Who are the “holdbacks” of the COVID vaccine?

As the United States faces the threat of the more transmissible Delta variant, experts are working harder than ever to understand the concerns of those “reluctant” to vaccines.

In interviews with public health experts, several key themes behind the remaining reluctance emerged, including misinformation, mistrust of the medical establishment, and specific concerns among those newly eligible, such as an impact on fertility.

To better understand what prevents about a third of American adults from getting even a single dose, MedPage today started in Arkansas, which has one of the lowest vaccination rates in the country, with just 34% of residents fully vaccinated.

Case Study: Arkansas

Jennifer Dillaha, MD, medical director of vaccinations at the Arkansas Department of Health, said misinformation was rampant in the state and was one of the main reasons for the vaccine’s refusal.

“There is so much misinformation, and a lot of people have misconceptions about the safety and effectiveness of vaccines,” Dillaha said. MedPage today. “They have a hard time sorting through the available information and they are unable to distinguish exact information from misinformation.”

Some Arkansans believe a dose of the Pfizer or Moderna vaccine is enough, and even more believe they have enough immunity to contract and recover from COVID, Dillaha said.

Dillaha also hears of people waiting for full FDA approval to get vaccinated.

“I think it’s unfortunate,” she said, because “it indicates that a person really doesn’t understand the safety and effectiveness of the trials that have taken place.”

Basically, the only evidence left from longer-term trials is the length of protection, she said. People mistakenly think that steps had to be skipped or that the technology behind mRNA vaccines is brand new.

Other southern states, including Alabama, Louisiana, and Mississippi, also struggle with low vaccination rates.

“I think southerners in general have more difficulty with health literacy than in other parts of the country,” said Dillaha.

Much of the south is rural and people with health literacy challenges need health care providers to help them sort through information, she said.

“We have such a shortage of health care providers,” she said.

Many people don’t have an established relationship with a health care provider, such as a doctor or nurse, Dillaha said. However, pharmacists have the option of providing information about vaccines. This is because even in areas where there is a shortage of providers, the only contact people are likely to have is a pharmacist.

The reluctance to immunize is part of the global struggle people have to “get accurate and reliable health information, and assimilate that information and use it to make health decisions that truly benefit them”, a- she declared.

“And for me, this is the raison d’être of health literacy,” she added. “Much of the hesitation about vaccines that we see is basically a health literacy issue.”

Distrust persists

Natasha Williams, EdD, MPH, assistant professor of population health at NYU Grossman School of Medicine, highlighted distrust of the medical community among people of color as another key reason for the remaining reluctance.

When the vaccination rollout began, there were concerns within the black community and underserved communities, Williams said. Working groups have been set up at city and state levels to help address equity and distribution, she said. However, it is not clear whether these particular efforts have helped reach certain communities.

One should focus on what happened with these health equity and immunization efforts, she said.

However, the “good news” is that “there has been some improvement in immunization among all Americans, regardless of race, ethnicity or other background,” Williams said.

“Doctors and healthcare providers, they remain an important resource in terms of who gets information and who they turn to for information about the vaccine,” she said.

Families, friends, religious leaders and the CDC are also helpful, she said, adding that taking the time to answer people’s questions about the vaccine is essential.

“People really want to have their questions answered,” Williams said. “I don’t think this is a major demand for people to have questions and get their questions answered from reliable sources.”

An important message, she said, is that “the question of reluctance or mistrust is really justified,” she said.

Having a conversation about the vaccine with marginalized communities without acknowledging the abuse that has taken place in the health system is doing a disservice, she said.

“We have to take a few steps back to create a way forward,” said Williams.

Young people

As people 12 and older are now eligible for the COVID vaccine, reluctance among children and young adults – and their parents – is the focus of attention.

Sean O’Leary, MD, vice chair of the American Academy of Pediatrics Committee on Infectious Diseases, said that in general, parents who are highly motivated to get immunized will immunize their children when they are eligible.

The rare incidents of myocarditis in young people after vaccination are of potential concern. However, O’Leary said he believed the agencies had approached the problem by stressing that the benefits of the vaccination far outweighed the low risk of the disease.

“For me, this is the way it should be done,” he said. “We’ll see how this lands on the parents.”

What O’Leary believes is playing a big role in getting adoption this summer is vaccination in primary care offices.

Until more recently, most vaccinations were done at mass vaccination clinics, he said. “Almost by definition, those who went were very motivated to get the vaccine. They were “not necessarily places where people went to get answers to a lot of questions.”

However, pediatricians are often parents’ most trusted source of vaccine information, O’Leary said. If teens come for checkups over the summer, pediatricians have an opportunity to allay their concerns, and “that can make a big difference,” he said.

Now that vaccine storage requirements have been relaxed, pediatricians could better reach parents who are about to vaccinate their children, he said. They can say things like, “I bought it for my own kids,” “It’s important that you get it,” and “I have it here at the office. “”

If there hadn’t been a pandemic and if there had been hundreds of child deaths from any other disease for which there is a vaccine, people would ‘jump on it’, he said. . “We are insensitive to the severity of this pandemic. “

Aisha Langford, PhD, MPH, also an assistant professor of population health at NYU Grossman School of Medicine, said in local town halls with high school students, some of the responses from unvaccinated youth were that they were worried about vaccines. in development. too quickly, that their parents do not want to consent to their receiving the vaccine, and that they have seen misinformation that the vaccines could cause long-term fertility problems, Langford said.

In fact, she said, fertility questions continue to be asked perhaps more frequently than many others. In response, medical organizations and agencies have issued statements in an attempt to combat this myth.

Other young people have expressed reluctance over cash lotteries to induce vaccination, Langford said, wondering why people should be bribed if vaccines were safe. Some said that getting a laptop computer for college could be more valuable to them than money, and they feared the vaccine could affect their sports practice.

One of the most important things is just to listen and try to understand people’s unique concerns, Langford said.

Where to move the needle

At the current stage of vaccine deployment, most experts believe that the most important opportunity to reach more people is through the “wait and see” group.

About 25% to 30% of people aren’t against the COVID vaccine, but don’t go get it just because someone tells them so, said Litjen Tan, PhD, head of policy and partnerships at the Immunization Action Coalition. .

Often the waiting group simply forgets, Tan said. One of the things to remind people is that “the time to wait and see is over. The vaccine has shown a “remarkable safety profile.”

Another thing to remind people is that the Delta variant is a real problem, he said. “Now it’s about protecting yourself and your community. “

After making sure there are no access issues, reaching people in this way can be effective, Tan said. Incentives can also work.

Dillaha from the Arkansas Department of Health also reiterated the importance of reaching people with the right message.

“One of the key elements is allowing people to have the opportunity to have their questions and concerns answered,” said Dillaha. “I think it can happen in a variety of contexts.”