Abstract
Vaccine hesitancy is a persistent but under-prioritized issue in North Carolina. Plans are needed for systematic data collection on vaccine hesitancy trends, enhancing access to trusted sources of information, strengthening policies encouraging vaccinations, and reducing missed vaccination opportunities to inform a multifaceted strategy for reducing vaccine hesitancy in North Carolina.
Background
Individuals’ reluctance to accept vaccines is termed vaccine hesitancy [1]. Vaccine hesitancy arises from concerns about the safety and efficacy of vaccines and from low trust in individuals or organizations promoting vaccines [2]. Reduced convenience of or incidental costs associated with accessing vaccinations, and complacency toward vaccine-preventable diseases (VPDs) also contribute to vaccine hesitancy [1]. In practice, vaccine hesitancy manifests as delays in receipt of or refusal to accept vaccines, resulting in under-vaccination of individuals.
Vaccine-hesitant individuals tend to cluster geographically, hence, communities where they live are at a greater risk for VPDs [3–5]. VPDs result in the diversion of public health resources, increased economic burden, and negative societal ramifications from unnecessary morbidity and mortality [6, 7]. The World Health Organization acknowledges vaccine hesitancy as a universal and significant threat to global health [8]. Despite this global acknowledgement, vaccine hesitancy remains the elephant in the room – an uncomfortable and often controversial topic when it comes to the policies, programs, and practices to encourage vaccination. In this commentary, we discuss challenges in addressing vaccine hesitancy in North Carolina and present recommendations for mitigation strategies.
Vaccine Hesitancy in North Carolina
Hesitancy is a contributor to vaccine coverage gaps in North Carolina. According to data from the National Immunization Survey, approximately 20% of parents in North Carolina are vaccine hesitant [9]. Many parents in North Carolina choose to delay or space out vaccines for their young children as opposed to following recommended schedules. As a result, childhood vaccine coverage in North Carolina is lower at age 2 compared to kindergarten, where vaccines are required for school entry (Table 1). Among adolescents in North Carolina, uptake of the human papillomavirus (HPV) vaccine remains lower than the HealthyPeople 2020 coverage goal of 80% (Table 1). As the table shows, HPV vaccine coverage is also lower compared to other school-mandated adolescent vaccines in North Carolina (such as the TDaP or MenACWY vaccines), suggesting lower prioritization of non-mandatory vaccines and missed opportunities for prevention of HPV-related cancers. In parallel, seasonal influenza vaccination rates among individuals aged 6 months and older remain low in North Carolina, with only 1 in 2 people getting the vaccine every year (Table 1). Although vaccine coverage rates among pregnant women are not readily available for North Carolina, data suggest that only 1 in 2 pregnant women in the southern United States gets the TDaP and flu vaccine [10]. In addition, many pregnant women decline vaccines that are offered to them, suggesting concerns with vaccine safety and efficacy, rather than convenience or complacency [10]. The primary consequence of vaccine hesitancy is under-vaccination—a situation where individuals are not fully protected against VPDs. From 2013 to 2018, there were annual reports of seven VPDs in North Carolina, with significant increases in the cases of two VPDs: hepatitis A and hepatitis B [11]. A reduction in vaccine hesitancy is necessary to bridge the coverage gaps and decrease the recurring incidence of VPDs in North Carolina.
Table 1:
Trends in Vaccine Coverage in North Carolina, 2011 – 2019
| Year | Pediatric vaccines | Adolescent vaccines | General | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| DTaPa (24 mos) | DTaPb (K entry) | MMRa (24 mos) | MMRb (K entry) | Vaccine exemptionsc | Tdapd | MenACWYe | MMRf | HPVg | Fluh | |
| 2011 | 94.5 (4.3) | NA | 93.7 (4.7) | NA | 0.2 | 77.8 (5.6) | 65.9 (6.3) | 89.4 (4.0) | 54.4 (9.8) | 46.5 |
| 2012 | 95.6 (2.8) | NA | 90.2 (4.9) | NA | 0.1 | 87.9 (4.5) | 68.2 (6.4) | 93.2 (3.2) | 53.3 (9.7) | 50.1 |
| 2013 | 92.1 (4.9) | NA | 91.5 (4.5) | NA | 0.1 | 89.4 (4.0) | 72.4 (5.7) | 87.1 (4.7) | 59.3 (9.5) | 51.0 |
| 2014 | 91.0 (5.5) | NA | 89.1 (5.6) | NA | 0.1 | 92.3 (3.7) | 74.1 (5.6) | 88.3 (4.3) | 71.1 (8.1) | 52.4 |
| 2015 | 95.6 (2.8) | 97.1 | 93.7 (3.4) | 97.3 | 0.1 | 93.4 (3.0) | 78.5 (5.1) | 91.5 (3.7) | 65.7 (8.5) | 50.9 |
| 2016 | 95.9 (2.7) | 96.1 | 92.1 (4.1) | 96.2 | 0.1 | 89.1 (4.0) | 75.7 (5.6) | 87.5 (4.6) | 57.5 (6.4) | 50.8 |
| 2017 | 92.1 (5.6) | 96.8 | 92.8 (4.9) | 97 | 0.2 | 91.9 (3.4) | 84.8 (4.8) | 93.0 (3.1) | 66.8 (6.1) | 46.0 |
| 2018 | NA | 93.2 | NA | 93.2 | 0.1 | 89.1 (4.1) | 86.1 (4.6) | 92.5 (3.5) | 68.6 (6.2) | 54.9 |
| 2019 | NA | 95.5 | NA | 95.5 | 0.1 | 92.0 (4.1) | 93.2 (3.8) | 94.3 (2.9) | 71.3 (6.5) | 55.8 |
Abbreviations: NA, Not available; DTaP, Diphtheria, Tetanus toxoid, acellular Pertussis; MMR, Measles, Mumps, Rubella; K, Kindergarten; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY, Meningococcal conjugate; HPV, Human Papillomavirus; mos, months.
Childhood vaccination coverage among children 2 years old in NC, National Immunization Survey-Child (NIS-Child), birth years 2011 through 2017. Data shown for ≥3 doses of DTaP and ≥1 dose of MMR vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/interactive-reports/trend/index.html
Estimated vaccination coverage among children enrolled in kindergarten in NC, School Vaccination Assessment Program, 2009–10 through 2019–20 school years. Accessed on January 25, 2021 from https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/coverage-trend/index.html
Estimated number and percentage of children enrolled in kindergarten with an exemption from one or more vaccines in NC, School Vaccination Assessment Program, 2009–10 through 2019–20 school years. Accessed on January 25, 2021 from https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/exemptions-trend/index.html
Tetanus-diphtheria toxoids (Td) or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination coverage among adolescents 13–17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥1 dose of Tdap vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/td-tdap/index.html
Meningococcal conjugate (MenACWY) vaccination coverage among adolescents 13–17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥1 dose of MenACWY vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/menacwy/index.html
Measles, mumps, and rubella (MMR) vaccination coverage among adolescents 13–17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥2 doses of MMR vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/mmr/index.html
Human papillomavirus (HPV) vaccination coverage among adolescents 13–17 in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Data shown for ≥1 dose of the HPV vaccine (2011–15: females only; 2016–19: males and females). Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/trend/index.html
Seasonal influenza vaccination coverage estimates for persons 6 months and older in NC, National Immunization Survey-Flu (NIS-Flu) and Behavioral Risk Factor Surveillance System (BRFSS), 2010–11 through 2019–20 influenza seasons. Accessed on October 30, 2020 from https://www.cdc.gov/flu/fluvaxview/reportshtml/trends/index.html
Drivers of Vaccine Hesitancy
The drivers of vaccine hesitancy are complex and subject to temporal, contextual, and vaccine-specific influences [1, 12]. For instance, vaccine hesitancy may be lower when there is an outbreak or increase when there is a new vaccine. Vaccine hesitancy may be influenced by individuals’ family or social networks, cultural practices, religious or political beliefs, notions about individual freedoms, and negative historical experiences with vaccination, research, or health care in general. In addition, the concerns driving vaccine hesitancy may be linked to specific vaccines (e.g., influenza vaccine, MMR vaccine, or HPV vaccine), vaccine components (e.g., aluminum or thimerosal), or specific vaccination practices (e.g., administration of multiple or combination vaccines in children). Exposure to online misinformation and anti-vaccine rhetoric can exacerbate vaccine hesitancy or lead to the development of new concerns. The complexity of influences surrounding vaccine hesitancy suggests that a one-size-fits-all approach is likely to fail. Instead, these influences compel a multifaceted mitigation strategy that is tailored to individuals’ concerns.
Challenges in Addressing Hesitancy and Recommendations for Mitigation
Key challenges in addressing vaccine hesitancy in North Carolina and recommendations for mitigating the challenges are summarized here and in Table 2. The Vaccine Confidence Subcommittee of the National Vaccine Advisory Committee, established in 2019, is likely to yield additional recommendations to curtail vaccine hesitancy in the United States [13].
Table 2:
Key Challenges and Recommendations for Mitigating Vaccine Hesitancy
| Challenges | Recommendations |
|---|---|
| Challenge 1: Lack of timely data on vaccine hesitancy | Include measurement of vaccine hesitancy in routine population-based surveys to enable timely data on hesitancy trends and reasons. Conduct routine screening of vaccine-eligible populations for hesitancy in health care settings for proactive targeting of counseling interventions. |
| Challenge 2: Inadequate access to trusted sources of information | Incentivize providers to counsel hesitant individuals through reimbursement and use of quality metrics for value-based care. Modify medical and continuing education curricula to train providers on vaccine hesitancy and effective communication strategies. |
| Challenge 3: Structural barriers to vaccination | Outreach to homes or community-based vaccination sites such as schools, churches, and pharmacies to increase vaccine access. Strengthen public health infrastructure and linkages to local health departments/federally qualified health centers to bridge insurance and access gaps for rural populations. |
| Challenge 4: Ease of seeking exemptions | Reduce non-medical exemptions. Increase oversight of vaccine mandates for homeschooling. |
| Challenge 5: Complacency toward vaccinations | Implement standing orders for routine and recommended vaccines in health care settings. Use digital health reminder-recall interventions to support series completion and uptake of seasonal vaccines. |
Challenge 1: Lack of proactive, longitudinal data on vaccine hesitancy.
There are no systematic efforts in North Carolina to capture longitudinal trends in vaccine hesitancy at the local or state level. Current population-based surveys and program metrics measure vaccination coverage, which includes structural barriers to vaccination and vaccine refusals. However, the measurement of vaccination coverage does not adequately represent vaccination delays, nor does it capture the concerns behind the delays. Hence, current measurements of vaccine coverage underrepresent the true magnitude of vaccine hesitancy in North Carolina. Since vaccine coverage is a retrospective measure, it doesn’t allow the proactive identification of under-vaccinated individuals and hinders implementation of targeted and timely interventions to reduce vaccine hesitancy. Many efforts to reduce hesitancy are retroactive (e.g., once an outbreak has already begun) or untailored (e.g., provide education but do not address specific concerns at the individual level).
Recommendations.
Timely longitudinal data are needed to inform proactive and tailored interventions to mitigate vaccine hesitancy in North Carolina. Questions that specifically probe for vaccine hesitancy are beginning to be incorporated into existing periodic population-based surveys, such as the national immunization survey [9]. Similarly, the routine use of measures that screen for or predict vaccine hesitancy in primary care settings, especially during pregnancy and well-child visits, could help provide early insights into vaccination behaviors. Individuals with concerns may be targeted by health providers for tailored interventions or additional vaccine education.
Challenge 2: Inadequate access to trusted sources of information.
Health providers are widely acknowledged in the scientific literature as trusted sources of information for individuals with vaccine hesitancy [14]. For the HPV vaccine, for instance, a strong recommendation from a provider is the best predictor of vaccine uptake.[15] However, the recommendation and its strength may be affected by the provider’s own hesitancy or misconceptions toward vaccines [16]. In addition, provider shortages, short medical appointment times, and low provider training in addressing vaccine-related concerns often leave individuals with unmitigated concerns and information gaps [14]. To pursue answers to unmitigated concerns and fill any information gaps, many vaccine-hesitant individuals seek information from online sources [17]. While online sources offer the advantage of 24/7 access, the quality of information can be inconsistent and impacted by deliberate efforts of anti-vaccine entities to spread misinformation (i.e., information that is false or incomplete) [18, 19]. Hence, access to online information can increase hesitancy rather than mitigating it (Figure 1).
Figure 1:
Online Information and the Downward Spiral of Trust
Recommendations.
Increasing visit times and permitting reimbursement for additional counseling visits by providers could help reduce individuals’ reliance on online sources for vaccine information. Incorporation of performance metrics (e.g., Healthcare Effectiveness Data and Information Set [HEDIS]) on the reduction of vaccine hesitancy may also help incentivize health care organizations to support provider time and reimbursement for hesitancy screening and counseling. Relatedly, updating the medical and continuing education curricula to include motivational interviewing techniques, content about vaccines and vaccine hesitancy, and opportunities to practice difficult conversations may help train providers to successfully address hesitancy in practice. Training opportunities must also include non-clinician providers such as nurse practitioners, nurses, and physician assistants, as they may play central roles in vaccinating patients in some practices.
Challenge 3: Structural barriers to vaccination.
Barriers such as limited geographic access to providers/lack of medical home and unavailability of vaccines during clinic visits can reduce motivation for seeking follow-up vaccinations and exacerbate vaccine hesitancy. These issues are of particular concern in rural settings in North Carolina and across the United States. Many smaller medical practices or those in rural settings may experience challenges with maintaining adequate vaccine supply due to the associated costs or cold-chain limitations. There may be fewer options for individuals with health coverage from public insurance programs, for instance in practices that see very few adolescent/pediatric patients and hence do not qualify for the Vaccines For Children (VFC) program or perceive it as worth the effort.
Recommendations.
Strategies for increasing vaccine access may include the introduction of mobile/outreach vaccination services for home visits or to support community-based vaccination sites such as schools, local churches, or pharmacies [20]. Currently in North Carolina, immunizing pharmacists can only administer vaccines to individuals who are aged 18 or older, or in the case of the seasonal flu vaccine to those who are aged 10 or older [21]. As a measure of increasing vaccine access and coverage during the COVID-19 pandemic, the US Department of Health and Human Services expanded the authorization for pharmacists to administer FDA-approved vaccines to anyone aged 3 or older [22]. However, such a measure does not replace the need for a medical home for patients, or for strengthening the public health infrastructure, particularly in rural settings. Expanding knowledge of referral processes and scheduling vaccinations at the local health department and federally qualified health centers may help bridge insurance and access gaps for rural populations.
Challenge 4: Ease of seeking exemptions.
The ease of seeking exemptions against mandated vaccines can facilitate vaccine hesitancy. The proportion of families opting for non-medical (e.g., religious or philosophical) exemptions from school mandates for vaccinations is 2.5% and rising in the United States. In response, many states have tightened laws to reduce non-medical exemptions. In North Carolina, philosophical exemptions are not allowed. However, parents can apply for a religious exemption by submitting a statement of religious objection, along with the name and date of birth of the child, to the school [23]. State law does not require validation or approval of the statement of religious objection. In contrast, families applying for medically valid exemptions must submit a form from a certified medical practitioner attesting to the reasons for the exemption. This form is subject to review by the state health director [23]. Although the overall exemption rates for child care or school entry in North Carolina are low (0.1%), there is prior evidence for the clustering of children with vaccine exemptions in school settings [5]. Relatedly, homeschooling is on the rise and an estimated 14% of the K-12 student population in North Carolina is homeschooled [24, 25]. Although vaccine mandates apply to homeschooled children, it is unclear whether or how those mandates are enforced by state agencies. Anti-vaccination groups are known to promote homeschooling as a mechanism for bypassing school mandates for vaccinations, and this issue deserves closer scrutiny in North Carolina [26, 27].
Recommendations.
The Community Preventive Services Task Force recommends vaccine mandates for encouraging vaccinations [20]. In parallel, policies that reduce non-medical exemptions and increase oversight of vaccination mandates for homeschooling may help bridge some delays in vaccine uptake for children and adolescents. Notably, a bill to remove religious exemptions for vaccinations failed in the North Carolina senate in 2015 [28].
Challenge 5: Complacency toward vaccines or VPDs.
In many cases, vaccine hesitancy may be tied to complacency toward vaccines or VPDs. Complacency, in turn, can be linked to low knowledge about vaccines, or to misconceptions about vaccines or VPDs [14].
Recommendations.
Vaccine education and awareness campaigns are the key strategies for reducing complacency [29]. These strategies may benefit from proactive tracking of vaccination status and identification of individuals who are due for vaccinations but have not received them. Several studies have examined the use of electronic health record data for tracking vaccinations and phone-based reminder-recall interventions to reduce complacency toward vaccines [20]. Such interventions may be particularly helpful for multi-dose series vaccinations and those that fall outside the routine immunization schedule (e.g., flu vaccine and additional doses of the HPV vaccine). Data on the misconceptions linked to complacency could also permit more effective tailoring of education and awareness campaigns. In some cases, low vaccine uptake is a result of complacency on the part of the health provider. The use of standing orders for vaccinations has been shown to increase age-appropriate vaccinations and reduce missed opportunities for vaccine recommendation [20].
Conclusions
The failure to systematically measure and address vaccine hesitancy at a system, practice, or individual level indicates under-prioritization of this issue, both nationally and in North Carolina. Future investments must prioritize research to understand trends and reasons for hesitancy, so that timely and effective policies and programs to curb vaccine hesitancy may be developed. Without adequate attention to decrease vaccine hesitancy, societal erosion of trust in vaccines and instances of VPDs are likely to increase in the coming years.
Acknowledgments
L.V. acknowledges funding support from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number 1KL2TR002554. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
The authors would like to thank Dr. John Bartlett (Duke Global Health Institute) for his feedback on an earlier draft of this manuscript.
Potential conflicts of interest. L.V. receives grant funding from the NIH and CDC for research on vaccine hesitancy. G.S. is the chair of the Independent Data Monitoring Committee for GlaxoSmithKline for novel RSV vaccine in pregnant women, chair of the Independent Data Monitoring Committee for Pfizer for novel Group B strep vaccine in pregnant women, and receives grant funding from NIH and CDC for research involving vaccines. E.W is an unfunded co-investigator for Pfizer and Moderna vaccine studies.
Contributor Information
Lavanya Vasudevan, Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina; Assistant Research Professor, Duke Global Health Institute, Durham, North Carolina; Member, Duke Human Vaccine Institute, Durham, North Carolina; Advisor, The Duke Program on Medical Misinformation..
Emmanuel Walter, Duke Human Vaccine Institute, Durham, North Carolina; Professor, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Affiliate, Duke Global Health Institute, Durham, North Carolina..
Geeta Swamy, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina; Member, Duke Human Vaccine Institute, Durham, North Carolina..
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