Vaccine communication in the age of COVID-19: Getting ready for an information war

‘The other night … .I had a terrifying thought: What if we get a Covid-19 vaccine and half the country refuses to take it?’ [1] Kevin Roose, The New York Times.

Fueled by widespread misinformation, vaccine hesitancy (a ‘delay in acceptance or refusal of vaccines despite availability of vaccination services’ [2]) has quickly become one of the most important global health issues of our time. The statistics speak for themselves.

Worldwide, vaccine hesitancy is becoming common and has been reported by approximately 90% of countries [3]. Vaccine hesitancy and refusal have been associated with outbreaks of Haemophilus Influenza type B (HiB), varicella, pneumococcus, measles, and pertussis [4,5], which are all severe and life-threatening vaccine-preventable diseases. In 2019, ‘influenza vaccination coverage [in the United States] decreased by more than 6 percentage points in adults, with only around 37% getting vaccinated [6].’ These trends may explain the recent higher rates of vaccine-preventable diseases, such as in the case of the 2019 measles outbreak in New York City [5] and the overall 30% increase in measles cases worldwide [7], as well as the substantial number of hospitalizations (including among children) and deaths attributable to influenza during the 2019–2020 season [8].

This is a people-made crisis that led the World Health Organization to declare vaccine hesitancy as one of the top threats to global health [7]. Let there be no doubt: immunization remains one of the most successful public health interventions of our time with unequivocal impact on disease control and eradication [9,10].

As an immunization advocate, and someone who has dedicated significant professional time to pediatric and adolescent immunization, I cannot help but worry that this trend will also affect the uptake of a COVID-19 vaccine worldwide. Recent studies on social networks and other global reports already highlight efforts to undermine much needed vaccine research efforts that could end the coronavirus pandemic by ‘seeding outlandish narratives’ and spreading false claims and misinformation [11]. A recent survey by the CUNY School of Public Health showed that ‘12% of New York City residents said they would not take a coronavirus vaccine and almost all of them (82%) said they would not take the vaccine because they are worried about vaccine side effects [12].’ Moreover, lessons learned from the H1N1 2009 pandemic flu show that communication efforts regarding the vaccine ‘were a big challenge’ [13] and that public compliance with immunization requires coordinated efforts to increase confidence in governments and local hospitals, and ‘the development of social and institutional trust [14].’ Finally, pandemics often weaken health, social, and communication systems in many countries and communities and result in lower immunization rates. For example, we already see a decrease in routine immunization coverage and a reduced demand for ‘recommended noninfluenza childhood vaccines and for measles-containing vaccines’ funded by the Vaccines for Children Program (VFC) in the United States [15] a trend that should be carefully monitored also in relation to its implications for coverage of a COVID-19 vaccine among the uninsured and other vulnerable groups. Other factors such as vaccine access or cost, or limited investment in promoting existing publicly-funded vaccine access programs, or the impact of the pandemic on already weak health and social systems also affect vaccine uptake and in turn could be affected by misinformation.

Communication can greatly contribute to addressing misinformation. For this we need a paradigm shift that engages those who have been most affected by the pandemic – such as low-income communities, communities of color, the elderly, and other marginalized and underserved groups – in the design of our communication efforts. Improving health and media literacy as well as civic literacy and helping everyone understand the impact of information and policies on their lives is also key to this paradigm shift. It’s only by empowering and developing local champions and adding our collective voices in support of immunization that we can effectively address false or misleading information on any future COVID-19 vaccine. The engagement of community leaders will also make sure that in promoting immunization behavior we consider the many social inequities people experience, and design policy solutions to address immunization barriers. Community leaders are also trusted sources of information and may be more impactful in discussing immunization given the many reasons that unfortunately contribute to mistrust among marginalized groups.

Ultimately, the vaccine information war that we are likely to enter needs a collaborative and multi-stakeholder approach, which recognizes the contribution we can all make to safely re-open society and protect others once a COVID-19 vaccine becomes available (hopefully soon). For example, clinicians have a key role in addressing vaccine hesitancy and limiting complacency to immunization. Professional associations, universities, and other organizations that interface with clinicians should start working on interventions and training modules to help healthcare workers engage in difficult conversations on vaccine hesitancy with their patients. Policy communication and advocacy efforts can help support policymakers not only in the development of immunization policies for schools, workplaces and other settings, but also suitable strategies to prioritize vaccine availability forthose groups whose differential exposure to or risk for the virus is greater (e.g. healthcare workers, food and pharmacy cashiers, sanitation workers, people living in shelters or nursing homes, and people who suffer from any condition that poses a higher risk for COVID-19 complications). The role of journalists in ensuring that media coverage is evidence-based and accurate is equally important, and so is training scientists and government agencies to discuss in plain language the benefits of a future COVID-19 vaccine with the media.

Social media should also be used strategically to promote positive information about the safety and efficacy of any vaccine that will be approved for use by regulatory agencies across countries. A lot of vaccine-related misinformation is spread via social media and poses a risk, especially for populations with low health literacy and other groups who haven’t had the opportunity and/or the resources to develop the kinds of skills that are needed to assess the quality and credibility of information. Communication efforts in support of a COVID-19 vaccine should give voice to trusted sources of information, such as religious leaders, parent groups, community leaders, and other key community influentials and local immunization champions. Local agencies, research organizations and nonprofit groups should provide assistance and training to these leaders – who are the real ‘celebrities’ in the communities they represent – to effectively participate in the immunization dialogue and develop a strong online presence if they don’t already have one. We know most people ‘follow’ those who share similar values and experiences – whether personal or professional – and speak the ‘language’ of their own communities. For example, I recently came across a blog post from a parent that started with a section entitled ‘To the parent of the unvaccinated child who exposed my family to measles [16].’ This kind of personal testimonial is often more powerful than anything any expert may say, and greatly complements information from official sources, such as the World Health Organization, the Centers for Disease Control and Prevention, and local governments and their leaders.

We ultimately need an integrated approach to communication that is inclusive of a variety of action areas and engages key stakeholders (e.g. organizations in the public, for profit, and nonprofit sectors, community leaders and members, policymakers, clinicians, etc.) across media and settings. Empathy, respect, cultural humility and genuine concern in discussing any doubts or fears people may have, and providing them with evidence-based information to positively shape immunization decisions should inform all our efforts. No matter which media or venue we use, we should never give the impression that someone is wrong for raising the topic and discussing their doubts. We should consider all encounters and communication activities as opportunities to dispel misconceptions, address doubts, and improve immunization coverage.

In preparing for this vaccine information war, my concern is primarily with low-health literacy and other vulnerable and marginalized communities where lack of resources, bias and limited investment have already resulted in a disproportionate COVID-19 burden. We need to make sure people feel supported in their decision to immunize, and responsible for protecting not only themselves but also vulnerable communities. Only a strong collaborative effort between clinicians, policymakers, community leaders, families, academia, and a variety of organizations from the public, for profit and nonprofit sectors will allow misinformation and false claims around a COVID-19 vaccine to be dispelled. If we fail, the implications for the future of our society could be immense. We should start to get ready now.

In this issue

For the rest of this year, every issue of our Journal will include information on the COVID-19 pandemic. In addition to this editorial – and in continuation of our Interview series on COVID-19 – we bring to our readers the voice of Dr. Antonio Brucato, Associate Professor of Internal Medicine, University of Milan, and Chief of Internal Medicine Unit, Ospedale Fatebenefratelli in Milan, Italy. From 25 March to 29 April, 2020, Dr. Brucato headed the COVID-19 Emergency Unit at the Fatebenefratelli, a major Italian hospital at the epicenter of the pandemic. Dr. Brucato spoke with JCIH about provider-patient-family-caregiver communication during COVID-19 and many other relevant topics.

The articles in this issue focus on a variety of media, countries, and health areas, and present new findings or perspectives on the key role health communication plays in addressing complex health and social issues, and encouraging behavior change among patients, clinicians, and young or older adults.

We know these are unprecedented times and hope you find the information in this issue of interest to your work. Stay well and be in touch with suggestions and comments. We love to hear from you!