December 1, 2020
Vexed on Vaccines: Vaccine Hesitancy, Fact Immunity, and a Pandemic of Misinformation
It is no secret we are in the middle of a pandemic, the likes of which our generation has never seen. Every day, clinicians care for thousands of patients infected with SARS-CoV2. One sick person can infect many more without proper precautions. Though we are making strides, progress is slow, and our efforts thus far have fallen short. The SARS-CoV-2 virus has proven to be quite a formidable and destructive opponent. However, a pandemic of misinformation can potentially be even more devastating.
Epidemiologists estimate the SARS-CoV-2 virus has an R◦ 1.4-4. [1,2] Therefore, one infected person can infect as many as four others. But, what is the R0 of misinformation? 1,000? 10,000? 100,000? The most popular peddlers include the highest elected US officials, celebrities, athletes, and social media influencers. Collectively they have hundreds of millions of followers and seemingly boundless reach. The true R0 of misinformation may be immeasurable.
In 2019, the World Health Order designated “vaccine hesitancy” as a top 10 threat to global health.  On January 13th of 2020, just two weeks after the first reports of COVID-19 in Wuhan China and one week before the first US case, the WHO listed “preparing for epidemics” as a top priority heading into the next decade.  The WHO stated: “A pandemic could bring economies and nations to their knees.” So how did we get here? Why are we not more prepared?
To date, there are more than 62 million cases and 1.4 million deaths worldwide. The US has only 4% of the world’s population but 20% of the COVID-19 related deaths. Nearly 1,800 Americans die every day due to COVID-19.  A vaccine will be here soon. However, multiple polls report only about 50% of the US population plans to be vaccinated.  Black Americans are 2x more likely to die from COVID-19 than white Americans,  yet surprisingly only 32% of Black Americans said they would take a vaccine when available. Although more recent polls reveal a more optimistic viewpoint, we still have a ways to go.  Epidemiologists predict about two-thirds of the population would require immunity (either through infection or vaccination) to reach sufficient protection from the continued spread of the SARS-Cov-2 virus. 
Those who are unwilling to be vaccinated cite the vaccine’s expedited development and link this to potential safety concerns.  This uncertainty triggers a compelling desire to fill the gaps in our knowledge. Peddlers of misinformation exploit this uncertainty and fill the void with blatantly false or misleading information.
We can use our prior experience and literature associated with the MMR vaccination to understand our current dilemma and combat misinformation surrounding meds, masks, and vaccines. A report published by Countering Digital Hate (CCDH) noted that anti-vaccine groups have nearly 50 million followers on Facebook and Youtube alone. These groups have increased their following by 7-8 million since 2019. The CCDH calculated that social media companies could generate $1 billion in annual revenue through advertisements targeting followers of anti-vaccine accounts.  One study found that 32% of videos on Youtube opposed vaccines, and those videos had more views and higher ratings than pro-vaccine videos.  In another study, researchers explored the content of the first 100 sites found after typing in “vaccination” and “immunization” into a Google search and discovered 43% of the websites contained anti-vaccination information.  In yet another study, 50% of tweets concerning vaccination between 2009 and 2015 contained anti-vaccine beliefs.  Researchers found that spending 5-10 minutes on an anti-vaccine site can increase perceptions of vaccine risk and decrease the perceptions of risk from disease,  and these misconceptions persisted five months later. 
For many patients, misinformation is more compelling. These sites, blogs, and social media accounts use the first-person narrative to draw an emotional connection. As health care providers, we use statistics, evidence-based medicine, and fact sheets from public health websites like the CDC. Thus far, our methods have been unsuccessful and we continue to see soaring numbers of COVID-19 cases. Again, MMR anti-vaccination studies may be helpful. One study found that attempts to dispel myths had the opposite effect and led to stronger beliefs against vaccinations.  In Another study vaccination perceptions significantly improved when participants reviewed the following: a first-person account from a mother’s perspective about her child contracting a vaccine-preventable disease, pictures of a child afflicted with a vaccine-preventable disease, and short warnings about how important it is for people to vaccinate.  Another study discovered that vaccine-hesitant college students were more likely to adopt pro-vaccine views after conducting interviews with individuals who contracted a vaccine-preventable disease. The study also uncovered an increase in pro-vaccine views when reference material focused on disease over vaccine safety. 
Misinformation has plagued other interventions and therapeutics and not just vaccines. Many have touted Hydroxychloroquine as life-saving and curative. Masks were branded useless and ineffective. Some have linked 5g cell phone towers to the pandemic. Even Bill Gates has made an appearance in misinformation theories as purportedly trying to microchip the entire population. The pervasiveness of social media allows for the rapid dissemination of misinformation – whether it be purposeful or due to errant interpretation. It may be difficult for the layperson to determine what is accurate from inaccurate, virtuous from deceptive, or fact from fiction. Social media companies also utilize another critical tool, content personalization algorithms. Individuals searching for information can easily be led astray and have a near-continuous feedback loop of misinformation amplifying the message and creating the false perception that these fringe views are more widely accepted.
Scientific and medical journals are guilty of disseminating misinformation as well. More than 23,000 Covid-19 related articles were published between January 1st and June 30th alone.  Nearly one-third were available for pre-print publication. Moreover, fear, uncertainty, and thirst for answers have strained many editorial boards. Many have adopted a rapid peer-review process. Some medical journals accepted articles for publication the same day as submission, many publications contained conflicts of interest, and many have been retracted. Science via press release is also becoming a more common phenomena. Despite the overwhelming amount of information, less than one-third of publications are randomized controlled trials and the majority of articles provide little new details.  The public has become the peer review process, and the result is a weakened public trust in science and medicine.
So what can we as clinicians do? It is vital to know the evidence if we hope to refute any misinformation. There are some incredible features of social media. Free open access medical education (FOAMed) has been cultivated on many social media platforms, which has resulted in the decentralization and democratization of medical knowledge. Staying current can be impossible due to the sheer volume and speed at which new literature is published. We can use trusted journal feeds, blogs, and podcasts for quick palatable bites of the most up to date information. We can use RSS readers to follow our trusted resources and be alerted for updates.
Very few patients are true believers of misinformation. Most are afraid and need reassurance from a trusted physician. In “How to Win Friends and Influence People,” Dale Carnegie gives us many principles to foster relationships. He stresses, “Make the other person feel important — and do it, sincerely.” We can not criticize or condemn. The only way to win an argument is not to have one, and we will not convince anyone by attacking their beliefs. These ideas highlight the importance of building the patient-physician relationship through empathy. Patients must understand, we know they are loving and caring, and they want what’s best. We are here to help them make the best decision.
Traditionally, the scientific community has felt the evidence should speak for itself. Anecdotes are not evidence. However, one of our duties is to bridge the gap between science and healthcare. Much of this information can be unintelligible for the layperson. We must make this information easily understandable so patients can make the best healthcare decision. Stories and anecdotes can help us bridge that gap.
We can all remember the patient with third-degree AV block, in vivid detail, in whom we got to float a transvenous pacer or the patient with ACE inhibitor angioedema who needed cricothyroidotomy or that time we performed a resuscitative thoracotomy. We can use accounts from our clinical experience when we cared for patients with the diseases we hope to prevent. We are all moved by a great story. These stories may penetrate more deeply. We connect with stories when characters face similar challenges that we face. We must be humble and remember we are not the hero in this story. The patient is the hero. We are mentors guiding our hero along their journey.
We wear masks continuously throughout clinical shifts; this visual alone may be enough to strengthen its importance. We can also use personal stories and stress how and why we protect ourselves and reinforce mask use. We can use anecdotes to supplement evidence and generate emotion, hopefully moving patients toward a common shared goal, good health. Soon the vaccine will be available to all, and frontline workers will likely be vaccinated first. We can also use the power of story to highlight why we choose to vaccinate ourselves and loved ones.
From an ED clinician’s standpoint, it is easy to pass the baton to our primary care folks when difficult discussions arise. We do not often discuss vaccines. However, many of our inner-city population use the ED for primary care, and these visits may be the only teachable moment. The pandemic has crossed specialties and become the responsibility of the entire medical community, and it will take our collective effort to prevail. We must counsel patients whenever and wherever the opportunity arises.
The COVID 19 pandemic has pushed our limits. It has put a tremendous strain on the healthcare system as a whole and each of us individually. But, this too shall pass. We will not break. There will eventually be widespread vaccination. The treatment will continue to improve. Prevention and containment strategies will become more robust. The world will rebound. However, misinformation is here to stay, and we must meet this challenge head-on. We are champions of progress and ingenuity. We will continue to push forward. We can and will adapt. Today, when your next patient presents to the ED, take that opportunity to talk, listen, and identify gaps in knowledge. We must fill those gaps with the truth.
- When counseling patients focus on disease and not on dispelling myths
- Use FOAMed and an RSS Reader to keep up to date on new literature
- Be empathetic and never criticize a patient’s beliefs
- Use the power of story to support the evidence and bridge the gap between science and healthcare
- Use personal decisions and highlight why we wear masks; why we choose one medicine and avoid others; and why we choose to vaccinate ourselves and loved ones
- Take ownership of the problem. The pandemic affects all specialties
Guest Post By:
Marco Propersi, DO
Assistant Clinical Professor
St Joseph’s Regional Medical Center
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Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
Marco Propersi, DO
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