by Nathan A. Fisher & Margaret A. Felix
Introduction
Medical planners have long known that disease and non-battle injuries (DNBI) claim more casualties on the modern battlefield than enemy action. As the COVID-19 pandemic reminds us, not only do infectious diseases threaten the health of individual service members (SM), the operational burden associated with public health mitigations can degrade overall mission effectiveness. Moreover, isolation and quarantine can remove entire units from the fight for extended periods. In order to maintain readiness and mission effectiveness, commanders and units must take proactive steps to prevent the spread of infectious diseases, including COVID-19, within their ranks.
Vaccination is a key component of the Department of Defense’s strategy to protect the deployed force from naturally occurring and intentionally released biothreats. Despite generally positive attitudes toward vaccination, approximately one third all service members initially declined the COVID-19 vaccine. This article provides unit leaders with an overview of vaccine hesitancy, an effective framework for discussing vaccines with hesitant troops, and a summary of the pertinent science behind risk perception, safety, and efficacy of COVID-19 vaccines.
Understanding Vaccine Hesitancy
Vaccine hesitancy, defined as the declination of one or more recommended immunizations, is on the rise in the United States. Since the military is a reflection of our larger society, it is not surprising that some service members are hesitant to accept a newly developed vaccine against COVID-19. Vaccine hesitancy is not an all-or-nothing decision. Service members do not make a single blanket assessment that applies to all vaccines. A SM may enthusiastically accept one vaccine while simultaneously rejecting another. Thus, COVID-19 vaccine hesitancy does not automatically qualify a SM as “antivaccine”. Leaders should avoid terms such as vaccine denier or “anti-vax” when referring to vaccine hesitant SMs.
Multiple studies have analyzed the underlying perceptions, beliefs and attitudes of vaccine hesitant individuals. These efforts consistently identify three main factors that contribute to hesitancy: perceptions of disease risk, vaccine safety, and vaccine effectiveness. To combat hesitancy, leaders should tailor their messages to address these key factors.
A small but noticeable portion of vaccine hesitant patients also cite concerns over civil liberties as a driver of their resistance to mandatory or recommended vaccines. Service members have raised similar concerns during COVID-19 vaccine town halls, stating that they are refusing the vaccine simply because they have the freedom to do so. For these individuals, focusing on risk perception and the shared responsibility for the health and welfare of our battle buddies can be effective in convincing them to accept the vaccine.
A Framework for Discussing Vaccines with Hesitant Patients
Open, honest, and frank discussions can influence vaccine hesitant individuals. During these discussions, keep in mind that SMs may have difficulty distinguishing evidence-based health information from propaganda or junk science. It is important to actively listen to and acknowledge each individual’s concerns without disdain. Condescending responses can reinforce anti-vaccination narratives that question the integrity and compassion of scientists, healthcare professionals, and government representatives. This type of response can actually worsen vaccine hesitancy and lower vaccine acceptance rates.
The American Academy of Pediatrics (AAP) suggests using the C.A.S.E. framework when discussing vaccines with hesitant individuals. The C.A.S.E. acronym stands for Corroborate, About Me, Science, and Explain. Jumping straight to the Science, which can be natural for medical professionals and highly technical leaders, can be counterproductive:
- The conversation should start by establishing Corroboration. That is, the medical professional or frontline leader should acknowledge the service member’s concerns and set the tone for a respectful discussion.
- The leader should take a moment to establish credibility by talking “About Me.” Medical personnel should describe education credentials and what they have done to build their knowledge base and expertise. Non-medical leaders should discuss their dedication to the welfare of SMs in their charge and what they have done to learn about vaccines from credible sources (e.g., medical professionals rather than social media). During this stage, it is permissible (even preferred) to share personal stories and anecdotes.
- After establishing rapport, the leader can then discuss the Science. Leaders should focus on all three key factors identified previously: risk perception, vaccine effectiveness, and vaccine safety. The following section summarizes essential facts and suggests talking points associated with each factor. Leaders can also tailor the conversation to specific SM concerns raised in the Corroboration phase.
- Finally, the leader should Explain their advice to the service member. That is, the leader should make a clear recommendation to receive the COVID-19 vaccine based on the leader’s expertise and the science.
Video demonstrations of this communication framework are available online.
About the Science: Risk Perception, Vaccine Effectiveness, and Vaccine Safety
Risk Perception: There are two key elements to COVID-19 risk perception: risk to self and risk to mission. The first is the risk that a SM will suffer a negative health outcome because of contracting COVID-19. Due to politicization of the pandemic, most SM underestimate the health risk associated with COVID-19. Between January and June of 2021, the authors conducted over two dozen town hall sessions across the USCENTCOM AOR to educate SMs about COVID-19 vaccines. When asked to compare COVID-19 with seasonal influenza, over half of the more than 1,200 town hall attendees responded that COVID-19 was less dangerous or equivalent to seasonal influenza despite mounting evidence to the contrary.
Importantly, exclusively focusing on mortality statistics detracts from the larger discussion of negative COVID-19 outcomes other than death. The reality is that there are many long-term complications associated with COVID-19, most of which remain poorly understood. In a study of so-called “COVID-19 long-haulers”, 55% of patients suffered from fatigue, 42% experienced shortness of breath, and 34% experienced memory loss at four months post-discharge. In a separate study of NCAA athletes, a patient demographic similar to young, healthy SMs, 46% of patients with mild or asymptomatic infections had signs of heart injury. In addition to protecting SMs from death, vaccination also protects them from negative health outcomes that could subject them to Medical Evaluation Boards (MEB) and possible separation.
The second element of risk perception is the threat COVID-19 poses to the mission. Regarding risk to mission, it is useful to discuss the 2020 COVID-19 outbreak aboard the USS Theodore Roosevelt, a nuclear-powered aircraft carrier. During the outbreak, 23 service members required hospitalization and one died. COVID-19 not only presented individual risk to the crew, but also rendered the Roosevelt Non-Mission-Capable (NMC) for more than three months. This drastic reduction in operational effectiveness of a key US military asset garnered international media attention. As a result, this incident degraded public trust in military decision-making capabilities and created a possible critical vulnerability for our adversaries to capitalize on. Ask SMs to consider what their team or unit brings to the fight and how our adversaries might exploit their absence if COVID-19 were to render them NMC.
Vaccine Effectiveness: Concerns about COVID-19 vaccine effectiveness typically focus on the variability between different vaccines. When confronting this concern, it is important to explain that prevention of all cases is an unrealistic and unnecessary goal for an effective vaccine program. Instead, vaccines (1) make it less likely that service members will be infected, (2) make it less likely that service members will suffer severe disease if they are infected, and (3) make it less likely that service members will spread the disease if they are infected. Vaccines lower the rate of infection through the cumulative impact of all three of these effects across the population. (This cumulative impact is what drives herd immunity).
Based largely on publicized efficacy results from clinical trials, some SMs have developed a preference for a vaccine made by a particular company. In some cases, the SM may decline an available vaccine, hoping that the preferred manufacturer becomes available at a later time. However, comparing overall efficacy results across different trials is like comparing apples to oranges. The trials for the Janssen, Moderna, and Pfizer vaccines took place at different times, in different geographic locations, and in different patient populations. The reality is that waiting for a preferred vaccine exposes the SM and their team to unnecessary risk. All currently authorized vaccines are effective in reducing COVID-19 risk to self and to mission. SMs should be encouraged to accept whichever authorized vaccine is available.
Vaccine Safety: Most SMs do not realize the difference between “normal side effects” and “serious adverse events”. Side effects (SE) occur in over half of all COVID-19 vaccine recipients and include low-grade fever, fatigue, headache, muscle aches, and injection site soreness. These are unpleasant but temporary signs that the vaccine is activating the immune system, which is the desired effect. In contrast, adverse events (AE) are extremely rare, medically significant complications such as anaphylaxis, seizures, or cardiac problems. The Phase III trials for all FDA authorized COVID-19 vaccines were large, well-designed studies that showed an acceptable safety profile with zero deaths attributed to the vaccines.
On 13 April 2021, the U.S. FDA and CDC issued a joint statement pausing administration of the Janssen COVID-19 vaccine pending a meeting of the Advisory Committee on Immunization Practices (ACIP). The ACIP is an independent body of unbiased healthcare professionals. The pause came after six reported cases of blood clots with low platelet count, out of nearly seven million immunized; further investigation identified nine additional cases (15 total) out of nearly 8 million vaccinated. The ACIP reviewed all available data, as well as statistical modeling for COVID-19 projected outcomes and death with, and without Janssen administration. On 23 April, the ACIP concluded the benefits of Janssen vaccination outweighed the exceptionally small risk of blood clots, and approved re-initiating Janssen vaccine administration. While non-medical SMs may view this event as a safety failure, it is exactly the opposite. It is an example of the vaccine safety system working to protect citizens and SMs by identifying and thoroughly investigating an extremely rare AE.
When discussing vaccine safety, it helps to return to risk perception, by comparing vaccine risks directly against COVID-19 risks. Risk of hospitalization from COVID-19 ranges from 150 hospitalizations per 100,000 cases in 20-29 year olds to 5,100 hospitalizations per 100,000 cases in 50-59 year olds. In contrast, AEs requiring hospitalization after vaccination with the Moderna, Pfizer, or Janssen COVID-19 vaccine occurs in less than one case per 100,000. The virus that causes COVID-19 is now well established in humans; most people will eventually contract COVID-19 unless they are vaccinated. Given that reality, direct comparisons of relative risks are appropriate. In addition, emerging COVID-19 variants, such as the Delta variant, necessitate continued efforts to combat vaccine hesitancy.
Conclusion
Leaders should use the C.A.S.E. framework to structure discussions with vaccine hesitant SMs. Do not start with the science; establish rapport first by acknowledging their concerns and describing your own expertise and military history. Hesitation usually centers around three key factors: risk identification, vaccine effectiveness, and vaccine safety. Ensure that your discussion presents facts aligned with these three factors and helps SMs contextualize risks to themselves and to their mission. By embracing difficult conversations with vaccine hesitant SMs, leaders can make durable positive impacts to unit readiness while simultaneously safeguarding their troops and the overall mission.
Major Nathan Fisher and Major Margaret Felix are US Army Reservists that served as the USCENTCOM Theater Microbiologist and the USCENTCOM Pharmacy Consultant, respectively, during the 2021 deployment of COVID-19 vaccines across Southwest Asia.
Major Fisher has served in a variety of research and clinical settings including vaccine development. He holds a Doctorate of Philosophy in Microbiology and Immunology from the University of Michigan Medical School, a Masters of Business Administration from Loyola University Maryland, and is a certified Public Health Emergency Officer (PHEO). When not on reserve duty, Major Fisher works as a Senior Scientist with Noblis ESI, LLC where he advises government agencies on biological threats and biosurveillance strategy.
In the civilian sector, MAJ Felix is a Clinical Cardiology Pharmacist at University of Kentucky Healthcare. She holds a Doctorate of Pharmacy from the University of Washington, a Masters of Operational Studies (MOS) from the US Army Command and General Staff College (CGSC), and is a Board Certified Pharmacotherapy Specialist (BCPS).
The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of Noblis ESI, the University of Kentucky Healthcare System, the Department of the Army, the Department of Defense, or the US government.
