Q&A: How to address COVID-19 vaccine hesitancy in primary care

A COVID-19 vaccine could become available to certain patient populations by the end of this year, according to a press briefing held by the CDC and HHS in late October.

“One of the beauties of Operation Warp Speed is we’re not waiting until we have all of the studies completed and the reviews done before we start the production process,” Jay C. Butler, MD, the deputy director of infectious diseases at the CDC and COVID-19 response incident manager, said during the briefing.

HHS Secretary Alex M. Azar II said there are six vaccines currently in clinical trials that are being manufactured for commercial sale production.

Azar also said that they expect to have enough FDA-approved vaccines to vaccinate the most vulnerable by the end of 2020, enough to vaccinate all seniors, health care workers and first responders by January 2021, and enough to vaccinate all other Americans who want a vaccine by March or early April 2021.

Despite the potential availability of a COVID-19 vaccine for Americans in the upcoming months, many have expressed concern or hesitancy to get vaccinated.

In one national survey conducted by the Pew Research Center in September involving 10,093 U.S. adults, 51% said they would definitely or probably get a COVID-19 vaccine if it were available today, while 49% said that they would definitely or probably not get a vaccine.

Among respondents who indicated that they would not get a COVID-19 vaccine if it were available, 76% said potential adverse events were a major reason for their decision and 72% said they would want to know more about its efficacy.

Healio Primary Care spoke with Paul A. Offit, MD, chief of the division of infectious diseases at The Children’s Hospital of Philadelphia, on how primary care physicians can address general and COVID-19 vaccine hesitancy in their practices.

Q: What is the best approach to addressing vaccine hesitancy in primary care practices?

A: What you have to do is find out what it is that the person is concerned about and then address that concern, for which there’s invariably data to show that the concern is ill-founded and arguably disproven. And then, present those data in a passionate, compassionate, compelling way to make it clear that there are no risk-free choices — that a choice not to get a vaccine is not a risk-free choice, it’s a choice to take a different and more serious risk. I think you have to be more emotional than physicians are generally willing to be. I watch my wife, who’s in general practice, go through this. You have to be willing to say, “Look — let me love your child. Don’t put me in a position where you’re asking me to practice substandard care, or you’re asking me not to give the vaccine, so then I would have to potentially watch your child come back to me with a serious infection — I can’t just do that. You can’t put me in that position.” And that, at least in her hands, has worked much better than when she just tried to just do the best she could. She made it more emotional.

Q: What can PCPs do specifically to address any COVID-19 vaccine hesitancy among patients?

A: I would consider myself a COVID-19 vaccine-hesitant patient right now. I want to see the data, right? There is no COVID-19 vaccine. So, let’s see what the data look like first and then you can at least say what you know and what you don’t know. What we’ll likely know by the beginning of next year is that the vaccine has been tested in tens of thousands of people and hopefully has been found to be safe — if it’s not, we’re not going to be giving it — and that it’s X% effective, let’s assume 70% effective. And we’ll know it’s effective for at least 4 to 6 months, and then we’ll see. But the choice not to get a COVID-19 vaccine is the choice to be among the almost now 230,000 people who have died from this virus. We tend to think that a conservative choice is not to get a vaccine, when in fact, that would be the radical choice.

Q: What else should PCPs tell patients about COVID-19 vaccines before they become available?

A: When you make a vaccine, you try to reduce uncertainty. You go from phase 1 trials, which is 20 to 100 people, to phase 2 trials, which is several hundred people, to phase 3 trials, which is tens of thousands of people. Each time you do that you reduce uncertainty, but you never eliminate that uncertainty. When you release a medical product like a vaccine, you’re doing it because you believe there is enough information to say that the benefits outweigh the risks. You don’t know everything.

We’re taking a much smaller gamble by moving forward with this vaccine now than, say, 1 to 4 years’ worth of study, during which time millions of people will die from this virus. I think we’re probably living with a little more uncertainty because the follow-up with these trials is shorter than the typical [follow-up period]. The size of the trials is typical — Pfizer’s is a 44,000-person trial, Moderna’s is a 30,000-person trial, Johnson & Johnson’s is a 60,000-person trial. The HPV [vaccine trial] was a 30,000-person trial and the pneumococcal vaccine was a 35,000-person trial, so these are typically sized trials. The only difference is that the follow-up is much shorter. The rotavirus vaccine that was invented in the Children’s Hospital of Philadelphia was a 4-year study. The HPV vaccine trial was a 7-year study. We can’t do 7 years’ worth of study for a COVID-19 vaccine; this is not reasonable or logical.

There was a death in Brazil associated with one of the vaccine trials. Everybody held their breath — did he get a vaccine? And then when they found out he got placebo, everybody breathed a sigh of relief. The truth is, if he was in the vaccine group, he probably wouldn’t have died — but for the flip of a coin, he dies of COVID-19. There’s a price to be paid for knowledge as we move forward with this, and the only way we’ll know whether or not these vaccines work is that people of the placebo group will suffer because they just happened to be on the wrong side of this coin flip. So, you don’t want to wait too long for the vaccine.

References:

• CDC. CDC Media Telebriefing Transcript on Operation Warp Speed. https://www.cdc.gov/media/releases/2020/t1021-cdc-media-briefing.html. Accessed November 2, 2020.
• Pew Research Center. U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. https://www.pewresearch.org/science/2020/09/17/u-s-public-now-divided-over-whether-to-get-covid-19-vaccine/. Accessed November 2, 2020.
• Reuters. AstraZeneca COVID-19 vaccine trial Brazil volunteer dies, trial to continue. https://www.reuters.com/article/us-health-coronavirus-brazil-vaccine/astrazeneca-covid-19-vaccine-trial-volunteer-has-died-brazil-health-authority-says-idUSKBN2762MO?il=0. Accessed November 2, 2020.