A striking 20% of nurses in the United States are refusing offers to be immunized with COVID-19 vaccine, according to the results of a national survey.1
“We found that only 5% of doctors refused, but 20% of nurses did,” says Hannah Kemp, MPA, director of programs at Surgo Ventures in Washington, DC. “We also saw much higher refusal rates among African Americans.”
The company conducted the survey from Dec. 17-30, 2020, netting 2,504 respondents comprising three groups: healthcare professionals (i.e., physicians, nurses, dentists); allied health professionals (i.e., health technicians, EMS personnel, home health workers); and health management and support personnel (i.e., administrative staff, operations staff).
The overall refusal rate for all healthcare groups was 15%, Kemp says. The most common reasons given for turning down COVID-19 vaccine were a lack of evidence of the vaccines’ effectiveness and safety (31%), personal safety concerns (24%), and worrying the vaccine approval process was rushed (16%).
High Refusal Rates in Long-Term Care Workers
Of the 2,504 respondents, 53% had been offered at least one of the approved COVID-19 vaccines at the time they took the survey. Among that group, the aforementioned 15% refused vaccine. However, 20% already had taken their first dose of the vaccine and were planning to received the second shot. In addition, 18% had not yet taken their first dose of the vaccine but planned to do so. Overall, the survey results show 49% of respondents reported they are planning to take the vaccine.
When breaking down vaccination declination by occupational groups, the highest refusal rate (22%) was among allied health professionals, followed by healthcare professionals (13%), and health management and support (10%).
“A number of allied health professionals work directly with patients,” Kemp says. “They often have patient interactions, but they may not have as much medical training.”
Even though they were classified as healthcare workers and given top priority to be vaccinated, the survey results revealed many long-term care staff were reluctant.
“The long-term care workers were one of the most hesitant groups, and that actually goes across categories of doctors, nurses, other support staff,” Kemp says. “When you compare them to hospital workers, long-term care workers felt less confident that their colleagues were going to be getting the vaccine.”
Indeed, healthcare workers at long-term care facilities rated themselves as less likely to receive the vaccine (with an average intention score of 7.5 out of 10) than workers in hospitals (8.1 out of 10). While 41% of long-term care facility workers believed only “some” or “a few” of their colleagues would take the vaccine, only 25% of hospital workers did.
“These numbers are worrying, given that these [long-term care] healthcare workers are serving the population at highest risk of severe complications from COVID-19 and are disproportionately low-wage workers,” the report authors noted. “Additionally, when asked whether they would recommend the COVID-19 vaccine to patients expressing reluctance, 14% of doctors in long-term care facilities said they would recommend against taking the vaccine, compared to 4% in hospitals and 3% in non-hospital facilities.”
Black HCWs Cite Inequities
When breaking down respondents by race, Black healthcare workers represented the largest refusal rate of 35%, followed by white (14%), Latino (13%), and other minority healthcare workers (12%).
“Black healthcare workers also showed a higher level of mistrust in the vaccine rollout process and were more likely to hold the belief that the healthcare system doesn’t treat them fairly,” the report authors noted. “The refusal rates are unsurprising given the significantly higher hesitancy measured in Black healthcare workers, who scored themselves 20% lower in vaccine likelihood than white healthcare workers. This pattern is consistent throughout the sample, even in populations with advanced medical training — including nurses and doctors.”
Nearly 55% of Black respondents disagreed with the statement “People of my race are treated fairly in a healthcare setting,” compared to 7% of respondents of other races and 5% of whites. Also, 12% of Black respondents disagreed with the statement that pharmaceutical companies test vaccines carefully, compared to 4% of other respondents. Both findings suggest that overcoming COVID-19 vaccine hesitancy with Black healthcare workers will require efforts to address long standing trust and equity issues in healthcare. These findings underscore the need to target information to the concerns of specific groups, using “trusted messengers.”
“Some of the historical factors could be contributing to this,” Kemp says. “Behavioral science tells us people feel more confident about their decision if they talk about it with trusted messengers through trusted channels. One of the recommendations is for Black doctors and nurses who have gotten the vaccine to talk about it with their co-workers, friends, and family.”
Overall, 69% of respondents said they believed they have a duty to receive the vaccine to protect patients. “There were a number of healthcare workers who were very likely and very excited to get the vaccine but had not been offered it,” Kemp says. “There is a clear need to accelerate vaccination among people who want to get it. We found that doctors, nurses, and healthcare workers who work at smaller clinics in places that have less than 50 employees were being offered the vaccine at less than half the rate of people who work at large facilities.”
Behavioral Science, Education
If vaccine supply is adequate, lessons from behavioral science indicate building momentum by giving employees appointments and sending messages and reminders as the date nears.
“Try to use messages to create a sense of urgency, building that intention to go to an appointment,” Kemp says. “These are things that have worked in flu vaccine campaigns.”
The survey also indicated people who generally understand how vaccines work are more likely to be immunized. “Our recommendation is to explain how the COVID vaccines were developed,” she says. “How do we know that they are safe and effective? What is the process of going through clinical trials? That type of knowledge was not uniform across all healthcare workers, so it is something important to reinforce.”
Real-world vaccination efforts underscore the importance of educational campaigns in encouraging uptake. Vanderbilt University realized there was a problem when it surveyed healthcare workers in anticipation of receiving the vaccine, finding a surprising level of reluctance and hesitancy, says William Schaffner, MD, professor of preventive medicine in the department of health policy and professor of medicine in the division of infectious disease.
“One of the reasons these [public health] jurisdictions are now opening up is that people in 1a are not completely accepting the vaccine,” he says. “There is a fair amount of skepticism among healthcare providers.”
Finding hesitancy among their own staff, Vanderbilt ramped up educational activities and question-and-answer sessions to assure healthcare workers the two available vaccines are safe and effective.
“It has helped move the needle,” Schaffner says. “More and more of our colleagues, employees, and staff are receiving the vaccine. We are not exactly where we want to be yet, but we keep working on that and going back to groups that are lagging. We’re making progress, but the lesson there is if it took that much work for healthcare workers, we have a have a lot of persuasion to do [in the community].”
There has been much confusion and chaos about prioritizing the groups, with some states and localities ignoring CDC guidelines and vaccinating those perceived at highest risk in their area.
“As I talk to colleagues around the country and my state health department, they all say the same thing: There is extraordinary heterogeneity out there,” Schaffner says. “Within states, sometimes from institution to institution within the same county, between counties, and certainly between states.”
Pregnancy and COVID-19 Vaccine
Although this issue was not assessed in the survey, other reports indicate young, female healthcare providers are holding off on vaccination due to concerns about pregnancy or conception. The CDC is equivocal on the issue, saying healthcare workers “may choose to be vaccinated.” However, COVID-19 infection during pregnancy can cause serious sequela.
“Observational data demonstrate that while the chances for these severe health effects are low, pregnant people with COVID-19 have an increased risk of severe illness, including illness that results in ICU admission, mechanical ventilation, and death compared with non-pregnant women of reproductive age,” the CDC stated. “Additionally, pregnant people with COVID-19 might be at increased risk of adverse pregnancy outcomes, such as preterm birth, compared with pregnant women without COVID-19.”2
On the other hand, there are limited data about COVID-19 vaccination during pregnancy, although animal studies have revealed no safety concerns. The Food and Drug Administration (FDA) approved two mRNA vaccines from Pfizer-BioNTech and Moderna for COVID-19, each with an efficacy of about 94-95%.
“Limited data are currently available from animal developmental and reproductive toxicity studies,” the CDC said. “No safety concerns were demonstrated in rats that received Moderna COVID-19 vaccine before or during pregnancy. Studies of the Pfizer-BioNTech vaccine are ongoing.” Both vaccine manufacturers also are following participants in the clinical trials who became pregnant.
Arnold Monto, MD, acting chair of the FDA’s Vaccines and Related Biological Products Advisory Committee, recently weighed in on this topic in an interview.
“I think a pregnant woman should look at her risk group and get vaccinated as she would if she were not pregnant,” he said. “By that, I mean that if somebody has underlying conditions, I would have no doubt that she should be vaccinated. There is always theoretical risk, especially during the first trimester. Looking at the flu story, we have come from most pregnant women not being vaccinated to pregnant women being the highest priority by the WHO [World Health Organization] to be vaccinated.”3
Beyond the issue of pregnancy, there is some hesitation among healthcare workers in general. CDC officials are emphasizing that healthcare workers should not decline the vaccine due to some of the circulating myths and misconceptions.
“I am definitely concerned that healthcare workers are electing to wait to get vaccinated,” Nancy Messonnier, MD, director of CDC’s National Center for Immunization and Respiratory Diseases, said at a recent press conference. “It really makes it exceedingly important that we get correct information to healthcare workers and that we quickly dispense with myths and misinformation.”4
For example, the CDC noted that “None of the authorized and recommended COVID-19 vaccines or COVID-19 vaccines currently in development in the United States contain the live virus that causes COVID-19. This means that a COVID-19 vaccine cannot make you sick with COVID-19.”5
Addressing another myth, the CDC stated that “COVID-19 mRNA vaccines do not change or interact with your DNA in any way.”
“We want [healthcare workers] not only to protect themselves, but we also want them to be educating their patients,” Messonnier said. “We are working in any way that we can to try to reach healthcare workers with this correct information. I think that if healthcare workers could really hear the data and see the information, it would help them make the decision to go ahead and get vaccinated.”
- Surgo Ventures. U.S. Healthcare Workers: COVID-19 Vaccine Uptake and Attitudes. Jan. 15, 2021. https://surgoventures.org/resource-library/survey-healthcare-workers-and-vaccine-hesitancy
- Centers for Disease Control and Prevention. Vaccination considerations for people who are pregnant or breastfeeding. Updated Jan. 7, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html
- JAMA Network. Coronavirus vaccine update with Arnold S. Monto, MD. Conversations with Dr. Bauchner. Jan. 11, 2021. https://edhub.ama-assn.org/jn-learning/video-player/18575715?linkId=108990338
- Centers for Disease Control and Prevention. Transcript: CDC update on COVID-19. Jan. 6, 2021. https://www.cdc.gov/media/releases/2021/t0106-cdc-update-covid-19.html
- Centers for Disease Control and Prevention. Facts about COVID-19 vaccines. Updated Jan. 28, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html#:~:text=No.,types%20of%20vaccines%20in%20development