Vaccine Access and Hesitancy: The Public Health Importance of Vaccines

Feature Story

By Stephanie Miceli

Last update June 5, 2020

Images of deserted streets, empty subway cars, and shuttered businesses paint a bleak picture of life during the COVID-19 pandemic. While health experts say a vaccine to prevent COVID-19 infection is needed to return to “normal,” several polls have indicated some Americans would be reluctant to receive a vaccine, citing safety concerns. The spread of disinformation on social media has only further complicated matters.

“We’re not going to get to reopening economies without effective treatment and control — and that includes vaccines,” said Peter Daszak, president of the EcoHealth Alliance, during a recent National Academies virtual workshop on vaccine hesitancy. “A COVID-19 vaccine doesn’t exist yet, but we’ve already seen hints of mistrust on social media. ‘Is it going to be harmful? Do we need it?’”

In 2019, the World Health Organization listed vaccine hesitancy as one of the 10 biggest threats to global health. Vaccine hesitancy is different from the anti-vaccine movement, emphasized Eve Dubé, senior researcher at the National Institute of Public Health of Quebec. It refers to the reluctance to vaccinate, despite the availability of vaccines; whereas the anti-vaccine movement refers to the outright refusal to vaccinate under all circumstances. Vaccine hesitant parents can be moved toward acceptance, said Dubé — but it may take a few visits or consultations.

What’s Driving Vaccine Hesitancy?
Questions about safety and effectiveness aren’t the only contributors to vaccine hesitancy, said moderator Heidi Larson, professor of anthropology, risk, and decision science at the London School of Hygiene & Tropical Medicine. Inherent mistrust in government and health care institutions also play a role.

“The issue of equity in itself is a driver of vaccine hesitancy. In the days of polio, people said, ‘we don’t even have running water. You don’t care about us, [so] why should we trust you about vaccines?”

Robin Nandy, UNICEF principal adviser and chief of immunization, also referred to the concept of the “intent-to-action” gap. “Often there’s the intent to vaccinate, but then families realize they don’t have time, they can’t afford the out-of-pocket expenses, or there are transportation barriers.”

Well before the coronavirus pandemic, measles, polio, and other vaccines were out of reach for 20 million children below the age of 1 every year, said Nandy. He described the unique challenges of vaccine uptake among four populations — people in remote rural areas, the urban poor, people in conflict-affected areas, and women. In addition to these challenges are persistent shortages of health workers, the displacement of refugee populations, gaps in data on who has and hasn’t been vaccinated, and long transport distances.

Getting Back on Track with Childhood Vaccinations

Vaccinations have also plummeted during the pandemic, as parents have postponed well-child checkups, fearing the risks of in-person visits. One-third of U.S. children are not vaccinated on schedule as it stands.

“We need to explicitly state it’s safe to go for well-child visits. The message is simple: Call your health care provider and get back on schedule,” said Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Disease. “Vaccinations are just one reason why we need to get kids back to the doctor’s office. It’s an opportunity to check on their emotional well-being and how they are coping with this health emergency.”

Messonnier described some of the precautions doctors’ offices are taking, such as using separate waiting rooms for well-child visits and sick-child visits. Pharmacies, clinics, and other providers may also need to get creative and establish drive-up clinics — popular with COVID-19 diagnostic tests — for childhood vaccinations. School nurses and administrators will also need more guidance in the coming months.

Preparing for a COVID-19 Vaccine

“As we prepare for a future COVID-19 vaccine — in the hopes it will be available in the fall or winter — CDC is working to identify priority groups for outreach,” said Messonnier. “We need to look at disparities in vaccination at the state and county level — by race, ethnicity, and insurance status.”

Experts are also working to understand public perceptions around possible candidates for a COVID-19 vaccine. The idea that vaccines are rushed to the market without enough scrutiny is a tenet of the anti-vaccine movement. Language such as “operation warp speed” (in reference to the administration’s search for a COVID-19 vaccine) can be problematic, and dismissive of the extensive safety and effectiveness testing that vaccines must undergo.

Lessons from the Polio Eradication Program
COVID-19 might set the world back in immunization goals by several years. But it’s also an opportunity to reimagine childhood vaccination as a core function of the primary care system.

In low- and middle-income countries, polio vaccinators have walked from door to door, and they’ve traversed conflict zones and remote villages to ensure no child misses the opportunity to get vaccinated. Similar outreach tactics will be needed when a COVID-19 vaccine becomes available, and they will continue to be crucial for other childhood vaccinations.

“We have to be mindful of where the unvaccinated kids are, especially in the post-COVID-19 world,” concluded UNICEF’s Nandy. “We’ll have to coexist with COVID and continue to deliver vaccine services.”