Biopharmaceutical companies are racing to develop a coronavirus vaccine. Blueprints for re-opening the US economy hinge on testing, treatment, and vaccination. While we wait for a vaccine, we can gain a better understanding of the behavioral and financial incentives that could achieve higher rates of vaccination.
Two vaccinations are recommended to prevent a leading cause of death for seniors: the seasonal influenza vaccine and the pneumococcal vaccine. Despite the pneumococcal vaccine’s well-documented ability to reduce death and suffering, only 42 percent of healthy people over 65 report receiving it. The vaccination rate for pneumonia climbs to 78 percent for seniors with four or more chronic conditions, which is far short of ideal. Vaccination rates are a little better for influenza, with 69 percent of people over 65 receiving the flu shot. But the pneumococcal and flu vaccines are free to seniors with Medicare and are available in clinics, pharmacies, and doctors’ offices. So what is getting in the way of universal — or at least near-universal — vaccination?
There’s another important point to remember during the pandemic: On an annual basis, roughly 60 percent of children get vaccinated for the flu, but vaccination rates are now in decline as the coronavirus has kept people indoors. New data has revealed measles vaccination decreasing by approximately 50 percent in under 24 months. As we face one pandemic, we are neglecting the life-saving vaccines we do have, setting us up for hotspots of vaccine-preventable diseases such as measles and whooping cough.
Herd immunity will reduce death and suffering from coronavirus but will require as many people as possible to be vaccinated or otherwise have resistance through past infection. Ultimately, herd immunity serves not only to protect those vaccinated but also those vulnerable who are unable to be vaccinated. Reviewing past experiences of employers, governments and private practices gives us some insight into how to increase utilization.
People know that vaccines exist, but don’t vaccinate unless their doctor tells them to. Most survey respondents were aware of vaccines for flu, pneumonia, and tetanus but would only get the vaccines if their doctors told them to. Physicians agree that patients should be vaccinated, but only 29 percent bring it up outside of well visits and often do not discuss the consequences of missing vaccines with patients. Providers should be encouraged to bring up vaccination in all visits, including telehealth, and prompted through reminders in electronic health records and quality metrics.
Scheduled appointments are more likely to be kept. When a large physician practice scheduled appointments automatically for people, flu vaccination rates increased. Large employers — particularly with high-risk employees who are in close contact with others — could proactively schedule clinics on behalf of their employees.
Mandates help, but exceptions make them imperfect. Requiring vaccines for entry into school or other organizations increases vaccination rates. However, mandates do not achieve perfect coverage because of refusal or non-medical exceptions. If a vaccine mandate is determined appropriate to protect the public health, non-medical exceptions can be reduced by requiring the requestor to attend an education session or file specific paperwork, thereby making it more difficult to file such requests.
Outbreaks motivate vaccination. People are more likely to get themselves or their children vaccinated following an outbreak of a disease. Continuous, targeted, specific publicity about coronavirus flare-ups that communicates clear consequences of harm — such as the number of deaths — would motivate more people to get vaccinated.
Provide accurate communication networks. Exposure to negative or inaccurate information about a vaccine has a strong discouraging effect that is not outweighed by positive information. Furthermore, rates of vaccine refusal tend to go up in communities that share negative or inaccurate information with each other. But when Facebook banned advertising links to fake news, the spread of misinformation declined. Community, religious, and cultural institutions play a role in sharing positive and accurate information, while private and public institutions should evaluate policies and processes that could slow the spread of false information.
Make vaccinations social. Individuals are more inclined to do something if told that others have already done it. So university students’ flu vaccination rates increased when they were told that their classmates had already received the vaccine. Using media to emphasize that most individuals are protecting themselves through vaccination can lead to increased adoption.
Account for cost and convenience. Free access to vaccines and vaccination at convenient locations — including pharmacies or workplaces — leads to higher rates of vaccination and disease protection. Waiving co-pays for required vaccines as well as having employers, care facilities, and community organizations support ubiquitous vaccine clinic locations can lead to increased vaccine adoption.
Dr. Benson Hsu is a pediatric critical care physician at Sanford Children’s Hospital in Sioux Falls, South Dakota, and he is a health innovator fellow at the Aspen Institute.