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Two comments posted yesterday on JAMA and a press release from the University of Michigan offer insights from behavioral science and other fields to drive acceptance of the COVID-19 vaccine in the United States and discuss the ethics of continuing placebo arms in vaccine trials against the coronavirus that have already been shown to be effective.
Evidence-based recruitment strategies
The first comment, from Kevin Volpp, MD, PhD, and Alison Buttenheim, PhD, MBA, of the University of Pennsylvania in Philadelphia, and George Loewenstein, PhD, of Carnegie Mellon University, addressed the problem of Americans’ hesitation to take a COVID. -19 vaccine.
They looked at a September survey of 10,093 American adults that showed that only 51% were definitely or likely to be vaccinated, 25% indicated a probable unwillingness to get vaccinated, and 24% said they were unlikely to get vaccinated. Black respondents, those with a high school education or less, and Republicans were particularly suspicious of vaccines. New data released today by the Kaiser Family Foundation Vaccine Monitor shows that 71% of American adults are now willing to receive the vaccine.
The authors of the comments offered five behavioral science-backed strategies for a national vaccine promotion program, including making vaccines free and easily accessible in places such as health centers, doctors’ offices, retail pharmacies, offices of occupational health in workplaces, long-term care facilities and schools.
“Given the current vacillation of vaccines and the complexity of administering some of these vaccines (such as the requirements for storage of the vaccine at extremely low temperatures), it is not clear if simplification is possible and will work, but it needs to be. easier possible to be immunized, “they wrote.
Not allowing access to valuable places like medical clinics, long-term care facilities, college dormitories, 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 change the perception of what is politically acceptable,” the authors said. “Employers can legally require vaccination as a condition for working in person, provided there are exceptions for concerns related to disability and religious beliefs and reasonable alternatives to continuing 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 publicly vaccinated, to set an example for employees. National leaders representing different demographic and political groups can also be role models for vaccination.
Vaccinating people who sign up first before vaccines are available to everyone, underscoring the initial shortage of vaccines, would increase their value, the authors said. And allowing people who get vaccinated to post their decision, similar to “I voted” stickers, could motivate others to do so as well.
“City and state health departments, civic organizations and employers can also take advantage of social factors to promote the community benefit of vaccination,” they wrote. “People who cannot do something for themselves often take the same action to benefit other people.”
These recommendations should be framed as part of a comprehensive strategy to slowly contain the virus rather than as a panacea, the authors said, and a national board comprised of experts in epidemiology, vaccine science, behavioral science, marketing and other fields will be necessary. to provide data on the safety and efficacy of vaccines and to guide advocacy efforts.
“The team must represent a spectrum of political views to depoliticize the response to the pandemic,” they said. “The potential of these vaccines to help stop the pandemic will be limited if comparable attention is not paid to traversing the behavioral ‘last mile’ necessary to ensure acceptance and acceptance of the vaccine.”
Problems with vaccination of all trial participants
The second comment, from 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 claims by vaccine manufacturers Pfizer / BioNTech and Moderna of an ethical obligation to vaccinate all placebo vaccine trial participants, given positive trial results and the important role of research participants. .
Rid and his colleagues argue that due to the limited initial availability of the vaccine, only COVID-19 vaccine trial participants who receive a placebo and would be eligible for the vaccine outside of a trial (i.e., members of groups priority) should have access to vaccines, because continuing with the placebo would not make their situation worse compared to what it would have been if they had not participated in the trial.
“In contrast, if participants are eligible for vaccination outside of 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 for these participants seem difficult to justify; in any case, they could simply withdraw from the study and seek vaccination outside of the trial.”
It would also lead to lower health benefits and health equity 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 healthcare staff or others who have a higher priority than the participants could not be vaccinated,” said Rid and his colleagues. “The resulting profit loss could be significant.”
Additionally, vaccinating trial participants who would otherwise have gone ahead with a placebo, they said, would eliminate the collection of valuable long-term safety and efficacy data needed to support their full license and government-funded use. Such data includes data on how long the immunity conferred by the vaccine lasts and whether people infected with the coronavirus experience more serious illness after immunity wanes.
“First, this would result in a significant loss of valuable research data without eliminating undue risks for participants who remain in the placebo group of trials,” they wrote. “Second, the gains in health and health equity would decrease because participants in the placebo group would receive the vaccine even when they were not prioritized for vaccination outside of the trial.”
The authors called for a regular review of their recommendations, particularly as more doses of vaccine and other potential vaccines become available.
Education, second dose reminders
In the University of Michigan news release, Mark Fendrick, MD, a university researcher and director of the Center for Value-Based Insurance Design, explored ways to ensure that people receive a second dose of the COVID-19 vaccine a few weeks after the first, which is needed to increase immunity.
“Vaccines that require more than one dose create additional environmental and behavioral challenges, including reports of side effects, false claims about vaccine safety, logistical barriers, and politicization of the program, which can deter people from getting vaccinated or returning. for your second dose, “Fendrick said. “Studies of other high-value chronic disease management drugs and vaccines show that even when given at no cost, patients take them half the time.”
A vaccine support program should include information about how the vaccine works, the side effects of the vaccine, reminders to schedule a second dose, facts to dispel misinformation about the vaccine, and transportation to the second dose appointment.
In addition to a card that clinicians can hand out to patients receiving their first dose of the COVID-19 vaccine to educate and encourage them to schedule their second dose, Fendrick recommends creating a vaccine adherence support program based on smart phones based on research from your team and others. He added that a phone call or email from a trusted source, especially for underserved groups like seniors and the homeless, can also help.
And while the authors of the first comment discouraged the use of monetary incentives, which they said could backfire by making vaccination seem undesirable or even dangerous, Fendrick proposed a $ 50 gift card after receiving 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 the first,” he said. “Why not give incentives to patients as well?”
