistant to infection that the disease cannot freely spread. We do not yet know for sure what that number is, but estimates are between 70-90%.
Right now in the US 47.7% of the population has received at least one dose of vaccine. This is good, and is likely contributing to the dropping case numbers. But it’s not enough. The rate of vaccinations is also dropping off, raising concerns that we may never achieve herd immunity. The decrease in demand is being driven by so-called “vaccine hesitancy” but this is a diverse groups with varying views. A recent survey clarifies the breakdown of this group, and suggest strategies for getting past the 70% mark.
Based on these results (actually taken from two surveys, 12/21/20 to 1/4/21 and 3/18/21 to 3/25/21) we can break people down first into three groups – vaccine enthusiasts (those who are already vaccinated or definitely plan to get vaccinated), vaccine hesitant (unsure but persuadable), and anti-vaxxers (the survey uses the term “skeptics” but this is not appropriate). The vaccine hesitant group is further broken down into three subgroups: the watchful (those who are waiting to see how everything goes), the cost-anxious (those with resource barriers like time or money to vaccination), and the system distrusters (those distrustful of the medical establishment, but not necessarily anti-vaccine).
The first survey found:
- Enthusiasts: 40%
- Hesitant: 43%
- Watchful: 20%
- Cost-anxious: 14%
- System distruster: 9%
- Anti-vaxxers: 17%
The second survey found:
- Enthusiasts: 62%
- Hesitant: 22%
- Watchful: 6%
- Cost-anxious: 9%
- System distruster: 7%
- Anti-vaxxers: 16%
As predicted, the dedicated anti-vaxxers are largely unmovable. Those in this group believe at least one conspiracy theory about COVID and/or the vaccines, such as the notion that COVID is entirely a hoax, it’s just another virus of no special concern, everyone is going to get it anyway so let it happen, the vaccines are unsafe or unproven, or they are a conspiracy to inject everyone with microchips or at least to control the population. We have extensively documented here (mostly David Gorski) the various lies, distortions, and conspiracy theories that the anti-vaxxers have been spreading. It is probably realistic to consider the 16% of anti-vaxxers to be a hard ceiling on vaccinations, unless truly draconian methods are imposed, which is unlikely to happen.
All of the focus, therefore, is on the middle group – the vaccine hesitant but persuadable. Already that group has dropped from 43 to 22%. If we want to get to 70% vaccinated we need to drop that group by half again, and if we want a buffer at 80% (which may be where herd immunity is) we will need to convince almost everyone in this group.
In this group the watchful dropped the most, which makes sense as millions of people received the vaccine. There have been no issues with the mRNA vaccines, which are most of the doses given. Time, almost by definition, will eat away at this group. The cost-anxious can be dealt with pragmatically, by making the vaccine free and as easy to get as possible. This may also involve encouraging employers to make it easy for their employees to get time off for the vaccine without penalty.
Surveys, however, are not a magic mirror into someone’s personal thoughts and feelings. People might say on a survey that they are waiting to see, or are concerned about cost, when really they have other concerns they are not willing or are too embarrassed to say. If you heard that Bill Gates is putting microchips in the vaccine it might be easier to just say you are concerned about cost.
The system distrusters will be the hardest group to crack. The survey did break down the categories by race, and it was no surprise that black (31-18%) and LatinX (11-11%) were higher than whites (2-4%). This hesitancy is more culturally and historically based, and as many have pointed out the black community in the US has good reason to be cautious about the medical system. I do think times have changed since Tuskegee and the medical profession has gone a long way toward earning back that trust, but historical memory runs deep.
So where do we go from here? We need to get the vaccine hesitant group down into the single digits. No one has the magic answer but we do have information to guide our approach. First, education and outreach is critical. The facts of the situation are really quite clear – the Moderna and Pfizer vaccines are incredibly safe and effective. COVID is a deadly illness, and even for those who survive there is the risk of long COVID or significant morbidity. You don’t want COVID. It’s not just a bad flu. The risk vs. benefit vastly favors getting the vaccine, even in low risk groups because the vaccine risk is so low. There is also the benefit of protecting the people around you. And further, there is the benefit of reducing the pandemic, and allowing society to get back to normal. If you want things to go back to normal (or at least close) then get vaccinated.
There is also the fact that those who are vaccinated have fewer restrictions. They don’t have to wear masks in public, for example. This is now being based on the honor system, however, and there is a bit of a debate about whether or not to require proof of vaccination in certain circumstances. Would this help or hurt?
Education can also help the system distrusters. While there are still racial disparities in medicine, systemic racism and ethical violations are no longer deliberately tolerated. Outreach to specific communities, by trusted members of those communities, is likely to be essential to further reduce hesitancy.
The anti-vaxxers are likely to remain unpersuadable, but their misinformation needs to be vigorously countered. I also do think that social media platforms need to look carefully at their algorithms to ensure they are not promoting anti-vaccine misinformation and dangerous conspiracy theories. They have been, and this is partly their mess, so they should help clean it up.
