As scientists raced to create new vaccines that would fight the novel coronavirus, Matthew Motta had a question: What did Americans expect from these vaccines?
Motta, a political scientist at Oklahoma State University who studies vaccine hesitancy, polled nearly 1,000 American adults on their expectations for the then-hypothetical shots. His peer-reviewed study, published this March in Social Science & Medicine, uncovered what he described as predictable results: Given the choice between various efficacy rates and single or multi-dose shots, the vaccine Americans would most prefer was a single dose that boasted at least 90 percent efficacy and almost zero chance of causing even minor side effects.
“It’s not too surprising that people would prefer safe and effective vaccines,” he says. But as Motta reviewed the poll’s results last year, he says he was worried because “these vaccines were never particularly likely to live up to the hype.”
And then they did.
The first two vaccines approved for emergency use authorization in the United States — shots created by Moderna and Pfizer-BioNTech using new-to-market mRNA technology — boasted 94 and 95 percent efficacy rates, respectively, shattering the U.S. Food and Drug Administration’s benchmark of 50 percent and causing the scientific community and the public alike to celebrate.
It was, Motta says, “amazing news.” But it also led him to another worrisome question: Would these spectacularly efficacious and safe shots — produced in record-breaking time — fundamentally change people’s vaccine expectations? In other words, would people come to expect that future vaccines be created as quickly and be as safe and potent as the COVID-19 vaccines?
Motta is seeking funding to find the answer. But he and other experts suspect that — at least in the short term — some people’s vaccine expectations have risen, with potentially serious consequences: Expecting quickly created, near-perfect vaccines could increase hesitancy in those already inclined to waver in their vaccine convictions if future vaccines fall short.
How people evaluate vaccines
Historically, “a vaccine for a disease was either available or not,” explains Rossi Hassad, an epidemiologist and professor of psychology at Mercy College. “Evaluating the efficacy and safety of vaccines has not been part of the public’s pre-COVID-19 psyche and vocabulary.”
For example, the yellow fever vaccine — a one-shot vaccine recommended for those traveling to at-risk areas in Africa and South America — carries a miniscule risk of severe reactions and even death. But “most people don’t know that,” says Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and a government adviser on vaccine policy. “I think most people don’t know the risks because we didn’t trumpet them like we trumpeted this.”
Amid the pandemic, however, almost all publications focused on covering the virus and potential ways to fight it, including the development of vaccines. The public could choose from dozens of articles each day relaying details of the vaccines’ development, including the potential risks they posed for those who would later decide to get inoculated.
In late 2020, Jennifer Trueblood, an associate professor of psychology at Vanderbilt University asked roughly 34,000 Americans about their willingness to take a COVID-19 vaccine. The subsequent study, published in March in Social Psychological and Personality Science, revealed that people who are risk averse were less likely to say that they would get a COVID-19 vaccine.
“What’s clear is that people are viewing [COVID-19] vaccines as a risky decision,” she says. And the public’s collective and all-consuming attention to “very specific information about the risks and rewards is shaping how people are thinking about vaccines more generally,” she adds.
A new standard?
To make decisions, many people need a reference point — information that helps them weigh the pros and cons of a particular choice. For example, if a college graduate is offered a starting salary of $50,000, she may not know whether that is a good deal. But if she learns the majority of her classmates have been offered only $30,000, then she is likely to believe that she is earning very good money.
In this way, the first COVID-19 vaccines to be authorized for emergency use in the U.S. may have set a reference point for people to evaluate future shots, says Gretchen Chapman, a psychologist and professor of social and decision sciences at Carnegie Mellon University.
Hassad adds: “The standard set by the mRNA vaccines — in terms of speed of development and the level of efficacy and effectiveness — will quite likely raise the bar in terms of public expectations: wanting more, better, and faster when it comes to … vaccines for other diseases.”
If a doctor recommends a particular vaccine, he explains, “I can hear people saying, ‘How good is that vaccine? How effective is it? Is it good for people like me? Are there any factors about my life that I need to consider?’ I think it’s just really upped the bar in terms of patient education in their personal health — which, of course, will contribute to their decision-making about health.”
The COVID-19 vaccines were also produced in less than a year. Decades of research and billions of dollars of government funding, combined with a single-minded focus from the scientific community, facilitated their swift production. But at the end of the day, what sticks for some is the headline: that a vaccine can be created and go to market in less than a year.
Offit rejects the notion that people’s vaccine expectations are shifting fundamentally, in part because he believes that people have always expected the very safest and efficacious vaccines.
But he says the quick creation of COVID-19 vaccines “should have awakened people to the fact that when you put an enormous amount of money into something, we have the scientific ability and know-how to do something as remarkable as this.”
Motta’s study, conducted ahead of the release of the vaccines’ final clinical trial results, showed that participants only had a slight preference for shots that take longer to develop: they were almost equally likely to take a vaccine that took a little more than a year to create and one that took a little less than a year to produce. “At the time, that was good news, because it meant that people were willing to take a shot that, relatively speaking, was developed quickly,” Motta says.
But he also wonders if the speed at which they were created could cause a future problem: “If a vaccine takes longer to develop, will people be less likely to take it?” Motta asks.
The answer, he says, is unknowable now. However, a national survey conducted in March by the Pew Research Center revealed that “a sense that vaccines were developed and tested too quickly” was a top concern for 67 percent of the respondents who say that they do not plan to get a COVID-19 shot. A separate April poll found that about one in five Americans say they will not get a vaccine.
Expecting a choice
The COVID-19 vaccines may have also set another reference point: that the public should have its choice among vaccines targeting a specific disease. Though many people have struggled to get their first shots, others have had the luxury of choosing which COVID-19 vaccine to get.
And for some, that choice was between what they perceived to be a better and worse vaccine.
The third vaccine to be authorized for emergency use in the U.S. was Johnson & Johnson’s shot, which scientists hailed as a success: Unlike its predecessors, the vaccine didn’t require ultra-cold storage, which meant it could potentially better reach rural communities. And its one-dose regimen could make it easier for vulnerable communities — such as those without transportation or paid time off work — to get inoculated. But when publications shared the vaccine’s efficacy rate for preventing COVID-19 infection, 66 percent, some people perceived it to be subpar. (The Johnson & Johnson vaccine trials included some of the more easily transmissible variants of COVID-19, which could have lowered its efficacy rates, but most experts agree it is an excellent vaccine.)
“There’s such a sensitivity about the vaccines and what they represent in terms of effectiveness and safety, especially since Johnson & Johnson entered the scene,” Hassad says.
And a nationwide poll conducted in mid-April by ABC News and the Washington Post found that people’s confidence in the shot plummeted when the FDA temporarily paused its distribution after six women contracted life-threatening blood clots: a majority of unvaccinated Americans — about 73 percent — said that they were unwilling to get the J & J vaccine. The FDA later lifted its pause, and recommended its continued distribution.
While the evidence is currently based on polls and anecdotal accounts, “it looks like we might be developing perceptions of a hierarchy of good versus not-as-good vaccines,” says Kasisomayajula Viswanath, a professor of health communication in the Department of Social and Behavioral Sciences at the Harvard T. H. Chan School of Public Health, “and that worries me.”
In the short term, unreasonable expectations of vaccines can have devastating consequences: By pausing the distribution of the J & J vaccine, Offit says the FDA put a “scarlet letter” on the shot — and with that red flag in place, “there are people who would have gotten that vaccine who now won’t, and because they won’t get that vaccine, they don’t get a vaccine.”
In the long term, having a choice between COVID-19 vaccines could also potentially create an “analogous phenomenon” that applies to other vaccines, whether COVID-19 boosters or other vaccines entirely, says Chapman. “If people know that a choice is possible — and especially for some savvy consumer patients who are going to read up on all the comparison points between the vaccines — it’s possible that now they’re going to come in and demand a particular vaccine.”
But overall, in the pandemic or out, “if people delay for long periods, unvaccinated, to wait to get access to what they perceive as a better vaccine, they put themselves and their communities at risk,” says Walter Orenstein, a physician and associate director of the Emory Vaccine Center.
Learning to evaluate risk
Trueblood says that people’s overall expectations of vaccines are “likely to be determined by their experiences with recent vaccines,” and that the COVID-19 shots could serve as a reference point for coronavirus boosters and even novel vaccines produced in the next couple of years.
However, it’s “really hard to tell” if those expectations will persist, she says. “It’s my hunch that they would have less of an influence as time goes on,” Trueblood adds.
Events that are similar to one another can cause people to recall specific memories: If another pandemic-causing disease emerged in a decade, “that’s going to cause people to remember this experience more,” Trueblood says. But if a novel vaccine is created to fight a different disease, under different circumstances, “it’s hard for me to believe that people’s experiences with the COVID-19 vaccines will have much of an influence,” she says.
Some experts believe looking to the upcoming influenza season could provide clues to whether vaccine expectations now will have a lingering effect later. “What I’m seeing is a year from now — when COVID-19 becomes very manageable — at that point, we will get back to the issue of flu vaccines,” Viswanath says. “And I'm wondering if people will start paying attention to them.”
Fewer than half of American adults get flu shots each year, which range in effectiveness from 40 to 60 percent. “I’m wondering now, if even more adults will say that, compared to COVID-19, the flu is really not that severe and the efficacy rates are so much lower — so why should I bother kind of a thing?” Viswanath says. Other adult vaccines are much more effective: The shingles vaccine, for example, is 90 percent effective at preventing the infection and pain.
In the meantime, the right kind of health communication is essential to helping people set reasonable expectations of vaccines — and encourage vaccinations in spite of perceived risk.
When people are oversaturated with vaccine information, targeted messages that appeal to their perceptions and beliefs are crucial, says Hassad. Motta agrees. “You can sometimes move the needle on vaccine hesitancy, pun intended, with information,” he says. “But a far more effective way to convince people to vaccinate is to make an effort to understand why they don’t want to vaccinate and then present them with information in a way that [assuages] those concerns.”