By Edward Chen
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Smallpox: 9.37 million search results.
COVID-19: 5.71 billion search results.
Vaccine: 983 million search results.
Hesitancy: 46.3 million search results.
Vaccine hesitancy: 7.9 million search results.
Search results aside, vaccine hesitancy is arguably a phrase that is greater than the sum of its parts. At a minimum, it’s an equal. Is the world concerned about designing vaccines? Or is the world concerned about vaccine hesitancy? A bit more of the first, you might say. But developing vaccines that work without causing harm, while necessary, is only part of the journey to protecting the world from deadly diseases. Vaccines don’t save lives. Vaccinations do. As you probably predicted, this month, we’ll be talking about vaccine hesitancy.
Vaccine hesitancy is an 18th century concept; we may hear more of it more now, but the sentiment has always been around. Ever since there have been vaccines, there have been qualms about them. Even in modern times.
In Boulder, Colorado circa 2002, vaccine hesitancy was so prevalent that whooping cough, a vaccine-preventable disease, caused outbreak after outbreak after outbreak until it was declared endemic to the region. More well-known is the Disneyland measles outbreak that started in California during the last month of 2014. While the term “anti-vaxxer” may have appeared more in the news then, the public health field has been shifting towards the more neutral term of “vaccine hesitancy.” Not everyone who doesn’t get vaccinated is “anti-vaccine,” the newer thinking goes. Because of this, in 2012, the World Health Organization (WHO) established a working group to define vaccine hesitancy and consider alternative terms.
Regardless of what the favored term is, this unsubsiding concept embodied by only two words has concerned physicians, researchers, governments, international organizations, and private citizens from centuries past to today. And, as history has shown, these two words affect everyone in the world. It’s unsurprising, then, that the WHO has listed vaccine hesitancy among the top 10 threats to global health, right up there with the inevitable yet-to-arrive influenza pandemics of the future, crisis-struck areas without basic care, antimicrobial resistance, and “priority diseases” such as Ebola.
We can see the tried-and-tested, real-world, global impact of vaccines. Just name a disease that humanity has completely eradicated, any disease.
What about … rinderpest! That’s true, and was eliminated with vaccines, though it’s not a disease that directly afflicts human beings like you and me. I (and you, too, probably) would first think about smallpox, the only human disease that has been eradicated.
In 1980, the WHO announced that smallpox was wiped off the face of the Earth with the dramatic headline “Smallpox is dead!” This was after over a decade of coordinated, intensive vaccination efforts. In India alone, upwards of 100,000 frontline healthcare workers made over 2 billion house calls. The smallpox vaccine made that possible. But the vaccine alone wasn’t enough; after all, the smallpox vaccine was developed nearly 200 years earlier, in 1796, and other methods to prevent smallpox were known even before then. Public health workers used innovative strategies such as ring vaccination – prioritizing the vaccination of those living near areas with rising numbers of smallpox cases – and people throughout the world had to be willing to receive the smallpox vaccine. The US Centers for Disease Control and Prevention (CDC) no longer recommends childhood smallpox vaccination because of the decisions made by literal billions of people around the world to receive the smallpox vaccine. Smallpox no longer circulates anywhere in the world.
This brings us to COVID-19. As of June 30, 66.5% of adults in the US have received at least one COVID-19 vaccine dose and 57.4% have been fully vaccinated. The numbers are about 3% lower when including all people eligible for the vaccine, which includes children as young as 12, and are about 12% lower when considering the entire US population, which includes those too young to receive the vaccine. Viewpoints on these figures differ and these statistics variously embody hope or despair. New virus variants continue to increase in prevalence. In the first half of this month, the Delta variant, which increases hospitalization rates and spreads 50% faster than previously circulating versions of the coronavirus, accounted for 26.1% of COVID-19 cases. Two weeks before that, it had caused 10% of COVID-19 cases.
Here’s a different perspective: A common-enough goal is to reach herd immunity, when disease transmission is prevented or significantly decreased through high vaccination rates (or, the unpreferred alternative, high rates of natural infection). Depending on who you ask though, achieving that goal is a “yes … in only a few months,” “difficult,” “unlikely,” “probably … unattainable,” or even, “probably impossible.” This is a sharp change in tone from the earlier “can do” attitude and estimates that a vaccination coverage of 60% to 70% would be enough for eliminating or drastically reducing community COVID-19 transmission.
Even though the US vaccine rollout began in 2020 and vaccine eligibility was expanded to all US adults on April 19 of this year, the US still surpassed 600,000 deaths from COVID-19 in the middle of this month. COVID-19 has repeatedly shown that it is nothing if not deadly. Despite these harrowing statistics, vaccine hesitancy appears to be here to stay.
This doesn’t mean, however, that vaccine hesitancy is the only challenge the world faces. Remember smallpox? The supply of vaccines was a significant issue, limiting the access of those very vaccines and introducing the necessity for ring vaccination. With COVID-19, the supply of vaccines is again a significant issue. Wealthier countries with greater financial bargaining power secured vaccine doses even before they materialized, leaving middle- and lower-income nations to fend for themselves in a competition for what few doses remained. Any surge in COVID-19 cases increases demand and inevitably locks up supply within countries like India that are able to make vaccines for themselves. This global inequity concerns the WHO: “High-income countries have administered 69 times more doses per inhabitant than low-income countries.”
But back to vaccine hesitancy. Gallup, the organization famous for its public polls, concluded on June 7 of this year that the “COVID-19 Vaccine-Reluctant in U.S. [are] Likely to Stay That Way.” Of slightly over 3,500 American adults surveyed, 24% do not plan to be vaccinated. And of those one in four that don’t intend to get a COVID-19 vaccine, 78% further responded that they “are unlikely to reconsider their plans.” This equates to approximately one in five Americans who “do not plan to get vaccinated and say they are unlikely to change their mind.” Varied reasons for COVID-19 vaccine hesitancy have been identified by Gallup, including concerns with the safety of the vaccine, the speed of its development, and a general mistrust of vaccines. There are non-vaccine related reasons too; a fifth of those who are vaccine-hesitant cited a low risk of getting seriously ill from the coronavirus.
The Kaiser Family Foundation, which has extensive coverage on the coronavirus, released similar results last month, supporting the Gallup theory that those not yet vaccinated are unlikely to in the future. A combined 20% of the approximately 1,500 American adults they surveyed said that they will “definitely not” get a COVID-19 vaccine or will get it “only if required.” The Kaiser Family Foundation also asked about incentives for encouraging vaccination. 32% of those who haven’t been vaccinated replied that they would “be more likely to get the COVID-19 vaccine if” a COVID vaccine receives full approval instead of only having an emergency use authorization. Smaller percentages of unvaccinated people said that they would be encouraged by paid time off, financial incentives from the government, and free transportation, among other possibilities.
As expected, vaccine hesitancy and the related concept of vaccine confidence has concerned government agencies as well. A recent CDC survey concluded that a quarter of American adults “probably or definitely would not get vaccinated.” Earlier this year, the CDC also surveyed reasons for vaccine hesitancy, which include “a lack of trust in the government” and a preference for waiting for more information on the vaccine’s safety. Beyond conducting research, the CDC additionally attempts to build public confidence in vaccines. As part of this effort, they have so far issued 10 reports on vaccine confidence and their perspectives on various trends in vaccine hesitancy. One of the major themes in the most recent report is that the recent “return to normal” seems to be decreasing the urgency for some people to get vaccinated, which in turn concerns families with children who are not yet eligible for the vaccine. The same report further noted that excessive pressure for individuals to get vaccinated may alienate those who aren’t yet vaccinated and that, perhaps surprisingly, questions on the origin of the virus decrease confidence in the vaccine.
As a final note, within the US, vaccine confidence has significantly varied by region. The US Department of Health and Human Services has gauged vaccine hesitancy among the population and generated predictions at the county level for many different sociodemographic groups. Based on their estimates, vaccine hesitancy ranges from a low of 2.7% in the Virginia city of Falls Church to a high of nearly 27% in Blaine County, Montana—essentially a ten-fold difference! Even without jumping from coast to coast, estimated hesitancy rates regularly surge and then drop across adjoining counties. Though seemingly without rhyme or rhythm, this is reflected in actual vaccination rates as well.
You might be happy to know that, today, the population of Boulder County in Colorado is estimated at 6% hesitant. Also, a 2019 case of a Boulder High School student diagnosed with whooping cough made the local news. This might mean that vaccines are back in Boulder and that cases of whooping cough are quickly becoming curiosities of a bygone era, just as they should be.
It might be safe to hope that as times change, so will attitudes toward vaccinations. The Boulder of the past doesn’t have to be the destiny of the world. In the future, will vaccine hesitancy become a relic of the past? Perhaps not. I will even venture a guess that vaccine hesitancy is here to stay. In no scenario, however, is there nothing you can do. You can always try talking to your friends and family. Vaccine hesitancy is personal and, even more so today, affects our everyday life. COVID-19 may have shined a spotlight on people’s perceptions of vaccines, but those sentiments, good or bad, have existed for as long as vaccines.
That’s it for this month! Thank you for reading!
A final paragraph for regular readers of our blogs. SvP’s most recent “Ask Us Anything” column fielded a question on the unofficial “mask honor system” that we now rely on as a result of new CDC masking guidelines. “Is there any way for states and stores to make sure that people who don’t wear masks indoors are in fact vaccinated?” Since we published our column, a Gallup poll has found that only 49% of those who do not plan to get vaccinated have worn a face mask in the past week. This is down 10% from the previous month, when the CDC had not yet revised its masking guidelines.
Results from ongoing research and the current understanding of COVID-19 are constantly evolving. This post contains information that was last updated on June 30th, 2021.
Edward Chen is a master's student studying immunology. He's also the national president of Students vs. Pandemics. @EdwrdChen