Two commentaries published yesterday in JAMA and a University of Michigan news release offer ideas from behavioral science and other fields to boost COVID-19 vaccine uptake in the United States and discuss the ethics of continuing placebo arms in trials of coronavirus vaccines already proven effective.
Evidence-based uptake strategies
The first commentary, by Kevin Volpp, MD, PhD, and Alison Buttenheim, PhD, MBA, of the University of Pennsylvania at Philadelphia, and George Loewenstein, PhD, of Carnegie Mellon University, tackled the problem of Americans' hesitancy to take a COVID-19 vaccine.
They noted a September survey of 10,093 US adults showing that only 51% were definitely or probably going to be vaccinated, 25% indicated a probable unwillingness to be vaccinated, and 24% said they were unlikely to take a vaccine. Black respondents, those with a high school education or less, and Republicans were particularly distrustful of the vaccines. New data published today by the Kaiser Family Foundation vaccine monitor show that 71% of US adults are now willing to receive the vaccine.
The commentary authors offered five behavioral science–backed strategies for a national vaccine promotion program, including making the vaccines free and easy to access at places such as healthcare centers, doctors' offices, retail pharmacies, workplaces' occupational health offices, long-term care facilities, and schools.
"Given current vaccine hesitancy, and the complexity of administering some of these vaccines (such as requirements for vaccine storage at extremely low temperatures), whether simplification is possible and will work is unclear, but it is necessary to make it as easy as possible to be immunized," they wrote.
Not allowing access to valued places such as medical clinics, long-term care facilities, college dorms, K-12 schools, workplaces, retail establishments, and gyms until a COVID-19 vaccine is received could motivate people to comply.
"A long winter of new cases, overcrowded hospitals, and more than 2,000 COVID-19 deaths per day may shift perceptions of what is politically acceptable," the authors said. "Employers can legally mandate vaccination as a condition for in-person work provided there are exceptions for concerns related to disabilities and religious beliefs and reasonable alternatives to continue to work for those who refuse to vaccinate, such as working from home."
Once high-priority groups such as nursing home residents and healthcare workers are vaccinated, states and cities could provide vaccines first to employers who get vaccinated publicly, to set an example for employees. National leaders representing different demographic and political groups can similarly be role models for vaccination.
Vaccinating people first who sign up to do so before vaccines are available to all, underscoring the initial scarcity of the vaccines, would increase their value, the authors said. And allowing people who get vaccinated to publicize their decision, similar to "I voted" stickers, could motivate others to do so as well.
"Social factors can also be leveraged by city and state health departments, civic organizations, and employers promoting the community benefit of vaccination," they wrote. "People who might not do something for themselves will often take that same action to benefit other people."
These recommendations have to be framed as being part of a comprehensive strategy to slowly contain the virus rather than as a panacea, the authors said, and a national board comprising experts in epidemiology, vaccine science, behavioral science, marketing, and other fields will be needed to provide vaccine safety and efficacy data and guide promotion efforts.
"The team should represent a spectrum of political views to depoliticize pandemic response," they said. "The potential for these vaccines to help halt the pandemic will be limited without comparable attention paid to traversing the behavioral 'last mile' necessary to ensure vaccine acceptance and uptake."
Issues with vaccinating all trial participants
The second commentary, by Annette Rid, MD, of the National Institutes of Health; Marc Lipsitch, DPhil, of Harvard University; and Franklin Miller, PhD, of Weill Cornell Medical College, discusses vaccine makers Pfizer/BioNTech's and Moderna's claims of an ethical obligation to vaccinate all vaccine trial participants who received placebo, given the trials' positive results and the participants' important role in the research.
Rid and colleagues argue that, because of limited initial vaccine availability, only COVID-19 vaccine trial participants receiving a placebo who would be eligible for the vaccine outside of a trial (ie, members of high-priority groups) should be given access to the vaccines, because continuing with the placebo would not worsen their situation compared with what it would have been had they not participated in the trial.
"In contrast, if participants are eligible for vaccination outside the trial, continuing in the placebo group would make them significantly worse off than they should have been outside of participating in the trial," the authors wrote. "The risks to these participants seem difficult to justify; in any case, they could simply withdraw from the study and seek vaccination outside the trial."
It would also lead to lower health and health equity benefits from vaccination overall if all non-priority participants in the placebo arms of the Pfizer/BioNTech and Moderna trials were vaccinated. "This would mean that currently up to 36,828 health care personnel or other individuals who have higher priority than the participants could not be vaccinated," Rid and colleagues said. "The resulting loss of benefits could be significant."
Also, vaccinating trial participants who would otherwise would have continued with a placebo, they said, would eliminate collection of valuable long-term safety and effectiveness data needed to support their full licensure and government-financed use. Such data include those on how long vaccine-conferred immunity lasts and whether people infected with the coronavirus after immunity wanes experience more severe disease.
"First, this would result in a major loss of valuable research data without eliminating undue risks to participants who continue in the placebo group of the trials," they wrote. "Second, health and health equity gains would decrease because participants in the placebo group would be given vaccine even when they have not been prioritized for vaccination outside the trial."
The authors called for regular review of their recommendations, particularly as more vaccine doses and other potential vaccines become available.
Education, reminders of second dose
In the news release from the University of Michigan, Mark Fendrick, MD, a university researcher and director of the Center for Value-Based Insurance Design, explored ways to ensure that people get a second dose of COVID-19 vaccine a few weeks after the first one, which is needed to boost immunity.
"Vaccines that require more than one dose create additional behavioral and environmental challenges, including reports of side effects, false claims regarding vaccine safety, logistical barriers, and the politicization of the program, that may deter people from getting vaccinated or returning for their second dose," Fendrick said. "Studies of other high-value vaccines and medications to manage chronic conditions show that even when provided at no cost, patients take them half the time."
A vaccine support program should include information on how the vaccine works, vaccine side effects, reminders to schedule a second dose, data to dispel vaccine misinformation, and transportation to the second-dose appointment.
In addition to a card that clinicians can give patients getting their first COVID-19 vaccine dose to educate and encourage them to schedule their second dose, Fendrick recommends creation of a smartphone-based vaccine adherence support program based on research by his team and others. He added that a phone call or email from a trusted source, especially for underserved groups like older and homeless people, can also help.
And while the authors of the first commentary discouraged use of monetary incentives, which they said could backfire by making vaccination seem undesirable or even dangerous, Fendrick proposed a $50 gift card after receipt of the second dose.
"The good news is that the federal government has put in place a financial incentive for those who dispense the vaccine by paying a higher reimbursement rate for the second dose than for the first," he said. "Why not also give incentives to patients?"