Vaccine Hesitancy and the Covid Pandemic
Overselling Covid vaccines during the pandemic has backfired and played into the hands of the anti-vaccine movement.
When COVID hit in the winter of 2020, hospitals were overflowing with the sick and dying. Public health experts worried that we’d be isolating for years because, although vaccines were possible, none had ever been developed in fewer than four years. Yet, within weeks of the identification of the virus’s genetic structure, two companies had settled on the basic frameworks for mRNA vaccines, which were then developed on an accelerated timeline. Just as remarkable, after six months of testing, we were told they were over 90 percent effective against COVID.
With businesses and schools operating remotely for most of 2020 and the early part of 2021, vaccines were the best hope for emerging quickly from the worst pandemic in a century. And, to a large extent, those hopes materialised. Vaccines saved countless lives and may have reduced disease transmission in early variants. But they were neither as effective nor long-lasting as had originally been touted, did not significantly lower transmission in later variants, and had nasty side-effects for a small minority. Perhaps most importantly, a large proportion of the population did not like vaccine mandates (which in many cases were deemed illegal).
The fallout from COVID vaccine policies continues, and it’s not a healthy sight. Vaccine rates appear to be dropping. And trust in public health advice is falling faster if my conversations with physicians in Montgomery County, Pennsylvania, are anything to go by. This has worrying implications. As vaccination rates fall, at first the impact will be small, until it isn’t. Depending on the disease and the vaccine, somewhere between 60 and 95 percent of a population must be vaccinated (or have had the disease and recovered from it) to reach herd immunity. Once rates fall below that threshold, the disease spreads rapidly. The health and economic costs of diseases such as measles, diphtheria, and smallpox were once enormous. Vaccination changed that. Indeed, smallpox was eliminated. But falling vaccination rates have already led to a resurgence in measles, a disease that deserves to be consigned to history.
Vaccines: a brilliant discovery
Over two hundred years ago, British physician Edward Jenner intentionally infected a boy with cowpox pus, hoping it would protect against the similar but far more lethal smallpox. Jenner’s success began the scientific formalization of centuries-old efforts to inoculate people against various maladies, in what is now known as vaccination (from the Latin for cow, vacca).
Paul A. Offit
Vaccines were so successful and their benefits so much greater than their risks that, in the 19th century, US states began mandating smallpox vaccination for children. Although there were legal challenges to these mandates, in 1905 they were upheld by the US Supreme Court in a key decision. It is worth reading from the decision to see that the notion of compulsory vaccination campaigns is not new:
The liberty secured by the Constitution of the United States does not import an absolute right in each person to be at all times, and in all circumstances, wholly freed from restraint, nor is it an element in such liberty that one person, or a minority of persons residing in any community and enjoying the benefits of its local government, should have power to dominate the majority when supported in their action by the authority of the State. It is within the police power of a State to enact a compulsory vaccination law, and it is for the legislature, and not for the courts, to determine in the first instance whether vaccination is or is not the best mode for the prevention of smallpox and the protection of the public health.
In line with the Supreme Court decision, federal agencies such as the Centers for Disease Control (CDC) have been recommending vaccinations since at least 1914 for whooping cough (pertussis), and states have been enforcing those recommendations by law.
The Pew Research Center chart below illustrates the panoply of useful vaccinations that have saved millions of lives and when they first were recommended by the CDC.
Pew also pulled together all the data on vaccine mandates, noting, “Of the 16 immunizations the CDC recommends for children and teens, all 50 states (plus the District of Columbia) mandate diphtheria, tetanus, pertussis (whooping cough), polio, measles, rubella and chickenpox.”
So we have been living with vaccine mandates for a long time. All except those with a medical or religious exemption have been required to take these vaccines, and the vast majority have done so without concern. And that is true across most developed nations. Growing up in England, I received most of those vaccines at roughly the same ages as my American counterparts would have (and I was required to prove that I had been vaccinated when I obtained my permanent residency here in the U.S.).
Pennsylvania, where I now live and the location of my original research, requires all of the above-listed vaccines. For children to access childcare and school, hepatitis A and B, rotavirus, Hib, pneumococcal conjugate, and influenza vaccines are also required.
And except for a few noisy skeptics, many of whom have touted discredited research that fraudulently and falsely claimed a link between autism and vaccines, these requirements have passed almost unnoticed. So, what changed with COVID?
The COVID vaccine story
With hindsight, it’s easy to see that COVID vaccines were oversold. The initial claims that they were more than 90 percent effective, might prevent transmission, and had no obvious side-effects didn’t survive scrutiny. While obviously a lifesaver for many—particularly those with two or more comorbidities—within a matter of weeks, stories of the vaccinated becoming sick and transmitting the disease to family members were rife. Vaccines did not prevent disease transmission but they did lower viral loads and hence probably reduced transmission of the Alpha variant—but not the much more virulent Delta.
Boosters were required as potency waned dramatically after about three months. The virus also mutated, becoming more virulent but less dangerous, which also changed the calculus of those considering taking the vaccine. Was it worth a sore arm and possibly a couple of sick days for a disease that, at worst, was likely to be just a bad cold for most people?
Nevertheless, federal authorities demanded vaccination even when someone had just had COVID, which was illogical given that the natural immunity provided by having contracted a disease is usually greater than the passive immunity obtained from vaccination. Social media became inflamed with stories about vaccinated young people with myocarditis who had not been infected with COVID (a rare but real, dangerous, and sometimes lethal side-effect), as well as disgust that the companies making the vaccines were making billions of dollars and were immune from prosecution when the vaccines caused harm. All the while, politicians—and scientists advising politicians—denied problems, maintained the story of high efficacy, and mandated vaccines for work and school.
Lastly, even the strongest vaccine advocates, such as former presidential advisors Francis Collins and Anthony Fauci, admit that vaccine hesitancy has grown.
As I spoke to physicians in Montgomery County, I expected to hear that these concerns have been raised by patients, especially in the more Republican-voting areas, partly because Congressional Republicans had been vocal in their opposition to vaccine mandates and may have influenced opinion in Republican areas. My early results offer a much more nuanced picture of the nature of vaccine hesitancy following the COVID vaccination campaigns.
Physicians in Montgomery County, PA
Primary physicians oversee many vaccinations and also address many questions from patients about vaccines, including ones about efficacy and safety. Montgomery County is predominantly Democrat-voting, but two of its fourteen districts are moderately Republican. I surveyed 124 primary physicians in the county to understand what changes, if any, in vaccine uptake and opinions had occurred among their patients since the pandemic began. I also split the sample between the large, heavily Democratic area (107 physicians) and the smaller, moderately Republican area (17 physicians).
It’s important to realize that my survey data are imprecise since they are primarily based on the recall (of up to four years) of busy physicians each dealing with dozens of patients. Thus, small differences over time or between districts may well be the results of poor recall or biases due to survey design. However, significant differences could well point to identifiable trends.
As expected, nearly all patients (adults, children, and infants) received the first round of COVID vaccines in early 2021. But by the fall of 2023, far fewer adults and very few infants had taken the latest booster. This trend was even more pronounced in the more Republican areas, where fewer than half the adults had taken the latest booster (and this was confined to those with comorbidities, signaling that, under the advice of their physicians, those patients knew they were most at risk and acted accordingly). Although some evidence indicates that Republicans are more likely to die due to lack of vaccine uptake.
According to most physicians, patients were fully aware that vaccines were less effective than had originally been touted. Physicians reported patient phrases like a “small chance of myocarditis” with a vaccine for a disease that would “likely be a bad cold”, explaining why few took the latest booster.
Other vaccines
COVID is one disease among many; the other diseases that require vaccinations have not disappeared. Not one physician reported an increase in vaccine uptake for these other diseases, and approximately a third reported no change. Two thirds (and slightly more in the Republican areas) saw a decrease in vaccination uptake. This is a very broad measure. More detailed surveys are required to understand exactly what types of vaccines are being missed: the yearly and not particularly effective flu vaccines; or the far more important and less frequent (often a one-off in childhood) vaccines for diseases such as measles, polio, and tuberculosis. We also do not know by how much vaccine rates are falling.
Nevertheless, that rates are falling is potentially worrying and deserving of attention.
I asked the physicians: Is it just the risks of COVID vaccines that are leading to a decline in all vaccination rates?
Most physicians report patient concerns about the safety of COVID and, increasingly, other vaccines. Patients are uncertain of, but worried about, social media reports of vaccine harm. One can scoff at social media as a source of scientific truth, but as one physician said, “Given that social media was the only place that supported the notion that SARS-CoV-2 came from a lab or that drugs like Ivermectin might work, were [patients] wrong to believe it?” Social media allowed discussion of other theories and concerns, some of which turned out to be true; thus, many patients were inclined to worry. These patients were less likely than average to take the vaccine and were definitely not likely to let their children. Some of these patients talked about the “lies” told by health authorities; Anthony Fauci was named repeatedly.
More than a few patients were apparently very angry about having to take a mandatory vaccine that might be unsafe and was not clinically required if one had recently had the disease. Even some physicians were concerned about the “scientific illiteracy” of health authorities demanding COVID vaccines be administered to people who had recently had the disease. This led to a “total” distrust of vaccine policy among some patients, which definitely led to a lowering of flu vaccine uptake. “It’s too early to tell for other vaccines,” said one physician.
Physicians mentioned several other concerns of patients ranging from arguably sensible ones such as distrust of pharmaceutical companies and the incompetence of government officials to more outlandish claims, for example, that tracker chips are inserted into vaccines and that the vaccines cause cancer. As one physician put it, when “government advice is unreliable, people can believe almost anything. For some people, every unexplained young death is now attributed to COVID vaccines.”
Michael Shermer
The bigger picture
One can understand the desire of health authorities to get everyone vaccinated. With herd immunity only being achieved through high levels of vaccination or recovery from disease, it is entirely reasonable to encourage vaccination. But the conclusion from my survey is that misleading the public and overselling the vaccines backfired and played into the hands of perennial anti-vaxxers.
It is not that surprising that uptake of COVID vaccine boosters by infants and children collapsed last year and fell markedly among adults. One comment made by a few physicians was that uptake was close to zero for adults under 40 while it was nearly universal among adults over 70 and those with comorbidities. This suggests that much of the public has a good understanding of the scientific situation—with those most at risk from COVID taking the vaccine and those least at risk choosing to avoid the side-effects—which is very positive news.
The lesson for health authorities is that they should trust people to understand the science and do what is in their self-interest instead of badgering them with simplistic (and often incorrect) information. While the Supreme Court has confirmed the right of federal authorities to impose vaccine mandates, and vaccine technology has improved so that vaccines can be designed and produced rapidly, it does not mean authorities should mandate vaccines. Or if they do, they should reassess the mandates routinely so as not to undermine public confidence in their authority.
