The Centers for Disease Control and Prevention had a problem: A new vaccine could save lives and end a viral epidemic that had infected millions of Americans. The immunization was safe, effective, and widely available. Most insurance companies planned to cover it. But few people were taking it.
That epidemic was human papillomavirus, or HPV, a sexually transmitted infection that sometimes causes cervical cancer and other serious conditions. In 2006, after federal regulators approved the first HPV vaccine, the CDC officially recommended that all adolescent girls be immunized. In 2011, the agency extended the recommendation to boys, too.
But uptake of the vaccine was, by all accounts, abysmal. So the agency launched a campaign to promote the importance of the HPV vaccine.
Extensive fact sheets, created by a consulting firm and released on the CDC's website, addressed parents' concerns that the vaccine would encourage their kids to become sexually active. Doctors and nurses began delivering talking points, provided by the CDC's communications team and disseminated by partners such as the Immunization Action Coalition, a foundation-, industry-, and government-funded nonprofit, that touted the vaccine's cancer-preventing qualities.
Immunizations jumped. By 2017, 49 percent of adolescents were up to date with the HPV vaccine.
That figure is still below CDC goals. But the HPV campaign, focusing on a vaccine that is entirely optional and given after early childhood, has become the subject of extensive research in the years since. And, as scientists edge closer to finalizing vaccines for Covid-19, lessons from HPV and other vaccine messaging campaigns are suddenly more relevant than ever.
Indeed, while it's possible a vaccine could be approved for public use as early as this fall, and widely available sometime next year, it's unclear how many Americans will be willing to take it. Many analysts are optimistic that an effective vaccine will be welcomed, but surveys indicate widespread suspicion. Officials appear to be preparing a response: In early July, CDC Director Robert Redfield testified at a Senate hearing that the agency has spent months developing a plan to build Covid-19 vaccine confidence, though he offered few details.
A preliminary CDC vaccine rollout plan, published in mid-September, describes good communication as "essential" to "a successful Covid-19 vaccination program," and notes the agency will "engage and use a wide range of partners, collaborations, and communication and news media channels" in an effort to reach different audiences.
"There's often this assumption that if we build it, they will come," said Kaitlin Christenson, vice president of vaccine acceptance and demand at the Sabin Vaccine Institute, a global nonprofit funded by a mix of government, pharmaceutical industry, and foundation sources. "But even the most effective vaccine is not going to produce results if it isn't taken up and delivered effectively."
Sometimes overlooked, vaccine messages — from brochures in doctor's offices to Instagram posts — are as vital to a vaccine campaign as the vaccine itself, some experts say. Over the years, vaccine messaging specialists have homed in on tactics, from those generating fear to others that evoke community values, that can boost compliance.
But results have been mixed, and fundamental debates remain over the best messaging strategies. And it's not yet clear what Covid-19 vaccine messaging campaigns — launched amid a global pandemic unfolding in the shadow of intense political polarization — will look like, let alone if they will work.
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Before the early 2000s, said Glen Nowak, a health communications expert at the University of Georgia and former communications director for the CDC's National Immunization Program, CDC leadership believed that vaccines needed little fanfare to convince the public of their value. Up until then, Nowak said, it was "assumed that vaccines will speak for themselves." Policymakers also often leaned on state day care and school vaccination mandates to win compliance.
But "telling people to do something because you say so isn't a really effective way of getting them to feel confident," Nowak added. He recalled that when flu recommendations changed to include children in the early 2000s, it became "clear that public and provider communications would be needed to foster awareness and compliance with the new recommendations." The HPV vaccine, released a few years later, underscored the idea that just posting new vaccine guidelines wasn't enough.
With the advent of Facebook and other online social media in the 2000s, anti-vaccine messages proliferated online, sharing stories of children harmed by vaccines. At the same time, more parents began taking advantage of philosophical and religious exemption policies that let them send their kids to school unvaccinated. That trend raised alarm among public health experts and created a need for persuasive messaging, wrote Xiaoli Nan, director of the University of Maryland's Center for Health and Risk Communication, in an email.
Today, the creation of vaccine messages, sitting at the intersection of marketing and medicine, can take months or years to unfold. Sometimes the process is spearheaded by vaccine manufacturers, hospitals, or pharmacies. Often, though, the campaigns are the work of government agencies trying to boost vaccine use or address looming concerns among hesitant parents.
The CDC's National Center for Immunization and Respiratory Diseases has a contract with a communications firm that develops millions of dollars' worth of educational materials and campaigns, mostly directed at flu and HPV messaging, according to Nowak. It also has its own communications team to develop materials, targeting messages based on data from the previous year about who did – or did not – have high vaccination rates.
In recent years, vaccine messaging has proliferated to include Twitter accounts, TV commercials, online ads, satirical campaigns, cartoon characters, doctor education efforts, brochures, posters, billboards, radio ads, and even dedicated YouTube channels.
What makes for an effective messaging campaign, though, is a more elusive question. Jody Tate, director of research and policy for the Health Policy Partnership, a consultancy, said effective messaging digs into survey and focus group data to understand people's reluctance — whether it's based on concerns about safety, or something more fundamental, such as a language barriers or access to medical care — and then tailors itself accordingly.
Who delivers those messages is also crucial, Tate said. Overwhelmingly, surveys find that doctors and nurses are the most trusted sources of vaccine information. A 2018 Wellcome Global Monitor survey found that roughly three-quarters of adults around the world trust their doctor or nurse ahead of family and friends, religious leaders, and celebrities. Doctors "are the ideal messengers," Nan wrote.
Rejecting the flash of some advertising, many experts favor a simple, fact-based approach. And simple messages, repeated often, can potentially be effective, said Christopher E. Clarke, a health and environmental risk communication scholar at George Mason University. (Indeed, in a metanalysis of 14 years' worth of influenza-related communications by the CDC, Nowak found that "visible and frequent reminders" raised vaccination rates).
Experts are divided, though, on whether a straightforward tell-the-facts approach is really enough. "There is growing evidence that traditional communication of vaccines — e.g., messages focusing on statistics — has not worked well," Nan wrote. "More successful strategies," she added, "rely on trustworthy messengers, telling stories rather than using statistics, and appeals to moral values."
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In 1999, when Nowak, then director of communications for the CDC's immunization program, looked at why more people 65 years and older weren't getting the flu vaccine, he discovered they didn't think the CDC's fact-based materials — which urged high-risk groups, including the frail and elderly, to get vaccinated — applied to them. They were, after all, in their 60s and 70s. They weren't frail or elderly, they told Nowak in focus groups. They were healthy and active.
Positive framing has proven, in some cases, to work well. A study published this May, which looked specifically at HPV vaccine messaging, found that negatively worded messages could actually increase the perception of risk associated with taking vaccine itself. "Negative messaging was not a good way to communicate," said Porismita Borah, an author of the study and an associate professor of communications at Washington State University. Kelly Moore, associate director for immunization education at the Immunization Action Coalition (IAC) and a former CDC adviser, said that "fear and uncertainty can lead to inaction."
Instead, she said, "it is messages that are positive — messages of hope and optimism and empowerment — that encourage people to take action, because they believe that by what they are doing, they can change their destiny."
But some experts argue that fear can offer a more effective push. The chickenpox vaccine was licensed and recommended for all children in 1995. But its uptake was poor for the first few years, said Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia and a frequent government adviser on vaccine policy who also helped invent a rotavirus vaccine that is produced by Merck.
"I think people thought of chickenpox as a benign right of childhood passage," he said. But as many as 13,000 people were hospitalized and 150 people died each year in the early 1990s as a result of chickenpox — and the vaccine's maker, Merck, used those figures to create a more aggressive advertising TV commercial campaign, which included interviews with parents who had lost children to chickenpox. "It was dramatic, and they were criticized for that," Offit said. But the campaign, in conjunction with increasing public school mandates, also worked: By 2014, 91 percent of U.S. children 19 to 35 months old had received one dose of the vaccine.
Similarly, HPV vaccine messaging has sometimes preyed on people's fear: In 2016, for example, its maker, also Merck, ran ads that featured adults with cervical cancer, asking their parents if they knew a vaccine could have prevented it. Some research suggests that, at least when it comes to the HPV vaccine, anticipated regret can be a powerful motivator.
"What convinces people?" Offit asked. "Sadly, I think fear is more powerful than reason."
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Some vaccine messaging campaigns simply fail. And some messengers can also endanger messaging campaigns.
In 2002, fearing that terrorists would use smallpox as a weapon, President George W. Bush ordered half a million military members to be vaccinated against the disease before launching a voluntary program for health care and emergency workers the following year. Amid concerns that the vaccine wasn't safe, he had himself vaccinated and announced it to the press.
But fewer than 40,000 health care workers accepted vaccination. Some people still didn't feel the vaccine, which can cause rare but serious complications, was safe. The administration didn't consult with doctors, critics say, and didn't anticipate that politics would play a role in people's decision to be vaccinated. The program was launched just months before the U.S. went to war with Iraq, and many liberals believed the vaccination campaign was propaganda.
Today's climate poses a distinctive, uncharted challenge: No other vaccine has been made at such breakneck speed, amid such publicity, and with such political division, said Clarke.
"There is no precedent for" this challenge, he said.
With at least several months likely remaining until the most ambitious Covid-19 vaccine will potentially go to market, a recent Gallup survey found that around one in three Americans say they would not get a free, FDA-approved Covid-19 vaccine. Surveys also suggest that Black Americans are more hesitant about the vaccine than White Americans — potentially a legacy of longstanding discrimination against Black people in the health care system.
Partisanship matters, too. The Gallup survey also found that only around half of Republicans currently plan to take the vaccine when available. The country has been divided along partisan lines on many preventative measures against Covid-19. That "political divide will likely spill over to the upcoming Covid-19 vaccine," warned Nan, who, like Clarke, believes tailoring messaging to people's political or religious views could be essential to uptake. While other kinds of public messaging campaigns match messages with the receiver's worldview, Nan explained the technique has rarely been used in vaccination messaging.
But Graham Dixon, a science and risk communication professor at The Ohio State University, said that a Covid-19 vaccine messaging strategy that presents a consensus not only in the scientific community, but among policymakers, could be effective in increasing vaccination. "There has been a great deal of political polarization in this issue," he said, "and it's almost inevitable that people's decision to get a Covid-19 vaccine will land in the same way if we don't create a messaging strategy that emphasizes a depoliticized message."
In the past, other messaging campaigns have drawn on anti-polarization strategies to try to build consensus around contentious issues. A climate change awareness campaign from 2008, for example, featured famous political adversaries — including the left-wing pastor Al Sharpton and the right-wing evangelist Pat Robertson — sitting together on couches, talking about their shared concern about the environment.
"If and when a Covid-19 vaccine becomes available, messaging should be consistent across the political spectrum, and in a perfect world should feature influential leaders from the Republican and Democratic parties," Dixon wrote in a follow-up email. But, he added, it was probably "wishful thinking to believe that Joe Biden and Donald Trump would appear together in a PSA encouraging Covid-19 vaccination."
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Despite what Redfield has described as months of planning at the CDC for how to build vaccine confidence, it's unlikely the agency will unveil official campaigns until a vaccine goes to market.
Asked in July for details about its plan, a CDC spokesperson sent Undark a link to the agency's existing framework for vaccinating with confidence and referred further questions to the U.S. Department of Health and Human Services. HHS declined repeated requests for comment and provided only unattributed information via email, writing that Operation Warp Speed (OWS) — the federal initiative to deliver 300 million doses of a safe and effective Covid-19 vaccine by January 2021 — is committed to "maximum transparency."
Since then, CDC has released some additional details of the campaign as part of a 57-page "interim playbook" that outlines vaccination plans for local and state public health officials.
Some journalists, legislators, and scientists have accused OWS of a lack of transparency about its process for selecting vaccine candidates. That opacity, critics say, exacerbates concerns over any potential vaccines' safety and efficacy.
If the operation's name foreshadows more messaging from government agencies, experts caution there is reason to be wary. "The term 'warp speed' was an unfortunate term," Offit said. That particular message, he said, suggests corners are being cut to create a vaccine.
"Constantly saying you're going fast makes people think you're going recklessly fast," said Arthur Caplan, a medical ethicist at New York University's Grossman School of Medicine.
Beth Bell, a clinical professor of global health at the University of Washington and member of the CDC's Advisory Committee on Immunization Practices, said she's not sure how the name came about. (The committee is not directly involved in the nuts and bolts of vaccine messaging.) "I think those of us who are looking at recommendations are quite serious about not cutting corners and not sacrificing safety for speed," Bell said.
To convince Americans already concerned about vaccine safety to take a vaccine developed at record — or warp — speed, transparency will be key: "Loud and clear throughout this period of preparation, and when a vaccine is available, it's going to need to be very clear what we know about the vaccine, and frankly, what we don't know," said Jason Schwartz, a health policy scholar at Yale University.
Experts believe that vaccine messaging that presents more information — even if that information is incomplete, or changes as more evidence emerges — can sway people toward vaccine confidence. "I understand why members of the public are skeptical and hesitant right now," said Moore, the Immunization Action Coalition staffer, during a conversation in July. "Someone recently asked me if I would take the first vaccine that rolls off the line, and I said, 'I would like to see the data and then I'll make my decision.' If that's my approach, then I respect others for having the same approach."
Nonetheless, experts hope that a safe, effective vaccine — and any messaging that accompanies it — will be welcomed by the majority of Americans who will have to receive it to reach herd immunity.
"I'd like to think it would be like the end of the movie 'Contagion,'" Offit said, "where everybody's lining up to get this vaccine."
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Jillian Kramer is a journalist whose work has appeared in The New York Times, National Geographic, Scientific American, and more.