• COVID-19

    Report Links Vaccine Hesitancy to More Deaths, Restrictions

    April 29, 2021, 2:30 p.m. Michael Devitt — This year, the Office of Minority Health announced #vaccineready as its theme for National Minority Health Month in April. According to OMH, the objectives of the #vaccineready campaign include confronting misconceptions about vaccines for COVID-19 and other infectious diseases as part of a larger goal to end the pandemic, reduce vaccine hesitancy, and increase vaccination rates among racial and ethnic minorities.

    vaccine hesitancy word cloud

    As National Minority Health Month comes to a close, a recently published report from researchers at Imperial College London’s COVID-19 Response Team illustrates the potential impact of vaccine hesitancy on the pandemic and the continued use of nonpharmaceutical interventions such as social distancing and mask wearing. The report found that high vaccine hesitancy rates could considerably prolong the time needed for nonpharmaceutical interventions to remain in place, and that over the next two years, COVID-19-related mortality rates could be significantly higher in countries with high vaccine hesitancy compared with countries with low vaccine hesitancy or ideal vaccination rates.

    “This report elegantly answers the important questions we have as a society: What happens if we don’t reach herd immunity? What will it look like if vaccine hesitancy remains high?” said Laura Morris, M.D., M.S.P.H., a 2018-2019 AAFP Vaccine Science Fellow and an associate professor in the Department of Family & Community Medicine at the University of Missouri School of Medicine, Columbia. “With very clear results, less-than-ideal vaccination rates will result in real differences in hospitalization and mortality in our country and globally.”

    “Our work demonstrates the importance of achieving high levels of vaccine coverage if we are to return to a normal way of life,” observed Azra Ghani, Ph.D, M.Sc., one of the report’s authors, chair of infectious disease epidemiology and a faculty member at Imperial’s School of Public Health, in a news release. “It is important to understand the reasons behind vaccine hesitancy so that those that remain uncertain about getting vaccinated can have their concerns addressed.”

    While evidence indicates that confidence in COVID-19 vaccines in the United States has increased, a substantial number of Americans are concerned about or opposed to getting a vaccine. The Kaiser Family Foundation estimates that more than one-third of American adults remain hesitant about receiving a vaccine as soon as possible, including 20% who have stated they definitely will not receive a vaccine or will do so only if required for work, school or other activities.

    Story Highlights

    Methods and Analysis

    The research team used a mathematical model of SARS-CoV-2 transmission to examine the effects of vaccine hesitancy on the general population. Using behavioral survey data that indicated the intent to get vaccinated, they created three scenarios in which populations had high, medium and low vaccine hesitancy levels. The researchers then compared each of the scenarios with an “ideal” scenario in which 98% of people 15 and older were fully vaccinated.

    In each scenario, the researchers assumed that a vaccination campaign started in January 2021 and was implemented in such a way that the campaign would take 10 months to complete in the ideal scenario, with shorter durations for each scenario that had some level of vaccine hesitancy. To account for variances in efficacy among existing COVID-19 vaccines, each scenario was also modeled with both high and moderate vaccine efficacy levels.


    Based on the mathematical model, the researchers found that in the ideal scenario, with 98% of the population vaccinated with high-efficacy vaccines, nonpharmaceutical interventions such as mask wearing, social distancing, and school and workplace closures could be fully lifted at the end of the vaccination campaign.

    In scenarios that used moderate-efficacy vaccines, however, the model found that some combination of nonpharmaceutical interventions or behavioral changes would likely need to remain in place to control the pandemic.

    Overall, the model predicted that in the ideal vaccination scenario, 1,124 deaths and 3,926 hospitalizations from COVID-19 per million people would occur through the end of 2022. At the opposite end of the spectrum, the high vaccine hesitancy, moderate-efficacy vaccine scenario estimated that 2,102 deaths and 8,491 hospitalizations would occur during the same time.

    The model also found that in any of the scenarios in which vaccine hesitancy was present, lifting nonpharmaceutical interventions and relying on vaccine-induced immunity to control virus spread would lead to periodic outbreaks, with the size of the outbreak greater in populations with higher levels of vaccine hesitancy.

    Even under the low vaccine hesitancy scenario, in which roughly 80% of the population were fully vaccinated and a high-efficacy vaccine was used, the model predicted that at the peak of the first outbreak, daily deaths per million from COVID-19 would be 8.7 times higher than under the ideal scenario.

    While most of the deaths would occur in unvaccinated people, the effects of vaccine hesitancy would affect both vaccinated and unvaccinated individuals. For example, the model predicted that in the high vaccine hesitancy, high-efficacy vaccine scenario, hospitalizations and deaths in vaccinated people would increase by 33% and 18%, respectively, through the end of 2022 compared with the ideal vaccination scenario.


    The authors noted some limits to the mathematical model. For example, while the model differentiated vaccine hesitancy by age level, it did not consider other factors such as race, education level or socioeconomic status. In addition, the authors said individual attitudes about getting vaccinated may improve over time as confidence grows in existing vaccination programs. Finally, they did not account for the emergence of COVID-19 variants, which could also affect decisions to get vaccinated.

    Despite these limits, the authors emphasized the importance of addressing vaccine hesitancy as an effective way of combating the pandemic.

    “Getting vaccinated is an individual choice, but these individual choices have population-wide effects that are likely to challenge current efforts to control COVID-19,” the researchers wrote.

    Noting that vaccine hesitancy could have a substantial effect on the duration and magnitude of the pandemic, the authors suggested that some nonpharmaceutical interventions may need to stay in place for extended periods of time. Keeping these NPIs in effect, however, would come at considerable economic and social costs.

    “Reducing vaccine hesitancy is therefore an important public health priority,” the research team said. They called for the use of resources such as community-based public education programs and positive role models to build trust and provide people with incentives to get vaccinated.

    Family Physician’s Advice on Counseling Patients

    Morris told AAFP News that family physicians should use two abilities for which FPs are particularly well-known — establishing rapport and maintaining strong relationships with patients — to explain the report’s findings.

    “Our efforts to increase local vaccination rates and support our public health infrastructure will make a real impact on the health of our communities over the next few years,” said Morris. “Moving the needle on vaccine hesitancy one patient at a time is worth the time we invest in our clinics.”

    Morris said she has made improving confidence in the COVID-19 vaccines a priority in her clinic, a process that involves all members of the care team.

    “Our patients hear and see consistent messaging about the COVID-19 vaccine from staff at the front desk, the nurse who rooms them and asks about their vaccination status, and the physicians who treat them,” she said.

    The messaging, Morris explained, begins with the assumption that patients want to receive the vaccine but may also need more information, which normalizes and reinforces the idea of vaccination overall.

    “Although it adds time to a busy clinic schedule, I make it a priority to ask each unvaccinated patient about their understanding of the vaccine and any concerns they may have,” said Morris. “Rather than giving a canned ‘vaccine spiel,’ I spend my time answering the patient’s specific vaccine-related concerns. Finding common ground is helpful, such as an agreement that we want to travel again soon, or that we are sad to see local small businesses suffer from the effects of the pandemic.

    “Even if my patient is still unsure whether they want to be vaccinated soon, I finish our conversation with a strong recommendation to get their shot. For patients who are ready to get a vaccine, we assist them with online scheduling if needed and provide a list of phone numbers for local vaccinators.”

    Along with recommending to patients that they get vaccinated, Morris pointed to a number of resources that FPs and other health care professionals can use to provide more information. These include the Academy’s COVID-19 Vaccine webpage, which includes several materials to help FPs counter myths about vaccines and answer patients’ questions, and audience-specific toolkits and other COVID-19 vaccination resources from the CDC.

    Finally, Morris offered a blunt assessment on the potential impact of the pandemic if herd immunity levels aren’t reached and considerable numbers of the population continue to choose not to get vaccinated.

    “The nonpharmacologic interventions studied in this report, such as masking and restricting public activities, are not sustainable,” Morris said. “Businesses want to reopen, children need to return to school and Americans all long to return to a sense of normalcy.

    “I don’t see many communities being willing to re-enter the most restrictive pandemic measures of the past few months now that many areas of the country have fewer cases of COVID-19. However, outbreaks of COVID-19 are bound to occur in the absence of herd immunity. This report sends a warning that without higher levels of effective vaccination, our tradeoff will be more deaths from COVID-19 and an unnecessary prolongation of the pandemic.”