Open for Debate

The Surprise of COVID Vaccine Hesitancy Among Health Care Professionals

The COVID vaccines were the one big hope story for the dismal year of 2020. The first shipments arrived in December to a few high-income countries and rollout started immediately amidst “joy and relief”.[1] The first phase of the rollout was supposed to be the easy part. Vaccinate residents in long-term care (LTC) settings as well as front-line health care workers. Both populations were seen as easy to organize for vaccine administration. Residents could be vaccinated on site. This effort went well. Health professionals would presumably show up to wherever the vaccines were provided to them. Here, the rollouts ran into difficulty.

Health officials, journalists, and members of the public were surprised to learn of vaccine hesitancy among first-in-line health care workers. A rush of news stories shared startling figures: in Toronto, for example, only 43% of roughly 3000 LTC staff in city-owned facilities had consented to vaccination in comparison to 91% of residents.[2] A December poll of 2000 LTC staff in France showed 76% did not intend to get vaccinated.[3] A German study of 2300 health professionals found half of nurses and a quarter of physicians would refuse COVID vaccines.[4]

This reluctance was not worked into vaccine rollout planning. The distribution plans presumed efficient up-take and offered no supportive resources for health care staff. Yet this “surprise” should have been expected. Health care workers have never been uniformly vaccine confident. A small body of research shows health care professionals wavering on seasonal and pandemic influenza uptake;[5] nurses unions have fought workplace mandates in courts.[6] So why was COVID vaccine hesitancy among health care workers so poorly predicted?

The surprise and ill-preparedness lie partly in the high-risk nature of health care work during COVID. Prioritized health care staff worked in close proximity to patients every day, even patients with COVID. But there was more. There was surprise, and lack of preparedness, because healthcare workers do not fit the profile of vaccine hesitators and refusers. Vaccine hesitators are widely thought to misunderstand the science, whereby low scientific literacy is popularly seen as the root cause of vaccine hesitancy.[7] Health care workers are presumably more scientifically literate than average due to professional training. The “surprise” points to this perceived dissonance. For example, Italy’s Deputy Minister of Health responded to COVID vaccine refusal by Italian health care professionals by saying,

I am perplexed when I hear of fellow doctors or nurses reluctant to get the vaccine. I can understand it regarding a member of the public who perhaps does not have the scientific understanding, but frankly, I think that those doctors and nurses, if they still have doubts after seeing everything that’s happened, are probably in the wrong job [8]

Science communicators, journalists, and bloggers have propagated this view of misinformed and uneducated people hesitating about vaccines for years in trying to explain why the problem persists and how to fix it. It has taken hold of collective thinking about vaccine hesitancy. Yet it is a false narrative.[9]  Vaccine hesitancy metrics do not correlate with levels of education; indeed, affluent and educated people are among the most vocal vaccine critics. Vaccine hesitancy, as well as vaccine confidence, strongly correlate with social group membership. Vaccine attitudes are tied to various political and ideological commitments. Indeed, politicians exploit those connections when they implore their constituents to “trust science” or, conversely, champion freedom of choice. Those social ties that bind every one of us to various social groups and identities are better predictors of vaccine confidence than education levels. That is not to say that evidence and logic are irrelevant. Rather, cognition is socially and culturally implicated.[10]

In addition to health care workers being part of professional communities, they, like every one of us, are members of other communities that define our social, emotional and cultural identities. There is then no reason to think health care workers do not have the same questions and concerns regarding the new covid vaccines, the same challenges navigating the many unknowns of new biotechnologies, and the same difficulties finding the information one needs in order to make a confident decision. Health care staff are also diverse in terms of their social locations, histories, and experiences, all of which bear on vaccine confidence and hesitancy.[11]

There is no reason to think that one’s employment within a health care system guarantees high levels of confidence in its norms and practices. Vaccine hesitant health professionals cited safety concerns due to the rapid development and authorization of COVID vaccines.[12] This is not scientific illiteracy, but suboptimal trust in regulatory practices.

It is well known that the public are wary of commercialized health care. Vaccine hesitators and refusers strongly criticize “Big Pharma” and weak regulatory oversight of this powerful industry.[13] It was with an eye towards shoring public trust, and with that, access to huge markets, that several vaccine manufacturers published their trial protocols in advance of trial completion. But transparency is not enough. The trials had not selected primary endpoints that patients and collapsing health systems are most interested in: reduction in severe illness requiring hospitalization and interruption of virus transmission.[14] It is commonplace for industry to tailor clinical trials towards meeting regulatory approval standards rather than measuring the outcomes that patients and providers really want to know. It was unfortunate lack of leadership by government purchasers for not demanding that the most useful endpoints be built into the studies. Health care professionals are feeling the impact, both in their vaccine communications with patients and the public, and in their own vaccination decision-making. Front-of-the-line health workers needed to decide on vaccination even with important gaps in our knowledge: Do the vaccines stop transmission to other people? Are they safe during pregnancy? Will they impact fertility? With no offerings of educational and decision-making supports, health care workers had little direction on how to navigate these uncertainties and unknowns.

Regarding social location, COVID has put in stark relief a tenet of population health: social determinants of health create grave health inequalities between communities. Racialized communities have suffered disproportionate harms of COVID-19. This is tied to its members’ living and working conditions. Those experiences of not being adequately protected and supported during the pandemic have elicited anger and mistrust of government efforts to prioritize vaccination in hard-hit neighbourhoods. [15] Many of these communities have antagonistic relationships with health care systems and government as a result of past and current experiences of medical racism and other injustices. Not trusting “the system” creates epistemic barriers to reliable vaccine information, and vaccine disinformants capitalize on this with targeted messaging that feeds on the insecurities and anxieties of racialized, religious minority, and immigrant communities. Many health care workers are members of these communities.

Health care professionals, like everyone, need culturally sensitive vaccine information from trusted sources. Vaccine supports must also be trauma-informed. The working conditions throughout the pandemic have been difficult, demoralizing, and even traumatic. For those reasons, health care workers deserve sympathetic recognition and response to their reasons for vaccine hesitancy. Health care leadership should ensure health professionals have the same opportunities to get information, ask questions, and express concerns as the rest of the population should be receiving. Numerous health care organizations quickly pivoted to offer “vaccine ambassador” programs for their staff. These conversations must be done with patience and kindness, starting with the assumptions that it is reasonable to have questions about the new vaccines and that those questions ought to be answered honestly and respectfully. It is from here that an equitable and responsive approach to health care worker vaccination can happen.

Citations

[1] Canada Administers its First COVID-19 Vaccine Shots. Globe and Mail, Dec 14, 2020. https://www.theglobeandmail.com/canada/article-canada-administers-its-first-covid-19-vaccine-shots/

[2] Uptake for the COVID-19 Vaccine has been High Among Toronto’s Long-Term-Care Home Residents. For Staff, Not So Much. Toronto Star, January 16, 2021. https://www.thestar.com/news/gta/2021/01/16/uptake-for-the-covid-19-vaccine-has-been-high-among-torontos-long-term-care-home-residents-for-staff-not-so-much.html

[3] Vaccine Scepticism Among Medics Spark Alarm in Europe and US. Irish Times, January 7, 2021.  https://www.irishtimes.com/news/world/europe/vaccine-scepticism-among-medics-sparks-alarm-in-europe-and-us-1.4452612

[4] Vaccine Scepticism Among Medics Spark Alarm in Europe and US. Irish Times, January 7, 2021.  https://www.irishtimes.com/news/world/europe/vaccine-scepticism-among-medics-sparks-alarm-in-europe-and-us-1.4452612

[5] Kose, Sukran, et al. Vaccine Hesitancy of the COVID-19 by Health Care Personnel. International Journal of Clinical Practice 2020; 75(5):e13917.

[6] Vaccination Policies in Workplaces: To Mandate or Not to Mandate. Gowling WLG, December 21, 2020. https://gowlingwlg.com/en/insights-resources/articles/2020/workplaces-vaccination-policies-to-mandate-or-not/

[7] For example, Lewis, Rick. Measles and an Outbreak of Scientific Illiteracy. PLoS DNA Science (blog), February 14, 2019. https://dnascience.plos.org/2019/02/14/measles-and-an-outbreak-of-science-illiteracy/

[8] Vaccine Scepticism Among Medics Spark Alarm in Europe and US. Irish Times, January 7, 2021.  https://www.irishtimes.com/news/world/europe/vaccine-scepticism-among-medics-sparks-alarm-in-europe-and-us-1.4452612

[9] Goldenberg, Maya J. Vaccine Hesitancy: Public Trust, Expertise, and the War on Science. University of Pittsburgh Press, 2021.

[10] Goldenberg, Maya J. Vaccine Hesitancy: Public Trust, Expertise, and the War on Science. University of Pittsburgh Press, 2021.

[11] Goldenberg, Maya J. Vaccine Hesitancy: Public Trust, Expertise, and the War on Science. University of Pittsburgh Press, 2021.

[12] Dror, Amiel A., et al. Vaccine Hesitancy: The Next Challenge in the Fight Against COVID-19. European Journal of Epidemiology 2020 35(8): 775-559/

[13] Lyman, Stuart. Pharma’s Tarnished Reputation Helps Fuel the Anti-Vaccine Movement. STAT News, February 26, 2019. https://www.statnews.com/2019/02/26/anti-vaccine-movement-pharma-tarnished-reputation/

[14] Doshi, Peter. Will Covid-19 Vaccines Save Lives? Current Trials Aren’t Designed to Tell Us. BMJ 2020;371:m4037

[15] Racialized Canadians have Some of the Highest Rates of COVID-19 Infections in the Country. Who can Allay their Doubts about Taking the Vaccine? Globe and Mail, January 26, 2021. https://www.theglobeandmail.com/canada/article-racialized-canadians-need-the-covid-19-vaccine-more-urgently-than-most/

Comments

  • Dane Leigh Gogoshin

    I’d love to see your balanced and insightful article appear in a mainstream news outlet. Thanks for writing and sharing this!

  • Greta

    Thanks for providing a neutral and non-patronising insight. Finally, someone expressed my thoughts! I’m not medical professional, however I understand exactly how vaccines work and what the regulatory process looks like. That is exactly the reason I decided not to vaccinate myself again COVID! I’ve never been afraid of being magnetised or injected dead foetuses’ cells and whatnot. I will gladly vaccinate myself against anything that I possibly can, but only with the vaccine that’s been approved in normal circumstances. I’m honestly sick and tired of people who don’t even know how the vaccines work and cannot differentiate between RNA and DNA tell me how ignorant and uneducated I am, then resorting to manipulatory tactics, such as guilt tripping, gaslighting and invoking sense of urgency, then proceeding to ridiculing any questions and name calling. I have all the concerns listed in the article and no answers yet, apart from those that boil down to “it’s safe because vaccines are safe and you’re concerned because you are stupid”. Until I get proper answers, I’m going to get my vaccine. I need those informations to make a calculated risk assessment and an informed decision. Until then, no jab for me.
    Speaking of name calling, it is very common for vaccine enthusiasts to call others selfish. However, there’s a huge question of what happens if someone does suffer severe side effects. Those are told to be extremely rare. Fine, but that doesn’t mean impossible. What if you’re the unlucky one? Who is going to pay your care and living expenses? As it stands now, there seems to be little to no responsibility bore by the government. Pharmaceutical companies providing the vaccine won’t be held liable for those. One has to remember that a sizeable portion of NHS workers are migrants workers. They aren’t entitled to benefits, sometimes unless they live here for more than 3 years, sometimes until they actually get U.K. citizenship, which might take even 10 years. If they get paralysed or disabled and unable to work as a result of having taken the vaccine, they’re on their own. They might even get deported for becoming a burden to the state. How is this not selfish to ask someone to risk their livelihood in such a way for one to entertain the illusion of safety from COVID, even though the protection isn’t as great or as guaranteed? No one answers those questions at all. They’re difficult and sometimes only time will tell – but everyone seems to be in a rush. Easier to throw an insult.

  • Nick Salmons

    appreciate the balanced article here, but it seems like your conclusion as to why there’s a significantly lower rate of vaccine acceptance amongst healthcare workers is still attributable to a “lack of knowledge” around vaccine efficacy… when it seems to me like the glaring reason that there’s lower uptake in vaccines from this educated and very informed front-line population might actuallybe due to the fact that they have more education about the reality of of vaccines than most of us, and are aware that that these vaccines can have serious side effects to reproduction as you allude to (especially these new emergency approved mRNA versions) and that there are potentially other profilactic and other treatments besides a rushed vaccine that would be a better public health solution without the downside risk of these rushed vaccines. Curious to hear your thoughts on that read of the data.

  • ARTHUR HUNTER

    Why is it surprising? You have taken the word “science” and turned it into politics, which is an abomination to what science really means.
    1. Person A has Covid Delta Variant
    2. Person A easily fights off Covid Delta Variant
    3. Person A’s own immune system has FACTUALLY and EMPIRICALLY defeated COVID with such ease, a common cold is worse.
    4. Person A has no fear of COVID since person A has a strong immune system and can destroy COVID easily
    5. Dumb politicians mandate that Person A needs a vaccine.
    6. Person A, rationally, and scientifically, concludes a vaccine is unnecessary.
    7. Irrational politicians demand that Person A has Pfizer (etc) made components in their bodies. (the same politicians who say “My Body!”)
    8. Person A refuses the irrational, unscientific mandate.
    9. A room full of Vaccinated zombies who bow to politicians feels threatened by the presence of person A in their midst.
    10. But everyone in the room is Vaccinated, what possible scientific reason should they have to fear person A? How does person A threaten them?
    11. Abandoning science, the vaccinated numbskulls in the room demand person A leave their presence immediately. (Remember person A easily fought off COVID.) And yet stupid vaccinated people feel that person A threatens them…EVEN THOUGH THEY ARE VACCINATED. (LOL!)
    12. The vaccinated now become the most discriminatory group of people on planet earth, worse than outright racists. The vaccinated won’t even let you on the bus at all. Forget that you have sit in the back of the bus, they won’t even let you board the bus!

    What scientific basis does a vaccinated person have to feel threatened by an unvaccinated person who has easily beaten COVID? Do you trust your vaccination? Obviously, you dont. And demanding a person who has easily beaten COVID get vaccinated from a mild disease no worse than the common cold as if they are some kind of risk to VACCINATED people….. is just plain idiotic and void of science. Furthermore, MANDATING it to them is dystopia and utterly oppressive.

  • Timothy

    This article seems to lean heavily on peoples distrust of the “system” administering the vaccine, while ignoring the issue of risk assessment in relation to the vaccination. Yes people are hesitant because we don’t know the long term effects of this experimental medicine. From what I’ve seen we have a virus that is 99.8% survivable, unless you’re over 65 or are obese. These things are never discussed in mainstream media or with politicians. Just like the HIV/AIDs crisis of the 80’s and 90’s the media and politicians are trying to convince the public that this virus is an “equal opportunity killer”; which is simply not the case. The massive push to disregard any prophylactic treatments by the media and politicians is also a giant red flag. Why are we ignoring treatments that have been shown elsewhere in the world to work? Why are physicians being banned from administering these treatments to sick patients? Why is the discussion “Vaccine or nothing”? Why are we ignoring natural immunity? In India over 60% of the population have antibodies, meaning the majority of the population there has natural immunity, in the U.S. that figure is estimated to be around 1/3 of the population. Add that to the 50ish percent of vaccinated people and really we should be at the “herd immunity” target. Why is it that the hospital my wife works at won’t do antibody testing for C-19? There are a lot of suspicious behaviors from the medical and political bureaucracies surrounding C-19 and this vaccine, and I haven’t even gotten into the negative side effects from the vaccines yet. You want to know the second vector of concern regarding the vaccine, look no further than the cases of thrombosis, myocarditis, etc. from the vaccine. These cases are often being under-reported or ignored, as is the case of our hospital here. For the majority of people within a certain age range, they are at greater risk of prolonged side effects from the vaccine than from C-19.
    Of course, the big elephant in the room is personal freedom. Getting or not getting the jab should be a personal choice. People naturally desire autonomy. The more you try to force someone to engage a course of action, the more push-back you’ll inevitably receive. Government coercion should always be met with resistance. I could go on forever here, but I feel like this brief reply should be enough.

  • BD

    You mentioned that the endpoint in the primary endpoint in the vaccine protocols was not severe disease or interruption of transmission and suggest that this has something to do with the vaccine hesitancy among health care professionals. I would argue that, as of August 2021, we have more than enough data to demonstrate that vaccines DO protect against severe illness/hospitalization/death. In fact, we have far more data in this regard (i.e. higher n) than we would ever gotten from the clinical trials which included tens of thousands of people instead of hundreds of millions. Additionally, the clinical trials referenced were conducted when the WT virus was dominant in this country, not the delta variant which is an entirely different can of worms. Whatever impact the vaccines had on blocking transmission in the past has clearly been diminished by the new variant as demonstrated by the recently released data from the CDC. We now know that vaccinated people can transmit the virus, but we also know that the vaccines are still effective in preventing infection and especially effective in preventing severe illness and death.

    I can understand that many people have concerns about *potential* side effects of the vaccines, but what I cannot understand is the failure to acknowledge the fact that observing millions of COVID survivors has shown us that a significant proportion of them end up with some long term effects, ranging from lung damage to neurological problems. Are people worried about the potential of myocarditis or blood clots from the vaccines aware that these complications are far more common as a result of COVID than vaccination? Are people worried about the way COVID vaccines might affect their fertility also concerned about the way SARS-CoV-2 infection might infect their fertility?

  • Karen

    Vaccine hesitancy in the medical profession? Well, most likely they know what most of us observers also know: Don’t Trust Big Pharma!

    Most people I know who’ve had Covid recovered. In fact, I don’t personally know anyone who’s died of Covid. As for long-term health effects: I experienced personally long-term health effects from having pneumonia. Long-term health effects sometimes happen. Chance you take.

    But, if any organization is going to require vaccine mandates, I want to know who is going to accept liability of adverse health effects from the vaccine? Will the Federal Government accept that liability? Also, if the vaccine doesn’t prevent you from getting Covid, why the mandate? What’s in the injection they want us to have ???

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