It is now a year since New Jersey’s COVID-19 pandemic story began. In January 2020, the New Jersey Department of Health began meeting to prepare for the expected influx of disease based on increasing concerns generated by reports of COVID-19 in China and other countries. The first New Jersey case was reported in early March, and as many of you experienced firsthand, it led rapidly to an initial peak of disease incidence, hospitalizations and deaths in April, with the Northeast becoming the epicenter in the first few weeks and months of the pandemic in the United States. By late spring, the burden of disease on New Jersey’s healthcare system had declined substantially due to numerous policy measures implemented by State government. Many of these policy measures emphasized the only preventive tools available to us at the time, so-called non-pharmaceutical interventions, including masking, social distancing, hand hygiene and testing for COVID-19. The major goal was to flatten the epidemic curve, and these measures were sufficient to do just that.
Even as the burden of disease in New Jersey declined significantly, there were concerns that there would be a surge of disease in the State in the fall. And that is exactly what happened. Although research into developing COVID-19 vaccines had begun, with support from the federal government through Operation Warp Speed, there was uncertainty that this tool would be available before the expected surge.
Beginning in October, all measures of disease began to climb slowly but steadily, placing a significant burden again on the healthcare system, but not to the level we experienced in the spring. Over that period, New Jersey, healthcare systems and the public had procured stockpiles of PPE to deal with the surge, yet the burden of disease continued to climb in New Jersey and throughout the U.S.
During the summer and into the fall, increasing attention was given to vaccine development efforts, culminating in the announcement of results from randomized clinical trials of two vaccines developed on a novel messenger RNA platform. Both have an overall efficacy of approximately 95 percent in adults, including more than 90 percent in many demographic sub-populations, with a favorable safety profile. These studies ultimately led to the U.S. Food and Drug Administration’s (FDA’s) Emergency Use Authorization of both novel vaccines, with recommendations for their use from the Advisory Committee on Immunization Practices, along with guidance on use from the Centers for Disease Control and Prevention (CDC). There is an expectation that with more data these vaccines will receive full licensure in mid-2021, and there are more vaccines under development.
“There is a recognition that achieving community protection, also called herd immunity, will require that at least 70 percent of the adult population be vaccinated.”
Despite these seminal events, the challenge now for the country and New Jersey is implementation—from a logistical distribution perspective and the encouragement of vaccine uptake. The logistics element is complicated by cold chain storage requirements and an expected scarcity of vaccine for months, requiring prioritization decisions on who initially gets the vaccine and in what order. Regarding vaccine uptake, there is a recognition that achieving community protection, also called herd immunity, will require that at least 70 percent of the adult population be vaccinated. This is a tall order, given that best we can do for the flu vaccine in adults is about 50 percent overall and 70 percent in those 65 and over. That’s with a vaccine with which we are very familiar. Overall, vaccination rates in adults with other vaccines (e.g., hepatitis B, pneumococcal) are nowhere near 70 percent, and these vaccines have been around for years.
Clearly, there is a large segment of the population that does not want to be vaccinated under any circumstances. On the other side of the coin, there is a significant segment that will stick their arms out for a jab, as long as efficacy and safety are assured. We know from a recent AP-NORC national poll that 47 percent of those surveyed will take the vaccine, 27 percent are unsure and 26 percent will decline. The same survey found that a significantly higher percentage of women and people of color are unsure or will decline vaccination. Individuals in the latter group are the very ones who have a higher risk of disease, hospitalizations and death. What accounts for this hesitancy? And what can we do about it?
Much has been written explaining the basis of this hesitancy, including mistrust of government and science, historical research trauma, fear of adverse events, misinformation distributed through social media and cultural deficits in communication. And in the case of the COVID-19 vaccines, we have the uncertainty of the rapid development of the vaccines and the politicization of the process. This was summarized well in the recent National Academies of Science publication entitled Framework for the Ethical Allocation of COVID-19 Vaccine. As the consensus report states, ensuring demand and promoting acceptance will be challenging. If we can shift the “unsure” group into the “yes” group, we could achieve our aspirational State goal of 70 percent.
To do that, we need to address the personal concerns of hesitant individuals, utilizing the appropriate messengers who can relate to the experiences of their communities. Culturally and linguistically appropriate messages need to be provided by the right people, at the right time, through the appropriate channels and with sufficient frequency, if we hope to change behavior. And we know that getting people to change their behavior is a difficult thing to do.
As healthcare providers and leaders, your opinion resonates heavily with the public, and it can help the State educate individuals about the vaccine. The Department hopes that you will provide information to your patients and community about the importance of receiving the COVID-19 vaccine. To assist providers in answering patients’ questions, the Department has created a Frequently Asked Questions document addressing questions about safety and efficacy, and other clinical considerations and offering information on the Department’s vaccination plan.
No single event will convince people to change their minds. It will take the concerted efforts of multiple stakeholders in the public and private sectors, singing the same tune but modifying the lyrics so that people will understand the personal, family and community benefits that will be gained when large numbers of people get vaccinated when the vaccine becomes available to them. To reprise a rallying cry from a 20th-century disease outbreak: “Be sure. Be safe. Get vaccinated.” Nothing less will get the job done and quell this pandemic.
