Vaccine confidence faced its hardest test during the COVID pandemic, as misinformation spread faster than the evidence to counter it and hesitancy fractured into many distinct groups rather than one. This report tackles landscapes head-on across four themes: the information vectors carrying fake science, the pandemic's lasting mark on public attitudes, the trust that nurses, obstetricians and frontline clinicians can build, and the tangled drivers of hesitancy itself, pairing a clear-eyed observation with the challenge it raises.
Draft Report
Observations · Challenges · Strategies
6th LifeCourse Immunisation Summit, 2021–2022
Excellence in Pediatrics Institute × Vaccines Together
Topic 01
The trend of anti-vaxxers using social networks and platforms to spread their messages and fake scientific evidence intensified during the COVID pandemic, especially after the new vaccines were made available.
The social platforms had been extremely slow to contain fake information and conspiracy theories across their networks, taking only a few reluctant steps later in the pandemic. Even then, the way it was done had limited results and, in some cases, fuelled the suspicion that the "big" players are trying to silence "independent voices".
The uncertainty and fear surrounding the pandemic increased people's need for information. Social media became one of the principal sources of information and opinion, so people were exposed more to fake news from untrustworthy sources.
People struggle to evaluate the credibility of the sources from which they get information to help them decide on health-related problems. We knew the issue existed before, but did not take steps to address it earlier, leaving people more exposed to fake information at the very moment they needed more information, guidance and reassurance.
People's attitudes and perceptions of vaccines can be captured, as part of public health surveillance, through social-media-based text mining. Public health monitoring on social media has proven a powerful tool for analysis and for political discussion on vaccination.
Using social media as a public health surveillance tool is relatively new territory. We must be careful how we collect, evaluate and analyse the information, taking various parameters into consideration; not everyone is active on social media or expresses opinions, and many hold accounts and monitor discussions without participating actively.
During the pandemic it proved extremely important to track attitudes to restrictions and vaccines, to identify and react to changes and dynamic shifts within the main social groups, and to adjust our messaging accordingly.
Rolling sentiment analysis, behavioural insights and social-marketing techniques are used by only a few healthcare authorities to predict future behaviour and develop effective strategies, rather than reacting to changes that have already occurred. Not all healthcare authorities are prepared to use such advanced tools.
Organisations, institutions, healthcare authorities and providers must become more active in using social media platforms to communicate the scientific evidence and fact-check the various arguments made by anti-vaxxers.
We must offer people a meaningful, easy-to-understand way of translating and testing the accuracy of the information they receive. We need to protect the credibility of the institutions we want to become the most trusted source of information, and ensure that those responsible for communicating it are trusted beyond doubt by the broader society.
Our campaigns and messages must become more flexible and easier to adapt, so we can counter anti-vaxxer messages quickly and in real time. We must use the various techniques available to stay one step ahead and set the narrative.
We must use social media monitoring tools to trace anti-vaccine discussions and arguments, allowing us to fact-check them and respond in real time. The priority is not to change the minds of hardcore anti-vaxxers but to limit the appeal of their arguments to those who read the discussion without actively participating.
Topic 02
A new fear was added by the novelty of the COVID vaccines, with some people afraid that, in response to the urgency of the pandemic, the usually slow and methodical vaccine-development process was abandoned — and that side effects and long-term implications had therefore not been studied thoroughly.
Initially, not enough attention was given to the information and education offered to GPs, and especially paediatricians, on COVID-19. With COVID infection appearing to have limited implications for children and being seen as more of a trivial disease, they could not justify to parents the risk associated with the vaccines' novelty.
The COVID pandemic and the vaccination campaigns that followed hardened the hard end of the anti-vaxxers. In their minds, vaccination is one more tool — alongside social distancing and the various restrictions imposed by governments — that they regard as an attack on personal freedom.
Sentiments at the far end of the anti-vaxxer spectrum are now politicised and polarised, making it extremely difficult to change views and attitudes simply through scientific evidence and facts, and leaving us with minimal tools and arguments to use successfully.
COVID-19 is a very tough test for vaccine confidence in general. We have a near-perfect vaccine, a target disease that is life-threatening and killing people, and public awareness at the absolute maximum level; our performance in vaccination coverage will show us the ceiling for other vaccinations.
We must not lose the momentum, and should immediately switch from COVID immunisation to a holistic approach protecting everyone against all vaccine-preventable diseases. After COVID, with people tired of living under constant threat for so long, it will be challenging to start talking about threats from other diseases, and a gap could open that causes problems with vaccination rates.
The COVID pandemic revealed variations in vaccine hesitancy, proving that anti-vaxxers must not be treated as a single solid group but as many different groups, each with different attitudes, thought processes and motives — and therefore requiring different strategies.
For a significant proportion of those previously considered anti-vaxxers, it turned out that their opposition to vaccines was soft, and the motive to get vaccinated and return to some normality of social life was stronger than their scepticism. The challenge is how to keep them on the positive side for other vaccinations in future.
GPs, frontline paediatricians and community pharmacists have the background to understand advanced information about the process, the trials and the safety data of the new vaccines, and to translate it for their patients. They must become our infectious disease prevention ambassadors.
We must prioritise our communication targets and stop treating all anti-vaxxers as one group with the same characteristics and sensitivities. Our priority should be the people in the middle ground, whose fears, concerns and doubts are often fuelled by a lack of the tools and knowledge to understand rapid changes in the difficult field of health science.
We must avoid treating everyone who is not vaccinated as an anti-vaxxer. Oversimplification could be harmful and could lead to losing people who might be persuaded to make the right choices. From vaccination records we know who decided late or was reluctant, and dedicated communication campaigns could help them stay on the right side.
We must now switch to communicating the importance of prevention through vaccination for all vaccine-preventable diseases, and especially the seasonal ones, for which vaccination should become routine at the start of each season.
Topic 03
Trust is powerful in every aspect of vaccination. Public trust in healthcare authorities, the government, healthcare professionals and the pharmaceutical industry affects a person's decision to get vaccinated and defines the success of vaccination programmes.
Although in an ideal world we would wish all those involved in immunization policy to be trusted by the public, the reality is that not all stakeholders are equally trusted, and people question their motives. Advice offered by governments is often rebuffed on the basis of political views.
The role of nurses and midwives is crucial to the acceptance of vaccines. They are seen as a trustworthy point of information, build relationships of trust, hold open discussions about concerns and fears, and are often more accessible than physicians.
The challenge is that we did not invest in educating nurses and midwives on infectious diseases and vaccination, leaving them without the knowledge, skills and tools to advocate and advise patients. Some improvement was made during the COVID pandemic, and we must ensure that trained nurses remain involved in immunization programmes.
Vaccine hesitancy among parents regarding childhood vaccination is even greater than for themselves. It is very high even among parents with good knowledge of immunization and increased acceptance of optional vaccines, and new approaches are needed to address it.
Questioning whether a vaccine is necessary for a child is a risk assessment made by the parent, who usually does not know the facts required to make it. It is challenging for the healthcare professional to build enough trust that the parent will leave the assessment — and, in turn, the decision — to the professional's judgment.
Vaccine hesitancy among pregnant women is higher, with significant concerns over implications that could affect the fetus. They need more attention, care and information to be persuaded of the vaccine's safety for the unborn child.
The obstetrician's role is decisive for immunization during pregnancy: pregnant women trust their doctors and are likely to follow their advice. The challenge is that obstetricians often do not consider vaccination an integral part of their role and of protecting the mother and child.
People often trust experts beyond their own views, and trust the organisation the person represents. Choosing the right person or expert to communicate the facts and de-politicise the scientific evidence is often a path to communicating efficiently.
Frontline paediatricians, GPs, nurses and pharmacists have acquired significantly greater knowledge of vaccines — not by choice or grand design, but out of the need to answer patients' questions. They must now become integral to the decision-making process.
Physicians outside infectious-disease specialties should stop considering vaccination beyond their scope. Spreading education on vaccination across all specialties is crucial to ensure that every physician advocates vaccination in every consultation.
Frontline healthcare professionals have a vital role and are crucial to implementing a successful vaccination policy. The first concern of policymakers must therefore be how to train frontline HCPs, involve them in the decision-making process, and engage them in implementation.
Topic 04
Vaccine hesitancy is a behaviour influenced by many factors, and COVID helped us understand the complexity of confidence. We must define the various groups by the primary factor driving their hesitancy — personal fear, suspicion of conspiracy, a "let others take the risk first" attitude, and so on — and develop targeted strategies for each.
There is no clear-cut boundary between the various groups, and hesitancy is often more personal, with more than one factor contributing to a decision. Other factors — social determinants, culture and socio-economic background — must be added to the equation to define the groups as clearly as possible, so that strategies are more effective.
People's choices are often shaped by their sense of duty and responsibility to their social circles, and their commitment to them: the obligation to protect the immediate family, the responsibility to the extended family and friends, the duty to the community, and finally the commitment to the country.
The approach must take cultural and social characteristics into account. In some societies, devotion to family is stronger than duty to the wider community and country; in others, family bonds are weaker than social responsibility and the greater good.
Anti-vaxxer arguments and polarised discussions are not always limited to the COVID vaccines but trigger broader debates doubting the value of vaccination in general and of other vaccines. It is uncertain how many of these doubts will remain after the pandemic and how they will affect decisions on other vaccine-preventable diseases.
Increased interest in the pandemic has undoubtedly pushed more people to seek information, exposing them both to credible information about vaccines and to the arguments of anti-vaxxers — who have found themselves with a greater platform than before, with more people paying attention to reasons unrelated to their strategies.
How people assess risk, and what data they use, is decisive for vaccination. The equation that drove hesitancy weighs the perceived immediate risk of taking a vaccine considered inadequately tested against the possibility of being infected at some future point by a disease that may only cause mild symptoms.
Future risk versus immediate risk perception is challenging to address. Fear of the unknown, fear of change, a lack of evidence and limited ability to process data all drive aversion to perceived risks. When the disease spreads and reaches a person's close social circle, often with severe implications, the balance of the risk equation shifts.
Vaccination is one of the very few medical practices for which people feel they have a right to their personal opinion and choice — which does not sit easily with the fact that, if infected and in need of hospital care, they expect the healthcare system to provide it, even at times of constraint that would otherwise limit services.
The health systems' limited capacity and resilience in times of pandemic have raised important ethical questions. Should personal choices define how we prioritise resources and capacity when availability is scarce? When does a personal choice that could end up in the public health system stop being personal and become public?
Healthcare professionals' own hesitancy, especially in primary care, often drives patients' hesitancy for COVID vaccination. Initial doubts and a lack of knowledge on vaccine safety during pregnancy or for patients with chronic conditions produced a "wait and see" approach, with patients advised to delay vaccination until others had been vaccinated and more data collected.
There is a significant difference in the level of education, information and real-time facts available to a healthcare professional in a hospital setting compared with a primary-care physician. The problem is that most patients are in touch only with primary care, not hospitals, and early decisions made on the basis of a provider's doubts or uncertainty are very hard to change later.
The various factors contributing to hesitancy offer a clear guide both to the paths and messages we must use to communicate efficiently and to the map of inequalities in education. We must take a step-by-step approach, identify the source of hesitancy for each group, and work beyond instant messaging.
Frontline healthcare professionals need continuous training on infectious diseases, immunisation and communication skills to become the primary source of information for their patients. The more they know and understand about vaccine-preventable diseases, the easier it is for them to decide to get vaccinated first themselves, and then explain it to patients.
Education on health literacy and prevention must become an integral part of our education systems. Starting early, through schools and during childhood, and continuing into adulthood through channels such as the workplace, we will empower people to make their own decisions based on scientific evidence.
We must avoid softening the consequences of infection for short-term political gain. Pressure on policymakers is significant, and no one wants always to be the bearer of bad news, but the scientific community must communicate the real consequences of the disease openly. Real-life examples often help people assess risk at a personal level.
The broader implications of the pandemic for patients with other conditions — delays in admission, lower quality of service under providers' constraints, fewer resources, or avoidance of admission for fear of infection in hospital — must be made clear to everyone, so that people understand the wider consequences of their decisions.
Communication strategies must become more targeted and astute. Different people, in different countries and social groups, have different priorities and respond to different messages, so communication campaigns must become more innovative and targeted.
