COVID Cautious: Quelling New York vaccine hesitancy

To say there has been confusion around COVID-19 protocol is an understatement. The Centers for Disease Control and Prevention recently announced that fully vaccinated Americans could mostly stop wearing masks. But doubts about the vaccine fully protecting one from getting infected by one of the various COVID-19 strains and the politicization of adhering to pandemic restrictions are causing conflicts for many people over wearing masks and getting vaccinated as states across the nation transition to a new normal. Government officials and other experts too are providing unclear guidance. At a recent press conference, New York City mayor Bill de Blasio said, “When in doubt, wear a mask,” as a precaution. However, after New York released guidance stating that child care camps and day and overnight camps in New York state must obtain the COVID-19 vaccination status of all staff and children, it is becoming clear that vaccinations may become institutionalized in various ways. New Yorkers will likely need to get vaccinated to fully participate in many spheres of society. To quell vaccine hesitancy, numerous campaigns and incentives are being invoked, such as the potential lottery de Blasio is considering for vaccinated New Yorkers. Despite many New Yorkers rapidly getting vaccinated, there is still widespread wariness of the vaccine that must be resolved to get New York closer to herd immunity. 

To assess the current state of vaccine hesitancy in certain New Yorkers, City & State spoke with Wafaa El-Sadr, a professor of epidemiology at Columbia University’s Mailman School of Public Health, Dave A. Chokshi, Health Commissioner of New York City, and Syra Madad, Senior Director of the System-wide Special Pathogens Program at NYC Health + Hospitals. Responses have been edited for length and clarity.

Why do you feel there is strong vaccine hesitancy amongst certain groups in New York, and what do you think can be done to quell this reluctance?

El-Sadr: The data on vaccination in New York City show that we are now witnessing a slowing in the daily number of persons vaccinated since about mid-April. This is at a time when we need to keep the momentum so that we can get to high coverage with vaccines. This slowing means that we have reached the people eager and willing to get vaccinated and now we have to work harder at getting to those who have more of a wait-and-see attitude or have logistical constraints in getting vaccinated. I am optimistic that some of the initiatives to make it easier to get vaccinated (e.g. in subway stations, no appointments required etc.) will facilitate getting more people vaccinated. It is critical to continue the link to community groups and trusted spokespersons in order to reach those who are yet to be convinced.

Chokshi: Vaccine hesitancy should be what we call in medicine a “diagnosis of exclusion.” It means we have to cross other reasons off our list, particularly access barriers, before we conclude that someone's decision reflects hesitancy. 

We're centering the next phase of our campaign around convenience and conversations. Have we made vaccination as convenient as possible, particularly for people juggling work and family obligations? And have we ensured that their questions are answered with empathy, optimally by someone that they already trust?

We must also contend with current and historical practices that have eroded trust in medicine and government, many of them rooted in discriminatory and racist policies. 

So vaccination will move at the speed of trust. That's why we are working with trusted community partners, from faith leaders to local nurses, pharmacists and doctors—to help us build confidence. The city has thousands of outreach staff in communities to distribute educational resources on the safety and efficacy of the vaccines, we are running (Public Service Announcements) across the city, and perhaps most importantly, we are doing it all with the notion that one-on-one and small-group conversations will be the most effective in changing people's minds.

Madad:Vaccine hesitancy is a fully loaded term and can include many different factors that can cause the delay or refusal to accept vaccines. It could be due to access issues, political or religious beliefs, personal experience, distrust in the medical and pharmaceutical establishment or concerns about the process and safety profile. Vaccine hesitancy is not new, and if you were around in New York City during the 2019 measles outbreak, vaccine hesitancy and the anti-vax movement was front and center. To address vaccine hesitancy in all its forms and facets requires an all-of-the-above approach. Meeting people where they are and providing information, access and resources in a culturally-competent manner and acknowledging long-standing and systemic racism, discrimination and negative personal experiences (is important). 

Do you feel that New York will be able to achieve herd immunity at current vaccination rates, despite anti-vaxxers and other reluctant groups?

El-Sadr:It will take a lot of hard work to get to where we want to be. Keeping vaccination focus in the media, using social media, knocking on doors, taking vaccines to the people rather than waiting for the people to come to the vaccines and utilizing the richness of NYC rich civil society structures (will help). For anti-vaxxers, the challenge is bigger. Every effort should be made to address their concerns, highlighting the threats of getting COVID-19, the often debilitating long term effects of COVID-19 in some people, the personal benefits from vaccination, sharing updated information on the vaccines and stressing the need to demonize such individuals.

Chokshi: Whether we reach ‘herd immunity’ or build ‘community immunity’ that keeps rates low, the important thing is that every vaccination is another brick in the wall between us and the virus. But this next phase of our vaccination effort requires us to work even harder – all of us – to help build our friends’, family and neighbors’ confidence in the vaccines. Share your vaccination story and spread the word.

Madad:The goal of minimizing risk, and not necessarily eliminating it, can be accomplished by our ongoing efforts of vaccinations alongside non-pharmaceutical interventions. New infection rates, cases, hospitalizations and deaths from COVID-19 are all tumbling down. So, we don’t have to cross the herd immunity threshold to see progress or to end the pandemic.

What are your thoughts on the mask mandate ending? How can we deal with people who falsely claim they are fully vaccinated?

El-Sadr:It depends. Outdoors, I believe the risk of transmission is limited and unmasking by vaccinated individuals makes sense. It behooves people who are not vaccinated to continue to wear masks as this is to protect themselves. As for indoors, at present, I think beyond... knowledge of being with fully vaccinated persons, it is important to continue to wear masks even if vaccinated.

Chokshi: First, it's important to point out that the recent CDC guidance being publicly discussed as ‘mask guidance’ is really guidance for fully vaccinated people. That's an important distinction, because the guidance is rooted in the astonishing effectiveness of the COVID-19 vaccines – just about everything is safer once you're vaccinated. But I want to be clear, if you are not vaccinated, you should continue to wear a mask and take other precautions. In the relay race against COVID, we should remember that masks, distancing, and other public health precautions are what put us in the lead heading into the final leg of the race – and vaccination is what will carry us through the homestretch. That's why masking and distancing will remain important – particularly in crowded indoor settings – until even more people are vaccinated.

We also need to acknowledge that even when they're fully vaccinated, people will need time to acclimate to the new guidance. This will be a period of adaptation that's hard for us—myself included. That's OK, particularly given what we've all been through over the past year. New York City has gotten through this because we've looked out for each other and made decisions to keep our communities safe. Let's keep it up even as vaccination helps us turn the corner on this devastating pandemic.

Madad:Ending mask mandates should be tied to low levels of community transmission and high levels of vaccination rates. The science shows us how powerful the COVID-19 vaccines are in preventing infections, reducing severe outcomes and transmitting the virus to others. But it’s important to stay nimble in this pandemic. It’s not over until it’s over everywhere and if cases rise again domestically or we begin to see a threat to our vaccine-induced immunity due to variants, we should be just as quick to reinstate COVID precautions. Being able to prove who is and is not vaccinated is tricky. In the absence of proof of vaccination and relying on the honor code, our calculus becomes individual risk tolerance. For me, as a vaccinated individual and mother of 3 young children under the age of 8, I plan to continue masking and abiding by COVID-safe behavior in large gatherings and indoor environments until we reach a significantly lower new infection rates and higher vaccination status.