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[00:00:04] Tony: Hello and welcome back to another episode of Microbe Matters, presented by ID Pitstop, where we discuss, dissect and demystify topics in infectious diseases with our experts here at UPMC and the University of Pittsburgh. I’m your host, Tony Morrison, media specialist here at Pitt ID, and I’m just as curious as you may be about navigating through a world full of microscopic organisms. Please join us as we examine both the dangerous and beneficial microbial microcosms that surround us, promote public health and showcase research and treatment of modern infectious diseases.

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Tony: Vaccine hesitancy, defined as reluctance or refusal to have oneself or one’s children vaccinated against infectious diseases, is certainly not a modern novelty. In recent years, however, the idea has inspired the emergence of sociopolitical groups and organizations that make up what is now referred to as the antivaxx movement.Once a fringe outlier in the public health sphere, the antivaxx movement has slowly but surely crept its way into mainstream politics. Although today’s anti vaccine sentiments are largely politically motivated, the growing opposition to vaccines has now begun to exhibit real world consequences. But how and when did it all begin? And what could lower vaccination rates in the US mean for the future of public health?

Today, we will explore the history of vaccine opposition, consider how the Covid-19 pandemic influenced vaccine hesitancy, and examine the current state of the antivaxx movement.

With me today to talk about vaccine hesitancy is Dr. Karen Byers. She is the associate chief of clinical care and clinical director for the Division of Infectious Diseases at the University of Pittsburgh Medical Center. Karen, thanks for joining me on the show today. I know that this is a rather complex topic, but a tremendously important one to address.

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[00:02:12] Karin: Thank you. I’m glad to be here.

[00:02:14] Tony: Also joining us today is one of our new fellows, Dr. Sahil Angelo. Thanks for joining us.

[00:02:20] Sahil: Thank you for having me. I’m really excited to be here.

[00:02:22] Tony: Why don’t we start at the beginning? When did people first start to oppose vaccines?

[00:02:27] Karin: So people have really opposed vaccines from the time that they first began. If we look back in history, the first vaccine that we recognized was when Edward Jenner first injected somebody with cowpox to prevent smallpox. And shortly afterwards, these vaccines were mandated in parts of Europe. And it did not take very long for there to be an anti vaccination league of people who felt like these were dangerous or it was not something that was natural. And so therefore they didn’t want to have these vaccines. And so really, as soon as we had a vaccine, we had vaccine hesitancy.

[00:03:03] Sahil: So there’s an anthropologist named Heidi Larson who runs the vaccine confidence project at the London School of Tropical Medicine and Hygiene. And she recently wrote a book called stuck on vaccine hesitancy and the controversies around vaccines. And she noticed that she got a first hand copy of Edward Jenner’s first published paper. And in the margins, when he was talking about the science around smallpox vaccine, that there was a note in the margins saying, ba humbug around, just like the science and what they thought about it. So I think Dr. Byers is right. From the very beginning, there was a lot of skepticism. And then once the mandate came in, in around 1850s, that’s when the first antivaxx league really came around in the UK.

[00:03:41] Tony: Why are people hesitant to receive vaccines today? What are the common concerns that you see people have?

[00:03:47] Sahil: So there are a ton of different reasons why people are hesitant to vaccines. But I think if you really distill it down, it comes back to the concept of trusts and relationships in our bigger institutions. So you have a lot of different factors, so you have the government who is saying, hey, there’s a vaccine, please take it. You have big businesses in pharma where there’s a lot of controversy around. Are the pharmaceutical companies only in it for money? Are they not? You have the scientific elite, I. E. Us, who will say, you should take this vaccine. But traditionally, there’s been a lot of paternalism there and a lot of mistrust around. And not only just mistrust around new technologies, but then also the ability to actually clearly and concisely communicate, what is the problem? Why is this the right intervention? And so there’s a huge gap between me as a physician and the patients I’m trying to help. And then I think, broadly speaking, apart from fresh water, vaccines really touch every single life to some degree or the other. So I think this is something that really affects almost everybody in the world. And so therefore, there’s a lot of concern about whether or not this is right for me or this is not right for me or my community. And so when you have these fundamental issues of trust with these bigger hierarchical institutions, there’s right for dissent.

[00:05:04] Karin: I think the only other things that I have to think about are, that’s really kind of the concept of, do I want to get a vaccine? And then there are some really simple things which are, I don’t like needles. It’s not convenient for me to get a vaccine. I have to travel somewhere to get it. Maybe I’m worried about the cost for vaccines. I think that still is a significant portion of what’s going on. But I think the topics that you addressed are really what we’re seeing changing over time in terms of increasing vaccine hesitancy.

[00:05:31] Tony: Back in 2019, the World Health Organization declared vaccine hesitancy as one of the top ten threats to global health. So, clearly, this isn’t a new public health concern. But do you think that the Covid-19 pandemic played a role in reinforcing this movement?

[00:05:48] Karin: I think it definitely did, and there are a number of reasons for that. Part of that is for most of the vaccines that we have, the science has been established for a long time. We grew up getting these vaccines, and there’s some familiarity with them. With the COVID pandemic. What happened is that we had a new disease and we didn’t know everything about it in the first week. In fact, we knew more about it in the first month, but we still had a lot to learn. And every step of the way, we were learning something new. And so what the public perceived sometimes was that we’re the experts, we should have the answers to everything and didn’t understand how the process works in terms of accumulating more knowledge. So I think that was one of the areas where this was on a broad stage, because now everyone has access to many opinions and the science was evolving, so everyone was watching that happen in real time. So I think that was part of it. And then I think that this is maybe the first time that I recall where politics played a big part into how people were perceiving vaccines. And if you look at vaccine uptake for the Covid-19 vaccine, it clearly falls along political lines in terms of who isn’t, isn’t willing to get vaccinated. So I think that this was something that had not played a role before, but now it was being magnified again on the public stage.

[00:06:59] Sahil: Yeah, I actually think that in the broader arc of the global vaccination, politics and vaccination have gone hand in hand. So, like, if, for example, in Nigeria with polio vaccines, there’s a lot of skepticism about big western organizations coming in who are supporting the Nigerian government through these polio campaigns, and that would foster a lot of fear or resentment. And I think this kind of goes back to a broader issue of the relationships we have, this relationship with the public, but we don’t necessarily do a good job of explaining what is it that we’re doing. How do we know for sure that these vaccines are safe or not safe? And that really comes down to establishing that trust.

[00:07:35] Karin: I agree. And I think that the point that you made is that we sometimes can’t convince people with necessarily the science and the numbers, and we really have to tap into their emotion or their trust. And so if they trust you, that gives you a much better opportunity to explain something to them and educate them about vaccines.

[00:07:52] Tony: Do you think that social media and its propensity to circulate misinformation has influenced the current antivaxx movement?

[00:07:59] Sahil: Absolutely. I mean, like we said before, vaccine hesitancy has always been there since the start of the first vaccine. But the role of social media, I think, does a couple of things. One, it provides people a community to organize, which in some cases we love. Right. When we talk about pro democracy movements or other things, in terms of finding information that’s really helpful, especially when you feel like you want to get engaged and do your own research. But the flip side of that is you can end up falling into community that might not have the most evidence based or who might propagate fears. So I think that’s one component of it. There is the, I would say the unintentional spread of information. Then there’s the intentional spread of information and disinformation, and the intentional goal to link it to other things and entangle it more into our social, political, economic fabric. That makes it much harder for that person to know what to do and what not to do. And I think that gets really complicated. And that’s really what social media has done, is it really has kind of poured gasoline onto the flame.

[00:09:03] Tony: How does vaccine efficacy in a world of an ever-evolving biological threat foster distrust in the public health sphere?

[00:09:11] Karin: So I think there are a couple of things that are important there. So one of them is that we are right now dealing with Covid-19 which we’re all now very familiar with. But we’re also entering our influenza season. We’re also entering RSV season. And so we’ve got some things that we know we’re going to see on a regular basis. We know that we will always have ongoing infectious threats, and we expect to have future pandemics, whether it’s due to avian influenza, which we think of as being a real risk, or some other new or emerging disease. So we always need to keep that in mind. And the measures that we use to try to prevent the transmission of Covid-19 will also be measures that would be similar to used to control a future pandemic. One of the concerns that I have is that now a large number of people have had some fears or some distrust of some of those measures, including the vaccines, which would make it much harder to control the next pandemic. I also think it’s difficult for people to understand when they’re looking at vaccine efficacy that there are a number of different ways that you can look at it. So it’s hard to give you one number and say it’s likely to decrease your risk of infection by 50% or by of hospitalization, or perhaps it’s going to decrease your risk of death, or perhaps it will decrease your risk of transmitting it to someone else, or perhaps it will keep you from getting an infection at all. And so there are a lot of different markers that you could use to try to determine whether or not a vaccine is useful. And I think people often think that there’s only one marker and it’s do I get sick or not? And there may not be an appreciation for the fact that, yes, you got sick and it was mild, but it would have been severe if you had not had a vaccine. So I think that there are a number of kind of moving targets that people need to pay attention to.

[00:10:47] Sahil: My big fear is when we have the next emerging or the new infectious disease pandemic, that we’ve kind of put ourselves in a lull between now and then, where we haven’t done the groundwork and the legwork we need to do to start rehabilitating the reputation of what vaccines are so that we can really start to restore the trust in our science and in our public health infrastructure.

[00:11:09] Karin: Yeah, and I think one of the things that maybe will become easier if we can have more consistent messaging. So I think one of the hard things when the vaccines came out is that depending on different risk factors, determined what you would get in terms of your preventive treatments. And if at some point we can just say one shot once a year, just like the flu shot, if that turns out to be a viable option, I think might make it much easier to convince people to do this. But so far it’s been, I need to calculate when I got my last shot, I need to calculate when I was last sick, and then do I get the vaccine or not? And so I think we’ve made it a little bit confusing, and hopefully that will change over time.

[00:11:44] Tony: It’s evident that vaccine hesitancy is a complex subject, and the reasons people aren’t getting vaccinated are multifactorial.

But can you tell me the reasons why people who aren’t necessarily opposed to being vaccinated still aren’t?

[00:12:00] Sahil: Yeah, actually, Tony, if it’s okay with you. I just want to define vaccine hesitancy for a second, because I think it has been associated with a behavior where I think it’s actually not the case. So the best way of defining it is that it’s a state of indecision about a vaccine. So you could have been vaccinated, but still be hesitant about the fact that you got that vaccine, or you could be unvaccinated and unsure if you want it. Or you can say, I’m never going to get it, but I’m maybe opening to changing my mind or having other people get it or talking about it. And so I think it’s very much a spectrum, and so I want to be very clear, and I think we should disentangle it from it being a behavior. So I think this goes back to rumors and misinformation. So the Kaiser Family foundation came out with a disinformation or misinformation poll, and it showed that close to 60% to 70% of people have heard false rumors around the COVID vaccine or the flu shot and don’t really know what to make of it, if it’s true or if it’s not true. And I think this is where when you have too much information and too many sources and you have seeds of doubt, makes people err on the side of, well, I’m going to be cautious and not put this foreign thing in my body because I don’t know if this is true or not.

[00:13:13] Karin: I think another part of that is just even, what is access and how does it even fit into somebody’s schedule? And I will say, as somebody who had side effects after my Covid vaccines, that lasted about 24 hours. I was trying to figure out what day I could get my COVID vaccine that wouldn’t interfere with work the next day. That would be at a time when it would be easy for me to get it. So I think that thinking about the access is really an important part. And when I went to look for a place to get the COVID vaccine and I typed in a certain zip code, I actually initially was told I had no place to get the vaccine. So I think that you need to think about how much effort you have to take to get a vaccine. And we need to think about maybe bringing vaccines to communities rather than expecting everyone from that community to go to a place where they would get their vaccines.

[00:13:53] Tony: Yeah, and I think we’re seeing too, that with this most recent Covid booster, there is a shortage of it already because of just supply issues. Supply chain issues. And if you’re someone who lives on a dairy farm in Utah per se, and the nearest hospital is 60 miles away and you’re trying to go to the closest metropolitan area to find it, and there’s not enough of them, then that’s also going to inhibit people from receiving the vaccine, even if they fully intend to receive it. There are a lot of people who are on the fence about receiving a certain vaccine.

How do you counsel these patients who are eligible to receive them but are maybe unsure?

[00:14:40] Karin: I usually start by trying to understand why they might not want to get a vaccine. So if I say, hey, have you gotten your flu shot this year? Do you want to get the COVID vaccine? And they say yes, then the conversation is done. But if they say, well, I’m not sure about it, then I think it’s my job to really listen to them, understand what their reservations are, and recognize that this is someone that I typically have built a relationship with over a period of time. And so I need to be conscious of the fact that my words might carry more weight than they would if we didn’t have that relationship. And it’s really important to not be dismissive of those concerns and really address them head on, because if I leave them wondering, or if I say, oh, well, that’s not important enough for me to talk about it, then you haven’t really met them where they needed to be met. And I think that’s really the most important thing, is understanding why they’re reluctant.

[00:15:30] Sahil: Yeah, I think making sure your patient feels heard goes a long way toward the next step of building that relationship. In addition, I try to be very honest, and you might not feel great. I actually liken it to working out. So I say, well, we tell people to go run and lift weights, and you’re sore afterwards, and nobody likes being sore, but we still say to do it and, you know, it’s good. Kind of say it’s the same thing with the vaccine where you might have a fever or a headache or your arm might be sore, but it’s a workout for your immune system. If you do the conversation right, they might say no today, but when they come back in three months or see their next doctor, you might have primed them to say yes. One other piece is I find helpful is coming just from a place of concern. So we often want to check the box like, you got your flu shot. We’ve made 90% vaccination rates, and we kind of focus on the rates of vaccination. But I think it’s helpful to step back and say, well, I’m really concerned for you. You have these medical problems, or you’re totally healthy, but you live with a mom who’s a little bit older or you have a kid. I’m concerned not only just for you, but for the people around your house. And I know I have seen the impact this has on kids or adults or a patient. And therefore, I don’t want you to go through that. I don’t want you to miss ten days of work because of this, or I don’t want you to be so sick that you develop new problems or new issues. And so really coming from at a place of concern other than like, oh, you’re just a number. You’re a quality measure. You’re a checkbox we have to make.

[00:16:55] Karin: But I think that’s a good point. Who are the other people that you are around that would be impacted by you getting this disease? And even if you might be someone who’s healthy, who might come through it without any significant consequences, would you be the person that gave it to your mom or to your cousin who’s going through chemotherapy or somebody else that’s at high risk of getting severe disease?

[00:17:16] Tony: Should we be concerned about a nearly eradicated disease making a devastating comeback if vaccine hesitancy remains largely unchanged?

[00:17:25] Karin: I will say saw Hill is probably the expert in this area, but we’re already seeing some of this. So if you look at just even in the last year, things like a polio outbreak in New York City, if you’re looking at like a measles outbreak in Zimbabwe, we’re starting to see this already with diseases that we know how to prevent. So this is something that’s already, I.

[00:17:43] Sahil: Mean, as the fears around vaccines and as the global opinion gets more divided, you run the risk of these diseases coming back. So, like, when we do have polio in New York, that was a huge shock. We should not be seeing polio in New York. We should not be seeing measles outbreaks at Disney or other things like that. But we do. And I think that’s just a sign of other things that we thought were previously gone are coming back in full force. And so we’re going to be in trouble.

[00:18:11] Karin: And on a positive note, there are, if we think about the progress we’ve made with vaccines. So the first disease that we ever really eradicated from the world was smallpox through the use of vaccines. And it used to kill about a third of the people who were infected with smallpox. So we’ve made great strides with vaccines if you think about things like tetanus, which is very rarely seen in this day and age, at least in the United States, because of how far we’ve come with tetanus vaccination. And while we talk about outbreaks of polio, there would have been a period of time where we would have all known someone who was paralyzed from polio. And now the only people that I know who have had polio are my older patients who have the sequela from the infections that they had as children. So I think that it’s still inspiring to see how much we’ve been able to accomplish with vaccines. And I just hope we don’t have a big setback in the next decade or longer because of vaccine hesitancy.

[00:19:03] Tony: How do you think that providers and organizations can act to deliver accurate information in the future, to properly inform people on vaccines and hopefully curve the so called swing vote towards favoring them? How do we get everyone on the same page?

[00:19:19] Sahil: Well, if you Google vaccine information, like the first ten websites are all antivaccination based websites, and we have to have an aggressive campaign. So there are some studies that show that the rate of conversion from the people who are hesitant or indecisive about vaccines is 500 times higher among the antivaccination than the pro vaccination group. The rate of conversion is much higher. And then, interestingly, there was a study looking at tweets and, like, pro vaccine versus antivaccination tweets, and it almost didn’t matter how much positive information you threw, that still led to more people refusing vaccines. And so I think we need a better way of going about it. And I don’t fully have the right answer, but I think it starts with your local doctor, your local GP, your nurses, and your healthcare staff. I really think this is an everybody problem. And so you might hate your primary care doctor or your infectious disease doctor because he spends all his time doing podcasts instead of seeing patients, but you might love your orthopedic doctor because he fixed your knee. And so that person might be the person who can say, hey, you know what? I fixed your knee. I wouldn’t do you wrong. Get this shot. And so we really need to unite across specialties, across fields. Nurses, I mean, oh, my gosh, they’re one of the most important providers in the hospital, and they’re constantly in contact with our patients. The trust between nurses and patients are almost always higher than the trust between doctors. And so I think they’re a huge benefit and asset when it comes to talking about the vaccines. And why this is important. They’re also usually the ones physically administering them. So we really need to start local. Kind of like all politics is local. I think all vaccine distribution and administration should be local as well.

[00:20:59] Tony: With all of this in mind, what do either of you think is our greatest lever in this debate, and what are some lessons learned?

[00:21:06] Karin: So I think it will start with really just having a good communication with your patients. But I think then it moves beyond that. It moves into making it easy and convenient for people to get vaccines. I think we need to work on education, and not just about vaccines, but having people understand how they’re developed, the scientific method, some of the critical thinking that needs to be involved in interpreting what the scientific community is telling you. But I think it really comes down to communication, understanding, and making it easy to get the vaccines.

[00:21:38] Sahil: And just to add to that, I actually have hope that things will get better in the future, particularly with the younger generation, who are a lot more aware of the perils of social media and the dangers of social media. And a lot of people are doing their own research and saying, okay, well, I know everything I see on the Internet or on Instagram or TikTok or whatever new platform it is is not true. So therefore, I need to really go to more trusted sources. Even with global political events like the war in Ukraine and everything that’s going on in the Middle east right now, there have been reports of people taking video games and saying, this is what’s happening in the war, editing footage or pulling things of old footage. And so a lot of people are becoming wise to the fact I need to be a little bit better at where I choose to consume my information. And so I do have hope that this will get better. And I think that we can work to kind of create more trusted repositories of information and kind of refer people back to trusted institutions as well.

[00:22:31] Tony: I’d like to ask you both one final question.

Apart from vaccine hesitancy in public health conversations, how does vaccine hesitancy affect the globe?

[00:22:41] Sahil: I mean, it’s a global issue at this point. These infectious diseases really do touch the lives of everybody. I’m sure everybody knows somebody who had Covid at least once, or had the flu or had some sort of infectious illness. And so this does really impact everybody. There are stories of something that happened in Pakistan or in Colombia, gets repurposed in the Philippines, or altered slightly to their local context. I mean, people are a function of their environment as well. And so when you take a rumor and you twist it to make it partially true to what’s going on here. It really freaks people out. And so, this is a global issue. There’s no way around it. And fortunately, the places that have higher rates of vaccines will not be as devastated. Whereas in other countries that don’t, you’ll see a disproportionate burden of the disease. And so, in terms of equity, we really have to be good at strengthening our infrastructure, our communication across the world.

[00:23:32] Karin: And I think we tend to think of the world in terms of geographic borders. And so we think about something happening in the United States, or in Canada, or in Mexico. But when it comes to a highly contagious disease, it doesn’t respect those borders. And so we may even say that we first detected a virus in one country or one region of the world. But as we know from things like SARS-CoV-1, SARS-COV-2, from influenza pandemics, that it doesn’t take very long for it to cross over those geographic borders. And so something that may just affect one part of the world initially, is likely to involve all of us eventually.

[00:24:03] Sahil: Yeah, exactly. And same thing with animals and animal products. Animals are usually the reservoir for an infectious disease that mutates, and then it becomes infectious to humans. And so it’s not just human practices, but then also getting at every stage of the literal food chain involved.

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[00:24:22] Tony: Thank you both again, so much for talking with me today about vaccine hesitancy. I know that it can be a quite polarizing and uncomfortable topic to discuss, but the multitude of misinformation out there today has demanded its attention.

Karen, thank you so much for coming on the show.

[00:24:39] Karin: Thank you.

[00:24:39] Tony: And Sahil, thank you as well for taking the time to come over here.

[00:24:43] Sahil: Thank you. Lovely being here.

[00:24:45] Tony: And that’s it for this week’s episode. Until next time, I’m Toni Morrison, and this is microbe matters.

Thanks for listening. If you enjoyed today’s topic, please rate, write a review, and be sure to subscribe to the show wherever you listen to podcasts, so you never miss an episode. Want to keep up with the latest ID Pitstop news? Follow us on social media at ID Pitstop, where you can view behind the scenes content, discover more of our research, and be the first to know about upcoming projects.

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