Addressing COVID-19 Vaccine Hesitancy: Lessons from the US Response to the COVID-19 Pandemic

Jeffrey Qi

INTRODUCTION

The Centers for Disease Control (CDC) has recently released new guidelines regarding COVID-19 vaccination, including recommendations for updated Pfizer-BioNTech, Moderna, and Novavax booster vaccines for children as young as six months old.¹ Arriving in waves that lasted months at a time, COVID-19 has become part of the set of pathogens endemic in our communities, joining the ranks of the common cold and the flu. This doesn’t mean that COVID-19 is any less dangerous. Misconceptions that COVID-19 is equally as dangerous as the cold have long been disproven. COVID-19 remains more contagious and prone to severe symptoms than the flu, and post-COVID health complications are not uncommon.² However, a significant portion of the population continues to doubt whether to get vaccinated.^3,4 The rollout of COVID-19 vaccines over the past three years has revealed the extent of distrust towards vaccines, medical institutions, and the federal government that has significantly hampered the US response to COVID-19. The government must do more to fix existing structural weaknesses in public health institutions and policies to better prepare for future disease outbreaks.

BACKGROUND

Vaccine hesitancy stems from a resurgence of hesitancy towards childhood vaccines from the late 1900s. Studies like the infamous 1998 Wakefield et al. study⁵ that falsely connected the MMR vaccine to autism used flawed methodologies and showed unreplicable results regarding the “adverse effects” of vaccines.⁶ Misinformation from such studies linking vaccines to harmful side effects has fueled vaccine hesitancy, decreasing vaccination rates for vaccine-preventable diseases such as pertussis, measles, and HPV.^7,8 The development of the COVID-19 vaccine has brought similar concerns about its safety and efficacy, accompanied by concerns about its production speed and general distrust towards government institutions.⁹ Trust is critical for governments to convince citizens to adhere to public health measures, often involving significant changes in individual behavior such as mask-wearing and social distancing.¹⁰ Studies show strong associations between trust in government and higher rates of compliance to public health measures,¹¹ including vaccination.^{12, 13} However, US government public health policy before and during the COVID-19 pandemic failed to address the pandemic effectively. Poor messaging, excessive decentralization of public health powers, and failure to standardize and collect public health data have exacerbated the spread of COVID-19. Ineffective government response undermined trust towards the government and public health institutions throughout the pandemic,¹⁴ hindering future efforts to protect public health. To restore lost trust, the government and public health institutions must take steps to address these structural weaknesses.

THE IMPORTANCE OF CLEAR MESSAGING

Mixed messaging downplayed the severity of the pandemic and the effectiveness of quarantine, masking, and vaccination, resulting in the US struggling to deal with the new threat. The most prominent example of this is President Trump’s administration persistently downplaying the virus against the advice of scientists.¹⁵ This led to less proactive federal responses and lasting opposition to pandemic response measures like masking, social distancing,¹⁶ and getting vaccinated.¹⁷ In addition, the CDC’s COVID-19 mitigation strategies and vaccination recommendations have oftentimes been contradictory and subject to abrupt changes,¹⁸ which has made it difficult to continue complying with guidelines. Booster recommendations are subject to the same problems of mixed messaging by public health institutions.¹⁹ Furthermore, concerns about vaccine safety and efficacy due to the development speed of the vaccine were not addressed adequately. The government must use coherent and concise public health messaging, establishing clear and evidence-based mitigation strategy guidelines accompanied by consistent messaging across all levels of government. Information about how vaccine safety is ensured should be distributed among physicians and community leaders. Physicians²⁰ and community leaders²¹ have been proven to be highly effective messengers for public health information, especially in marginalized communities.²² For instance, Florida’s Statewide COVID-19 Vaccine Community Engagement Task Force, a grassroots organization of Black faith leaders, business leaders, physicians, politicians, and historically Black colleges and universities, has coordinated with Florida’s state government to promote vaccine uptake in minority communities.²³ As a result, governments should cooperate with physicians and community leaders to address vaccine hesitancy using data about the safety and efficacy of the COVID-19 vaccine.

CENTRALIZATION OF PUBLIC HEALTH AUTHORITY

Consistent public health measures are vital for maintaining trust in government during times of crisis. However, during the COVID-19 pandemic, the federal government opted for a minimal role in pandemic response. This meant that drawing up pandemic guidelines was left up to individual states and localities,¹⁸ hindering efforts for a coordinated response and contributing to confusion and misinformation surrounding the pandemic. For instance, inconsistent pandemic guidelines between localities led individuals to travel to areas with looser pandemic guidelines, sparking surges in cases in states like Florida with lax restrictions.²⁴ To avoid these situations, the federal government must assume a greater role in pandemic response, implementing more consistent guidelines between states, counties, and hospitals according to CDC recommendations. Establishing baseline standards for disease surveillance and containment measures tied to federal funding would allow the federal government to respond quickly and uniformly to new pandemic developments. Demonstrating preparedness and efficacy when dealing with the pandemic would maintain high levels of confidence in public health institutions and ensure that recommendations continue to be followed. Meanwhile, states would still be afforded the flexibility to adjust their response from the baseline, depending on the threat level of the disease and other local concerns. This would help ensure compliance with public health measures, which may extend to COVID-19 vaccination compliance. Similar models were proven to be quite successful in European countries in terms of developing and coordinating effective public health guidelines^25,26 and promoting COVID-19 vaccination.^27,28 The US can learn much from these more centralized responses.

STANDARDIZATION OF PUBLIC HEALTH DATA AND REPORTING

The federal government’s decentralized approach to public health has also contributed to failures in communication between hospitals, state and local governments, and the federal government. For instance, local health departments used antiquated data systems²⁹ that could not communicate with each other to track case and mortality rates,³⁰ preventing epidemiologists from visualizing patterns of COVID-19 spread. Some hospitals and healthcare providers faced delays in reporting data or did not report data at all,³⁰ causing significant gaps and worsening the effects of the pandemic. In addition, due to a lack of electronic public health infrastructure, lab data was often sent to state officials using faxes, emails, and through the US Postal Service,³⁰ which is highly inefficient and prone to error. The federal government must modernize its public health infrastructure, standardizing data sharing and collection technologies between healthcare providers, localities, and states and creating a national surveillance database for diseases to which localities and states can directly upload electronic data. The UK’s National Health Service (NHS) in particular has been able to make significant progress against COVID-19 this way. Their centralized data system allows comprehensive and standardized data from every region of the UK to be uploaded to a common database almost instantly,³¹ which has allowed policymakers to take quick and decisive action against outbreaks. The large amount of protected patient data that the NHS collects has also allowed scientists in the UK to make significant breakthroughs regarding the epidemiological characteristics of COVID-19.³² More accurate and consistent data would allow epidemiologists and other public health experts to better respond to outbreaks, improving trust towards public health institutions.

CONCLUSION

The COVID-19 pandemic has exposed widespread hesitancy towards the COVID-19 vaccine, associated in part with government mistakes made during the response to COVID-19 and structural weaknesses within public health institutions and policy. The federal government must work to restore confidence in public health institutions and increase trust towards vaccines. This involves using decisive and coherent public health messaging, working with physicians and community leaders to disseminate information about vaccine safety and efficacy, assuming a greater role in future pandemic responses, and modernizing the country’s public health infrastructure. These measures would help to address structural weaknesses in public health institutions and public health policy, better preparing the US for future pandemics.

Reference

1. Centers for Disease Control and Prevention. Stay Up to Date with COVID-19 Vaccines [Internet]. Centers for Disease Control and Prevention. 2023. Available from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html
2. Centers for Disease Control and Prevention. Similarities and Differences between Flu and COVID-19 [Internet]. Centers for Disease Control and Prevention. 2020. Available from: https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm
3. Centers for Disease Control and Prevention. COVID Data Tracker [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2023 Nov 17]. Available from: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-fully-percent-pop18
4. Lopes L, Schumacher S, Presiado M, 2022. KFF COVID-19 Vaccine Monitor: December 2022 [Internet]. KFF. 2022. Available from: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-december -2 022/
5. Wakefield A, Murch S, Anthony A, Linnell J, Casson D, Malik M, et al. RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet [Internet]. 1998 Feb 28;351(9103):637–41. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)11096-0/fulltext
6. Sathyanarayana Rao TS, Andrade C. The MMR vaccine and autism: Sensation, refutation, retraction, and fraud. Indian Journal of Psychiatry [Internet]. 2011 Apr;53(2):95. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136032/
7. Larson HJ, Gakidou E, Murray CJL. The Vaccine-Hesitant Moment. Longo DL, editor. New England Journal of Medicine [Internet]. 2022 Jun 29;387(1). Available from: https://www.nejm.org/doi/full/10.1056/nejmra2106441
8. Poland GA, Jacobson RM. The Age-Old Struggle against the Antivaccinationists. New England Journal of Medicine [Internet]. 2011 Jan 13;364(2):97–9. Available from: https://www.nejm.org/doi/full/10.1056/NEJMp1010594
9. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 Vaccine Monitor: December 2020 [Internet]. KFF. 2020. Available from: https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
10. Bollyky TJ, Hulland EN, Barber RM, Collins JK, Kiernan S, Moses M, et al. Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet [Internet]. 2022 Feb 1;399(10334):1489–512. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00172-6/fulltext
11. Goldstein DAN, Wiedemann J. Who Do You Trust? The Consequences of Partisanship and Trust for Public Responsiveness to COVID-19 Orders. Perspectives on Politics [Internet]. 2021 Apr 16;20(2):1–27. Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3580547
12. Lee C, Whetten K, Omer S, Pan W, Salmon D. Hurdles to herd immunity: Distrust of government and vaccine refusal in the US, 2002–2003. Vaccine [Internet]. 2016 Jul;34(34):3972–8. Available from: https://pubmed.ncbi.nlm.nih.gov/27344291/
13. Van Oost P, Yzerbyt V, Schmitz M, Vansteenkiste M, Luminet O, Morbée S, et al. The relation between conspiracism, government trust, and COVID-19 vaccination intentions: The key role of motivation. Social Science & Medicine [Internet]. 2022 May;301:114926. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928706/
14. Latkin CA, Dayton L, Strickland JC, Colon B, Rimal R, Boodram B. An Assessment of the Rapid Decline of Trust in US Sources of Public Information about COVID-19. Journal of Health Communication [Internet]. 2020 Oct 2;25(10):764–73. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968001/
15. Parker CF, Stern EK. The Trump Administration and the COVID-19 crisis: Exploring the warning-response problems and missed opportunities of a public health emergency. Public Administration [Internet]. 2022 Mar 29;100(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9115435/
16. Kaushal N, Lu Y, Shapiro RY, So J. American Attitudes Toward COVID-19: More Trumpism Than Partisanship. American Politics Research [Internet]. 2021 Sep 23 [cited 2021 Oct 5];50(1):1532673X2110462. Available from: https://journals.sagepub.com/doi/full/10.1177/1532673X211046251
17. Hornsey MJ, Finlayson M, Chatwood G, Begeny CT. Donald Trump and vaccination: The effect of political identity, conspiracist ideation and presidential tweets on vaccine hesitancy. Journal of Experimental Social Psychology [Internet]. 2020 May 1 [cited 2020 May 9];88:103947. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0022103119302628
18. Ngo TD. Bad COVID Public Health Messaging Is Blocking Our Path to a “New Normal” [Internet]. Scientific American. 2022. Available from: https://www.scientificamerican.com/article/bad-covid-public-health-messaging-is-blockin g-our-path-to-a-new-normal/
19. Pipes S. Mixed Messaging On Boosters Leaves Americans Dazed And Confused [Internet]. Forbes. 2021 [cited 2023 Nov 14]. Available from: https://www.forbes.com/sites/sallypipes/2021/10/11/mixed-messaging-on-boosters-leaves-a mericans-dazed-and-confused/?sh=771ab3325bb0
20. Nagar S. Medical Communication in the Age of COVID-19: A Conversation with Dr. Jeremy Faust [Internet]. Harvard Undergraduate Health Policy Review. 2021 [cited 2023 Nov 14]. Available from: http://www.huhpr.org/volume-20-issue-1-2/2021/5/21/medical-communication-in-the-ag e-of-covid-19-a-conversation-with-dr-jeremy-faust
21. Tjilos M, Tamlyn AL, Ragan EJ, Assoumou SA, Barnett KG, Martin P, et al. “Community members have more impact on their neighbors than celebrities”: leveraging community partnerships to build COVID-19 vaccine confidence. BMC Public Health [Internet]. 2023 Feb 16;23(1). Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15198-6
22. Dada D, Djiometio JN, McFadden SM, Demeke J, Vlahov D, Wilton L, et al. Strategies That Promote Equity in COVID-19 Vaccine Uptake for Black Communities: a Review. Journal of Urban Health [Internet]. 2022 Jan 11;99(1). Available from: https://link.springer.com/article/10.1007/s11524-021-00594-3
23. McLernon LM. Experts seek to allay COVID vaccine hesitancy in Black Americans | CIDRAP [Internet]. www.cidrap.umn.edu. 2021 [cited 2024 Feb 3]. Available from: https://www.cidrap.umn.edu/experts-seek-allay-covid-vaccine-hesitancy-black-americans
24. Kim S. Spring Break COVID Surge as Florida Infections Rise After Crowds Arrive [Internet]. Newsweek. 2021 [cited 2023 Nov 14]. Available from: https://www.newsweek.com/coronavirus-florida-covid-cases-rise-following-spring-break-cro wds-1579518
25. Waitzberg R, Hernández-Quevedo C, Bernal-Delgado E, Estupiñán-Romero F, Angulo-Pueyo E, Theodorou M, et al. Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges. Health Policy [Internet]. 2021 Oct [cited 2021 Nov 27];126(5). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8507573/
26. Janssen M, van der Voort H. Agile and adaptive governance in crisis response: Lessons from the COVID-19 pandemic. International Journal of Information Management [Internet]. 2020 Jun;55:102180. Available from: https://www.sciencedirect.com/science/article/pii/S0268401220309944
27. Antonini M, Eid MA, Falkenbach M, Rosenbluth ST, Prieto PA, Brammli-Greenberg S, et al. An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes. Health Policy and Technology [Internet]. 2021 Dec 24;11(2):100594. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702636/
28. Peltier E, Holder J. How Europe, After a Fumbling Start, Overtook the U.S. in Vaccination. The New York Times [Internet]. 2021 Jul 29 [cited 2023 Nov 17]; Available from: https://www.nytimes.com/interactive/2021/07/29/world/europe/europe-us-vaccination.html
29. LaFraniere S. “Very Harmful” Lack of Data Blunts U.S. Response to Outbreaks. The New York Times [Internet]. 2022 Sep 20; Available from: https://www.nytimes.com/2022/09/20/us/politics/covid-data-outbreaks.html
30. Banco E. Inside America’s Covid-reporting breakdown [Internet]. Politico. 2021. Available from: https://www.politico.com/news/2021/08/15/inside-americas-covid-data-gap-502565
31. Blauer B. Universal Healthcare for Unified Data [Internet]. Johns Hopkins Coronavirus Resource Center. 2022 [cited 2024 Feb 2]. Available from: https://coronavirus.jhu.edu/pandemic-data-initiative/data-outlook/universal-healthcare-for-unified -data
32. Ferguson C. It took a pandemic, but the US finally has (some) centralized medical data [Internet]. MIT Technology Review. 2021 [cited 2024 Feb 2]. Available from: https://www.technologyreview.com/2021/06/21/1026590/us-covid-database-n3c-nih-privacy/