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Evolving Hesitancies and Objections to COVID-19 Booster Shots: Separating Facts From Fiction

Authors: Rosemary A. Leonard, MBE, MA, MB, BChir, MRCGP, DRCOG; Thomas Frese, MD, PhDFaculty and Disclosures


Activity Transcript

Rosemary A. Leonard, MBE, MA, MB, BChir, MRCGP, DRCOG: Hello. Today we are discussing vaccine hesitancy. The topics we're generally discussing come in 3 categories, the evolution of vaccine hesitancy, the key drivers of vaccine hesitancy, and addressing drivers to increase confidence and vaccine uptake. So what is vaccine hesitancy? Well, vaccine hesitancy is defined as a delay in the acceptance, or refusal of vaccination, despite availability of vaccination services. A lack of confidence in vaccines for COVID-19 poses direct and indirect threats to health, and could derail efforts to end the current pandemic. And the WHO has identified vaccine hesitancy as a major threat to global health. Vaccine hesitancy isn't new, we all know it's been around for ages, and we've had MMR [measles, mumps, and rubella] problems, all sorts of issues with vaccine hesitancy, but it's escalated in scope. It's been amplified hugely by social media. Attitudes about vaccines have always been volatile, but today acceptance of vaccines is more dynamic, and it's rapidly changing.

Thomas Frese, MD, PhD: The current vaccine uptake in Europe is displayed on this slide. You can see COVID-19 vaccinations with at least one dose, the second dose, and then booster sessions. And you see that the first 2 doses have been uptaken quite well, with rates to 72 to 75%, but first booster, and then second booster, and third boosters are really, in a large extent, lower uptaken by the people. However, you have to consider that for the second and the third booster not everyone will be eligible. The vaccine hesitancy evolves and evolved over the time. First, there was some impatience waiting for vaccines to be available. Then initial hesitancy appeared when vaccines were first available, and the pathway split into acceptance of the vaccine, or refusal of the vaccine. This was summarized as the ‘emotional epidemiology’, and it was not a new phenomenon, it was already described with the H1N1 vaccines in the specific H1N1 flu.

Vaccine hesitancy also evolves over the time at the population level, but also at the individual level. This emphasizes the need to track hesitancy, longitudinally, and to approach vaccine hesitancy differently in the time course. The vaccine hesitancy also broadly varies by location. For example, the graphic shows you regional differences in the United States, so there are not just international, but also regional and local differences regarding the vaccine hesitancy. So targeted approaches are needed to increase the vaccine acceptance, and these targeted approaches may have to come in very small units like communities, specific subpopulations, and others. So please, when talking about vaccine hesitancy, be aware of your local situation, the situation of your practice population, of your patients, and anticipate concerns.

Dr Leonard: So evolution of vaccine hesitancy drivers. Now, there were some that existed before COVID-19, the burden of the vaccine schedule, especially for childhood vaccinations, we had parents saying, "Well, how can you give 6 vaccines in one? Six bugs in one vaccine, can the immune system cope?" Then there's been concern about vaccine ingredients, this big worry, "Is the mercury in it? Is it going to do any harm?" Then there's been perceived vaccine risks, the big one was the perceived and completely inaccurate risk about autism. And then the other issue has been the low-perceived risk of infection, "Why should I vaccinate my child against polio? Against diphtheria? They're not around anymore, are they?" So those existed before COVID-19.

Then we had, early on, some different drivers that emerged with the first wave of vaccination. There were those that were saying, "Well, hang on, this is a brand-new vaccine, you've got no data on it, how do you know it's going to work? Is it going to be safe?" There was a lot of misinformation and disinformation about the vaccines. There was a lack of confidence in the institutions and the scientific experts, people just didn't believe them, and there was political polarization. So that happened early on in the COVID-19 pandemic, and we all had to deal with people who felt that the vaccine wasn't safe, and it wasn't going to prevent them getting severe illness, and they just weren't going to have it. But now, we've got different drivers, emerging drivers. So we've seen vaccine fatigue in people who've received prior doses. And interestingly, the vaccine fatigue that we are seeing with COVID boosters has also spilled over into the annual flu vaccination campaign. People are jabbed-out, they don't want to be a pin cushion anymore, they've had enough vaccines.

Also, they have overconfidence in the immunity from prior disease with COVID, "Well, I've had COVID now." They're saying, "Why should I have a vaccine? I've got no need to have a vaccine, my immune system... I've had it, I'm not having a vaccine for that now." And then we have the lower perceived risk of Omicron. They're saying, "Well, it's not serious, it's not going to put me in hospital, I don't need to worry about that. Why should I be vaccinated against Omicron?" And on top of that, they're saying, "Well, look, we've had Omicron, the vaccine didn't work against Omicron, we're going to get new strains, why should I have a vaccine against Omicron? What's the point in having a vaccine now when there's a new strain likely to appear?" So we've got these new emerging drivers that we're having to deal with.

Dr Frese: Yeah. This slide presents booster hesitancy data from the EU, so from actually free states, Austria, Germany, and Switzerland. And data was estimated during summer 2021, based on a survey of approximately 2500 people. And the main question was, "Are you willing to receive annual COVID-19 boosters?" And 82% of the people agreed to be willing, and 17.6% of the people disagreed to accept an annual booster of COVID-19. Factors which were associated with the willingness was older age, it was being residing in Austria or Germany, vs Switzerland. It was being a voter in the last national election. People which had no regular religious attendance were more likely to accept annual COVID-19 boosters. And people which approved totally or partially COVID-19 mitigation measures were also more likely to accept annual COVID boosters. What has to be said regarding this work from Weitzer, et al. which was also published in Lancet Regional Health Europe, is that it was based on people who already received 1 COVID immunization dose, so it's not the whole population which had been asked.

Dr Leonard: So, data from the United States, this is another survey in just over 1500 US adults who'd received a booster shot, so they'd had one, only 34% said they were very likely to receive a second booster shot. And then if you go into the reasons why, the big drivers for this were side effects, and as I said before, not convinced it was necessary. Then there were those that were taking the altruistic view, taking the vaccine from others who need it, missing work again due to side effects, missing work to actually get the vaccine, and then those who were saying, "Just don't have the time."

Dr Frese: But what are the key drivers of COVID-19 vaccine hesitancy? At first, there are efficacy concerns. So preventing the infection, or preventing a severe disease is seen critically by many patients. Also, there is a low-perceived COVID-19 risk. So the risk of any infection, severe disease is underestimated. And a very important point from the perspective of daily practice are safety concerns, that the patients and the people fear side effects are critical and suspicious about harming long-term effects of the vaccinations, and of the substances applied.

Dr Leonard: When we go into the myths, and we've all come across this, some common myths about vaccine efficacy. So first, we have efficacy concerns. Does it work? "The vaccine doesn't work because you can still get COVID-19." And unfortunately, we have seen that. Of course, once you've had the vaccine, you are far less likely to have severe disease, but people are still saying, "Well, it doesn't work." And then, which we'll go into again in a minute, having the infection, or the natural immunity, is actually better than having the vaccine, "Let my body get it naturally, that's how I'm going to become immune." So those are efficacy concerns. Then there are the safety concerns, which of course, were very big initially in the vaccination campaign, and they're still there for some people, "The vaccines are new, and there's not enough data on their long-term safety."

Then, again, we'll talk about this shortly again in a minute, the vaccines affect fertility, "They're not safe for pregnant women." Safety concerned. Then we have, again, a misconception, and a safety concern, "Side effects of vaccines are as dangerous as having COVID-19." Then, again, another one, a misconception, and a safety concern, myocarditis risk outweighs the benefit of vaccination in younger people, worried that the vaccine's more dangerous than the illness itself. And then, something new that's happened with this, because people have learned that it's an mRNA vaccine, and they go, "Ah, it's RNA, it's going to affect my own DNA, so I don't want that." So we have these new misconceptions that have come in with the COVID-19 vaccine campaign.

Dr Frese: There are also other drivers of COVID-19 vaccine hesitancy, and some drivers are of course not related to the vaccines themselves. Think about the role of social media, which provides information, influences broadly attitudes and behaviors of the population, and of the patients. Misinformation or disinformation. So false information which is spread, regardless of the intent that's misinformation, or spread intentionally to mislead people, that is disinformation. And this also has a role in vaccine hesitancy. The mistrust in institutions which was in general more likely to be seen in the first waves of COVID, like the mistrust into governments, into public health organization, into scientific experts, into physicians at all, and the healthcare systems, they're also drivers of vaccine hesitancy, and may not only be relevant in the context of COVID-19.

Dr Leonard: Social networks matter as well, hugely. Again, a survey done in October, 2021, so more than a year ago, but it's still relevant, so you can see from this graph that your social network, if you had family or close friends who are being vaccinated, then you are more likely to be vaccinated yourself. On the other hand, if you've had family or close friends who've had the vaccine, and then they've got infected, it will mean that you'll say, "Well, what's the point in me being vaccinated?" So beyond also individual factors, a person's social network very much can influence vaccination decisions. If again, you've had the illness yourself, you can say, "Well, I'm immune, I don't need to have a vaccine." Your household income, and there is more and more research come out recently about this, household income, higher socioeconomic class, being more educated, you are more likely to be vaccinated. Men and women about the same. Age, about the same, but there is this big, big difference in ethnicity.

And as a practitioner, I work in South London, where we have a huge people of Afro-Caribbean origin, and they have been incredibly hesitant to have the vaccine, and that again, shows on this slide. So social media is a source of health information as well. These social media outlooks have emerged as major information and sharing channels during the pandemic, and they're facilitating the spread of misinformation. Facebook, Twitter, TikTok, YouTube, and during the pandemic, the use of social media platforms has increased between 20 and 87%.

Dr Frese: So not only by social media, there are different layers of information, you see it displayed on the right side. So social media is the bottom, then news media, maybe the next layer, policy and healthcare practice, again, maybe the next layer, and in some sense, science and scientific information is on the top layer of different information. So science, and science-based information is the smallest layer of the ‘information cake’ in terms of the amount of information, but it represents rigorous and very selective information production cycles. Social media, again, is the largest segment, and Rosemary already stressed, with nearly unfiltered and uncontrolled information, which is generated, and amplified, and changed by the public.

What is the impact of vaccine misinformation? Misinformation, and especially those amplified by social media, can have severe, adverse consequences, and may lead to mistrust of scientific truths from experts in general. Misleading information can also have, and has had adverse effects on the COVID-19 vaccination campaigns. In March to April, 2020, social media posts containing misinformation about vaccines had 4.5 billion views, so it's an incredible huge amount of views. And think back to the information layers and the ‘information cake’, it illustrates very well how big the role of social media can be, and how big the role of misinformation in social media can be. Incorrect information abounds on the internet regarding prevention and management of COVID-19, and least, misinformation, can cause detrimental health outcomes by encouraging people to engage in ineffective and even harmful remedies. Think about chloroquine, think about ivermectin, and their role in the COVID-19 pandemic.

Dr Leonard: So the Omicron and current vaccines. The Omicron variant has many novel mutations, not only in the structural, but also in the non-structural proteins, leading to concerns about vaccine failure, immune escape, and increased transmissibility. But despite this, there is now evidence emerging that vaccination or previous infection with the other variants of COVID, so the old Delta variants, partially protect against COVID-19 caused by Omicron. And also, Omicron tends to cause less severe disease, especially, and very importantly in vaccinated populations. But fair's fair, we do need more research now on how immunity to Omicron changes over time.

Navigating the pandemic in the Omicron era, we do need more research. We need to know how effective the vaccines are that we are giving now. And the vaccines we're giving now, the bivalent vaccines which are against Omicron, as well as the Delta variant, we need to have data from clinical trials to see how good these vaccines are against the new variants. So you do need to stay informed, so that you're prepared for that discussion with your patients, who say, "Well, this is against the old variants, how good is it against Omicron? How good is it against the new variants?" We also need trust in institutions and experts, which, in the past, has been hindered by misinformation and poor communication, and we need to make efforts to establish long-term public trust.

We also need to be very careful to avoid further alienation of at-risk populations. So we need to identify target populations, and address their specific concerns, such as those of ethnic minorities, and also some people of certain religious beliefs. And this could help prevent the conversion from someone who is vaccine hesitant, to being someone who is vaccine resistant. We don't want to alienate these populations.

Dr Frese: What could be strategies to address vaccine hesitancy? What usually works, also works based on data, is personal engagement from healthcare providers who share positive information which is relevant to the individual patient. Tailored communication that targets specific communities, which targets specific subpopulations of your practice population, but which may also target on special people which have a multiplicator role in their subpopulation or their community can be very important. Bringing vaccines to the community, so increasing accessibility can be a very important point. So lowering the barrier to access may facilitate vaccination campaigns, and may address vaccine hesitancy very well. What usually doesn't work, our top-down approaches which will not reach a population that mistrusts institutions. Also, vaccine passports are liked by people willing to be vaccinated, but further alienate those who do not want to be vaccinated.

Dr Leonard: So, addressing misinformation... you have a patient, or a patient comes in, and they don't want the vaccine, and you ask where they've got the information, you inquire about where their messages have been received. And certainly I sometimes long to say to them, "That source is rubbish." But, actually, that just alienates them. So we mustn't rubbish their source of misinformation, but rather we must build trust, and acknowledge their concerns and their mistrust, and try and shift the conversation into where can they get good, trustworthy information. So rather than being negative about their source of information, it's directing them to a source that is good, and sharing resources and facts, and as I say, avoid stigmatizing language, so they learn to trust us, and we try to be friends, and empathic with them.

Dr Frese: So, myths regarding COVID vaccines, "The vaccines don't work, because you can still get COVID-19." These are just examples displayed here, "I don't think the vaccines even work, I heard some people still got COVID after taking them." So one common myth. COVID-19 may continue to circulate after achieving immunity through natural infection or vaccination, suggesting the need for long-term transmission mitigation efforts. Therefore, individuals regardless of history of infection, should continue to participate in mitigating the spread of infection. A very important point if you go from the individual perspective to the population perspective. It is important to emphasize that approved COVID-19 vaccines are highly effective in preventing severe illness from COVID-19, and not just avoiding, let's say, easy, or simple COVID infections.

Dr Leonard: So the other one, natural immunity is better than vaccine immunity. So it's important to explain that all immunity is natural, whether it's being induced by a vaccine, or it's by being infected with COVID-19. But immunity from vaccination has some really important additional advantages which we can tell our patients. Vaccines prompt your immune system to respond in a more controlled way than with the infection, and they avoid the severe damage that natural infection with COVID-19 can sometimes cause people. It's so unpredictable who is going to become severely ill, who is going to get long COVID. That's another thing we need to address. As well as the fact that vaccination comes with a reduced risk of transmitting the virus to others, compared with getting the disease itself.

The other thing that's interesting is the immune response after COVID-19 infection is very variable, whereas the response to vaccines generally is strong and consistent.

The other thing I've come across particularly, because I work a lot in women's health, COVID-19 vaccines affect fertility. And headlines have appeared across multiple social media platforms, Mumsnet, and other medias where they're dealing with fertility, questioning the effects of COVID-19 vaccines on fertility. And this has largely come from the fact that it has been reported that having vaccination can affect the menstrual cycle. So although the effects were of future fertility were not studied in the initial trials, at present, there is no evidence that the COVID-19 vaccine has any effect on future fertility.

Yes, the timing of menstruation may alter, but then your cycle goes back to normal, and your fertility is unchanged. But unfortunately, disinformation and misinformation regarding the impact of the vaccine on future fertility, this needs to be controlled really hard to avoid any hesitancy among young women attending clinic for vaccination. We need to reassure them that vaccination during pregnancy is safe, that vaccination before you get pregnant is safe, but if you get COVID-19 during pregnancy, your immune response is changed because of the pregnancy, and if you get it whilst you're pregnant, you're much more at risk of getting severe illness, and vaccination during pregnancy is recommended by all the obstetric and gynecological societies.

Dr Frese: Yeah. Another, myth is that COVID-19 vaccine side effects are dangerous as COVID-19. But an analysis of published clinical trial data and real-world data revealed that although the spectrum of vaccine related ADRs [adverse drug reactions] is extremely broad, most ADRs are tolerable, and mainly in grade 1-2 in severity. So for example, fever is usually mild and transient if it occurs, so it's lasting 1 or 2 days at all. Some severe ADRs have been identified though, the incidences were extremely low, especially compared with the natural disease. You see here the number displayed for thromboembolic events with 21 to 75 cases per million doses given. Myocarditis, pericarditis, 2 to 3 cases per million doses given to patients.

Neurological complications of COVID-19 vaccines have been described, but are much rarer than the neurological complications which can last for a long time after COVID-19 infections. And most symptoms appear soon after the vaccinations, and many people recover without any medication within a few days. So on the next slide, you see numbers compared between predicted prevented COVID-19 associated hospitalization, so severe courses of COVID-19, and predicted cases of myocarditis due to vaccination separated by age groups. And you see, especially for the adults, that the benefits of avoided hospitalizations are much larger than the risk of myocarditis cases, for example.

Dr Leonard: So, another one, "COVID-19 mRNA vaccines will alter my DNA." And of course, this has come about because people learnt what is in these vaccines, they've got messenger RNA. There then becomes a belief that there is evidence that COVID-19 can alter your DNA, and it's actually become a distinctive theme in terms of a predictor of vaccine unwillingness. We need to be able to reassure our patients that the mRNA technology behind these vaccines has been in development for almost 2 decades, and we, again, need to reassure our patients that translation of the antigen takes place in the cytoplasm, not in the nucleus, and therefore, it's much less possible for the mRNA to integrate into the genome, into their DNA.

Healthcare professionals remain the most trusted advisors and influencers of healthcare decisions. And I've had patients who've come in for a flu vaccine, and said, "Well, I don't want a COVID vaccine." And then I've been able to talk to them. And one of the things they say, "Well, doctor, have you had it?" And I'll be able to say, "Yes, I've had it." And they say, "Oh, well, if you've had it must be okay then, I'll have it too." But we can also, as well as that, give our patients the advice, and the information, the accurate information about the vaccine. So we need to be aware of the local situation to anticipate patient concerns, and we need be able to tailor the discussion to the individual. And tailoring includes matching each individual's specific beliefs, attitudes, and experiences to the message or information they are provided, and thus, improving the personal relevance of the information, and the likelihood that it will change behavior.

Dr Frese: What could be communication strategies? Ask questions to elicit individual concerns, provide answers to specific questions when possible. So try to assess patients' expectations, concerns, perceived risks, et cetera. Reinforce vaccine benefits at multiple encounters if needed. That's the privileged role we as GPs have, we do see patients many times, and we do not have to solve the problem in the first consultation. Have reliable, up-to-date, and accessible sources of information on hand to distribute it to the patients, so you provide clear and up-to-date guidance. Repeatedly check understanding while discussing about the vaccinations. Adjust styles for differing literacy, education, and language levels as we usually do in general practice, then giving a very patient-centered approach. Remain always open and empathetic.

Dr Leonard: There were pathways to vaccine hesitancy. How has it come about that a patient has become vaccine hesitant? So these are 2 pathways, the neoliberal logic that they believe health is an individual responsibility. They assess available information, and make a choice that is best for them. And this may well conflict with the concepts of public health and vaccination campaigns. So it's done very much on an individual basis of, "I've looked into this, and I've made my decision." On the other side, we have social exclusion from marginalized groups that may distrust institutions. They feel that big government doesn't really address the needs of their small minority group. They may have a lack of social connectedness, and they actually may resist vaccination as a form of agency to say, "This is what I want to do." So they're vaccine hesitant.

And then you've got other forms of vaccine-hesitant individuals. Some believe in conspiracy theories. "Someone's going to be monitoring my DNA. Someone's going to be tracking me with this vaccine." But not all vaccine hesitant individuals believe in conspiracy theories, and underlying the identifying drivers of hesitancy enhances communication, and enables delivery of relevant information.

Dr Frese: This is a very important slide, don't forget the RULE, so the principles of motivational interviewing. R, is for resist the righting reflects, don't try to resist the vaccine hesitant patient's position. U, is to understand motivations. Ask questions that elicit values and concerns, and listen. Although your patient list may be very full, try to listen, providing that the vaccine hesitant patient with the information doesn't automatically cause the change. And empower the patient, also very important, guide the patient through the process of thinking aloud, and deciding better, and how to change.

Dr Leonard: This is a very interesting program, particularly for me working in South London with a large Black population. Black Women in Health is a UK non-profit organization, and it's initiated a COVID-19 outreach program to educate Black, Asian and minority ethnic communities in the UK who had been shown to have a large... There were a large number of them who were vaccine hesitant. We could see we were having real problems vaccinating these communities. So Black Women in Health, they engaged in social media, they did podcasts in multiple languages, they were done by people within their own communities. They also did a 2-hour webinar conducted to debunk the myths that people had heard about COVID-19 vaccines. And this was attended by more than 150 members of the BAME community. And it did change some perceptions about the vaccines. So if we look here, I mean, yes, the numbers are small, but before the webinar, 66% willing to have the vaccine, but that went up to 90% afterwards, and repeated throughout the Black and the BAME populations within the UK. This did make a big difference to vaccine uptake.

Dr Frese: There's one small case example, think about a 70-year-old woman with severe asthma comorbidity, which had already received 2 shots of COVID vaccines in 2021, and her first booster 10 months ago, and she's planning to conceive. How would you approach this discussion if she's hesitant to be boostered again, and to receive the next booster? Think about the rules, just think about how to approach this patient case.

Dr Leonard: It's been a tricky time for us as GPs trying to give people their boosters. But we need to remember where vaccine hesitancy is evolving, we now have different drivers, different people who are hesitant, the standard drivers still persist, the efficacy concerns, the safety concerns, and ongoing of course, social media and misinformation. Then new drivers emerging, particularly vaccine fatigue, overconfidence in prior doses, or the fact they've had COVID before, the low-perceived risk of Omicron, and uncertainty about the effectiveness against future strains. So what steps can you take? Well, we are a trusted source of information. We need to be aware of the local situation to us, and anticipate questions and concerns, and tailor discussions to the individual.

So now, we welcome questions and answers. And so I'm going to ask, now, what is the evidence we have of the efficacy of the COVID-19 booster doses in patients that have had COVID-19 in the past?

Dr Frese: Yeah. Basically, I do not know a very exact population about this question, but basically, it can be said that immune prevention goes down in the time. So there is clear data showing that, again, a booster patient will benefit with easier courses of COVID if they acquire an infection again.

Dr Leonard: We've got another question here.

Dr Frese: Yeah.

Dr Leonard: There are still people who suffer from severe COVID even after the booster dose. How can this be explained?

Dr Frese: I'm not sure about this, but you have to say there are such cases, we all know this from the practice, and maybe the question goes into the direction asking, "Okay, why did the vaccination not work on that respective patient?" But on the other end, you should also think, how would the course be if that respective person would not have received basic vaccination and booster dosages? What would then be often the course? And we see this with Omicron infections, and people which are COVID naive, which still have severe courses more likely than those which were vaccinated.

Dr Leonard: Yeah, yeah. Another one, current vaccines are made for the first variants, how we convince people that they still work for emerging strains? Do we have any evidence they work for emerging strains? It's a big one, isn't it?

Dr Frese: Yeah, it's a big question. And it's true that vaccination which may be adapted to your current strain will come to the market quite late for the current strain, but on the other hand, you should consider that there is always an overlap, which is more or less between the strains. So this is one important point, and the other important point, like it is hypothesized for flu, for example, and flu vaccinations, if a new variant comes up, which may be a partially immune escape variant, it's also nice that you have a basis protection, and it may help you not to suffer from a severe course. And although we see that Omicron and other variants are going less pathogenic through the time, we cannot exclude the possibility that there could come up new variants, which are a much higher risk to our populations than Omicron currently is.

Dr Leonard: Yeah. So we have to hope that, A, that doesn't happen. We have to hope. But also that having been vaccinated against Omicron and Delta, you have some baseline immunity against an emerging strain. Thank you all very much indeed for participating in this activity, and I hope you found it useful and educational.

Dr Frese: Thank you very much.

This transcript has not been copyedited.

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