Two comments posted yesterday in JAMA and a University of Michigan press release offers ideas from behavioral science and other fields to accelerate COVID-19 vaccination in the United States and discuss the ethics of continuing placebo arms in trials of coronavirus vaccines already proven effective.
Strategies for assimilating evidence
The first comment by Kevin Volpp, MD, PhD, and Alison Buttenheim, PhD, MBA, from the University of Pennsylvania in Philadelphia, and George Loewenstein, PhD, from Carnegie Mellon University, addressed the problem of Americans ’reluctance to take COVID – 19 vaccine.
They noted a September survey of 10,093 U.S. adults showing that only 51% would definitely or likely be vaccinated, 25% indicated a probable reluctance to get vaccinated, and 24% said they would not get vaccinated. Black respondents, those with high school education or less, and Republicans in particular were distrustful of the vaccines. New data released today by the Kaiser Family Foundation’s vaccine monitor shows that 71% of U.S. adults are now ready to receive the vaccine.
The commentary authors offered five behavioral-supported scientific strategies for a national vaccine promotion program, including making the vaccines free and easily accessible in places such as medical centers, medical offices, retail pharmacies, occupational health offices, long-term care. facilities, and schools.
“Given current vaccine hesitation, and the complexity of administering some of these vaccines (such as requirements for storing a vaccine at extremely low temperatures), whether simplification is possible and will work is unclear, but needs to be done as easily as possible to be immunized.” they wrote.
Not allowing access to valuable sites such as medical clinics, long-term care facilities, university dormitories, K-12 schools, workplaces, retail establishments and gyms until receiving a COVID-19 vaccine could encourage people to comply.
“A long winter of new cases, overcrowded hospitals and more than 2,000 COVID-19 deaths a day can change perceptions of what is politically acceptable,” the authors said. “Employers may legally require vaccination as a condition for in-person work provided there are exceptions to concerns related to disabilities and religious beliefs and acceptable alternatives to continue working for those who refuse to vaccinate, such as working from home.“
Once vaccine priority groups such as nursing home residents and health care workers, states and cities could provide vaccines first to employers who are publicly vaccinated, to set an example for employees. Heads of state representing different demographic and political groups may similarly be role models for vaccination.
Vaccinating people first who register to do so before vaccines are available to everyone, emphasizing the initial scarcity of the vaccines, would increase their value, the authors said. And allowing people who get vaccinated to publicize their decision, similar to “I voted” stickers, could encourage others to do the same.
“Social factors can also be harnessed by municipal and state health departments, civic organizations, and employers that promote the community benefit of vaccination,” they wrote. “People who may not do something for themselves will often do the same action to benefit other people.”
These recommendations should be framed as part of a comprehensive strategy to slowly contain the virus rather than as a panacea, the authors said, and a national board consisting of experts in epidemiology, vaccine science, behavioral science, marketing and other fields will be. required to provide data on vaccine safety and efficacy and to guide advertising efforts.
“The team needs to represent a spectrum of policy perspectives to depoliticize a pandemic response,” they said. “The potential for these vaccines to help stop the pandemic will be limited without comparable attention to traversing the behavioral ‘last mile’ necessary to ensure vaccine acceptance and consumption.”
Problems with vaccination of all trial participants
The second comment, by Annette Rid, MD, of the National Institutes of Health; Marc Lipsitch, DPhil, of Harvard University; and Franklin Miller, PhD, of Weill Cornell Medical College, discuss the claims of Pfizer / BioNTech and Modern vaccinators on the ethical duty to vaccinate all vaccine participants who received placebo, given the positive results of the trials and the important role of the participants in the research. .
Rid and colleagues argue that due to limited initial vaccine availability, only COVID-19 vaccine test participants receiving a placebo that would be eligible for the vaccine outside of testing (i.e., members of priority groups) should receive access to the vaccines because they continue with the placebo would not make their situation worse compared to what it would be if they did not take part in the trial.
“Conversely, if participants were allowed to be vaccinated outside the trial, continuing in the placebo group would make them significantly worse than they should be outside participation in the trial,” the authors wrote. “The risks for these participants seem difficult to justify; in any case they could simply withdraw from the study and seek vaccination outside the process.”
It would also lead to lower health and health benefits of vaccination in general if all non-priority participants in the placebo arms of the Pfizer / BioNTech and Moderna trials were vaccinated. “This would mean that currently up to 36,828 health personnel or other individuals who have a higher priority than the participants could not be vaccinated,” Rid and colleagues said. “The resulting loss of benefits could be significant.”
Also, vaccinating test participants who would otherwise continue with placebo, they said, would eliminate a collection of valuable long-term safety and efficacy data needed to maintain their full license and government financial use. Such data include those on how long a vaccine given immunity lasts and whether people infected with the coronavirus after immunity decline experience a more severe disease.
“First this would result in a significant loss of valuable research data without eliminating unwanted risks for participants who continue in the placebo group of the trials,” they wrote. “Second, healthy and healthy equality gains would decrease, as participants in the placebo group would receive a vaccine even when they were not prioritized to vaccinate outside the trial.”
The authors called for a regular review of their recommendations, especially when more vaccine doses and other possible vaccines are available.
Education, second dose reminders
In the University of Michigan press release, Mark Fendrick, MD, a university researcher and director of the Center for Value Assurance Design, explored ways to ensure people get a second dose of COVID-19 vaccine a few weeks after the first, which is needed to boost immunity.
“Vaccines that require more than one dose create additional behavioral and environmental challenges, including reports of side effects, false claims about vaccine safety, logistical barriers, and program policy that can prevent people from getting vaccinated or returning for their second dose. , ”Fendrick said. “Studies of other high-value vaccines and medications to manage chronic conditions show that even at no cost, patients take them half the time.”
A vaccine support program should include information on how the vaccine works, vaccine side effects, reminders to schedule a second dose, data to dispel vaccine misinformation, and transportation to the second dose appointment.
In addition to a card that clinicians can give patients receiving their first COVID-19 vaccine dose to educate and encourage them to schedule their second dose, Fendrick recommends creating a support program to deliver a vaccine based on a smartphone based on research from his team. and others. He added that even a phone call or email from a reliable source, especially for unserved groups like older and homeless people, can help.
And although the authors of the first comment discouraged use of monetary incentives, which they said could fail, making vaccination seem undesirable or even dangerous, Fendrick offered a $ 50 gift card after receiving the second dose.
“The good news is that the federal government has created a financial incentive for those who deliver the vaccine by paying a higher refund for the second dose than for the first,” he said. “Why not also give incentives to patients?”