The Threat of Vaccine Hesitancy and Why Inoculating the Young First Isn’t Such a Bad Idea

Before a mutant bat virus crippled the planet, the World Health Organization compiled a top-10 list of threats to global health. Along with air pollution and climate change, cancer and heart disease, in 2019 the WHO ranked people’s reluctance to be vaccinated against infectious diseases as a major hazard to the world’s well-being.

At the time, the global health agency was referring to rising opposition to shots for polio, whooping cough, mumps and measles, old contagions making a comeback as the anti-vax movement spread from Western nations to other countries. Now, a little more than a year later, when the new scourge of COVID-19 has brought humanity to its knees, vaccines look like the only hope of stopping it. The consequences of vaccine hesitancy could be catastrophic.

Yet recent polls and surveys suggest the phenomenon has become its own pandemic, unmasking millions of people – from Northern Europe to South Africa, from Asia to Canada – who say they are unsure when or if they will take a COVID vaccine. The reluctant cite safety concerns, misinformation, mistrust, and a general fear of the unknown.

It’s hardly surprising: never in human history have vaccines been developed in such record-smashing time. The average is 10 to 15 years, yet the revolutionary technology behind the first shots to combat the novel coronavirus went from labs to human arms within the span of 12 months.

Pfizer-BioNTech and Moderna, makers of the first COVID vaccines approved in Canada, received the go-ahead based on short-term data from their clinical trials. These involved more than 70,000 people combined, and show both shots are safe with efficacy rates of more than 90 per cent. They have been cast as a triumph of science – the light at the end of the pandemic tunnel – with the potential to save countless lives, the economy, schools, social and cultural norms, and our collective sanity.

Yet, with no long-term safety and efficacy data from human trials, the shots also represent an ethical quagmire like no other. The federal government has said the vaccines will not be mandatory. But to achieve herd immunity – that coveted goal when most people will be protected from infection – public health authorities need to persuade about 70 per cent of the population to get immunized and possibly even more given the emergence of new highly contagious strains of the COVID virus. And with international demand expected to outstrip vaccine supplies for months to come, policy-makers must also make life-and-death decisions on who gets to roll up their sleeves. The question is how many really want to be first?

“When we have a brand-new virus and a brand new vaccine, how do we decide whether this is a good thing or a risky thing to be first in line?” says bioethicist Alison Thompson, an associate professor at the University of Toronto and a specialist in vaccine hesitancy. “So these [shots] are fairly safe from what we know. The standards for licensure haven’t been dropped. But we don’t know in the long term how effective they will be, whether we will need one or two boosters or whether that efficacy will wane over time … and we don’t know some of the rarer side effects.

“It’s perfectly reasonable for people who are first in line to consider themselves somewhat as guinea pigs.”

Those prioritized to receive the first doses are effectively subjects in an unprecedented global experiment, one that is gathering safety and efficacy data at the same time a worldwide immunization campaign is underway. Since their debut, for instance, there have been worrisome reports of the vaccines triggering severe allergic reactions and anaphylactic shock in some recipients. Most cases, though not all, involved those with a history of severe allergies, and Canadian public health officials advise people allergic to any of the vaccine ingredients not to take it and those prone to allergic reactions to consult their doctors before taking it. In January, the U.S. Centers for Disease Control and Prevention (CDC) reported allergic reactions appear to be rare, occurring at a rate of 11.1 cases of anaphylaxis per one million vaccines.

At press time, the CDC was also investigating the case of Gregory Michael, a 56-year-old Florida obstetrician who died Jan. 3 of a brain hemorrhage, 16 days after receiving the first dose of Pfizer’s COVID-19 vaccine. In a Jan. 5 Facebook post, Michael’s wife, Heidi Necklemann, wrote that she believes the severe blood disorder her otherwise healthy husband suddenly developed was a side effect of the COVID shot, a suspicion now under wide investigation.

The success of this immunization campaign depends largely on how effectively public health officials can address safety concerns as they surface and how well they can contain the spread of vaccine hesitancy as the shots roll out.

Canada has shown signs across the country. An Angus Reid poll of 1,605 Canadians in December, for instance, found on average nearly half wanted the shot immediately, but 31 per cent wanted to wait a while. But in January, as COVID cases surged and social restrictions tightened, a new Angus Reid poll showed vaccine enthusiasm had jumped 12 per cent, with 60 per cent of Canadians saying they want the shot as soon as possible.

The federal government’s COVID-19 Snapshot Monitoring survey (COSMO Canada) – a rolling national poll of 2,000 randomly recruited men and women over 18 – suggests the high rates of COVID infections and deaths, which Indigenous people and visible minorities have suffered disproportionately, have not been enough to fully counter vaccine hesitancy in these communities. The COSMO survey found they are less willing than others to be vaccinated.

That reluctance partly reflects the long reach of an ugly history. First Nations leaders, for example, have called on the federal government to prioritize Indigenous people for vaccination. Canada’s National Advisory Committee on Immunization has recommended Indigenous people be among those to get the first doses. But social media posts and news reports suggest not all are keen to receive it. In the 1930s, Indigenous children were unwitting test subjects for a tuberculosis vaccine. In the 1940s, they were deliberately malnourished as part of a government-sponsored nutrition study. For years, Indigenous women underwent forced sterilizations. All of it is part of a painful past that makes many people understandably apprehensive about any government-sponsored health intervention.

“This all hinges on people’s levels of trust,” says Thompson. “Those same groups that are bearing those burdens from COVID disproportionately also, historically, have very low levels of trust in the health system. The optics of giving the groups who are most vulnerable in society priority access makes sense to protect them if it works and if there is no terrible side-effect profile, and I think we’re pretty sure that there isn’t. But it’s a question for those communities as well, and I don’t know that we’re engaging enough with those communities to find out what they’re thinking.” 

 

A Great Leap of Faith for the Greatest Generation

 

Each province in Canada is deciding which high-risk groups it will prioritize. Unsurprisingly, all have named the elderly, in particular nursing home residents who account for about 80 per cent of the country’s COVID deaths so far, along with the staff who care for them.

Yet while vaccine clinical trials included healthy volunteers in their 70s and early 80s, no frail elderly subjects were among them. “So we just have absolutely zero data about how well these vaccines are going to work in that context,” says Dawn Bowdish, the Canada Research Chair in Aging and Immunity at McMaster University in Hamilton. “The [frail elderly] are not good indicators of whether a vaccine works.”

Since the elderly are prone to multiple underlying conditions, it can be tricky to attribute any adverse reaction to a true side effect of the vaccine. They also tend to have weak immune responses to vaccines, making them unattractive candidates for companies trying to prove their shots can generate a strong immune response. The flu vaccine, for example, is estimated to be 60 to 70 per cent effective in protecting the general community but, among those over 65, that rate falls to about 30 to 35 per cent.

Still, says Bowdish, it’s a misconception that the immune systems of the elderly simply don’t work. Over a lifetime, it is “constantly remodelled by all the things that it’s exposed to.” The 2009 H1N1 flu pandemic, for example, was expected to “absolutely decimate people in long-term care,” Bowdish says, but it didn’t. About 70 years before, a relative of the H1N1 virus had been circulating when elderly residents were five or six years old. “The immune responses they had generated as children were protecting them when they were in their 80s and 90s.”

Bowdish suspects immune memory might play a role in how the elderly have responded to COVID-19. While SARS-COV2 is a new pathogen, other related cold- and flu-causing coronaviruses have circulated for years, which may explain why roughly a third of seniors in long-term care – an unexpectedly high number – had asymptomatic infections or mild cases. “There are stories in the news of 100 year olds leaving the hospital having beat the coronavirus,” says Bowdish, who is studying the phenomenon.

“It may be that previous exposure to the relative viruses have afforded them some protection or it could be that for some people, those previous exposures have trained immune systems to respond in the wrong way … [with] a hyperactive response.” This, Bowdish says, could trigger the notorious cytokine storm that sends inflammation into overdrive as the body attacks its own cells – “and that’s actually what’s killing some people in the context of SARS COV-2.”

So how might long-term care residents respond to a vaccine that offers their immune system a preview of COVID-19? “There’s always a chance of things not going well, but there’s a greater chance of it being ineffective than it being harmful,” Bowdish says, because the capacity to generate new immune responses usually wanes with age. 

Given the limited supply of early doses, some experts wonder if it would be more beneficial to immunize younger people first (in whom the shots are known to be more effective) to prevent them from passing the virus on to elderly friends or relatives. “It’s a great question,” says Bowdish, “but we won’t actually know until we start vaccinating some older people.”

As with the flu shot, even a partially effective COVID vaccine may be enough to protect the elderly from severe infection, hospitalization or death. “So even if it’s not perfect, it might still be helpful,” she says. “If it was my loved one in a long-term care facility, I would be anxiously awaiting a vaccination to keep them safe.” 

The COSMO Canada survey suggests most older Canadians are keen to receive it: among those 55 and older, 72 per cent said they would roll up their sleeves, whereas only 57 per cent of respondents between the ages of 35 and 54 felt the same way.

That willingness may reflect the isolation and loneliness many older adults faced while shut away through the year-long pandemic. As well, they remember when polio, measles, diphtheria and whooping cough ravaged the world before vaccines were developed in the first half of the 20th century. Having lived through the Depression and the Second World War, the Greatest Generation is also known for its self-sacrifice and serving the good of the country. And as stacks of studies have found, the elderly are also more likely to trust their doctors and follow the advice of health authorities.

But for other COVID vulnerable populations, trust in any government institutions or health authority is a very tall ask.

 

A Lopsided Burden

 

For 20 years, the Health Association of African Canadians (HAAC) has implored public health officials in Nova Scotia to collect health data based on race, ethnicity and language so it can identify the medical and broader health needs and inequities of its Black community, and how to address them.

To this day, Canada’s oldest Black community, with 400-year-old roots that include forebears who were Black Loyalists from the American Revolution and escaped slaves from the Underground Railway, relies on information from the United States and the United Kingdom to gauge the health of its 22,000 members. Sharon Davis-Murdoch, co-president of the association based 11 kilometres east of Dartmouth in Cherrybrook, N.S., says there is a
disproportionate level of many illnesses in the community “but we only hear about Black health concerns and inequities through American media, which may or may not have relevance in Canada.”

The request for race, ethnicity and language-based data collection “is not that it be done on us but with us,” so the community participates in the analysis and how the data is used. “We have advocated for it in every respectable and responsible way – meetings, letters, more meetings,” she says. “We have tried and tried and tried for 20 years.”

The inertia is emblematic of the wider problem that prompted Davis-Murdoch and four other health advocates to found HAAC in 2000. They’d seen too few health services delivered in a “culturally competent way,” too few educational programs and public health messages specifically designed to engage and inform communities of African ancestry.

In the pandemic’s early days, the dearth of reliable information meant some African Nova Scotians believed a bogus social media theory that COVID only posed a threat to East Asians and Caucasians.

“Unfortunately, it wasn’t taken seriously initially by our population because there was a myth that it didn’t affect Black people the way it affected other populations, that we were somehow immune,” says Dr. David Haase, a retired infectious diseases specialist in Halifax and a past co-president of HAAC.

The association held a town hall last March to debunk the myth and provide culturally specific information about the novel coronavirus so people could protect themselves. But HAAC leaders believe their community is suffering disproportionately. They infer it from reports out of the U.S., where COVID-19 is killing Black Americans at at least twice the rate of whites, and from other parts of Canada where the coronavirus has
finally forced the collection of race-based health data.

Statistics from Ontario show people from racially diverse communities are two to four times more likely to catch COVID, to be admitted to intensive care and to die of their infections. In Toronto, where visible minorities account for 83 per cent of reported COVID cases, Blacks constitute just nine per cent of the city’s population but represent 21 per cent of reported cases.

It’s a lopsided burden of disease that reflects profound socio-economic disparities in how and where racialized communities live and work. No province has prioritized the Black community to receive the vaccine. Even so, many African Canadians will be among those tapped to receive early doses given their representation in front-line jobs such as health-care workers and personal support workers in nursing homes.

“There are a lot of chronic health conditions in our community already and so you add COVID on top of that, and we know that we are at high risk of poor outcomes,” says Haase. “We know that the vaccine is going to be one way to reduce that risk, but our community members are dealing with a long, long history of mistrust.”

Haase points to the chilling legacy of the Tuskegee syphilis study, a 40-year experiment that began in Alabama in 1932, when hundreds of Black men were intentionally untreated so researchers could observe the natural course of the sexually transmitted disease. Many of the men, who died as a result, had no idea they were subjects in the study and passed the disease on to their wives and children. It may be the most notorious example of the medical mistreatment of Blacks, Haase says, but subtler forms of “being marginalized” continue.

“So things have gotten to the point where our African Nova Scotia community members do have a sort of reticence to step up to the plate when you bring in a vaccine, and you have not really been paying much attention to our other areas of concern.”

Davis-Murdoch, a retired senior health policy analyst and special advisor to the provincial government, points out there is not one Black member on the 13-seat Nova Scotia Health board, which oversees health care for nearly a million people – 22,000 of whom are Black – nor has there been one since 2015.

“We live with structural racism, overt racism, systemic racism, internalized racism,” she says. “It affects us every day in some way, shape or form. It is our history and lived reality, and so that also has an impact on trust in the health system and any of the institutions in Canada.”

At press time, HAAC was planning a virtual town hall meeting for Jan. 15 to address the impact of the COVID-19 vaccine in the community, in part to extinguish concern that the shots aren’t safe for Black people and to encourage members to get immunized. Haase lamented that, with all that’s riding on it, no public health officer had yet reached out to build the Black community’s trust and confidence in the vaccine. “If you haven’t gotten them to buy in, you’ve wasted your funds buying all that vaccine, and it’s just going to sit in your freezer.”

 

The Reluctant Swedes

 

Time may be the only cure for vaccine hesitancy during the pandemic. Regardless of how many politicians or celebrities offer up their own jabs for the cameras – a list that so far includes U.S. President Joe Biden, who has received both shots, actor Ian McKellen and baseball Hall of Famer Hank Aaron – persuasion will depend on how safe and effective the shots are when given to millions of people, some with health conditons and even COVID survivors, who were not part of the original vaccine trials.

McMaster immunologist Bowdish says those who receive the shots in Canada will be added to a registry and tracked to ensure no important side effects are missed. “The whole world is watching carefully,” she says. “We all know that if we screw this up, we lose the public’s trust. Then we’re back to where we are right now.”

Though few details have been released, the federal government has also announced that anyone who experiences a severe adverse reaction to a COVID-19 vaccine will be eligible for compensation.

While severe or lasting vaccine reactions are rare, some shots have been known to result in utterly unpredictable side effects. In 2009, Finland and Sweden noted a mysterious spike in cases of narcolepsy among those who had received a vaccine to fight the H1N1 influenza pandemic.  More than 1,300 vaccine-associated cases of the sleeping disorder have since been reported in Europe, notably in Scandinavian countries where the link was first spotted in children and young adults. A 2015 study published in the U.S. journal Science Translational Medicine suggests the Pandemrix swine flu shot used in Europe, which is no longer sold, triggered an autoimmune reaction that led to narcolepsy in those who had a genetic risk for the chronic neurological condition.

According to a recent survey from Novus, a Swedish polling firm, the 2009 experience has made a quarter of Swedes wary of taking a fast-tracked vaccine for COVID-19. Meissa Chebbi, a 21-year-old who developed narcolepsy after getting the swine flu vaccine in childhood, told Agence France-Presse she would wait five years to take a COVID shot, “when we know what the risks are.”

Even in places where COVID has become an unyielding crisis, a
substantial number of front-line health-care workers are also balking at the vaccine, given their fears of the unknown. The Los Angeles Times reported in December that 20 to 40 per cent of the county’s hospital staff who were offered priority access to the vaccine were refusing it. In December, after the Windsor Regional Hospital in Ontario offered to vaccinate 4,088 staff working in area seniors’ homes, 21 per cent declined the shot or opted to delay it.   

Along with the fear of unknown side effects, a general distrust of the pharmaceutical industry also drives vaccine hesitancy. University of Toronto bioethicist Alison Thompson says this is partly because society treats vaccines like commodities instead of “public goods … even though millions and millions of dollars of public funding go into the research behind these vaccines, the pharmaceutical companies are the ones who are going to profit. It is still really problematic, and the companies get to decide who they are going to give it to so, once again, high-income countries will get priority access.”

AstraZeneca, which developed its jab in collaboration with Oxford University, has pledged to forgo profits during the pandemic to ensure all nations that need the shot can afford it. Britain, India and Mexico were among the first countries to approve the AstraZeneca-Oxford vaccine; Canada is expected to do so this year. But for Pfizer and Moderna, it has been “business as usual,” Thompson says. In fact, when Pfizer and Moderna announced the remarkable efficacy rates of their COVID vaccines in November, their executives had prearranged the lucrative sell-off of company stocks. “That really undermines people’s trust in these things,” she says.

 

A Year of Living History

 

Before the pandemic, when the WHO or other public health advocates tried to counter vaccine hesitancy, the efforts invariably involved a history lesson, describing how gloomy the world was before vaccines came along: more sickness, more disability, more death, even among babies and kids. Quarantines were common, and life was much shorter.

But the anti-vax movement, which grew in the West out of utterly discredited reports that vaccines for measles, mumps and rubella cause autism, has not been swayed by history. Its adherents tend to have a deep mistrust of the pharmaceutical industry and believe the risks of vaccinating children outweigh the benefits. With misinformation rife on social media, the movement has gone global.

Still, after a year of living with COVID-19, the modern world has glimpsed the bleak shape of a life without a vaccine, reliable treatment or cure for a highly contagious virus. Quarantining has become routine. Now a hug can be risky behaviour, and a gathering of friends could land someone in the ICU.

Whether all the social, mental and financial hardship of the 21st-century pandemic dilutes the anti-vax sentiment that existed in pre-COVID times is unclear. Thompson hopes the fanfare and excitement that accompanied the December rollout of the first COVID-19 vaccines will last, just as it did when immunizations for polio and measles changed the world and dramatically extended life expectancy half a century ago.

“If we don’t get this right, we won’t be celebrating for long,” says Thompson. “And that’s part of the fear around the vaccine hesitancy stuff. It could get worse and it won’t just impact this outbreak – it will impact future outbreaks if people aren’t willing to be vaccinated.”

A version of this article appeared in the Feb/March 2021 issue with the headline “A Shot of Hope,” p. 65. 

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