Healthcare workers (HCWs) immunized against COVID-19 can be trusted voices to instill vaccine confidence in their colleagues and communities, public health officials and clinicians emphasize.

“As a trusted messenger, remember that vaccine confidence begins with you,” said Stephen Perez, RN, PhD, of the COVID-19 response team at the Centers for Disease Control and Prevention (CDC). Perez spoke at a recent CDC webinar on encouraging uptake of COVID-19 vaccines to an audience of clinicians and HCWs.

“It’s important to get a COVID-19 vaccine if you haven’t already done so,” he said. “The example you model in choosing to receive the vaccine is critical, as is your willingness to share and celebrate that experience. The importance of your role in this cannot be overemphasized.”

Role-modeling of immunization also might encourage HCWs who are reluctant to take a vaccine. In a recent poll of 1,327 HCWs, 27% said they do not plan to take a COVID-19 vaccine, or have not yet decided. Breaking down the results, 17% of the HCWs polled do not plan to take the vaccine, and 10% were undecided.1

The CDC recommended “identifying trusted leaders from various areas of the facility to serve as vaccine champions. These leaders should look like the healthcare personnel in your workforce. Ask them to lead by example by getting a COVID-19 vaccine and being photographed while doing so. Invite leaders to share with staff their personal reasons for getting vaccinated and the importance of vaccination.”2

Hold meetings and discussions where personnel at all levels — including food services and housekeeping — can provide input and ask questions. “These open discussions can help you address staff questions and concerns and get their input on how to best build vaccine confidence within your facility,” the CDC stated.

Perhaps the lowest level of vaccine confidence is among workers in long-term care, where almost two-thirds of healthcare workers in thousands of skilled nursing facilities have turned down the vaccine.3

“People feel like the vaccine was rushed, shortcuts were taken. They’re worried about long-term side effects,” said David Gifford, MD, MPH, senior vice president of quality and regulatory affairs at the American Health Care Association (AHCA).

These were the most common questions, but HCWs also expressed concerns based on misinformation that has spread along with the virus, said Gifford, who has been working with nursing homes nationally trying to increase vaccination rates.

“I try not to refer to them as conspiracy theories because that sort of sends a signal to the individual that their views and their information is [being] discredited in some way,” Gifford said at a recent CDC forum on empowering HCWs. “The decision that the staff are making based on the information they hear makes sense. The information they’re hearing is what doesn’t make sense.”

Drawing that distinction and listening carefully have proven key to successfully change HCWs’ minds, particularly if a trusted source delivers the information. If possible, ensure the information is personal and targeted to the individual, addressing their concerns in a nonjudgmental way.

“[With these measures], we have seen facilities with 75%, 85%, 90% vaccine uptake rates among the staff, while others are at 30% and 40%,” Gifford said. “A lot of the divide is around different type of belief issues and where people get their information — from families and friends.”

Successes should be celebrated by reminding all staff of the benefits of vaccination after someone is immunized.

“It’s not just about protecting you and protecting your family, which are two important messages,” he said. “It’s about protecting your residents. It’s about getting back to normal, being able to visit families, going out and doing the activities we have been all restricted from doing. I think those are messages that really resonated very well.”

Fire Walkers

A recent poll of the general public revealed 24% say that will not take the vaccine.4 Vaccinated HCWs are respected voices on immunization in their communities, as they have been through the fire.

“They are the first-line response, the people who have been working with patients suffering through COVID-19,” says David Sanchez, PhD, associate professor of pharmacy at Western University of Health Sciences in Pomona, CA. “They have seen firsthand what is going on. They can encourage the public.”

Healthcare workers are rightly called heroes, and part of that can be taking a vaccine leadership role in their communities. “In some ways, I think it is our responsibility when we hit the community to be constantly educating people about the pros of the vaccine,” says Anthony Harris, MD, a hospital epidemiologist at the University of Maryland. “We need to be transparent about the side effects, but relay the basic message that the benefits far outweigh the negatives. [Tell them not to] jump the line, of course, but if you have a chance to get a vaccine, the best vaccine to get is the one you can get right now.”

In that sense, the new Johnson & Johnson/Janssen one-shot vaccine may have gotten a bit of a bad rap, a CDC official noted in the webinar. While its overall efficacy is lower than the 94%-95% range of the Moderna and Pfizer vaccines, it was trialed at a different time in the pandemic and faced more of the emerging variants, explained Kathleen Dooling, MD, MPH, co-lead of the COVID-19 Vaccines Work Group on the CDC’s Advisory Committee for Immunization Practices. The committee approved all three vaccines without expressing a preference for one over the other.

“The three vaccines, in fact, were not studied head to head and the results of the Janssen Phase III trial are not comparable with the mRNA vaccines,” she said. “That’s because the trial was conducted at a different calendar time, as well as different geography. Those both resulted in different circulating variants as well as higher background incidence of the virus.”

Phase III clinical outcomes for Janssen were observed from November 2020 to January 2021, as opposed to September 2020 to October 2020 for the other two vaccines. The one-shot Janssen vaccine was tested in the United States, South Africa, Brazil, Chile, Colombia, Peru, and Argentina.

There were 173 symptomatic COVID-19 cases in the vaccinated group of 19,514 participants, with 509 in a similar size placebo group, Dooling said. That translates to an overall vaccine efficacy of 66%. The most common reactions were the same as the other vaccines — pain, redness, swelling at the injection site, and general fatigue and headache. Hospitalizations due to COVID-19 infections were rare, with two in the vaccinated group and 29 in the placebo participants. There were no COVID-19-associated deaths in the vaccinated group vs. eight in the placebo group in this trial.

“The [Janssen] vaccine efficacy against hospitalizations was 93%,” she said. “All the recommended vaccines have demonstrated high efficacy against severe COVID-19. With respect to hospitalization, there was an efficacy of more than 89% for all three vaccines.”

It is critical to remind patients they still need to take precautions to protect themselves and their families, including wearing masks and washing hands. However, the CDC has released guidance about what vaccinated people can do differently, which may help the hesitant reconsider the vaccine.

Empathy

Perez stressed the importance of “strengthening the capacity of healthcare professionals to have empathetic vaccine conversations, to address myths and common questions, and to provide tailored vaccine information to their patients.”

Speaking honestly about what one does not know also is important for building trust. “Patients will likely ask you if you’ve been vaccinated yourself,” Perez said. “If you have not, they might ask you why. Your response might have an impact on their own decision-making.”

People with high-risk medical conditions and allergies might be anxious or confused about vaccination. “When having these conversations, there are important evidence-based strategies you can use to make them more effective,” Perez said. “These include starting from a place of empathy and understanding. This pandemic has been stressful for many people, and the first step is to acknowledge the disruption COVID-19 has caused in all of our lives.”

Additionally, hesitancy may stem from feelings of mistrust in the medical establishment or the government due to mistreatment and collective or individual trauma. “[Be] sensitive to the longstanding health and social inequities faced by racial and ethnic minority groups and other groups experiencing health disparities,” Perez said. “Many people from these groups may also have a mistrust or fear in healthcare institutions or the government after experiencing very real trauma or mistreatment from these same institutions.”

HCWs of color are deeply influenced by their communities and their historic legacies, so they may experience vaccine hesitancy even in medical settings, said Aletha Maybank, MD, the chief health equity officer for the American Medical Association (AMA).

“When it comes to approaches for empowering healthcare personnel, especially people of color, they don’t escape the history or cultural concepts,” Maybank said at the CDC forum. “We are human beings. I think overwhelmingly that people who are in positions of leadership really need to better understand that context — that healthcare workers are not separate from their own communities.”

It is a good opportunity to explicitly engage employees in pandemic listening and planning sessions. For example, there is a perception that the pandemic response has valued speed over equity. “Urgency without that prioritization of equity really prevents us from having these conversations that we need to have with our healthcare workers and to learn from their real experiences with discrimination and racism, sexism, ableism, and xenophobia,” Maybank said. “Oftentimes, in the context of urgency, we will see an excuse given to overlook the realities.”

The Horror

The national dialogue on immunizing people of color against COVID-19 has brought past atrocities to light, forcing a very uncomfortable conversation on the deep distrust engendered by government “medical care” like the infamous Tuskegee experiment.

“We have to understand that science has not always valued people,” Maybank said. “It has not always been trustworthy, and has actually exploited [them].”

Begun in 1932, the Tuskegee experiment studied — then unethically ensured — the progression of syphilis in hundreds of poor Black men for 40 years. The Black sharecroppers enlisted in the study were told they were receiving treatment for “bad blood,” a catch-all diagnosis taken from the community vernacular.

In fact, they were followed for the progression of latent syphilis, a sexually transmitted disease caused by the bacteria Treponema pallidum. They were not told they had syphilis. Given the situation with COVID-19 vaccines, it should be emphasized the Tuskegee experiment was performed by researchers with the U.S. Public Health Service (PHS), which, at that time, was roughly equivalent to what we now call the CDC.

PHS researchers used Black community medical people and churches to perform grassroots recruitment for “free healthcare.” In fact, they were essentially conducting a death watch to study the effects of untreated syphilis — even encouraging participants and families to agree to autopsies so they could study the bodies. A financial incentive that went toward burial services was offered to agree to autopsy.

That macabre detail was made worse by the refusal to treat the men with penicillin after it proved highly effective against syphilis in the late 1940s. Easily treated with antibiotics in the early stage, syphilis can cause blindness, brain damage, and a host of other maladies if left untreated. The PHS researchers even convinced the Army not to draft any Tuskegee participants when penicillin was first administered to soldiers in WWII.

There was an attitude among PHS researchers that Black men did not merit ethical concerns as research subjects, with one saying in a 1976 interview that “the men’s status did not warrant ethical debate. They were subjects, not patients; clinical material, not sick people.”4

The experiment ended after it was exposed by the press in 1972. Although it led to public outrage, lawsuits, and widespread human research reform, Tuskegee’s real legacy is the infamy of becoming “the longest nontherapeutic experiment on human beings in medical history.”5

African Americans, even if they do not know all the details, know the pain and betrayal that resonates after Tuskegee. “They have the stories,” Maybank said. “They have the trauma that’s been passed down over generations. They have those experiences of discrimination and exclusion and harm from our institutions.”

Considering this history, the goal should not be to “coerce” communities of color to be immunized, but ensure they can make an informed decision on their own. “People definitely have concerns. Healthcare workers and their patients have anxieties all around that,” she said.

Speaking at the same forum was Kimberly Manning, MD, a self-described “vaccine champion” with the diversity, equity, and inclusion program at Emory University in Atlanta.

“In my lived experience, I think a lot of it starts with who we are,” she said. “I’m a Black American woman, a descendant of slavery, whose family is from Alabama. I attended two historically Black colleges, one of which is Tuskegee University. These conversations have been things that I have been hearing for my entire life.”

This background has enabled Manning to speak with credibility to communities of color. These social interactions became an opportunity to bring up the pandemic vaccines with a simple question: “How do you how you feel about the COVID vaccine?” she said.

“Not ‘Are you going to take it?’ or ‘You need to take it,’ but ‘How do you feel about the vaccine?’” she said. “What I found is that it is not one size fits all. Specifically, as it relates to Black Americans, there’s a lot of heterogeneity in why people feel eager to get the vaccine and why [others] are not yet sure.”

In this way, Manning raises the vaccine profile, but is careful to humanize each individual and truly listen to what they say.

“[I’m] not doing the thing where you ask something and you’re plotting what you’re going to say next, but to really start this habit of listening and engaging in unique ways,” she said. “I think we can do that.”

REFERENCES

  1. Kirzinger A, Kearney A, Hamel L, Brodie M. KFF/ The Washington Post Frontline Health Care Workers Survey. March 19, 2021. https://www.kff.org/report-section/kff-washington-post-frontline-health-care-workers-survey-vaccine-intentions/
  2. Monmouth University Polling Institute. Monmouth University public satisfied with vaccine rollout, but 1 in 4 still unwilling to get it. March 8, 2021. https://www.monmouth.edu/polling-institute/reports/monmouthpoll_US_030821/
  3. Gharpure R, Guo A, Bishnoi CK, et al. Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program — United States, December 2020-January 2021. MMWR Morb Mortal Wkly Rep 2021;70:178-182.
  4. Jones J. Bad Blood: The Tuskegee Syphilis Experiment: A Tragedy of Race and Medicine. New York, NY: The Free Press; 1981.
  5. Thomas SB, Quinn SC. The Tuskegee Syphilis Study, 1932 to 1972: Implications for HIV education and AIDS risk education programs in the black community. Am J Public Health 1991;81:1498-1505.