Vaccine Hesitancy and COVID-19

0:04 Narrator: In the last few months, we've seen emergency usage authorization for the Pfizer, Moderna, and Johnson & Johnson COVID-19 vaccine, and now more and more people are receiving vaccines each day. But many still feel unsure about receiving a vaccine. Is it safe? How can you trust it? Are there side effects you should worry about?

Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast, focusing on the ongoing Coronavirus pandemic.

In this episode, we explore a term you may be hearing a lot these days, vaccine hesitancy. We'll dig into the history of vaccine hesitancy and how it relates to this pandemic with two faculty experts from the University of Michigan. First is Abram Wagner, a research assistant professor of Epidemiology at the University of Michigan School of Public Health. He's an expert in vaccine preventable diseases and vaccine hesitancy.

01:21 Abram Wagner: Vaccine hesitancy is a broad term, and it refers to a wide range of attitudes and behaviors, but at it’s basis, somebody who is vaccine-hesitant is somebody who will be refusing or delaying a vaccine despite their availability. So right now, if somebody's not getting a COVID-19 vaccine because they're not prioritized, they can't have access to it, that's not vaccine hesitancy. Vaccine hesitancy means that you've been offered a vaccine, it's easy for you to get a vaccine, but you've purposely chosen to not get it or to delay it for some reason or another.

There's a number of reasons why people are vaccine hesitant. It could be that they don't think the disease is serious enough. So we see often that people nowadays might think, “Oh, influenza, it's not too severe. It's just like the common cold. Why would I need a seasonal influenza shot?” So that's one reason. It could be that they think that the vaccine might cause them to get sick or might cause them to get the disease. So you hear that a lot, where people might think that they got the influenza vaccine, and then a couple of days later they got the flu. There's no way that getting vaccinated with influenza can give you the flu and similarly getting vaccinated with COVID-19 could give you the COVID-19 disease just because the way the vaccines produce, there's no way that it can result in a natural disease in the body.

It could also be that people think that they already get too many vaccines. I think that's more so parent beliefs about their children. They might think that the vaccines, there's too many of them and they're given too early to their kids. Again, that's not the case. Our body's immune system is amazing, and it can deal with everything that the real world and vaccinations can throw at it.

But I think with COVID-19 in particular, there's concern that it has been rushed, that it's been developed too quickly and that it hasn't gone through certain full approval processes. However, we have seen over time, there's been an increase in the number of people who've intended to get the vaccine, there's been a decrease in the number of people who have concerns about safety and who have concerns about how fast the vaccine was developed. So a large proportion of healthcare workers have gotten the vaccine and I think they're able to tell their patients how they got the vaccine, how it was safe, and I think that connection will be really important in the future to make sure that people in the general population are vaccinated against COVID-19.

03:30 Wagner: There's actually not a huge number of individuals who have medical contraindications. So contraindications are those which for medical reasons, they're not supposed to get the vaccine. But in general, if somebody has had a severe reaction to a similar type of vaccine in the past, they might be contraindicated from getting this. There's been also some concerns about pregnant women, given the pregnant women haven't been in any of the clinical trials, or at least that's been some of the exclusion criteria. But the experts in the field of Obstetrics and Gynecology have stated that pregnant women should be offered this vaccine and that there's been no evidence that there's been any unsafe outcome for the pregnant individual or for the fetus. So all signs speak to this vaccine for being very safe for pregnant individuals, it's just they weren't included in the original study design, so we're pulling a bit of catch-up with that safety data.

4:31 Wagner: One thing that I like to make sure that people know is that there's a small fraction of individuals who are very anti-vaccine, who will not get any vaccine ever. They seem to be very vocal on social media. You hear about them alot. They're actually probably a very small proportion of the population. So if we're thinking about getting enough herd immunity or stopping outbreaks of disease, these stringently anti-vaccine individuals probably aren't super epidemiologically important.

05:00 Wagner: But probably what we see with vaccine hesitancy with COVID-19 and with other vaccines is there's a lot of people who are what we would call “fence-sitters”. So they could be persuaded to get the vaccine, they could be persuaded to not get the vaccine. And I think it's our job in public health to of course, rigorously evaluate a vaccine, but then produce the messaging which states that this is a safe and effective vaccine, to make the vaccine as convenient to get, to reduce the costs of getting the vaccine - and I think that would go a long ways and making sure that people get this vaccine on time. Because I think what we could see for a lot of these fence-sitters is if they're just not really sure if they want to get the vaccine or not, they're probably getting pushed in the direction of not getting the vaccine or maybe delaying to get the vaccine, especially if the vaccine is it convenient to get. Some of the things that we see now where it's been really difficult to sign up for COVID-19 vaccination list, rolling out to seniors but making them have to sign up on something online, that just makes it really difficult. So if somebody's even slightly vaccine-hesitant, they're not going to go through all that effort, and as a result they're gonna have a delayed vaccination.

6:10 Narrator: While social media seems to help those who doubt vaccines reach people in an instant, caccine hesitancy has actually been around for centuries.

06:19 Wagner: Vaccine hesitancy has been around since the first vaccine. So the first vaccine is probably what we think of as the smallpox vaccine, and it was developed in the late 1700s. It was actually developed from a cowpox virus. The first few years after this vaccine was introduced in the United Kingdom, there's this anti-smallpox vaccine society because we just don't want this unnatural substance in us. There were religious concerns, people thinking that vaccines were against God's will. There were all sorts of concerns. But the vaccine nonetheless was the first vaccine, and smallpox was the first virus that we were able to eradicate completely from the world. So definitely gives us a template for how to control other vaccine-preventable diseases.

07:07 Wagner: But what we see in the aftermath of the 1800s is this anti-vaccine sentiment didn't just disappear, it sort of was always there. But what we saw after the introduction of say the polio and the measles vaccines in the middle of the 20th century is that there was a high demand for these vaccines because people knew what these 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 or who had died from polio and similarly with measles. I think what we've seen in generations since is that people have lost this experience with the disease. So parents nowadays don't know what polio is. Parents don't know what measles is. So a lot of the hesitancy with getting vaccines is that they just don't see this as a severe disease. They don't know people who've died from the disease and there's sort of a survivorship bias, because if you do know somebody who's gotten measles you only know it because they survived from it.

08:11 Wagner: We've come at a point now where there's a worldwide experience with COVID-19. Everybody knows what COVID-19 is. Many people know individuals who've gotten COVID-19 and who've died from COVID-19. So I'm working on this study in Detroit and a large proportion, like 30% to 40% of adults in Detroit, know somebody who's died from COVID-19. So this is something which touches people intimately. They know how serious COVID-19 is as a disease. And I think the pathway we'll have to use going forward in promoting the vaccine is showing people that getting vaccinated against COVID-19 not only can protect them from severe disease, but it can make them protect individuals around them. So if an individual is protected against COVID-19, then that means that they are protecting their family, they're protecting their community, they're protecting their neighborhoods.

9:02 Wagner: There's a number of different reasons why members of certain racial and ethnic groups might be more distrustful of a COVID-19 vaccine. Certainly there’s historical reasons in which the medical community and the public health researchers especially have used black communities for unethical research. But I think in the day-to-day lives of many black and brown individuals, they face medical racism. They feel like their healthcare provider is treating them differently then that healthcare provider would treat, say, a white person, and there are a lot of studies to back this up to say that that actually is the case. So for that reason, I think there are many individuals, especially from the black community who just might be a bit more hesitant about getting this vaccine, but that's a different strain of vaccine hesitancy.

10:02 Narrator: To look deeper into the relationship between race and vaccine hesitancy, 2e spoke with Dr. Trina Shanks, a Professor of Social Work and Director of the University of Michigan School of Social Work Community Engagement. In her work, she studies the impact of income, weather, social economic status, income, and race on important health outcomes. At the beginning of the COVID-19 pandemic, she began surveying communities in Ypsilanti, Michigan to understand their views of the pandemic.

10:27 Trina 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 they 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. And then since then, we know from data that comes from the Kaiser Family Foundation and other sources, that African Americans were more likely to die from COVID, 15% of all deaths, but they're 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.

11:24 Shanks: Rather than assuming that there is some cultural reason Black people don't want to take the vaccine, here's two things I would keep in mind. One, the way that African-Americans are treated when they go into healthcare providers, go into hospitals, interact with their primary care physicians, probably has a lot to do with the way they feel about their local public health systems and where they're being treated. And then also, the fact that there's been a lot of difficulty knowing exactly how and when to get the vaccine in many local areas. So access, I do believe is a problem. Access at many levels. So part of it is just poor communication about exactly where you go. Then other, more practical accessibility things like lack of access to transportation, inconvenient locations and methods, particularly since you have to usually get two doses of the current vaccines that are available. Do you have to take off work and do it between 9 to 5? That can be difficult for some people. And then also things like past discrimination in public healthcare and policies and practices that just make it less likely for them to want to take the vaccine. So I think if you can reduce some of the barriers, do particular outreach and have trusted messengers talk about receiving the vaccine and getting the vaccine themselves, I think some of that hesitancy can go away, but because it's not widely available now, it's not easy to get, I think that until some of those access and structural issues go away, we're still gonna have lower numbers of vaccine access in the African-American community.

13:00 Narrator: Grave historical realities also play a role in the black community's view of healthcare.

13:05: Some of the reasons that there is distrust between the Black community and some health care systems, sometimes it's real historical trauma. So sometimes people refer back to the Tuskegee Experiment where dozens of African-American men were not treated for syphilis and were allowed to die awful, horrible deaths. And when they did have the initial results from the experiment, they should have said, “okay, well, let's give everybody the Penicillin so that people won't be dying as a result of this experiment when we know there is a cure or something that can be helpful”, and they really wanted to see the final legs of the disease in a way that made it almost seemed like African-Americans weren’t human, they were just someone to study and to look at and to examine and didn't have concerns for their families or their lives. And so I think that obviously historical trauma, and then, of course, given that Black people live often in neighborhoods that have higher poverty rates and more concentrated poverty. They may be in just hospital systems that are more over-run, that have more people in emergency rooms, that may not have the same level of resources as hospitals and care systems in majority white areas or suburban areas, let's say.

14:14 Narrator: A key question is, how can public health and medical professionals build relationships and become more trustworthy as they seek to serve Black communities?

14:22 Shanks: It's almost like politicians, you don't want people to come around just every four years when a vote is coming up in the next month or so. You want them to continue to come back and to have conversations about things that are of interest to the community and not just an emergency that is something that you are interested in or trying to push. So I would hope that in addition to reaching out and having better communication, addressing concerns, having trusted messengers, in addition to those sort of things around the vaccine because it’s seen as sort of an emergency, have those same concerned conversations, that same outreach, that same “we care about you and your life matters” around things that are concerning to the local community, I think that will go a long way. So that if there's another pandemic or some other situation, that it's not just, oh well it’s another emergency so we’re going to come to you again when we need you, or when there's something that is pressing and that you think is important, we're not going to listen to you or bring resources or be responsive to things that are concerning to you. If there could be some sort of sense of, this is a restart, and we realize that maybe there's been some devaluing of Black patients and Black communities in the past, kind of start over to see if we can have better lines of communication, we can continue to hire community health workers who could be kind of some of the translational forces figuring out ways to maintain lines of communication and not just come when there's an emergency or you need a particular response.

15:57 Shanks: After all the pain and death and devastation that this disease has caused in the Black community, 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 of that pain and devastation and death, we need to do all that we can to make sure that we protect ourselves, protect our families, protect our loved ones. And the best way to do that, in addition to social distancing and wearing a mask, is to as soon as you can, get the vaccine so that yourself and your loved ones and the people you're around are protected.

16:44 Narrator: This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.