COVID-19 vaccines are worthless if people aren’t vaccinated

The finish line in the race to develop a COVID-19 vaccine is in sight. Yesterday, an independent advisory panel to the U.S. Food and Drug Administration (FDA) green lighted the use of Pfizer’s vaccine, setting up an FDA decision that could result in Americans being vaccinated in the next several days. This decision follows announcements from Pfizer and Moderna that their vaccines for COVID-19 were more than 90 percent efficacious, fueling speculation that COVID-19 vaccines could be distributed in the United States by the end of the year. But as the race to develop a COVID-19 vaccine concludes, a new one begins: the race to ensure that enough people are vaccinated to end the pandemic.  

Many Americans are reluctant to seek COVID-19 vaccination. In a recent survey, just half of Americans indicated that they would likely get a COVID-19 vaccine. These individuals are concerned about the fast pace of COVID-19 vaccine development, poor communication about the science and perceived politicization of vaccine approval. There is also reluctance among America’s front-line health care workers. A recent study found that 66 percent preferred to delay vaccination due to a lack of confidence in vaccine development and resistance to being “guinea pigs” when vaccines are distributed. These and other surveys suggest that there may not be sufficient COVID-19 vaccine uptake in the United States. At least 75 percent of Americans will need to be vaccinated to stem the spread of COVID-19.

Vaccine hesitancy – reluctance or refusal to take an available vaccine – has been identified by the World Health Organization as one of the top 10 threats to global health. But vaccine hesitancy for COVID-19 differs from the resistance sometimes seen to routine child immunization. Many people who express a lack of confidence in COVID-19 vaccines are still accepting of other vaccinations. For them, the speed and politicization of vaccine development are the sources of concern. 

How can we ensure that COVID-19 vaccine uptake is adequate? Here, we highlight six strategies that might be used over the coming months, keeping in mind that communities will have varying attitudes about vaccination and that no “one-size-fits-all” approach is likely to succeed. 

Earn trust, don’t expect it. 

Governments and pharmaceutical companies must earn the public’s trust. Missteps earlier in the pandemic response – for example, the Trump administration’s baseless endorsement of hydroxychloroquine – have compromised public trust. The same must not happen for vaccines. Steps should be taken to ensure that COVID-19 vaccine development and approval is transparent and rigorous. Moreover, after vaccines are available, monitoring should be in place to provide real-time safety information, and compensation should be available to people injured by side effects. Vaccines are urgently needed, but opacity and haste will ultimately be more detrimental than helpful. 

Ensure access to vaccines.

Lack of access can hinder vaccine uptake, even among people who are otherwise willing to be vaccinated. Removing barriers to COVID-19 vaccination could include making it free or providing other supports such as child care, transportation and paid time off of work to facilitate vaccination. Plans are already being made to house vaccine distribution in community centers, such as drive-through pharmacies, churches and even beauty salons, to facilitate access.

Mobilize at the grassroots. 

Grassroots approaches to promoting vaccination, which emphasize engagement with trusted community leaders, may be effective at reaching people who distrust the government. Studies conducted in Pakistan and India demonstrate improved childhood immunization rates after religious leaders engaged parents about vaccination. Empowering trusted leaders might allow government agencies to address particular reasons for vaccine hesitancy germane to individual communities.          

Share positive vaccine narratives.

Stories from the public and from celebrities about getting vaccinated – shared, for example, over television and social media – may encourage COVID-19 vaccine uptake. Positive narratives might also prove useful in counteracting misinformation campaigns. 

Incentivize vaccination. 

In developing countries, modest nonfinancial incentives can improve immunization rates. Incentives might also be used in the United States to encourage COVID-19 vaccination. Some have gone so far as to argue that Americans should receive cash for COVID-19 shots. But large financial incentives for vaccination could backfire. Cash payments would be expensive, could be inefficient if people are already motivated to be vaccinated and may cause people to second guess the risks of vaccination, especially if the financial reward is large. Small incentives in targeted areas with low vaccination rates may be justifiable, but further research is needed to determine whether this is effective.

Mandate vaccination.  

Finally, as a last resort, COVID-19 vaccination could be mandated by governments or employers if voluntary uptake remains low. Although this approach is legal and familiar to Americans, vaccine mandates must be implemented with caution, as they could do more to fuel anti-vaccine sentiment than to further the goals of public health. The modern anti-vaxx movement, for instance, was born in 19^th century UK after smallpox vaccination was mandated for infants. Yet targeted vaccination mandates may be justified and useful in our response to the current pandemic. For example, COVID-19 has ravaged long-term care facilities in the United States, contributing 100,000 deaths to the 280,000 tallied to date. Vaccinating long-term care employees for seasonal flu is already mandated in several U.S. states. Extending these mandates to include COVID-19 vaccination would prevent unnecessary deaths and suffering among vulnerable older adults.

We hope that an overwhelming majority of Americans will gladly roll up their sleeves and be vaccinated to protect themselves and their neighbors. But throughout the COVID-19 pandemic, even simple acts of social solidarity – such as wearing masks and physical distancing – have been rejected by some as an affront to individual liberty. If what’s past is prologue, we should expect resistance to COVID-19 vaccination. Governments must prepare now to address this problem. A vaccine that we don’t take can’t protect us.

Andrew Peterson PhD is assistant professor and Greenwall Faculty Scholar in George Mason University’s Department of Philosophy and Institute for Philosophy and Public Policy.

Charles Weijer MD PhD is a professor in the Western University’s Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, and a member of the WHO Working Group for Guidance on Human Challenge Studies in COVID-19.

Emily A. Largent PhD JD RN is an assistant professor and Greenwall Faculty Scholar at the University of Pennsylvania’s Department of Medical Ethics and Health Policy.