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Viewpoint
COVID-19: Beyond Tomorrow
May 18, 2020

Planning for a COVID-19 Vaccination Program

Author Affiliations
  • 1Division of General and Community Pediatrics, Children’s National Hospital, Washington, DC
  • 2The George Washington University Elliott School of International Affairs, Washington, DC
  • 3The George Washington University School of Medicine and Health Sciences, Washington, DC
JAMA. 2020;323(24):2458-2459. doi:10.1001/jama.2020.8711

The long-term solution to the coronavirus disease 2019 (COVID-19) pandemic, hopefully, will be a globally implemented, safe vaccination program that has broad clinical and socioeconomic benefits. Dozens of vaccines are in development, with 8 currently in phase 1 trials. Some scenarios predict the earliest, widespread availability of a COVID-19 vaccine to be in 2021.1 As launches of prior mass vaccination programs have demonstrated, careful planning to ensure readiness of both the general public and the health community for a COVID-19 vaccine should begin now.

To substantially reduce morbidity and mortality from COVID-19, an efficacious and safe vaccine must be delivered swiftly and broadly to the public as soon as it is available. However, the mere availability of a vaccine is insufficient to guarantee broad immunological protection; the vaccine must also be acceptable to both the health community and general public. Vaccine hesitancy is a major barrier to vaccine uptake and the achievement of herd immunity, which is required to protect the most vulnerable populations. Depending on varying biological, environmental, and sociobehavioral factors, the threshold for COVID-19 herd immunity may be between 55% and 82% of the population.2

Given that certain individuals will be ineligible for COVID-19 vaccination due to age, immunocompromise, and other preexisting medical conditions, a vaccine refusal rate greater than 10% could significantly impede attainment of this goal. Recent surveys, that included 493 and 2200 individuals, suggest only 3 in 4 people would get vaccinated if a COVID-19 vaccine were available, and only 30% would want to receive the vaccine soon after it becomes available.3,4 Confidence in vaccines lies along a spectrum, and individuals who have hesitation about routine childhood vaccines have expressed various concerns.5 In their report on vaccine hesitancy, Edwards and Hackell5 identified 3 broad categories of parents’ concerns regarding childhood vaccines: (1) the necessity of vaccines, (2) vaccine safety, and (3) freedom of choice.5 This Viewpoint describes these categories of concerns with regard to a future COVID-19 vaccine and presents suggestions to enhance the likelihood of rapid, widespread vaccine uptake in the United States.

Potential Objections to a COVID-19 Vaccine

Individuals who question the necessity of vaccines have historically questioned the underlying principle of mass vaccination. Among the most common misconceptions are that vaccination benefits do not outweigh the risks, and that immunity derived from surviving a disease is superior to immunity from vaccination.5 Concerns about the necessity of a COVID-19 vaccine may be reduced by recent memory of the overwhelming morbidity and mortality associated with the disease. Chen and Orenstein6 demonstrated that enthusiasm for vaccines is highest during a pandemic, prior to, and immediately following the release of a novel vaccine. As such, the health community should capitalize on an anticipated, early public enthusiasm for a COVID-19 vaccine with a well-organized, rapid vaccine distribution plan.

Vaccine safety will likely be a significant concern given the rapid development and testing process, underlying suspicion about vaccines among segments of the population, and mistrust of the government’s pandemic response. As such, vaccine safety concerns should be addressed before and during vaccine program roll out. The public should be informed about the rigorous testing and ongoing monitoring required by the vaccine approval process. Educational campaigns also should include information about the contribution of individual vaccination to herd immunity. Transparency about vaccine effectiveness and adverse events to set public expectations will likely improve trust in a COVID-19 vaccine, but messaging should take care to avoid unintentionally overemphasizing the risk of rare adverse events.

Arguments based on freedom of choice may reflect mistrust of the medical community. While various subpopulations have their bases for mistrust, the perspectives of African American individuals, in particular, are critical to consider as a matter of health equity. Early reports from cities and states demonstrate the disproportionate burden of COVID-19 disease borne by African American people.7 Studies link mistrust of the health care system and fears of experimentation among some African American people to historical and contemporary mistreatment and disparities in care.7 Fu et al8 found among a sample of African American individuals (n = 110) higher levels of trust in vaccine advice from race-concordant vs race-discordant physicians, as well as high levels of trust in community advisors including disease survivors, school nurses, and other parents. This suggests public health campaigns should enlist cultural leaders outside of traditional medical and public health communities as vaccination champions. Cultural leaders should be made partners to develop and spread culturally relevant messaging and ensure educational content is shared via readily accessible venues and formats.

Mounting a Proactive COVID-19 Vaccine Educational Campaign

Robust public health campaigns should harness traditional and social media to engage a diverse audience. Social media serve as a conduit for both factual and false information, and it is important that the health community counteract anti–COVID-19 vaccine tropes on social media in real time or these harmful ideas may become normalized by individuals. According to the nonprofit Public Good Projects, currently trending stories question the safety of a future COVID-19 vaccine, criticize a potential vaccination mandate as “tyrannical,” and promote conspiracy theories that forced vaccination will be used to inject a microchip to track individuals, as well as to cull the global population. Emerging evidence suggests that correcting misinformation on social media—either through individual comment or link to evidence-based information—may be effective in changing health beliefs.9 Public health campaigns must engage with traditional and social media platforms now to monitor, counter, and prevent the spread of fringe notions about a future COVID-19 vaccine before dangerous myths take root in the public psyche.

Frontline health care workers will play a central role in encouraging COVID-19 vaccination. Many studies have found that physicians are the most important influencers of vaccine decision-making.5 Thus, strong physician recommendations can bolster public and individual support for a COVID-19 vaccine. Physicians who share personal anecdotes about being immunized and immunizing their family members are effective in encouraging vaccine uptake in vaccine-hesitant families.10 As such, achieving a high vaccination coverage level of health care workers early on not only ensures an adequate workforce to treat infected patients, but also allows medical authority figures to share their positive vaccination experiences with patients. While most studies have focused on the role of physicians, the influence of nurses and allied health professionals on patients’ vaccination attitudes and beliefs also is important. Health care workers are exposed to the same media stories as the general public and may be subject to the same cognitive biases that can lead to excessive reliance on anecdotal evidence and false conclusions. Ensuring that all individuals who interface with patients in the clinical setting are confident about the safety and effectiveness of a future COVID-19 vaccine is critical for presenting a unified message of strong vaccination support from the medical community.

Conclusions and Recommendations

The groundwork for public acceptance of a COVID-19 vaccine must be carefully started before a vaccine becomes available. The health community will likely benefit from early public enthusiasm for a COVID-19 vaccine, and it is critical to build on that momentum to encourage swift, broad vaccine uptake as it becomes available. To promote future COVID-19 vaccine uptake, the following approaches are suggested.

First, a COVID-19 vaccine should rapidly be delivered to the public as soon as rigorous testing has been completed, and efficacy and safety have been established. The vaccine should be equitably and justly distributed, particularly targeting individuals at highest risk for complications and disease transmission to others if initial vaccine supply does not meet demand. Second, the plan for a COVID-19 mass vaccination program should proactively address known potential obstacles to vaccine acceptance using linguistically and culturally competent messaging. Third, public health officials should develop a robust COVID-19 vaccine educational campaign harnessing traditional and social media, with a particular focus on involving social influencers and targeting misinformation. Fourth, frontline health care workers should be taught how to make strong recommendations for COVID-19 vaccination, including, if relevant, sharing their personal experiences with COVID-19 and the vaccine.

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Article Information

Corresponding Author: Sarah Schaffer DeRoo, MD, Division of General and Community Pediatrics, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010 (sschafferd@childrensnational.org).

Published Online: May 18, 2020. doi:10.1001/jama.2020.8711

Conflict of Interest Disclosures: Dr Fu reported receiving grants from Pfizer Inc. No other disclosures were reported.

References
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Rowland  C, Johnson  CY, Wan  W. Even finding a COVID-19 vaccine won’t be enough to end the pandemic. Washington Post. May 11, 2020. Accessed May 13, 2020. https://www.washingtonpost.com/business/2020/05/11/coronavirus-vaccine-global-supply/
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Sanche  S, Lin  YT, Xu  C, Romero-Severson  E, Hengartner  N, Ke  R.  High contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2.   Emerg Infect Dis. 2020;26(7). doi:10.3201/eid2607.200282PubMedGoogle Scholar
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Trujillo  KL, Motta  M. A majority of vaccine skeptics plan to refuse a COVID-19 vaccine, a study suggests, and that could be a big problem. Published May 4, 2020. Accessed May 6, 2020. https://theconversation.com/a-majority-of-vaccine-skeptics-plan-to-refuse-a-covid-19-vaccine-a-study-suggests-and-that-could-be-a-big-problem-137559
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LX/Morning Consult.  National Tracking Poll #200395: March 24-25, 2020. LX/Morning Consult; 2020.
5.
Edwards  KM, Hackell  JM; Committee on Infectious Diseases, the Committee on Practice and Ambulatory Medicine.  Countering vaccine hesitancy.   Pediatrics. 2016;138(3):2016-2146. doi:10.1542/peds.2016-2146PubMedGoogle ScholarCrossref
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Chen  RT, Orenstein  WA.  Epidemiologic methods in immunization programs.   Epidemiol Rev. 1996;18(2):99-117. doi:10.1093/oxfordjournals.epirev.a017931PubMedGoogle ScholarCrossref
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Yancy  CW.  COVID-19 and African Americans.   JAMA. Published online April 15, 2020. doi:10.1001/jama.2020.6548PubMedGoogle Scholar
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Fu  LY, Haimowitz  R, Thompson  D.  Community members trusted by African American parents for vaccine advice.   Hum Vaccin Immunother. 2019;15(7-8):1715-1722. doi:10.1080/21645515.2019.1581553PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    Too Early to Start Communicating?
    Luigi Roberto Biasio, MD | Contract Lecturer in Vaccinology, Rome, Italy
    How to prepare and support the start of a COVID-19 vaccination program seems to be similar to those proposed for other pandemics, such as influenza H1N1, the main differences being that steps and timelines for the development and manufacturing of the vaccine were more evident to the producers, as well to the health community, policy makers and, likely, the public.

    The authors of this Viewpoint say the health community should capitalize on an anticipated, early public enthusiasm for a COVID-19 vaccine: this seems quite complex at this time, as several vaccine projects are going on, based on different
    platforms some of which have never been authorized for mass production, nor used in immunization campaigns.

    Thus, it appears problematic to tailor a communication strategy now, presuming that the first vaccine will be available in 2021, without knowing how it will be effective and safe, and the quantity of doses the facilities will produce. Without this, it will be also difficult to understand and explain why certain individuals will be ineligible for vaccination.

    The public in particular at this time is saturated with emotions, often mistrust toward decision-makers, and is over-loaded with conflicting information from the health providers, experts, organizations, and individuals strongly active on the web and in the social media, producing conflicting opinions. These can be the reasons why only 30% would want to receive the vaccine soon after it becomes available.

    Managing the emotions, providing evidence and taking into consideration the health literacy levels of the population are three key 'tools' for the success of health communication in general and, specifically, for vaccination (1): for COVID-19 future vaccines it looks like some of these elements are still missing.

    As the authors say, the groundwork for public acceptance of a COVID-19 vaccine must be carefully started before a vaccine becomes available. This is true for all new vaccines; however, in this case it seems preferable to wait for at least some more data, hopefully available in a short time.

    REFERENCE

    (1) -LR Biasio et al - Health literacy, emotionality, scientific evidence: Elements of an effective communication in public health - Human Vaccines & Immunotherapeutics, 2018, 14:6, 1515-1516, DOI: 10.1080/21645515.2018.1434382
    CONFLICT OF INTEREST: None Reported
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    The System Needs to Improve Vaccine Access
    Shawn Baca, MD, FACR | Rheumatology Associates of South Florida, Past President Palm Beach County Medical Society, Affiliate Professor Schmidt School of Medicine, Florida Atlantic University
    What is apparent is that even during "normal times" vaccine distribution has become difficult for physicians. Most physicians no longer vaccinate in their offices due to the confluence of of big chain pharmacies and payers creating monopolistic barriers for some patients. These self created monopolies push aside hard working primary care physicians and specialists who feel they can no longer vaccinate patients in their offices due to poor reimbursement and supply chain issues. Local pharmacy chains and grocery stores often have vaccines available for sometimes one or two months prior to doctors who take care of the most vulnerable. This especially affects those patients who have difficulty with transportation and ambulation by having to travel to additional locations when then should be able to receive their vaccinations at their normal doctor's visit. Hopefully when the Covid 19 Vaccine does become available the AMA will work with payers and point out monopolistic barriers to make sure that physicians and facilities on the front line will be able to vaccinate and improve access to their patients in a more efficient and expedient fashion.
    CONFLICT OF INTEREST: None Reported
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    Getting Human Beings To Accept COVID-19 Vaccination
    Stephen Green, M.D. | University of Sheffield & University of Plymouth, United Kingdom
    DeRoo et al’s article was both very thoughtful & pragmatic. It certainly recognized the great difficulties that lies ahead of us even if a good vaccine or two do eventually emerge.

    More recently, Usher in the Lancet argued for the worldwide availability of effective vaccines if & when they eventually emerge. (1) It is heartening to see that already widespread goodwill, & a degree of financial commitment, are coming into being to ensure such vaccines would be made available & affordable worldwide, while important players in the international political community already appear to be prepared to support such
    a vital initiative. (2)

    However, as discussed by DeRoo et al, delivering the vaccine to some in the wider population is likely to be rather less straightforward than a simple “offer & acceptance” scenario.

    Achieving adequate levels of herd immunity is definitely a key factor if a vaccination program is to be successful. However, there are already concerns that future preventative COVID-19 vaccine initiatives may fail to achieve the impact they could & should be capable of, as a consequence of non-medical factors.

    Indeed, pre-coronavirus, “vaccine hesitancy” had a long history (3) & already COVID-19 vaccines have not been immune from attention of this type (4,5).

    It is also important to note that even when, in the past, highly effective vaccines able to prevent the spread of one or other particular infectious disease have become available, the worldwide impact on the prevalence of the target infectious disease has sometimes been disappointing. For example, although good commercial hepatitis B vaccines have been available since 1981, worldwide the virus still affects 0.25 billion human beings. (6) Furthermore, despite their being vaccine-preventable to varying extents, dangerous infectious diseases such as polio, rabies, cholera, measles, mumps, rubella, yellow fever & tuberculosis continue to remain significant global scourges.

    Everyone wants to be rid of COVID-19. However if an effective vaccine does eventually come along, persuading people - including those who are skeptical - that vaccination is an acceptable response to the COVID-19 crisis & that they & their offspring would benefit from consenting to having it administered to them, is the next critical challenge. In fact, the success or failure of any eradication program may well depend pretty well entirely on that.

    We must, for all of our sakes, make as certain as we can that all around the world COVID-19 vaccines are used in a maximally efficacious way, but we have to recognize that relying entirely on evidence-based science might not win the day.

    Accordingly, this will not be an issue for the healthcare fraternity alone, but also a matter for politicians, lawyers, businessmen & other leaders to stand side by side with their fellow professionals from the worlds of healthcare & science - & take things forward.

    Authors: S.T. Green & L. Cladi.

    REFERENCES

    1. Usher AD. Lancet 2020; 395: 1822-1823. DOI:10.1016/S0140-6736(20)31354-4
    2. Paton J. Bloomberg, 5 May 2020. https://www.bloomberg.com/news/articles/2020-05-05/nations-back-pushfor-universal-access-to-covid-19-vaccines
    3. Drew L. Nature 2019; 575: S58-60. DOI:10.1038/d41586-019-03642-w
    4. Ball P. Nature 2020; 581: 251. DOI:10.1038/d41586-020-01423-4
    5. Srikanth A. The Hill, June 3, 2020. https://thehill.com/changing-america/well-being/prevention-cures/501020-anti-vaxxers-are-organizing-even-
    6. World Health Organization. July 18, 2019. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b
    CONFLICT OF INTEREST: None Reported
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