Early in the fall, when Ashley Wenaas, MD, an otolaryngologist based in Cypress, Texas, talked to colleagues about the expected availability of vaccines for COVID-19, she heard enthusiasm, but it came with a dash of hesitation.
Explore This IssueJanuary 2021
“People would say, ‘I’m going to get the vaccine, but I’m not going to be the first one,’” Dr. Wenaas said. “‘I’ll be in the second wave. I don’t want to be the guinea pig.’”
She suspected this outlook had to do with a lack of communication on how the vaccine development process works. Recently, as treasurer of the Houston Society of Otolaryngology–Head and Neck Surgery, she helped arrange a virtual meeting with a vaccine expert as a guest speaker, helping to illuminate the process and sparking a productive conversation. Her own eyes were opened as well, she said.
The federal effort to get COVID-19 vaccines to the American population quickly, dubbed Operation Warp Speed, expedited some manufacturing aspects and laid the groundwork for fast distribution. The speaker, Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at the Baylor College of Medicine in Houston, reassured the 40 attendees that the science aspect of the initiative—the investigation of the vaccines’ safety and efficacy—has followed the usual rigorous process.
Such exchanges of accurate and important information are vital, infectious disease experts and otolaryngologists say, as patients turn to their physicians for information and guidance on the vaccines—especially since conversations like these, when multiplied by the millions, can have profound public health implications in determining how quickly COVID-19 transmission is interrupted.
Still, many physicians are often hesitant to raise the subject of vaccinations. Becoming comfortable raising the topic and having a smart approach with patients who might be skeptical of whether vaccinations for diseases including COVID-19 and HPV are safe and can truly work starts with being armed with the correct information.
COVID-19 Vaccines: Where We Stand
According to the U.S. Department of Health and Human Services (HHS), vaccines generally fall into four categories:
- Live-attenuated (vector) vaccines (MMR, smallpox, chickenpox), which use a weakened form of the germ that causes a disease.
- Inactivated vaccines (hepatitis A, flu shots, rabies), which use the dead version of a disease-causing germ.
- Subunit, recombinant, polysaccharide, and conjugate vaccines (hepatitis B, HPV, shingles), which use specific pieces of the germ, such as a protein, sugar, or capsid, to form the immunity.
- Toxoid vaccines (diphtheria, tetanus), which use a toxin made by a disease-causing germ.
The first two COVID-19 vaccines (as of press time) approved by the FDA are mRNA vaccines that contain material from the SARS-CoV-2 virus that acts as instructions for the body to make the virus’ spike protein, which, by itself, is harmless. Recognizing the protein, the immune system then ramps up and is poised to fight off an actual infection from the virus.
People would say, ‘I’m going to get the vaccine, but I’m not going to be the first one. I’ll be in the second wave. I don’t want to be the guinea pig.’ —Ashley Wenaas, MD
Pfizer and BioNTech’s vaccine was found to be safe and 95% effective at preventing infection, and particularly at preventing severe cases. Moderna’s vaccine has also been found to be safe, with a 94.5% efficacy in preventing infection, and, like Pfizer’s, highly effective at preventing severe COVID-19 cases.
A vector vaccine being developed by AstraZeneca contains a weakened version of the live virus that carries genetic material from SARS-CoV-2 into cells. That genetic material prompts production of the spike protein, instigating an immune response. Johnson & Johnson has also developed a vector vaccine, which, as of December 2020, was being assessed in a trial. Sanofi and Novavax are running separate trials to test the efficacy and safety of a protein subunit COVID-19 vaccine.
Even as Operation Warp Speed fed billions of dollars to pharmaceutical companies to manufacture the vaccines, those vaccines were still being studied to see whether they would be safe and effective. Infectious disease experts said the accelerated timeline has been the product of urgency, funding, and raw will—but not through an abandonment of the scientific process.
“Necessity is the mother of invention, and there’s a huge need here,” said Kenneth Alexander, MD, PhD, chief of infectious diseases at Nemours Children’s Health System. “Although this is being done on an accelerated schedule, the researchers aren’t taking shortcuts.” In addition, the sheer number of people in the studies—tens of thousands—should be reassuring. “If you examine the mathematics, an undetectable side effect would have to happen in the neighborhood of 1 in 10,000 people or fewer,” he said.
Despite this rigorous process, the U.S. population is split in its views of COVID-19 vaccines. Survey data released from the Pew Research Center in September 2020 showed that 51% of U.S. adults said they would definitely or probably get a vaccine, while 49% said they would definitely or probably not get one.
Those percentages have been fluid: Earlier, in May 2020, 72% said they would be at least likely to receive a vaccine. But after the September drop, more recent poll results, released in December 2020 by the Kaiser Family Foundation, found that 71% of respondents would definitely or probably get a vaccine.
Dr. Hotez believes the number of people who would get a vaccine will increase as the rollout continues. “I think a large part of that [hesitation] could evaporate as people start to get vaccinated and see no untoward effects,” he said. “I think there’s a group that is concerned about all the politicization they’ve seen in regard to the COVID-19 vaccines. With adequate communication, that part can be fixed.”
Communication and Promoting Vaccination
The dug-in anti-vaccination movement, rooted largely in conspiracy theories, is a more difficult problem requiring a more forceful counteroffensive to battle coordinated disinformation efforts, Dr. Hotez said. Amplifying and fine-tuning a pro-vaccine message is part of the effort, he said, but he has also advocated for a federal interagency task force, including HHS and the Department of Justice, dedicated to dismantling the anti-vaccine message.
I communicate that the safety of the vaccine is high in many large studies, and that the studies show that they’re helpful in protecting families and communities and keeping us all healthy. —Caleb Simmons, MD
On an individual level, good communication from physicians—both inside the exam room and, some experts say, outside of it—can boost faith in vaccines. But otolaryngologists aren’t always eager to bring up the topic of COVID-19 vaccines, Dr. Wenaas said. “I don’t offer my opinion unless asked because what’s most important is my physician-patient relationship,” she said. “When patients visit my office, they’re coming to me for specific things. It’s important that we maintain a good relationship and the ability to talk freely.
“A lot of people will ask my opinion about various things, however, and then I’m happy to offer it,” she continued. In the case of a patient who asks her opinion on COVID-19 vaccines but might harbor some reservations, Dr. Wenaas said she reminds them that there are risks and benefits in acting, but also risks and benefits in not acting. For example, she might say, “For me, the benefit of the vaccine significantly outweighs the risk. We can talk about the details if you like.” But she added, “Some people have very specific feelings about the COVID-19 vaccines, and I’m not necessarily going to change their mind if they aren’t looking for an opinion.”
Caleb Simmons, MD, an otolaryngologist at the Austin Regional Clinic in Texas, said he isn’t inclined to bring up the COVID-19 vaccines with patients on his own due to the lack of availability—although he will when availability improves—but he does discuss the HPV and flu vaccines with certain patients.
When a patient initiates a discussion about vaccines, he said, they’re usually doing so in good faith and are truly interested in his opinion. When he has these conversations, he usually sits down to show that he’s listening. When a patient expresses doubt, he asks why they feel that way and about their sources of information, letting them share their viewpoints.
“I usually lead the next part by Socratic method, asking them why they believe one part of the evidence over another, why they believe one source over another,” he said. “My main goal is to get them to examine how they’re thinking and to challenge their assumptions, and I’m listening for any personal stories that they share.
“Finally, I mention what I’ve been reading and how in the process of making these vaccines we’re building on the foundations of what’s been done before,” he said. “I communicate that the safety of the vaccine is high in many large studies, and that the studies show that they’re helpful in protecting families and communities and keeping us all healthy.” He also makes it known that he will get the vaccine.
Dr. Hotez said that patients should be made aware that the available COVID-19 vaccines all work in more or less the same way, by provoking an immune response to the virus’s spike protein. “Don’t let patients overthink it—you want them to take advantage of whatever vaccine is available to them,” he said. “We won’t know what the best vaccine is for months or years in terms of durability of protection and other issues, so this isn’t a time to cherry-pick which vaccine you think might be the best.”
Dr. Alexander cautioned physicians against saying too much or offering statistics, which can often solidify someone’s preformed opposition to vaccinations. “Patients want to know three simple things: Is it safe? Does it work? and What is the doctor’s recommendation? When I go to the grocery store and ask for the jam, I don’t want a discussion on how you built the shelf that holds it,” he said.
And when it comes to the recommendation, be unequivocal, he said. “Families aren’t looking for advice like, ‘It’s available if you want it,’” he said. “What they’re looking for is, ‘I’m a physician, I took this vaccine. My wife has taken this vaccine. We gave it to my parents. Vaccinating people is what you do for those you love.’ Turn it into a story or an emotional case.”
Todd Wolynn, MD, MMM, chief executive officer at Pittsburgh-based Kids Plus Pediatrics, which was the target of a massive social media attack after the practice posted a video promoting HPV vaccination in 2017 (see “Attacked for Being Pro-Vaccine,” below), said that bringing up vaccinations should be a matter of course. “Just educate people,” he said. “If it becomes part of your culture, then it doesn’t seem so odd.”
He describes his approach with an acronym: AIMS (Announce, Inquire, Mirror, Secure). First, he announces that a patient needs a vaccine. If they’re hesitant, he inquires, “Can I find out a little bit more about why you’re hesitant?” Then, he mirrors them, repeating their comment back to them. “Just by repeating back their words, you’ve shifted the dynamics of the entire conversation because they now know you’re listening to them. It opens up an opportunity for you to share the science-based information.”
Finally, if a patient still doesn’t want the vaccine, a physician should secure the physician-patient relationship. “You could say something like, ‘We can agree to disagree on that, but I appreciate you hearing me out. We can always revisit it,’” said Dr. Wolynn.
Dr. Simmons said there are thorny issues that, in the end, will be difficult to resolve, especially since so much political division has evolved from COVID-19. But that doesn’t mean physicians shouldn’t try.
“I think we have to acknowledge political, cultural, and religious reasons patients have for not getting the vaccine,” he said. “I’m not always sure what to do, but I think we can listen and see if we can help the patient find a way to the vaccines,” he said. “Sometimes, we have to help patients navigate familial relationships and religious implications. That might mean simply helping patients keep the end goal in mind: We all want our families to be healthy and safe, and we want a healthy country to share.”
Thomas R. Collins is a freelance medical writer based in Florida.