Infectious Disease

‘Trusted messengers’ can improve COVID-19 vaccine hesitancy

March 24, 2022

8 min read


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Frieden, Hlatshwayo Davis, Offit, and Walensky report no relevant financial disclosures.


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As of late February, just 64.5% of Americans were fully vaccinated against COVID-19, and less than half of eligible people had received a recommended booster dose.

Paul A. Offit, MD, director of the Vaccine Education Center at The Children’s Hospital of Philadelphia, fears those figures will remain stagnant.

Matifadza Hlatshwayo Davis, MD, MPH

When it comes to vaccine hesitancy, “the onus should be upon health care officials, public health officials and government to earn that trust and to do the work,” said St. Louis health director Matifadza Hlatshwayo Davis, MD, MPH.

Source: City of St. Louis Department of Health

“It’s free, it’s available,” Offit told Healio | Infectious Disease News. “I don’t know why people would still be waiting at this point. You can’t be waiting for more information. You have all the information you need to make your decision. People are choosing not to get it.”

We spoke with Offit and other vaccine and public health experts about the roots of COVID-19 vaccine hesitancy, including fears that the vaccines are experimental, and how clinicians can help address it.

‘Listen before you talk’

A leading reason why someone would go out of their way not to receive any vaccine is denialism that vaccine-preventable diseases of the past will reemerge if enough people go unvaccinated, Offit said.

“We don’t see much measles anymore, we don’t see much mumps anymore, or rubella. We don’t see any polio anymore. So why get a vaccine? It’s not necessary,” he said, describing their thinking. “If you don’t see the disease, then why take the risk, even if it’s a small one of getting a vaccine?”

Former CDC Director Tom Frieden, MD, MPH, thinks there are still some people who may be swayed by the right information. He said he believes only a small portion of Americans — less than 5% — are “inflexibly anti-vaccine.”

“Nothing, essentially, that is said to those individuals is going to make a difference,” Frieden told Healio | Infectious Disease News. “In fact, outreach is likely to harden their resistance. For that reason, that’s not a group that’s a priority for outreach, other than through their own doctors.”

In March 2021, Frieden spoke over Zoom with vaccine-hesitant Republicans who were part of a focus group convened by the de Beaumont Foundation to understand the reasons behind their reluctance to get vaccinated against COVID-19.

Tom Frieden, MD, MPH
Tom Frieden

The session began with group members sharing certain words or phrases about COVID-19. One called it “a weaponized, engineered disease, which has been cynically and irresponsibly used for the politicization of medicine.” Other words or phrases included “controversy,” “isolation,” “government manipulation,” “a hyped-up version of the flu” and “a weapon used in many different ways.”

When asked what they thought of the COVID-19 vaccine, many voiced concerns about the development process being rushed, as well as not knowing about potential long-term side effects.

“It’s a new class of vaccination,” one participant said. “I think the short-term testing was extremely good. But again, we don’t know the long-term side effects. My fear of the vaccine is more than my fear of getting the illness.”

When the rest of the group was asked if they felt the same way, almost everyone raised a hand.

Paul A. Offit
Paul A. Offit

“At this point, you can’t argue it’s an experimental vaccine,” Offit said. “I mean, 4.5 billion people in this world are fully vaccinated. This is the largest vaccine program in the history of humankind. And they’re now fully licensed products.”

Frieden shared facts with the group about COVID-19 and the available vaccines, including the fact that more than 95% of doctors opted to get vaccinated as soon as possible, and that vaccination would save at least 100,000 American lives.

Some still had reasons to believe they should not get vaccinated. Frieden said participants had a lot of understandable fears about COVID-19 vaccines and most felt disrespected because they believed no one was listening to them.

“People who have concerns deserve to be heard and deserve to get unbiased information from messengers they are likely to listen to,” Frieden said.

He said the No. 1 thing to avoid when speaking with a vaccine-hesitant patient is disrespecting them or talking down to them.

“Seek first to understand, then to be understood,” he said. “I think when people are listened to, that’s the first step in building a relationship.”

CDC Director Rochelle P. Walensky, MD, MPH, echoed that sentiment in a discussion during the opening session of the Conference on Retroviruses and Opportunistic Infections in February.

“People always ask me, ‘How do you convince somebody to get vaccinated?’ And the truth is, I think you listen before you talk,” Walensky said. “The problem is that takes a long time because you have to listen one by one. It’s not a monolith as to why people have not gotten vaccinated yet. That’s a lot of work and a lot of hard work, and that’s the work we have ahead.”

Rochelle P. Walensky, MD, MPH
Rochelle P. Walensky

Walensky said changing a vaccine-hesitant person’s mind may take more than a few conversations.

“There is much that we can do,” she said. “We put many resources toward it, but much is going to be done at the local level, as we look at what’s happened and who our trusted messengers are.”

[Editor’s note: For more on Walensky’s talk, click here.]

‘Vaccine confidence’

Contributing to general vaccine hesitancy are “ill-founded” fears that vaccines may negatively impact health, like the thoroughly disproven but long-standing belief that the measles vaccine is linked to autism, Offit said.

“Now, it’s government off my back. Don’t tell me what to do. I will decide what’s best for myself and my family. I don’t want to have anything mandated, including a COVID-19 vaccine — and so, that’s the predominant story now, which is more of a cultural issue than anything else,” he said.

However, governments have been mandating vaccines since not long after Edward Jenner first vaccinated someone against smallpox in 1796 — 184 years before the disease was eradicated. According to Vaccination Mandates: The Public Health Imperative and Individual Rights, a 23-page review of vaccine mandates in the United States, the first state mandate was enacted by the Commonwealth of Massachusetts in 1809 for smallpox, which later was extended for the state’s public school admittance policy in 1855.

Matifadza Hlatshwayo Davis, MD, MPH, director of health for the city of St. Louis, said for many people, the decision to get vaccinated comes down to one thing — trust. Hlatshwayo Davis does not like to use the term “vaccine hesitancy” anymore. She prefers “vaccine confidence.”

“My work throughout the pandemic has made me very respectful of the fact that especially in minoritized communities, there’s nothing hesitant about the questions, the approach and the lack of confidence,” Hlatshwayo Davis told Healio | Infectious Disease News. “The reason I’m intentional about using ‘vaccine confidence’ over ‘hesitancy’ is because I believe the onus should be upon health care officials, public health officials and government to earn that trust and to do the work.”

According to Hlatshwayo Davis, since the beginning of the pandemic, there has been a belief that those who choose not to get vaccinated against SARS-CoV-2 are science deniers.

“I strongly believe that that misses the mark,” she said. “Especially in minoritized communities, there are valid reasons for that lack of vaccine confidence that speak to a long-standing history and current-day issues around systemic racism, surrounding the health disparities that are born out of systemic racism.”

As an infectious disease physician and public health expert, Hlatshwayo Davis said she knows the CDC is a trusted resource. However, she understands why people may be distrustful toward the agency, which disappoints her.

Hlatshwayo Davis cited the Tuskegee experiment, during which Black men with syphilis were given placebo treatments under false pretenses for decades, and Henrietta Lacks, whose cells were used for research without consent or compensation after she died in 1951 of cervical cancer, to illustrate why members of minority communities may be reluctant to trust the public health system in America.

“When you then go to those communities, and you give them any reason to believe that maybe you’re withholding something, or maybe you’re not being transparent — you need to help people set their expectations and educate them from the beginning as to why that may take place,” she said. “I don’t think we always did a good job. So that’s going to be an important lesson.”

COVID vaccination fast facts

Sources: 1. CDC; 2. Cole MB, et al; 3. Vaccination Mandates: The Public Health Imperative and Individual Rights

Hlatshwayo Davis said right before vaccine rollout campaigns began, she received calls asking if there had been enough outreach in minority communities. Should pamphlets with vaccine information be sent to Black communities? She referred to these as “slapstick approaches that totally missed the mark.”

In a survey of nearly 1,500 parents in Chicago and the surrounding area that was conducted months before COVID-19 vaccines were available, nearly half of Black parents said they were hesitant to get their child vaccinated. However, Hlatshwayo Davis said Black communities have experienced one of the biggest improvements in terms of vaccine confidence among all minority groups. A study published in January in JAMA Network Open reported that, as of July, federally qualified health centers had administered more than 60% of their COVID-19 vaccines to people of races and ethnicities other than white.

“I think it’s because there was this very concerted push to understand the role of trusted messengers, to understand that you cannot manufacture trust overnight,” Hlatshwayo Davis said. “So, you need to lean into federally qualified health centers and community groups. When it’s a pediatric rollout, you need to lean into places where children and their parents or caregivers are most comfortable — schools, pediatric offices, and those same community groups.”

Hlatshwayo Davis wants the CDC and other state and federal institutions to engage more with communities long term rather than reaching out at the last minute for help.

“[I want] folks like me called at the beginning,” she said.

Click here to read the Point/Counter to this Cover Story.


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