Public health scientists and officials shared information about ways to increase uptake of COVID-19 vaccines and reduce vaccine hesitancy, during a hearing of the House Committee on Science, Space and Technology on Friday. The key focus included strategies to eliminate hassles; leverage effective, targeted messaging; and engage “trusted communicators.”
Committee chair Rep. Eddie Bernice Johnson (D-Texas) warned that vaccine hesitancy could delay the U.S. recovery from the COVID-19 pandemic: “We simply cannot and will not bring this virus to an end unless we vaccinate a high percentage of the American population and in fact, the globe,” she stressed.
Panelists at the hearing shared that concern.
In addition to a strong and predictable supply of vaccine, overcoming COVID-19 can happen only if enough Americans are willing to receive the vaccine and if that vaccine is equitably distributed, said Philip Huang, MD, MPH, director and health authority for the Dallas County (Texas) Department of Health and Human Services.
Vaccine supply remains a challenge, he said. For example, in Dallas, he noted, there are currently 650,000 people who signed up to be vaccinated, but the health department receives only 9,000 doses per week.
On the demand side, public health experts need to engage “trusted messengers,” employ targeted outreach, and ensure that those who are reluctant to be vaccinated have an opportunity to ask questions and have them answered, Huang said.
Vaccine advocates and public health experts must pay special attention to communities of color and tailor the messaging to individual communities, he said, noting that among the African-American community, there remains deep-rooted medical mistrust due to the Tuskegee study in which treatment for syphilis was withheld from rural Black men.
And among Latinx populations, he continued, hesitancy appears to stem from general mistrust of the government and skepticism around how the vaccine was developed. Among undocumented immigrants, many are worried that if they supply personal information it could be misused.
More specifically, Keith Reed, MPH, CPH, deputy commissioner for the Oklahoma State Department of Health in Oklahoma City, noted that in his state, undocumented immigrants worry that by registering for vaccine appointments they may be targeted because of their immigration status.
Mistrust of the vaccine is also a concern among healthcare workers in long-term facilities, where in some facilities only 42% of staff received the vaccine, Huang said.
Reed said that in Oklahoma, the latest survey conducted by the department of health found that 33% of residents there said they do not plan to get vaccinated. These vaccine holdouts worry about the lack of information about the vaccine and how it was developed, as well as about the potential for side effects.
In addition to needing “clear, accurate information about vaccine safety and efficacy,” Oklahomans, like Texans, also need “greater vaccine accessibility” to ensure equity, Reed said.
Another witness, Alison Buttenheim, PhD, MBA, associate professor of nursing and healthy policy at the University of Pennsylvania School of Nursing in Philadelphia and a behavioral scientist whose research focuses on vaccine hesitance, recently co-authored a National Academies of Sciences Engineering and Medicine report on the topic.
She said it is not true, as some believe, that vaccine distribution cannot be both efficient and ethical, that it can only be either fast or fair, but not both. “We have the science to do both, but we have to be deliberate, intentional, and innovative in our approach to both tracking and achieving those complementary goals,” she said.
In addition to leveraging creativity, Buttenheim described other key steps to improving vaccine confidence: “Fix the easy stuff” first, she said.
Even people who are willing to be vaccinated can be put off by “hassle factors” such as difficult logistics, inconvenience, or confusing instructions, she noted.
Finding ways for people to make and keep their vaccination appointments is critical and far easier than changing a vaccine-hesitant person’s mind, Buttenheim continued.
It’s also important to “keep doing the hard stuff” — i.e., the time-intensive one-on-one engagement — even if it doesn’t produce outsized results, she added.
Some of the key concerns that vaccine-hesitant people raise center around the speed of vaccine development, the diversity of the clinical trials, and trust in medical research, she explained. The best way to answer those worries is through “sustained, repeated one-on-one conversations with trusted peers or vaccine validators.”
Regarding the speed of development of the vaccines, Kathleen Neuzil, MD, MPH, director of the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine in Baltimore, who has been involved in the COVID-19 vaccine development process from early on, stated: “I can attest that safety was never compromised by the speed of this effort.”
Trial designs were vetted by ethics boards and the FDA, and a group of independent experts “with no ties to the products” monitored vaccine safety, she stressed.
For those concerned that the vaccine trials did not include diverse populations, Neuzil pointed out that the trials included a minimum of 30,000 people, with high percentages of minority populations and different age groups: “So, everybody can point to the trial and say somebody that looked like me received this vaccine,” she said.
As for concerns about potential side effects, Neuzil pointed out that most adverse events relating to vaccines occur shortly after vaccination, and that the FDA required a median of 2 months of follow-up data before granting emergency use authorization. In addition, she said, the trials themselves and their safety assessment are ongoing and will continue for at least 2 years.
Buttenheim echoed that: “We have incredible safety profiles … So I think it’s sort of hitting those three [points] again, and again and again, but making sure that if people have another set of concerns that we hear those and address them as well.”
Another effective strategy, she said, is using “fun and delight” to promote evidence-based messages — for example, the #SleevesUpNOLA campaign, where New Orleans residents explain their reasons for getting the vaccine.
Buttenheim also argued for those involved in vaccine efforts to “fail fast, learn fast.”
She explained that behavioral scientists generate hypotheses and test them in experiments, in the same way that lab scientists do. To see results, the same “rigor and speed” that was successful in vaccine development research should be applied to research about vaccine acceptance, she emphasized.
Asked by the hearing chairwoman about specific strategies that would make it easier for Americans to register for the vaccine and actually receive it, Huang highlighted the importance of phone banks and in-person registration events to help those without digital access to register. He also suggested drive-through vaccination sites for older adults and those with mobility issues.
Also, he said, in Dallas County, in order to improve equity, after observing that many more affluent people had registered for the vaccine there, health officials began to base distribution on a “vulnerability index.”
Reed said it’s important to give people as many options as possible to register, and that Oklahoma uses its 211 hotline for that purpose as well as encouraging “pandemic providers” to use their own systems to help provide appointments.
He noted that Oklahoma has set up dispensing sites in places like churches and fairgrounds.
Several committee members asked about the effectiveness of current COVID-19 vaccines against new variants.
Neuzil noted that the variants that emerged abroad did so in settings where people were not yet vaccinated. “So, the variants are yet another argument to get vaccine out … fast, and to have a global response, because variants that emerge anywhere are a threat everywhere,” she said.
While the ability of mRNA vaccines to stop the growth of the virus is “diminished” against some variants and researchers are currently studying this issue, the vaccines are still effective, Neuzil added.
“When you’re starting at 95%,” she said, referring to the efficacy rates of the Pfizer and the Moderna vaccines, “you can lose a little effectiveness and still be an extremely good vaccine.”
Similarly, Rep. Ami Bera, MD (D-Calif.), said he worries that if Johnson & Johnson’s COVID-19 vaccine is approved, some Americans may refuse it and instead try to access the Moderna or Pfizer vaccines — both of which have demonstrated efficacy of about 95% in preventing symptomatic disease compared with 72% with the J&J vaccine.
To avert such a problem, public messaging is again critical, Buttenheim said, adding that when someone gets a flu shot, no one asks which kind it is.
Therefore, it will be important to find ways to communicate that “any vaccine is a good vaccine,” and that “the best vaccine is the one you can get tomorrow,” she said.
Rep. Mike Garcia (R-Calif.), however, countered that while trying to get as many people vaccinated as possible, a strategy that tries to discourage people from asking questions about the vaccine or removes choices could backfire.
The COVID-19 vaccines are different from the regular flu vaccine because of the publicity they’ve received and because of how informed the average American is about them.
Garcia said he agreed with Buttenheim “at an academic and science level,” but that rather than discourage questions, “we should make the answers to those questions more readily available and in the end communicate that ‘they’re all great products and you’re going to be saving your life with any of these vaccinations.'”
As to whether certain individuals should be warned against receiving the vaccine, Huang noted that “the only real contraindication is to have a history of anaphylaxis to any of the actual components in the vaccine.”
In addition, he said, health experts recommend delaying the vaccine if a person has had a different vaccination in the prior 14 days.