If scientists build it, will people take it? It's a question drugmakers should be asking as they race to deliver a vaccine for the new coronavirus.
As few as half of Americans say they will get vaccinated, according to recent polling, well short of the 70% to 90% needed to achieve the 'herd immunity' that can prevent the spread of the SARS-CoV-2 virus. While convincing vaccine opponents might not be possible, public health officials, governments and drugmakers need to be thinking about reaching those who may hesitate to get a vaccine or doubt its effectiveness.
"I couldn’t worry about this more," Julie Gerberding, a former director of the U.S. Centers for Disease Control and Prevention, and now an executive at Merck & Co., told a House of Representatives subcommittee on Tuesday.
The question of trust looms large as the public health system gears up to mount what could be the biggest vaccination program of this century. The groups in charge of organizing will need to make addressing doubts a priority, said Arthur Caplan, professor of medical ethics at New York University's medical school.
"If you have a vaccine that 30% of the public doesn't want to take, you've already lost," he said in an interview.
With nearly 200 experimental vaccine projects underway, the chances are good that one or several will eventually prove safe and effective, and be made available. At least five drugmakers are advancing candidates into large late-stage trials within the next few months. Under the best-case scenario, at least some people could receive the first injections of an authorized vaccine later this year or early next.
Public health officials from the federal level down to county and city public health departments are now preparing for the vaccination campaign to come. They’re doing so amid a pandemic that, particularly in the U.S., has become politically charged, adding to the challenge.
Winning the public’s trust
When polled, the share of Americans who say they will get a coronavirus vaccine ranges from 49% to 72%. The higher figure came from a Pew Research Center poll that asked a binary question, while the lower number is from an AP-NORC poll that included "not sure" as an option, to which 31% responded.
The share of respondents who said they would not get vaccinated appears similar in both polls, 27% in Pew and 20% in AP-NORC.
Gaining the trust of the uncertain or resistant will be a critical task, as the government’s ability to mandate vaccination primarily applies to children, through mechanisms like school health requirements.
But there's some debate over the best way to do that.
Communication about coronavirus vaccines will need to be open and transparent about the risks and benefits of inoculation, experts agree. Beyond that, however, the keys to persuading people may involve appeals to community benefits, to fear or the desire to more quickly end other public health-related restrictions.
"Giving the impression that you're telling people what they should do is never well received," James Blumenstock, chief of health security at the Association of State and Territorial Health Officials, said in an interview. "That immediately puts up the defense shield that really is a barrier to effective communication."
Instead, people should be shown how vaccination protects their families and communities from further spread of disease, Blumenstock said.
That's an idea that Mark Navin, a bioethics professor at Oakland University in Michigan, rejects.
"I don't think you're going to get very far with solidarity and fairness arguments. There's no evidence that that kind of messaging works for people," Navin said. "What motivated more than a million Americans to let their kids participate in the polio trials at schools was fear," he said.
Another approach, Caplan argued, is to link vaccines to uniquely American values like liberty, allowing those who receive them a return to pre-pandemic lifestyles.
"If you don't like masks and you don't want to socially distance … the road runs through vaccines," he said.
Getting the word out
The methods used to communicate could be just as important as the message. In the past, recruiting local community influencers like pharmacists or religious leaders has helped to persuade people to receive a vaccination.
"The minister who not only gives a Sunday sermon but at the end there's a vaccination clinic in the rectory or the cafeteria — that's the sort of thing that makes or breaks a campaign," Blumenstock said.
Local contacts are essential, Navin said. He cited a case in Michigan involving a measles outbreak in an orthodox Jewish community sparked by a sick traveler who had visited several synagogues, causing the virus to spread among unvaccinated people.
The public health department contacted local rabbis to offer vaccination clinics, an initiative that helped to blunt the outbreak. "In 48 hours the local health department gave out 2,000 doses of the MMR vaccine, because the rabbis told them to go and do it," Navin said.
Healthcare practitioners will also need to be engaged to answer questions their patients might have about the risks and benefits of a vaccine, Merck’s Gerberding told the House subcommittee Tuesday.
"It's not enough to have a government spokesperson or a manufacturing spokesperson, we really need to engage people who are trusted and often those are doctors," she said.
Social media has strengthened anti-vaccination activists, and public health specialists are preparing to respond to that.
"[People] have to figure out who’s telling the truth and then absorb the information that’s being shared," Blumenstock said. "We're looking at how we can level the playing field using the formats that today's members of the public are looking at."
Vaccination by law
Mandates may still come into play, although they may be easier to enforce by employers and schools than a broad population order.
Healthcare workers, for example, could be one group required to get a coronavirus shot. Fears of legal liability, though, could push more types of employers to consider mandates, especially since workplaces like call centers and meatpacking plants have been sites of "superspreading."
In a recent commentary in the New England Journal of Medicine, public health law scholars set out standards that should be met before any government imposes a broad population mandate. Most deal with availability, accessibility and supply, but voluntary uptake among priority groups must also be lower than the level required to prevent epidemic spread, they wrote.
The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) is developing a framework for a vaccination program. It will prioritize which people will qualify for the first doses of an authorized vaccination, likely based on employment in a critical role, if the pattern from the 2009-2010 influenza pandemic is followed.
ACIP will meet next on July 29.
Even a mandate won't guarantee universal vaccination. The government can only penalize a person for refusing vaccination, and can't actually force them to get vaccinated, Navin noted.
Previously, when states have tightened laws on vaccination requirements for schools, he said, they have been on party-line votes, which has had the effect of politicizing the issue of vaccination.
Working within current approaches to vaccination mandates could help ensure greater adherence, said Y. Tony Yang, a professor and executive director of the Center for Health Policy and Media Engagement at George Washington University School of Nursing.
"Say, for example, if you want to get an exemption, you should have to watch a video or have a counseling session with your doctor," Yang said.
The federal government may have encouraged vaccine doubters in the way it has portrayed the coronavirus development effort as a race, and moved with unprecedented speed to authorize late-stage trials, said NYU's Caplan. The haste could leave the impression that pharma companies, researchers and regulators are cutting corners on safety, he said.
"Safety has to be part of all the language and communication about any vaccine. You have to talk about the race to find a safe vaccine," he said.
Gerberding and other pharmaceutical company executives testifying on Tuesday repeatedly stressed that their development speed would not compromise the quality of scientific evidence they're collecting. FDA officials have similarly said the agency will not cut corners in a review of any vaccine.
Unfortunately, the federal government's trustworthiness on any measure to control the pandemic will likely be called into question, Navin said, citing the advice from the surgeon general's office and other agencies early on discouraging facemask use, which was given to preserve the supply of personal protective equipment for hospitals.
"They told the public that masking was not beneficial even though that maybe that was a deliberate lie," he said. The disappointing levels of face mask use shows that public health officials' achievement of a short-term objective "undermined long-term things they care about."