Vaccine Hesitancy and COVID-19

A black patient receives a vaccine

Q&A with Abram Wagner and Trina R. Shanks

March 16, 2021

Several vaccines have now been approved in the US for emergency use. More and more people receive a vaccine every day. But many still feel unsure about the COVID vaccines. Are they safe? How can you trust them? And are there side effects to worry about?

To explore a term you may be hearing a lot these days—vaccine hesitancy—we spoke with two experts on how vaccines work in populations. Abram Wagner is research assistant professor of Epidemiology at the University of Michigan School of Public Health.

Trina R. Shanks is the Harold R. Johnson Collegiate Professor of Social Work, director of the School of Social Work Community Engagement, and a faculty associate of the Survey Research Center at the Institute for Social Research.

Take a brief, enlightening look at the history of vaccine hesitancy, the relationship between vaccine hesitancy and race, and how those factors relate to this pandemic.

What is vaccine hesitancy?

Wagner. Vaccine hesitancy is a broad term that refers to a range of attitudes and behaviors. Fundamentally, somebody who is vaccine-hesitant will refuse or delay a vaccine despite the availability of that vaccine. If somebody is not getting a COVID-19 vaccine because they are not prioritized or don’t have access to the vaccine, that is not vaccine hesitancy. Vaccine hesitancy means you’ve been offered a vaccine, it is easy for you to get a vaccine, but you've purposely chosen not to get it or to delay it for some reason.

Getting vaccinated against COVID-19 cannot give you COVID-19 disease.

People are vaccine hesitant for a number of reasons.

One reason is that the disease is not serious enough. We often hear, “influenza is not that severe. It’s just like a common cold. Why would I need a seasonal flu shot?” Some think the vaccine might cause them to get sick or even to get the disease. We hear often from those who think they got the flu from receiving the influenza vaccine. Because of how we produce vaccines, flu vaccination cannot result in natural disease in the body. Similarly, getting vaccinated against COVID-19 cannot give you COVID-19 disease.

A second reason for vaccine hesitancy is that some people believe they already get too many vaccines. This is especially the case with parental beliefs about the child vaccination schedule. They might think we give too many vaccines too early to children. As we know from decades of studies, the recommended vaccination schedule is safe and effective for children. The body’s immune system is remarkably adaptable. It deals with just about everything the real world throws at it, and vaccines use that adaptability to make our immune systems stronger.

What concerns do you hear about the COVID vaccines?

Wagner. With COVID-19 in particular, we hear concerns that the vaccines were rushed—developed too quickly and didn’t go through the full approval processes. We know the parts of the approval process that were accelerated were not related to safety. And we have seen in recent months an increase in the number of people intending to get a vaccine and a decrease in the number of people with concerns about safety, including how quickly the vaccines were developed. A large proportion of health care workers have received a COVID vaccine, and they are able to tell their patients how they got the vaccine and that it was safe. That connection will be important for people in general populations feeling confident about receiving a vaccine against COVID-19.

A few individuals will have contraindications for vaccines, a medical reason for which the vaccine would be inadvisable. Someone who has had a severe reaction to a similar type of vaccine in the past might be contraindicated from getting this vaccine.

Given that pregnant women weren’t included in any of the clinical trials, some have concerns about pregnant women. Some pregnant women have received a vaccine, we have no evidence of unsafe outcomes for the pregnant individual nor the fetus, and obstetrics and gynecology experts have stated that pregnant women should be offered these vaccines.

Why does it seem like there are so many people who don’t want vaccines?

Wagner. Of the total population, only a small fraction of individuals are very anti-vaccine—those who will not get any vaccine ever. They can be very vocal on social media—if you’re listening there, you will hear from them a lot. When it comes to herd immunity or stopping disease outbreaks, these stringent anti-vaccine individuals are probably not epidemiologically important.

With COVID and with other vaccines, we see more of what we call fence-sitters. They could be persuaded to get the vaccine or persuaded not to get the vaccine. In public health, our job is not only to rigorously evaluate each vaccine but to produce messaging that the vaccine is safe and effective, to make receiving the vaccine as convenient as possible, and to reduce the costs of getting the vaccine.

Addressing the whole process would go a long way to making sure people get this vaccine on time. Many fence-sitters could easily be pushed in the direction of not getting the vaccine or delaying it if the vaccine is inconvenient to access. And we see how difficult it has been in some regions to get onto a COVID vaccination list. Some places rolled out the list to seniors in online-only formats. That makes it really difficult for that demographic. If somebody is even slightly vaccine-hesitant, they likely won’t go to all that effort and as a result will have a delayed vaccination.

How long has the phenomenon of vaccine hesitancy existed?

Wagner. Vaccine hesitancy has been around since the first vaccine—probably the smallpox vaccine, developed in the late 1700s from a cowpox virus. After this vaccine was introduced in the United Kingdom, an anti-smallpox vaccine society organized claiming they didn't want this unnatural substance in their bodies. Religious concerns included the idea that vaccines were against God’s will. There were multiple concerns. Nonetheless, smallpox was the first vaccine, and smallpox was the first virus we were able to eradicate completely from the world. So it gives us a template for how to control other vaccine-preventable diseases.

In the aftermath of the smallpox vaccine, throughout the 1800s and beyond, this anti-vaccine sentiment didn’t disappear. It held on. After the introductions of vaccines for polio, measles, and other infectious diseases in the middle of the 20th century, we saw high demand for the vaccines because people knew what those diseases were. People rushed to get the polio vaccine and to get their children vaccinated because they saw the devastation from polio outbreaks. They knew people who had been paralyzed by polio or died from polio or measles.

Why does vaccine hesitancy continue when we know vaccines are safe and effective?

Wagner. In the generations since the arrival of the polio and measles vaccines, because the vaccines were so successful, people have lost any experience with these diseases. Parents today don’t know what polio is. They don’t know what measles is. A lot of vaccine hesitancy is not understanding how severe these diseases are. Few of us know someone who’s died from these diseases. And if you know someone who’s survived it, you could have survivorship bias—all you might know about measles is that someone you know or heard of survived from it.

How does severity of disease affect how we communicate about the COVID vaccines?

Wagner. At this point, most people in the world have some experience with COVID-19. Everybody knows what COVID-19 is. Many people know individuals who have had the disease and perhaps also died from it. A large proportion of Detroit’s population—30-40% of adults in Detroit—know somebody who has died from COVID-19.

COVID-19 has touched intimately the lives of many people, including in and around the Detroit area. We know how serious COVID disease is. Going forward, these experiences with the disease can help promote the vaccines. We can remind people that getting vaccinated against COVID-19 not only protects them from severe disease but protects the individuals around them and their entire community. Every individual who receives the vaccine is protected against COVID-19 themselves and is helping protect their family, their neighborhood, and their community.

Why does vaccine hesitancy seem to be higher in some populations?

Wagner. For a number of reasons, members of some racial and ethnic groups might be more distrustful of a COVID-19 vaccine. Certainly, we should keep in mind historical reasons in which the medical community and the public health researchers especially have used black communities for unethical research.

In the day-to-day lives of many Black individuals, they face medical racism. They often feel that their health care provider is treating them differently than that health care provider might treat others. So for that reason, I think there are many individuals, especially from the Black community, who might be more hesitant about getting this vaccine, but that is a different variety of vaccine hesitancy.

How widespread is vaccine hesitancy in Black communities?

Shanks. In our survey, one of the things that really stood out for us is that 33% of Black respondents either disagree or strongly disagreed that an eventual COVID-19 vaccine would be safe and effective. That’s compared to 14% of whites and 11% of Latinx population. So Blacks are more than twice as likely to disagree or strongly disagree that the COVID-19 vaccine that was coming at that point would be safe and effective. Since then, we know from the Kaiser Family Foundation and other data sources that African Americans were more likely to die from COVID (15% of all deaths) but are receiving about 5.5% of all vaccinations. So they're more likely to have the worst health outcomes, but they're the least likely to be vaccinated. It's shocking in some ways, and potentially life-threatening in other ways, that Blacks are not eagerly anticipating the vaccine.

Why is vaccine hesitancy so prevalent in Black communities?

Shanks. Rather than assuming there is a cultural reason Black people don’t want to take the vaccine, I would keep in mind two things.

First is the way that African Americans are treated when they go into health care providers and hospitals and interact with their primary care physicians. Vaccine hesitancy probably has a lot to do with the way they feel about their local public health systems and the way they are treated.

Second is the difficulty around knowing exactly how and when to get the vaccine in many local areas. Access at many levels is a problem—poor communication about exactly where to go, access to transportation, inconvenient locations and methods, particularly since some of the vaccines currently available require two doses. Work and family commitments are a concern. Do you have to take off work and do it between 9 to 5? That can be difficult for some people. Combining all that with past discrimination in health care policies and practices makes it less likely for them to want to take the vaccine.

If you can reduce some of the barriers, do focused outreach, and have trusted messengers talk about receiving the vaccine and getting the vaccine themselves, some of that hesitancy can go away. But because the vaccines are not widely available now and not easy for everyone to access, until some of those access and structural issues go away we will still have lower numbers of vaccines accessed in the African American community.

What are some of the historical realities that play a role in Black communities’ views of healthcare?

Shanks. The distrust between Black communities and health care systems sometimes goes back to real historical trauma. Sometimes people refer to the Tuskegee Experiment, where dozens of African American men were not treated for syphilis and were allowed to die awful, horrible deaths. Initial results from the experiment should have led to everybody receiving antibiotics so that people wouldn’t die from the experiment. But they really wanted to observe the final stages of the disease, and it made it almost seem like African Americans weren’t human but were just bodies to study, observe, and examine without concern for these men’s families or their lives. That historical trauma is part of the situation.

Distrust of medical systems also has to do with the fact that Black people often live in neighborhoods with higher poverty rates and more concentrated poverty. Hospital systems in these neighborhoods are more likely to be overrun, might have more people in emergency rooms, and likely do not have the same level of resources as hospitals and care systems in majority white areas or suburban areas.

How can public health and medical professionals build relationships and become more trustworthy as they seek to serve Black communities?

Shanks. Like with politicians, you don’t want people to come around only every four years when a vote is coming up or you want people to take a certain medical action. You want them to come back and have conversations about things of interest to the community, not just during an emergency around something you are interested in or trying to push.

Almost everyone in the Black community has a friend or relative or at least someone they know that has contracted COVID-19 and possibly died.

With regular reaching out, better communication and addressing concerns, having trusted messengers around the vaccine, it communicates that “we care about you and your life matters.” Then, with the next pandemic or other situation, the community knows you’re there for the right reasons and not just because it’s important to you.

Are you hopeful we can reduce vaccine hesitancy in Black communities and rebuild trust with medical systems?

Shanks. In some sense this could be a restart. We realize there has been devaluing of Black patients and Black communities in the past. We can start over with better lines of communication and continuing to hire community health workers who can be translational figures, establishing consistent interaction and not when systems need a particular response.

Almost everyone in the Black community has a friend or relative or at least someone they know that has contracted COVID-19 and possibly died. After all the pain and death and devastation this disease has caused in Black communities, we need to do all that we can to make sure that we protect ourselves, our families, and our loved ones. The best way to do that, in addition to social distancing and wearing a mask, is to get the vaccine as soon as you can so that you, your loved ones, and the people you’re around are protected.

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