POST 144. March 20, 2021. CORONAVIRUS. ““The vaccine hesitancy we are seeing isn’t just about Covid vaccines,”… “It is a general reflection of Americans’ lack of trust in science, the pharmaceutical industry, and large health care institutions. We need a full court press on science and vaccine education right now to prevent more aggressive Covid-19 variants from developing and taking hold.”

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“Refusing a vaccine when one is available is known as “vaccine hesitancy.” In recent years, vaccine hesitancy has increased worldwide — so much so that the World Health Organization considered it a top 10 global health threat in 2019. Misinformation is a major cause of vaccine hesitancy, and there is much misinformation about both COVID-19 and its vaccine because they are new.

Vaccine hesitancy or distrust is a problem because it can make it harder to contain a disease. To improve disease control in a community, the community must reach “herd immunity.” Herd immunity means that the majority of people cannot get sick or spread the disease to others. In this way, the whole community is protected.

The percent of people that need to be immunized to achieve herd immunity is different for different diseases. For COVID-19, experts estimate that between 70% and 90% of a community would need to be immunized against the virus to achieve herd immunity, although the exact number is not known. People can become immunized either by having a COVID-19 infection or through taking a vaccine.

Since COVID-19 can be a very serious illness, if 70% to 90% of Americans became sick, a large number of people would need to be hospitalized and many could die. This is why having a vaccine that works is so important. With a vaccine, many more people could become immunized without getting sick. If not enough people take the vaccine, though, achieving herd immunity becomes much more difficult.

Why are some people hesitant to get the COVID-19 vaccine?

There are many reasons why people may hesitate to take the COVID-19 vaccine.

Distrust of vaccines: Some people will not accept any vaccines at all. For example, some people choose not to get the yearly flu vaccine because they think it does not work or they worry that it will make them sick. Others worry about links between vaccines and autism disorder, and although these links have been disproven, they choose to skip recommended childhood vaccines. 

Vaccine timeline: Others may accept common vaccines, but may hesitate to take the COVID-19 vaccine because it is new and was created quickly. In the past, development and approval of most vaccines took years. For the COVID-19 vaccine, creation and approval took less than a year. This seems rushed to some, and may contribute to concerns about vaccine safety. However, development of the vaccine was not as rushed as it seems. Scientists have used the technology behind the COVID-19 vaccine for 20 years. This is why they were able to create the vaccine as fast as they did.

Effectiveness: While some people worry about safety, others worry about effectiveness. After development of the vaccine, scientists studied it in human volunteers. These early studies have shown that the vaccine is safe and effective, but there is still much that is unknown, including how long the vaccine is effective, if it works against new strains of the virus, and whether or not someone who is vaccinated can still spread the disease to others.

Side effects: Fear of unknown side effects and frustration about unknown long-term effects are other reasons that some people may not accept the vaccine.

Lack of concern about the virus: Finally, there are also some communities where people do not consider COVID-19 to be a serious risk. In these communities, people may not accept a COVID vaccine because to them the risks of the vaccine seem greater than the risks of the disease.” (A)

“The views of one-third of Americans may not always amount to a national crisis, but those views matter a lot when the country needs to do something that requires nearly everybody on board. That’s the case with the Covid-19 vaccination campaign, where 70 or 80 percent — or more — of the country will need to get vaccinated to reach herd immunity. So surveys that show as many as one-third of Americans are skeptical amount to a real public health crisis.

Compounding that is the reality that a Covid-19 vaccine still hasn’t been approved for children — and that might not happen until later this summer or even 2022. Given that kids make up 22 percent of the population, herd immunity probably can’t happen without them. But even if herd immunity only requires the lower estimate of 70 percent of Americans, that still will be impossible if more than 30 percent of adults refuse a vaccine.

Based on public surveys, particularly in-depth ones from the Kaiser Family Foundation, the skeptical report a variety of concerns regarding the Covid-19 vaccine.

A major one is concerns about side effects, particularly long-term health consequences. The Covid-19 vaccines do have side effects, but they’re almost entirely minor — temporary aches, fever, and cold-like symptoms — aside from rare allergic reactions, which require monitoring but are treatable. Still, people worry about the risks.

Some of the skeptics worry that the vaccine approval process, given its record speed, was rushed. But the Covid-19 vaccines still went through the three-phase clinical trial process required by the Food and Drug Administration, testing for safety and efficacy. The vaccines have also been out in the real world for months now, with still no reports of previously unknown and serious effects.

Some people of color also distrust the health care system, based on their experiences with a system that’s often discriminatory and a history of experimentation on Black bodies, such as the Tuskegee study. Surveys show that Latinos and Black people, in particular, are less likely to trust doctors and hospitals in general. That’s likely fed into distrust toward the vaccine, too.” (B)

“IHME forecasts that no more than 40 percent of U.S. residents will be immune to COVID-19 by July ’21

First, if the population is hesitant to get vaccinated, it could halve coverage: in the United States, surveys of adult Facebook users indicate that approximately 25 percent will refuse the vaccine and a further 25 percent are uncertain. Assuming that half of the uncertain people can be persuaded to be vaccinated, 62.5 percent of the adult population will be covered. (The vaccine is only currently approved for adults, so this would cover less than 50 percent  of the total population)…

The second factor is the protective impact of the vaccines. If half the U.S. population were vaccinated, what share would be immune? The Moderna and Pfizer vaccines are highly effective at preventing severe disease but there is very limited evidence as to whether they prevent infection or infectiousness. The Astra Zeneca vaccine is less effective, and in a subset of trial participants appeared to block infection in around half of those vaccinated. Early data from Israel suggest that the fraction protected from infection may be between 30 and 60 percent. In our modeling at the Institute for Health Metrics and Evaluation, we estimate that vaccines are half as effective at blocking infection as they are at preventing severe disease.  To further complicate this picture, a vaccine may fail to prevent infection yet still reduce patients’ infectiousness, but no data are currently available to assess this.

In the United States, if we assume that by vaccinating half of the population by the fall we render a quarter of the population immune, and combine that with those immune through previous infection, we get to levels of overall immunity of 40 to 50 percent. Most high-income countries will have similar experiences. This level of immunity may be enough for summer herd immunity, but is unlikely to prevent a third wave in the winter of 2021 — even if due to the high clinical efficacy of the vaccines in preventing severe disease, we would expect there to be far fewer deaths.

A third variable is the spread of new viral variants, such as B.1.1.7 (first identified in the United Kingdom) and B.1.351 (first identified in South Africa), whose higher transmissibility raises the threshold needed to reach herd immunity. Available evidence suggests these variants will become dominant within two to five months. Moderna reports that their vaccine produces 20 percent of the neutralizing antibodies for B.1.351 that it did for the original virus; this may render the vaccine less clinically effective, and less effective in preventing infection. Rapid spread of B.1.1.7 in Portugal in recent weeks indicates that other countries presages its arrival in other countries in the Northern Hemisphere. These variants can extend the current winter surge later into the spring, and also make it more difficult to achieve herd immunity in order to prevent a third wave. Randomized clinical trials or effectiveness studies to test vaccines’ actual clinical effectiveness against the variants will be critical for determining the path to herd immunity.”

Finally, if immunity from infection or vaccination wanes over time, a real possibility, the level of cumulative infection and vaccination required to achieve herd immunity will also be higher, increasing the likelihood that COVID-19 becomes a seasonal disease like flu. So far, we do not have data to model for this.” (C)

“All eyes are on the nation’s chaotic COVID-19 immunization rollout, as public health officials struggle to outpace the coronavirus and its variants by quickly inoculating those most likely to be hospitalized or die if infected.

But in the months ahead, as the vaccine supply chain unkinks, the demand for shots is expected to ebb, leaving public health agencies with a different and perhaps greater challenge—coaxing people who aren’t sure they want a shot to roll up their sleeves.

The goal is to reach herd immunity, a widely debated concept that most scientists say can be achieved by vaccinating roughly 80% of the adult population, leaving the coronavirus with so few hosts that it all but disappears.

“We’ve never done that before with any other adult vaccine,” said Dr. William Schaffner, professor of preventive medicine at the Vanderbilt University School of Medicine. It’s a worthy goal, he said, but it will take a monumental effort.

In some places, local health departments already are making inroads in minority and immigrant neighborhoods where people may mistrust the medical community and refuse vaccinations, he said.

But even within the priority groups designated in the federal Centers for Disease Control and Prevention’s guidelines—health care workers, long-term care residents and staff, and people 65 and older—a substantial number of people are holding back.

According to January survey data from the Kaiser Family Foundation, a San Francisco-based nonprofit that researches national health issues, roughly 3 in 10 health care workers express hesitancy about getting a COVID-19 vaccine. That proportion is higher for staff in long-term care facilities, where 6 in 10 health care workers did not get a shot during the first month of vaccine distribution, according to the CDC.

Vaccine hesitancy is lowest among people 65 and older of all races, with only 10% of older White people and 14% of older Black people saying they plan to wait and see whether the shots cause serious side effects before rolling up their sleeves, according to Kaiser.

“The more people we vaccinate, the harder we’ll have to work to get the next group in,” Schaffner said. “Once we vaccinate the eager early acceptors, we’re going to have to go out and find people in the general population who haven’t lined up yet.”

When that happens, public health experts warn that states, cities and counties will face an array of challenges. Among them: reaching large immigrant and Black, Hispanic and Native American populations who mistrust the government, and combatting the disinformation that well-organized anti-vaccine groups are spreading across social media. Public health workers also will need to create pop-up and mobile clinics to vaccinate residents in rural areas and urban neighborhoods with limited access to hospitals, doctors and pharmacies.

“Figuring out how to get vaccines to people who can’t get to the clinics is only part of the problem,” Schaffner said. “The other part is the persuasion, the reassurance, the comfort that inherently reluctant populations need to come forward and get vaccinated. You have to work on both of those at the same time. That takes people and people take salaries.”…(D)

“Nearly a third of the people who took part in a recent Kaiser Family Foundation survey fell into the “wait and see” category, and that’s enough to imperil the chances of reaching the goal of vaccinating 70 percent of the population to stunt the pandemic and allow American life to get back to normal, they said.

“We’re in a race now, if you will,” Dr. Marti Sharkey, who is the health officer in the city of Fayetteville, Arkansas, told NBC News. “It’s vaccines versus variants. The virus is constantly mutating, so we need to reach herd immunity as quickly as possible, and the way to do that is to vaccinate as quickly as possible. The vaccines are going to be more effective the faster we get them into arms.”

Summer Johnson McGee, who is dean of the University of New Haven’s School of Health Sciences, agreed.

“Every time there is a new Covid-19 infection, we are giving the virus a chance to mutate and develop more transmissible or deadly variants,” she said. “The sooner we reach herd immunity and stop chains of transmission, the less impact these variants are likely to have because it will be so much harder for Covid-19 to find an unvaccinated individual.”

The problem, however, is that the fence-sitters have built up their own immunity against that kind of messaging, the experts said. And the potentially dire consequences of not breaking through to them wound up being a big part of the discussion this week at a meeting of the Fayetteville Board of Health.

“My fear is that we plateau at less than 50 percent vaccination rate in the community and that would make it a difficult summer — not what it could be — which is why messaging is so critically important,” said Dr. Hershey Garner, a local physician who treats cancer patients…

The fence-sitters were also “a politically diverse group” with 42 percent identifying as Democrats or Democratic-leaning independents, 36 percent identifying at Republican or Republican-leaning independents, and 14 percent who claim to be independents “who don’t lean either way,” according to the researchers.

“The vaccine hesitancy we are seeing isn’t just about Covid vaccines,” McGee said. “It is a general reflection of Americans’ lack of trust in science, the pharmaceutical industry, and large health care institutions. We need a full court press on science and vaccine education right now to prevent more aggressive Covid-19 variants from developing and taking hold.” (E)

“Once you’re looking at around 200 million vaccines available for first injections, I think we’re going to run out of demand,” said former FDA Commissioner Scott Gottlieb in a CNBC interview on Monday. “I think we’re going to run out of demand sooner than we think.”

The number of Americans willing to get vaccinated rises as more of their friends and family do so. A January poll by the Kaiser Family Foundation found that while 47 percent would be willing to get vaccinated as soon as possible, 31 percent said they wanted to wait and see how the vaccine is working.” (F)

“But we have still some very important work to go,” McClellan said. “We could in theory have enough vaccines for all adult Americans who want them by early this summer, at the pace we’re on now. But that’s going to require a big gap to close between having the vaccines for everybody who wants them and having enough people who want them.”

McClellan also noted that the presence of the variants highlights the need to ramp up vaccinations to make sure the variants are not widely spread in the country.

“The very important thing now is: We need to get people vaccinated before those variants spread,” McClellan said. “Instead of aiming for getting to 70% herd immunity levels between vaccinations and immunity from people who have recovered by late summer, the numbers are there to potentially do it sooner by June.”

For this reason, the faster people are vaccinated, the fewer opportunities there will be for variant versions to spread and for more variants to emerge, McClellan explained. This will allow for life to begin to return to a greater level of normality soon.

“I think in a matter of months, Americans should be able to go back to doing a lot of the things that they did before. Maybe not the summer 100,000 person concerts, but more group activities, restaurants reopened, schools reopened, more businesses reopened, and more travel,” McClellan said.

This process is going to occur in steps as we reach higher levels of vaccinations throughout the country while simultaneously continuing to conduct COVID-19 testing, McClellan explained.

“If you have those things in place, the virus will still be out there and still be something to watch for mutation, but we won’t have anything like the consequences we’re having now. People won’t be going to the hospital, they won’t be losing loved ones, they won’t have to worry if they can go out and enjoy a dinner in a restaurant. So, it is going to take all of these steps to get there,” McClellan said.

However, McClellan noted that it remains important to recognize that the pandemic is a global issue, so it’s important to increase vaccination rates beyond just the United States in order to protect Americans in the long-term.

“As long as there are high rates of outbreaks in other parts of the world, there is going to be continued spread,” McClellan said. “So that’s a big job that is going to take more into next year, but I think we’re making progress, and hopefully we can keep accelerating that and have a much more normal life, not the same as pre-pandemic, but much more normal life not that far off.”” (G)

“Trying to convince someone to be vaccinated? Here are seven more key pieces of advice from these U-M experts:

Provide emotional support. Say “I know there is uncertainty, but this disease is scary. I got the vaccine (or am planning to) and I want it for my family and want you to get it too.”

Acknowledge uncertain risk. People react very strongly to any kind of new risk, or perceived risk from something they have no experience with. But it’s not the case that we go through life never facing risk: we face it every time we drive our car, or allow our kid to ride their bike down the street. The threat of COVID-19 is real and increasing, and while it is reasonable to wonder about the vaccine or seek more information from reliable sources before deciding to get vaccinated, getting vaccinated will reduce risk to yourself, your loved ones and society as a whole.

Talk about known risks. Let people know what to expect when getting the vaccines, from common side effects like muscle soreness and fever to the rare risk of allergic reactions. Talk about what’s being done to monitor and respond to those reactions.

Provide information for information-seekers. Share articles from reputable sources to combat misinformation about the vaccines and their safety and efficacy.

Partner with communities. Approach patients who are skeptical with transparency and respect. For example, with Black communities, acknowledge the problems that exist and partner with those with long-standing relationships in the communities to provide information.

Share your experience. Saying “go get the vaccine” is one thing; showing that you are willing to do it openly is another, and even more powerful.

Tap into people’s desire to protect. Use those pre-existing motivations to protect friends and family, and frame getting vaccinated as something you and everyone can do concretely for the people you love.” (H)

“Epidemiologists said they viewed the current moment in the pandemic as a sprint between vaccinations and newly confirmed cases of the virus, particularly infections that are spreading because of variants that can be more contagious. Dr. Anthony S. Fauci, the nation’s top infectious-disease expert, warned Friday “that it’s really quite risky to declare victory before you have the level of infection in the community to a much, much lower level than 53,000 cases per day.” (I)


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