How to fight SARS-COV-2 vaccine hesitancy in patients suffering from chronic and immune-mediated skin disease: four general rules

ABSTRACT

All public health ministries have implemented strategies to contain the spread of COVID-19 worldwide. Vaccines against SARS-CoV-2 still represent the most effective weapon to combat the circulation of the virus, in order to decrease the impact of COVID-19 on the general health of the population, to prevent the emergence of new SARS-CoV-2 variants and avoid excessive hospitalization. However, the success of a vaccination campaign largely depends on the penetrance of the message addressed to general population, which takes on an even more strategic value when vaccine candidates suffer from chronic diseases. In this view, patients suffering from immune-mediated skin diseases could represent a “weak link in the vaccine chain.” Our main objective is to focus attention on four main elements in support of vaccination strategy in order to promote the patients’ awareness to be at highest risk of negative consequences in case of SARS-Cov-2 infection, and to build, strengthen and maintain trust in vaccines’ efficacy and safety.

KEYWORDS:

• COVID-19
• vaccines
• hesitancy
• dermatology
• immune-mediated skin diseases

The development of herd immunity of populations toward COVID-19 is seen as definitive solution to extinguish the COVID-19 pandemic. As herd immunity of populations is a product of several factors, including SARS-Cov-2 virulence vaccine effectiveness and percentage of the population vaccinated,¹ the development of a safe and effective vaccination for COVID-19 is seen as the most effective long-term solution to extinguish the COVID-19 pandemic.

Increasing concerns about vaccine hesitancy (being unsure about getting a vaccine) and vaccine resistance (objecting vaccines) are making their way among clinicians.

A cross-national representative survey of over 7000 participants in seven European countries (Denmark, France, Germany, Italy, Portugal, the Netherlands, and the UK) reported that across these countries 19% were hesitant (not sure) and 7% would not get vaccinated.² However, there was substantial variation between countries with vaccine hesitancy 12–28% while resistance ranged from 5% to 10%.²

At this moment, a critical challenge for clinicians is to vaccinate the highest possible proportion of the population in the context of increasing misinformation, and this is particularly true for dermatologists directly involved in assistance of patients suffering from immune-mediated and inflammatory skin disease in treatment with immunosuppressive or immunomodulatory drugs. This subset of patients could be considered fragile, at high risk to develop severe forms of COVID; thus, adherence to vaccine campaign should be considered a crucial step for them. However, the perception to be at high risk is actually low among these patients, and this should be considered a major potential pitfall driving them to underestimate vaccination.

Although fight against low adherence to vaccine campaign is a well-known history among general practitioners, dermatologists should cooperate with them as never before, sharing a strong and clear strategy whose goals should be listed as follows:

• To promote in these patients the awareness to be at highest risk of negative consequences in case of SARS-Cov-2 infection, compared to general population matched for other well-known risk factors.^3–5 The existing evidence indicates that the most important risk factors leading to severe illness for COVID-19 patients are such comorbidities as hypertension, diabetes, and obesity, which represent common comorbidities in patients suffering from immune-mediated skin diseases.⁶ In addition, it should be considered that patients with immune-mediated skin diseases often receive immunomodulant and/or immunosuppressive therapies, which may expose them to a higher risk of COVID-19 infection or a worse course of infection.⁷ In particular, with regard to biological therapies, the greatest risk of infections appear to occur with CD20 inhibition. For non‐biologic immunotherapies, the greatest risk of infection appears to occur with the use of high doses of oral corticosteroids. A slight increased infection risk is seen with cyclosporine, although cyclosporine has been shown to inhibit coronavirus replication and did not increase susceptibility in transplant patients.⁸

• To use clear and positive language in describing mode of action, efficacy and safety of vaccines. Dermatologists should discuss with their patients, addressing and talking openly about the possible adverse events of vaccines, reassuring patients that these effects are reversible and exploring how they can be addressed and mitigated. Several data from behavioral science emphasize the importance of ensuring clarity in language and reducing cognitive load.⁹ “Crisis language” could incite selfish or competitive reactions and undermine people’s sense of collective support and care among some patients,⁹ who, consequently, may not seek for vaccines. By contrast, the use of “gain-frame language” to highlight the collective gains already achieved and the benefits that could still be achieved may create more self-consciousness,¹⁰ reinforcing compliance with vaccinations.

• To build, strengthen and maintain trust in vaccines currently available through transparent communication on “what is known”, “what is not known” and “what efforts are being taken to learn more”.¹⁰ By their nature, pandemics create inconsistency and uncertainty of a temporal, spatial and normative nature. Moreover, vaccines have become available in a time frame that was not foreseeable at the start of the pandemic. In less than one year, three vaccines passed the phase III of clinical trials, received EMA authorization for emergency use in Europe, and then they are actually in post-marketing surveillance. In this scenario, data on efficacy and safety of vaccines are increasing day by day, and rapidly registered and divulgate; thus, vaccinal strategy may be tailored to certain contexts and be based on emerging considerations. This can produce inconsistencies between risk of viral transmission and adherence to vaccination. Patients’ associations engagement could exert a positive effect in reducing the negative pressure both in hesitant or opposed patients, by demonstrating that patients being heard and that their views are being considered by clinicians and other decision-makers in vaccinal campaign^11,12 and promote trust in vaccination.

• To anticipate and manage misinformation. The WHO recognized the existence of an ‘infodemic’ running in parallel with the pandemic. The term ‘infodemic’ refers to the availability of an overwhelming amount of information, which can create confusion regarding which, if any, sources can be considered trustworthy.¹³ Prebunking and debunking approaches (i.e., prepare people against misinformation before it spreads and correcting misinformation after it appears) is crucial, as misinformation about this topic is actually ongoing.

In conclusion, dermatologists should be aware about strong recommendation to suggest SARS-CoV2 vaccines to their patients with immune-mediated diseases undergoing immunosuppressive therapy, as they are categorized among vulnerable patients.¹⁴

To be successful, any vaccination campaigns toward patients with inflammatory and immune-mediated skin diseases must recognize in the dermatologist a pivotal and mediating role between the patient’s cognitive needs and the information disseminated by social media. Moreover, for this subset of patients, dermatologists, more than other health-care professional, can suggest the most appropriate vaccine for each patient.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Additional information

Funding

No funding sources have supported the work.