The Critical Public Health Value of Vaccines Tackling Issues of Access and Hesitancy: Proceedings of a Workshop (2021) / Chapter Skim
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7 Reflections and Ways Forward
7 Reflections and Ways Forward
Pages 143-176
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From page 143... ...
Van der Linden discussed his work on developing the Bad News Game, a psychological vaccine against misinformation. Lindenberger discussed the need to empathize with vaccine rejectors and anti-vaccine advocates.
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Because there is not yet a strong vaccine candidate for COVID-19, vaccine confidence is being considered without the benefit of data on safety, efficacy, and characteristics. This dynamic poses a number of challenges to development, vaccination campaigns, and vaccine confidence, Lurie noted.
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From page 145... ...
However, the SARS outbreak ended before a vaccine was developed, and government funders and others lost interest in seeing vaccine development through to completion or to a later stage of advanced development. In the case of Zika, vaccines progressed quite far, but then the U.S.
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In recent years, CEPI has made efforts to promote collaboration among regulators from around the world to discuss vaccines early and contribute scientific advice about how to move forward with vaccine development. During the COVID-19 outbreak, regulators have formed an international organization that includes FDA, the European Medicines Agency, Chinese regulators, regulators from African countries, and WHO.1 In this forum, regulators have come together to share ideas about regulatory science, procedures for authorizing the use of vaccines, and approaches to vaccine manufacturing.
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From page 147... ...
Furthermore, she advised that continuous, clear, transparent information about adverse events following immunization be provided to the public, because there will be health events that happen by chance but are attributed to vaccines. Thus, maintaining vaccine confidence involves helping the public better understand efficacy data and safety monitoring to build confidence that vaccine information being shared is truthful.
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From page 148... ...
Prior to the COVID-19 pandemic, there was no global entity to enable vaccine development at the international level in the ways the United States does at the national level, such as: • Funding phase 3 pivotal trials; • Scaling up manufacturing capacity to produce large numbers of doses; 2 More information about prioritizing diseases for research and development in emergency contexts is available at https://www.who.int/activities/prioritizing-diseases-for-research-anddevelopment-in-emergency-contexts (accessed November 2, 2020)
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COVID-19 Vaccine Acceptance Global partners responsible for distributing vaccine and assisting with vaccine campaigns, especially in low-income countries, are planning and developing protocols to distribute and administer COVID-19 vaccines, said Lurie. Work is also under way around vaccine literacy, vaccine confidence, and putting systems in place to understand people's concerns and current confidence in vaccines.
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" While more challenges undoubtedly lie ahead, everything that can be accomplished collaboratively as a global community will set the stage for bigger, better, and faster responses in the future, said Lurie. Lurie's hope is that in addition to scientific and regulatory collaboration spearheaded by NIH and FDA, collaboration is also ongoing regarding vaccine development and shared financing.
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This approach could be characterized as an insurance policy in paying premiums to avoid larger issues later on, added Kester. Lessons Learned from Ebola for Vaccine Confidence Kester asked whether there are learnings, case studies, testimonials, or other insights -- aside from what has been published -- about the early use of the Ebola vaccine in health workers that can be adapted for building confidence more broadly.
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Given the difficulty in differentiating true vaccine adverse events and events that are unrelated to vaccines, Kester asked about the strategies to instill vaccine confidence. Lurie noted that unrelated medical events are frequently attributed to vaccines by the public, such as people believing they got seasonal influenza from the vaccine.
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From page 153... ...
Medical events will happen that are completely unrelated to vaccines, yet people will attribute them to the vaccine and amplify those putative associations on social media and other channels -- some of which is maliciously intended. She emphasized that in addition to back-end work to maintain public confidence, front-end work is also needed to establish background rates, help people understand what they are, disseminate them, and standardize definitions.
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Just as weakened doses of a pathogen can be injected into the human body to trigger the production of antibodies and confer resistance against infection, psychological "inoculation" exposes individuals to weakened doses of misinformation, fake news, and other techniques of deception about vaccination to create "mental antibodies" -- that is, to trigger a psychological process of resisting and arguing against these deceptive techniques. Psychological Inoculation Against Misinformation Van der Linden explained how psychological inoculation is analogous to biological inoculation, where a psychological "vaccine" can trigger "mental antibodies" against misinformation.
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Van der Linden explained how the Bad News Game works. The game's interface includes a follower count, which tracks the player's number of ingame social media followers, and a credibility meter.
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Van der Linden and his colleagues are beginning to experiment with "booster shots" by having players revisit the game to remain alert and able to spot misinformation techniques. In partnership with the United Kingdom and the Harvard Kennedy School Misinformation Review, the Bad News Game was translated into several languages and tested cross-culturally with players from around the world.6 In conclusion, van der Linden invoked the words of Severus Snape, a character from the Harry Potter series, who said that one's "defenses must be as flexible and inventive as the arts you seek to undo" (Rowling, 2014)
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Empathizing with Vaccine Rejectors and Anti-Vaccine Advocates Lindenberger shared reflections from his vaccine advocacy work and insights from his personal experience being raised by his mother, who rejected vaccines and chose not to have Lindenberger immunized as a child. He applauded the work presented by van der Linden, highlighting the importance of prebunking against misinformation and conspiracy theories of all kinds.
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He compared this real-life experience to the in-game experience of playing the Bad News Game and concluded that education is key for addressing misinformation. A Social Science Approach to Fighting Vaccine Hesitancy Considering the personal experience and the gamified approaches to curbing misinformation presented by the panelists, Buttenheim asked how these might be folded into evidence-based campaigns to promote vaccination, especially for the COVID-19 vaccines.
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Using Data Versus Experience to Combat Misinformation Tactics Buttenheim asked how the affect heuristic informed the design of the Bad News Game and what is known about how the specific emotional responses to disinformation differ from the responses to data. Van der Linden reiterated that presenting vaccine-hesitant individuals with data is inadequate for overcoming the emotional stories at play in their minds.
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The game is intended to be a tool that increases awareness of misinformation and the ways in which individuals can be misled. 8 Van der Linden acknowledged that, while the game allows players to draw their own conclusions, it is designed to steer the players toward a particular set of conclusions.
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Buttenheim commented that the experience of a family member or colleague pointing out how one has been deceived may be just as unpleasant as being confronted with facts that refute false beliefs, although this coming from a trusted source may make a difference. Van der Linden agreed that trusted sources, such as family members and other in-group individuals, have more leverage to reveal misinformation.
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Van der Linden has found that, similar to experimental therapeutic vaccines, the Bad News Game has some therapeutic effects and can make players less extreme in their misinformation beliefs, that is, rather than abandoning their beliefs in misinformation, they have become more reflective about their beliefs. This suggests that those who have already been exposed to misinformation can benefit retroactively from vaccination against misinformation.
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Van der Linden said that this is among the frequently asked questions about the Bad News Game, and that the game was carefully designed to avoid actually fooling players into believing in-game misinformation. Much time was spent pretesting the game's content, ensuring that the humor was appropriate and that the game's content was too ridiculous for players to actually believe.
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Such investigations may help vaccination advocates tailor clinical counseling to the ideas and preconceptions of individual patients. Lindenberger reported that some of the factors influencing misinformation are able to be identified by the platform operators themselves, and recent improvements have been made in the ways social media platforms handle misinformation.
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. During the pandemic, the anti-vaccine movement has made 10 More information about the effects of the COVID-19 pandemic on routine pediatric vac cine ordering and administration is available at https://www.cdc.gov/mmwr/volumes/69/wr/ mm6919e2.htm (accessed November 5, 2020)
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However, around the same time, similar vaccine hesitancy and refusal issues emerged in a wide-age MMR immunization campaign in Indonesia. Within 4–6 months, an additional challenge emerged when a religious group began asking for a government 11 More information about Biological E is available at https://www.biologicale.com (ac cessed November 5, 2020)
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Innovative Approaches to Improving Vaccine Uptake Presented by Monika Naus, British Columbia Centre for Disease Control Naus addressed current trends in British Columbia. Canada has a publicly funded national immunization program that is managed, along with health care services, at the provincial and territorial level.
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In British Columbia, approximately 20 percent of residents are unattached to a family doctor, with the use of walk-in clinics increasing. This reduces the ability to have a relationship with a trusted health care provider, which Naus added has been repeatedly identified at this workshop as the most important driver of vaccine acceptance.
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Lastly, evidence-based tools for addressing the pain associated with immunization are being used.16 These are focused on children and improve the experience of pain and reduce anxieties and needle phobias. The goal of all public health immunization programs is to achieve and maintain high levels of vaccine uptake; thus, the slowness of growth or stagnation of coverage rates has been demoralizing for public health, Naus described.
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Naus noted her appreciation of the ability that web interfaces like Zoom provide in spreading information via forums, which enables the sharing of information and successful strategies and avoiding reinventing the wheel. Lastly, Naus noted the similarities of vaccine hesitancy issues across the globe and the potentially wide applicability of these tools and strategies, mentioning that vaccine hesitancy often stems from affirmation 19 More information on Vaccine Status Reporting Regulation in British Columbia is avail able at https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/146_2019 (accessed December 18, 2020)
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Efforts were initiated to map and refer children identified as previously having received a vaccination during an oral polio vaccine campaign. However, Olivé said it was soon realized that the essential immunization services did not have the capacity to access and vaccinate these children, as they could offer doses of routine vaccination to only 30 percent of them.
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Ultimately, polio vaccination will enable the final eradication of wild polio virus circulating in these remaining persistent reservoirs, he concluded. DISCUSSION Addressing Vaccine Acceptance During the COVID-19 Pandemic Given the decline in immunization services during the COVID-19 pandemic, and knowing that efforts will need to be intensified in order to bring coverage rates to pre-pandemic levels, Cohn asked the panelists
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The likelihood that multiple COVID-19 vaccines are forthcoming could present an opportunity for researchers to share how they arrive at information about vaccine safety. Arora noted that the COVID-19 pandemic caused substantial disruption to the health system in general and vaccine coverage decreased as immunization services were halted.
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Transparency and Data Communication In the context of misinformation, Cohn asked how vaccine safety monitoring and data can be communicated to the public in a transparent way that introduces confidence. Arora responded that in India, the national Adverse Events Following Immunization (AEFI)
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national track record of success in vaccine safety. Arora said, "honest and proactive." Olivé offered, "build trust." CLOSING REMARKS Daszak said that the issue of vaccine hesitancy is at the core of the complexity of the issues faced by global health and national public health.
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Vaccine hesitancy is part of that lesson. Daszak was optimistic that once COVID-19 vaccines are available and government campaigns to promote uptake of these vaccines are under way, a future will emerge in which the public is better informed and everybody understands how individual actions affect everyone.
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