Time to come clean about COVID-19

Bring back 'may' versus 'should' language to restore trust

RATES OF COVID-19 vaccination in this country are too low. Less than half of those over 65 have received a second booster and, among children under 5, the rate of vaccination with any dose is in the single digits. Uptake of the new bivalent booster is worryingly slow, with just 31 million Americans (10.1 percent of those eligible) having received it despite the Biden administration having ordered over 170 million doses. In a recent poll by the Kaiser Family Foundation, only a third of adults said they had received the new booster or planned to. Perhaps we should have expected this for COVID. After all, these are novel vaccines that were developed and rolled out under highly politicized conditions. But childhood vaccination rates for other conditions, including influenza, polio, and measles, are dropping as well, suggesting that people who would have vaccinated their children in the past are starting to think differently about vaccines. In addition to being a critical public health concern, this represents a serious issue with trust in public health authorities and their messengers. And it is these “science communicators” who need to take ownership of their messaging failures and fix the problem before it is too late.

To be clear, misinformation surrounding vaccines has had a damaging impact on vaccine acceptance. Claims that have absolutely no basis in reality, such as the presence of microchips in the formula, or the ability of the vaccine to make you magnetic, somehow gained traction among a proportion of Americans who believe those lies. Certainly, there also was already a base of true “anti-vaxxers” – often naturopathy-inclined politically left-leaning people in the years before COVID-19 vaccines came on the scene, and primarily far right-wing followers of Donald Trump since COVID vaccines became available. But it cannot be true that the over 90 percent of parents of children between the ages of 6 months and 5 years who haven’t opted into vaccination are anti-vaxxers, or even that they have fallen prey to nefarious misinformation spreaders. The messaging from public health authorities, government officials and doctors and scientists like us who speak to the media is simply not working. What could we do better?

We can and should tout the amazing success of vaccines at preventing severe disease while simultaneously acknowledging not only their shortcomings at preventing infection and transmission, but also the many unknowns that exist about these vaccines at any given moment. For example, though the time was right to update the vaccine to cover the currently predominant strain, BA5, we must be transparent about the fact that we do not have human trial data to inform efficacy estimates nor do we know exactly who stands to benefit from the new boosters. As much as it might be desired, a simple message is not always an honest message, and truth is paramount to trust.

We must acknowledge the power of immunity from prior infection, the steep age gradient of risk for severe disease from COVID, and the preserved T cell immunity that still prevents severe disease in a large proportion of society even when protection against infection wanes. Admitting uncertainty about which demographics will experience a reduction in hospitalization and death (which is, after all, the stated goal of the vaccination program) also means conceding that vaccine passports and mandates can’t be relied on to make places “safer” from transmission. Claiming they do erodes trust. Further, vaccination and prior infection appear to reduce transmission by the same amount (~20 percent).

A May 2022 WHO policy brief entitled “COVID-19 and mandatory vaccination: ethical considerations” stated that “the World Health Organization (WHO) does not presently support the direction of mandates for COVID-19 vaccination.” CDC would do well to now issue something similar, given that anger from those who oppose vaccine and booster mandates in places with low-risk populations like public schools, colleges and universities has caused unnecessary rifts in society, distracting from other public health goals. The public quickly loses faith in health experts when the rules they impose don’t make sense, and it is abundantly clear that vaccinated and boosted individuals are becoming infected at a high rate. In fact, hybrid immunity (a combination of vaccination plus infection) reduces transmission better (~40 percent) than either vaccination or prior infection alone. Messaging on this should be clear, direct, and not favor one form of immunity over another.

To improve rates of vaccination for all preventable infectious disease, we propose a solution: a campaign of honesty. This campaign would eschew fearmongering claims such as the need to vaccinate children because so many of them are dying (fear is not an effective public health tool and death from COVID is still, thankfully, rare among children). It would not overstate the truth by using phrases such as “get vaccinated to protect grandma,” but rather would center on honesty above all. An appropriate message would be: get vaccinated/vaccinate your children because, even for those without risk factors, and even though the vaccine won’t provide durable protection from infection, it might prevent the rare case of severe disease. For those between 16 and 30, we don’t know for sure whether the benefits of repeated boosters (on top of the original vaccine series) outweigh the risk of myocarditis, especially for males and especially for those with prior COVID, but we are working on it and will come back with the data when we know.

When the first boosters rolled out a year ago, the CDC used “may receive” versus “should receive” language to differentiate the populations for which their recommendations were strong and evidence-based (e.g., people over the age of 65 “should” receive a booster) from those for whom they wanted to make the booster available but were not certain of its benefit. At a subsequent meeting of the Advisory Committee for Immunization Practices, a non-voting representative gave feedback that such language was confusing physicians and the public, and the approach was, permanently it seems, retired. We believe it is time to bring back “may” versus “should” language as part of a commitment to honesty, full transparency, and restoration of trust and vaccine acceptance.

Current rates of vaccination across the US population, not just for the COVID-19 vaccine, are unacceptable. There are counties in New York with <40 percent vaccination rates against polio among children 2 years of age and younger. An ongoing measles outbreak in Ohio shows us what can happen in an undervaccinated community.

Meet the Author
Meet the Author
We can and must reverse the loss of trust in public health and its messengers. An honesty campaign would be an important and effective first step in the right direction.

Shira Doron is is an infectious disease physician and hospital epidemiologist at Tufts Medical Center. Monica Gandhi is a professor of medicine at the University of California – San Francisco.