Sept. 2, 2021 -- In between the people strongly for and against vaccines are individuals who carry certain fears and concerns that stop them from getting immunized. And experts believe that with the right approach and the recent full approval of the Pfizer COVID-19 vaccine, many in this group could be moved to get vaccinated.

These "in-betweeners" share two things in common: They have their reasons, and they don't want to be called "anti-vaxxers."

And that's where the similarities of people in this group generally end. Who they are, where they live, and the reasons why they don't want to get vaccinated are as diverse as the regions that make up the U.S.

"Certainly the reasons people are hesitant about the vaccine are many," Kathryn M. Edwards, MD, scientific director of the Vanderbilt Vaccine Research Program at Vanderbilt University School of Medicine in Nashville, said during a recent media briefing sponsored by the Infectious Diseases Society of America (IDSA).

Health concerns, a disabling fear of needles, general anxiety, and a historic mistrust of medicine are among the reasons for COVID-19 vaccine reluctance.

Walter A. Orenstein, MD, agreed that "people who are hesitant are a heterogenous group." Although the full approval of the Pfizer vaccine by the FDA could make a difference through reassurance or vaccine mandates, "there are people who are very strongly against getting vaccinated. I don't think they will be impacted that much" by the full licensure.

However, "there is a substantial proportion that has had a wait-and-see attitude. And I'm hoping that they will be willing to get vaccinated now," Orenstein, professor and associate director of the Emory Vaccine Center in Atlanta, said during the briefing.

Differences by Race, Ethnicity, and Sex

Early in the COVID-19 pandemic, public health officials identified lower vaccination rates among some communities of color. A lack of confidence in medicine was a widely cited reason for such vaccine racial disparities.

More recently, investigators in a new study report that vaccine hesitancy among Black people has declined dramatically over the course of the pandemic.

"Our findings point out that the hesitancy among Blacks is largely driven by confidence and circumspection issues but not so much by complacency issues. This means Blacks are hesitant not because they underestimate the risks of COVID-19, but because they have concerns with the effectiveness and side effects of COVID-19 vaccines as well as confidence issues with the system," said Ran Liu, PhD, the lead author of the study.

Liu evaluated nearly 444,000 people who responded to weekly Household Pulse Surveys conducted by the U.S. Census Bureau between January and March 2021. Over 6 weeks, for example, the percentage of Black people with overall hesitancy declined from almost 35% to below 20%. The study appears in the September 2021 issue of SSM Population Health.

On a positive note, "the dramatic decline in vaccine hesitancy among Black people across time shows that we are doing something right this time -- the unprecedented efforts in public communication and federal support could have helped to address some of the concerns across the country," said Liu, an assistant professor in the Department of Educational Policy Studies at the University of Wisconsin-Madison.

The research also reveals nuanced gender differences. "These results may indicate that women are more likely to adjust their vaccine attitudes according to evolving information and rely less on ideological and political contextual factors than men do," said study co-author Gabriel Miao Li, a PhD candidate at the University of Michigan.

In other words, women might be mainly concerned about the costs, benefits, and risks associated with a particular vaccine. In contrast, men's hesitancy is more likely associated with disbeliefs about the seriousness of COVID-19 or a distrust of vaccines.

A caveat is that gender could intersect with race, class, and other characteristics and social contexts to make things more complex, Liu said.

"It is dangerous to reduce people to one single dimension and develop policies based on that. It is always important to get into the community and listen to people's actual concerns to develop targeted strategies to reduce vaccine hesitancy," he said.

Revelations on Reddit

The internet -- the source of so much dangerous misinformation -- can also provide additional insight into the many reasons regarding COVID-19 vaccine hesitancy and to the titanic tug-of-war underway in the U.S. between the vaccinated and unvaccinated.

In the Change My View community on Reddit, for example, people challenge others to convince them to switch their views. One recent post proposed that "voluntarily unvaccinated people should be given the lowest priority for hospital beds/ventilators." It drew more than 2,000 comments in its first 3 days.

It would be even more challenging if doctors had to triage people based on culpability instead of clinical severity, one user posted. Another said in many areas with full hospitals, the challenge to prioritize patient care is even greater now. Another pointed out that people "who are not getting a shot are making a choice."

To get a broader view beyond individual viewpoints on Reddit, Arash Shaban-Nejad, PhD, MPH, and colleagues evaluated public sentiment across 13 Reddit community groups focusing on COVID-19 vaccines.

Overall, the researchers found more positive than negative perspectives, a finding that remained relatively steady during their study from Dec. 1, 2020, through May 15, 2021. People more often focused on side effects vs. "outlandish conspiracy theories," they report in their study in the August 2021 Journal of Infection and Public Health.

Although it was not a primary focus, "a closer look into some of the posts and comments does reveal that the undecided exists within these communities to some extent," Shaban-Nejad said.

"Interestingly, one can see some posts where community members express willingness to accept a COVID-19 vaccine but are generally against vaccination, as well as the opposite," said Shaban-Nejad, associate professor of the University of Tennessee Health Science Center-Oak Ridge National Laboratory Center for Biomedical Informatics.

Concerns over rapid vaccine production also emerged in the study. Many people who post on Reddit seem unfamiliar with the history of vaccine development, he said. As a result, they "appear to have reservations because they feel like development was rushed in some way."

Bridging the Divide

In terms of solutions, Shaban-Nejad said, "We emphasize the importance of clear, consistent, targeted, unambiguous messaging, which considers differences in populations' dynamics, characteristics, and their nature of concerns."

While not possible for all health care professionals, Ryan Knopp, MD, a family physician in Manhattan, KS, recommends spending as much time as necessary to listen to and address patient concerns. He reported success with this approach on a recent Twitter thread:

"Happy day for me. Several people I care a lot about got the COVID vaccine today, overcoming some hesitancy. What do I say to my patients who are unsure about the vaccine? This:" he wrote, and then outlined his approach to talking with them in subsequent tweets.

Discussing extensive safety data with people who are vaccine-hesitant could be a useful strategy, a national online poll from Morning Consult on behalf of the de Beaumont Foundation indicates. Administered just days before the full Pfizer vaccine approval, 35% of 956 unvaccinated adults indicated the FDA's action would address most or all of their concerns about the COVID-19 vaccine.

Almost 4 in 10 people chose full FDA vaccine approval as their first or second motivating factor. Employer requirements, less testing, access to public events, and encouragement from their children were other factors.

A Role for Well-Informed Providers

Although it remains to be seen if full approval of the Pfizer vaccine will dissipate such concerns, Joseph A. Bellanti, MD, said that a belief in inadequate safety testing has prevented some from getting vaccinated.

Confidence that natural immunity is sufficient for protection and that vaccines are overused or unnecessary are additional drivers of hesitancy, Bellanti said.

Doctors who engage directly with patients, such as allergists and immunologists, can play an essential role in promoting the COVID-19 vaccine to patients, Bellanti said. He outlines effective strategies in an upcoming publication in the September-October Allergy & Asthma Proceedings.

For example, to counter the "diminished level of confidence and trust by segments of the public in the nation's leaders in government, medical and business communities that these groups once enjoyed," he suggested health care professionals engage in a conversation along the lines of shared clinical decision-making.

"Professionals should be pursuing an ongoing dialog that empowers the public to be actively involved in science and medicine as key stakeholders rather than passive recipients," said Bellanti, professor of pediatrics and microbiology-immunology (emeritus) and director of the International Center for Interdisciplinary Studies of Immunology at Georgetown University Medical Center in Washington, DC.

Bellanti's strategies for allergists and immunologists, including a need to stay up to date on the risks of relatively rare vaccine adverse events, "apply to all health care providers," he said.

Show Sources

Kathryn M. Edwards, MD, scientific director, Vanderbilt Vaccine Research Program, Vanderbilt University School of Medicine, Nashville.

Walter A. Orenstein, MD, professor and associate director, Emory Vaccine Center, Atlanta.

Science Direct: “Hesitancy in the time of coronavirus: Temporal, spatial, and sociodemographic variations in COVID-19 vaccine hesitancy.”

Ran Liu, PhD, assistant professor, Department of Educational Policy Studies, University of Wisconsin.

Gabriel Miao Li, PhD candidate, University of Michigan.

Reddit: “Change My View.”

Arash Shaban-Nejad, PhD, MPH, assistant professor, UTHSC-OAK-Ridge National Lab (ORNL) Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center.

Journal of Infection and Public Health: “Public sentiment analysis and topic modeling regarding COVID-19 vaccines on the Reddit social media platform: A call to action for strengthening vaccine confidence.”

Ryan Knopp, MD, family doctor, Manhattan, KS.

de Beaumont: “Poll: 1/3 of Unvaccinated Adults Say FDA Approval of Pfizer Vaccine Will Address Their Safety Concerns.”

Joseph A. Bellanti, MD, professor emeritus, Pediatrics and Microbiology and Immunology, director of the International Center for Interdisciplinary Studies of Immunology at Georgetown University Medical Center in Washington, D.C.

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