As an infectious diseases physician, I find it hard to talk to my patients about vaccine refusal.

When a safe and effective intervention is provided at no cost, in the setting of a global public health threat, why would a reasonable person refuse it?

Addressing fear and misinformation

My response has often been emotional instead of objective.

As we approach the point in the COVID-19 pandemic when under-vaccination begins contributing to prolonging the duration of the negative impact on society, I need to understand the reasons behind vaccine refusal more clearly.

My role should be to address fear and misinformation with transparent reassurance and truth.

Today, the global COVID-19 daily death rate has fallen slightly below one per million, and the reproductive rate remains slightly above the critical value of 1.0 new cases/case, indicating ongoing growth of the epidemic.

“Constant evolution in disease control tools, public health policy and social change has created fatigue.”

In Canada, the fifth wave has started, the Omicron variant has emerged and 770 Canadians per million have died of COVID-19. Seventy-six per cent of Canadians and 43 per cent of the world are now fully vaccinated against COVID-19.

The spring of 2021 saw a rapid uptake of vaccination in Canada, and the pace of increase has slowed considerably, yet continues to rise. Governments and industries have implemented vaccine regulation, which has increased vaccine uptake.

Being a rapidly evolving outbreak, COVID-19 has created distrust of the pace of scientific discovery. A pandemic provides a unique opportunity for to focus on a single threat, leading to an explosion of advancement which we are proud to achieve.

However, constant evolution in disease control tools, public health policy and social change has created fatigue.

Smallpox vaccine resistance

Vaccination is a scientific breakthrough that has become a political problem, dividing families, threatening the security of hospitals and further isolating people.

The mechanism of vaccination is the induction of protective immunity at lesser risk than infection, which is the way vaccines are evaluated and licensed.

“People refuse vaccination for complex reasons, which the scientific world is beginning to explore.”

Edward Jenner (1749-1823) faced resistance to his smallpox vaccination in London based on fear of harm, but smallpox eradication was achieved, using only vaccination.

People refuse vaccination for complex reasons, which the scientific world is beginning to explore. Some refusal is based on lack of information, including uncertainty about vaccine safety or effectiveness.

This refusal may be addressed with evidence, if presented sensitively and objectively. Some refusal is based on misinformation circulated on social media, in which traditional sources of scientific evidence have been replaced by opinion or reputation or policy decisions.

During a threat to security that can be compared to a war, decisions must be made in the absence of complete evidence, and these decisions create inconsistency which erodes public trust.

Some refusal is based on anti-science aggression, political motivation or deliberate manipulation, all considered disinformation.

Lost generational memory

It is hard to imagine that in 1900, global life expectancy was only 32 years, and is now 69 years.

Progress in public health is created using interventions such as vaccination, considered among the most cost-effective means available to advance global welfare.

In Canada we enjoy freedom from tetanus, polio, diphtheria, Haemophilus influenza B, smallpox and rubella because of vaccination.

Ironically, vaccination may be too successful, causing us to lose generational memory of the harm caused by these diseases, and adopting complacency regarding the need for ongoing vaccination.

“Serious adverse events are more common following COVID-19 infection than following vaccination.”

After 95 doses delivered per 100 people globally, the accumulated evidence on COVID-19 vaccine safety and effectiveness is very strong, in fact stronger than the evidence that we have for most medical treatments.

Following vaccination, local pain or fever is common, indicating immune activation. Serious adverse events are extremely rare (anaphylaxis 5/1,000,000 doses, myocarditis 40/100,000 person years).

Serious adverse events are more common following COVID-19 infection than following vaccination.

Initial COVID-19 vaccine clinical trials demonstrated 95 per cent effectiveness at prevention of death due to COVID-19.

Real-world evidence since regulation has confirmed 90 per cent effectiveness at country level, including the Delta variant, to prevent death.

Death is the most important prevention outcome, but vaccination also reduced risk of COVID-19 infection by 91 per cent among 3,975 health-care workers tested weekly for 17 weeks.

Vaccine development for more than 20 years

Although COVID-19 is the first clinical application of messenger RNA (mRNA) vaccine technology, this approach has been under development for more than 20 years.

mRNA is a natural, temporary instruction from the cell’s genes to the cell’s ribosome to create a protein, like a “text message.” Following vaccination, the human cell produces viral spike protein, which induces a memory immune response, like during actual infection.

Neither mRNA or viral protein last longer than days, nor influence cellular genes. Being a novel mechanism and lacking years of safety data, it is expected that patients have reservations.

The previous false association between MMR vaccine and autism and other chronic autoimmune conditions has created fear of long-term vaccine toxicity.

There have been vaccines developed that have been associated with serious toxicity, but these did not pass the scrutiny of regulatory bodies.

Sometimes serious illnesses occur after vaccination, but at the same rate as among unvaccinated populations, and these associations create false concern.

A public decision

Some argue that vaccination is a personal choice, which should not be mandated. Some health choices are personal choices, such as taking diabetes treatment.

Some health choices are public choices, influencing the health of people who are not making the choice, such as cigarette smoking, which also causes lung cancer among non-smokers.

Vaccine-induced immunity within a population reduces COVID-19 transmission according to the percentage immune, protecting the community and allowing the reduction of public health restrictions.

“This argument considers the health of the individual more important than the health of the vulnerable members of the community.”

Vaccination is therefore a public decision, based on the assumption that no one is completely socially isolated.

Some vaccine refusal is based on perception of a low personal risk of infection. This argument considers the health of the individual more important than the health of the vulnerable members of the community.

The perception of personal risk may also be biased by lack of complete information about local virus transmission or denial of evidence.

Some vaccine refusal is based on religious beliefs. Christian faith and history prioritize service to humanity and commitment to health care and scientific discovery.

Jesus healed the sick and told a story of a Samaritan who acted kindly toward a stranger.

Many infectious diseases outbreaks have been associated with vaccine refusal among religious groups, including COVID-19 in church groups in Canada.

Vaccines benefit us all

I hope that objective information is useful, and I recommend the reliable COVID-19 information available here and here.

I welcome in-person interactions with patients regarding COVID-19 vaccination.

I don’t want controversy or emotional language, but I do want people to understand that vaccine is safe and effective, and that vaccine is an important tool that will contribute to ending the pandemic, to benefit all of us.

Let’s work together.