Increasing Public Acceptance and Uptake of COVID-19 Vaccines, by Brandon DL Marshall, PhD


As we count down the final days of 2020 and find ourselves in the midst of a colossal, nationwide surge in COVID-19 cases, it’s challenging to remain hopeful and optimistic for a brighter future. Over 300,000 Americans have lost their lives to the coronavirus: by the time the pandemic has subsided, it will be one of the deadliest events in US history (behind only the 1918 flu pandemic, World War II, and the Civil War). There are currently over 100,000 people hospitalized with COVID-19, with healthcare systems across the country at their breaking points.


Yet there is much reason for optimism. Over the past several weeks, the US Food & Drug Administration (FDA) has issued emergency use authorization for two COVID-19 vaccines, both of which have been found to be highly effective at preventing COVID-19 disease. Both the Pfizer-BioNTech and Moderna vaccines were found to prevent more than 90% of cases in phase III clinical trials, far exceeding the expectations of many leaders in the field.


With vaccine roll-out now underway, the challenge now turns to vaccinating as many Americans as possible. To reach what is known as the ‘herd immunity threshold’—the point at which viral transmission starts to die out because so many people have acquired immunity, which in turn indirectly protects those who have not yet been vaccinated—at least 70% of the population will probably need to receive the vaccine.  Even states with the highest rate of flu shot coverage (e.g., Massachusetts and Rhode Island) typically vaccinate less than 60% of the adult population each year. Therefore, public health leaders and politicians will need to work extremely hard to ensure that the vast majority of US adults receive the COVID-19 vaccine. In this commentary, I lay out four key strategies to help overcome vaccine hesitancy and address strong anti-vaccine sentiment, which has been a pervasive feature of the public health landscape in the United States over the past few decades.


First, we must directly tackle erroneous perceptions that, because the vaccine was developed very quickly, it might not be safe for the public. The speed at which COVID-19 vaccines have been developed, tested, and authorized for emergency use is due to the unprecedented amount of resources and expertise dedicated to the process: never before in human history has so much money and so many scientists been focused exclusively on one vaccine. Importantly, no corners were cut in the federal authorization process.  Career scientists at the FDA conducted their own comprehensive analyses of the pharmaceutical companies’ data, and an advisory committee consisting of highly respected, independent researchers from top academic institutions met to review and carefully vet all of the trial results. Both the Pfizer-BioNTech and Modern phase III clinical trials were well-executed (successfully enrolling tens of thousands of participants), and both vaccines were recommended for authorization by wide margins.  The American public should have an extremely high degree of confidence in the safety and efficacy of these vaccines.


Second, public health departments and health care providers must be clear and transparent about transient, minor side effects that often accompany vaccination. Localized adverse reactions at the injection site (e.g., pain, swelling) occurred in almost 90% of participants receiving the Moderna vaccine, 70% of participants reported some fatigue, and 15% reported fever. However, in the vast majority of cases these adverse reactions only lasted 1-2 days, and side effects lasting longer than 7 days were uncommon.  Serious adverse events following vaccination were very rare and no more common than participants who received placebo. Nonetheless, with so many people getting vaccinated in a short period of time, it will be extremely important for public health leaders to clearly communicate that tragic events like strokes, heart attacks, and deaths will continue to occur, and by chance some of these outcomes will happen after people receive a COVID-19 vaccine.  However, this does not mean that vaccination was the cause. The public should be assured that comprehensive post-marketing surveillance will be conducted by the FDA to determine the longer-term safety of the COVID-19 vaccines.


Third, we should rely on evidence-based and behaviorally-informed strategies to promote vaccine uptake. Decades of research has shown that clear, easy-to-understand messaging and endorsements from well-regarded community members, celebrities, and thought leaders greatly increase engagement in desired public health behaviors.  The diversity of voices in this approach is crucially important: national, state, and local health departments should engage leaders from the entire cross-section of civic society to champion the benefits of COVID-19 vaccination in their own communities.


Finally, and most importantly, COVID-19 vaccines should be made widely and freely available to all Americans, with focused efforts made to reach those who have been historically disenfranchised, marginalized, and discriminated against by the medical community. Due to the iniquitous effects of systemic & structural racism, Black/African American, Hispanic/Latino and Indigenous populations have been disproportionately affected by COVID-19. Given the fact that people of color are more likely than white Americans to live in crowded housing conditions and work in frontline jobs that do not allow for social distancing or working from home, racial/ethnic disparities in COVID-19 transmission are likely to continue. Substantial public and private foundation resources should be dedicated towards addressing the history of racist policies, practice, and research in public health, including medical exploitation and unethical experimentation, that undergirds the vaccine skepticism and hesitancy in racial/ethnic minority communities. 


As the largest vaccine effort in American history gets underway, now is the time to commit to using epidemiological science and proven public health approaches to ensure that COVID-19 vaccination programs reach all members of our society, including those who are most vulnerable. Ensuring equitable access to COVID-19 vaccines and addressing racial injustices must be paramount.  The recent breakthroughs in COVID-19 vaccine development are just the start of a long, challenging public health process to end the pandemic. But proven strategies are available: it’s now up to politicians and leaders across all elements of civil society to adopt them.