>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living, and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> The first vaccine was developed for smallpox.

That was in 1796.

And with the use of this vaccine, smallpox went on to become eradicated worldwide.

For centuries, vaccines have been used to combat millions of deaths caused by pathogens.

But now, the World Health Organization has identified vaccine hesitancy as a leading global health threat.

Joining us today on "Second Opinion," primary-care physician from the University of Rochester Medical Center, Dr. Lou Papa... >> When I sit down with patients that are hesitant or even resistant or anti-vaxxer, I'll explain to them, they've been coming to me for years trusting the science, and this is all about trusting the science.

>> ...international infectious-disease and public-health expert, Dr. Rupali Limaye from Johns Hopkins... >> It's all done by independent individuals, again, looking out for the best interests of the community of, "How do we reduce morbidity and mortality and protect the health of the public?"

>> ...and world-renowned vaccine expert and professor of pediatrics, Dr. Paul Offit from Children's Hospital of Philadelphia.

>> The beauty of science, in many ways, is that it's circumspect.

As more and more data become available, then recommendations can change.

But I think for the general population, they see that fluidity as disconcerting.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

Thank you, doctors, everyone, for being here with us today.

Lou, I want to start with you, because I think it's important to talk about the difference between vaccine-hesitant and anti-vaccine.

>> Right.

>> For our conversation today and just, I mean, in general, for public health.

>> Yeah, good point.

So, anti-vaxxers, as they've been come to call, are individuals that just have a general distrust of vaccines and the science behind it, and they feel that they are inherently dangerous, whereas vaccine-hesitant are a group of people that have more questions.

They have some distrust, but they also are open to some discussion.

>> Alright.

Dr. Limaye, you are an expert in public and international health, as well as vaccine behavior and decision-making.

What are the main reasons that we're seeing for being vaccine-hesitant?

>> It's a great question.

And I think they have shifted a little bit over time, particularly within the context of COVID.

Pre-COVID, we heard, essentially, four main reasons as to why individuals did not want to get a vaccine.

One had to do with vaccine ingredients.

The second was related to vaccine side effects, i.e.

the misperception that vaccines could lead to autism.

The third was related to the vaccine schedule.

And the fourth was really low levels of risk perception.

People had not heard of many of the diseases that vaccines prevent, and they did not think that they were severe enough to warrant an action, i.e.

getting a vaccine.

That shifted slightly during the context of COVID.

We still hear all of these issues, but the larger issue now that we're hearing is a really a distrust in the healthcare system, and that really goes hand in hand with many communities of color because of historical experimentation and issues related to current racism, but also issues with regards to just lack of understanding and clear communication of the process related to vaccine development and rollout.

And so it's become really multifaceted, with misinformation also playing a role.

>> I want to talk about a lot of those things, but Dr. Offit, I want to ask you about this 2020 analysis of CDC immunization data.

It found that parents of more than 1/3 of U.S. children ages 19 to 35 months were not following the recommended early-childhood immunization schedule.

As a professor in pediatrics and an expert in infectious diseases and hesitancy, like, you're really at the forefront of this issue.

Let's talk about the dangers not just for those children who aren't getting the vaccine, but for other children and as a public-health issue.

>> Sure.

Well, it's a crowded schedule.

I mean, you know, children get vaccines to prevent 14 different diseases in the first few years of life.

They get another three vaccines in adolescence.

So it's a lot of shots in a relatively short period of time.

It's hard to keep it all straight.

So there always is gonna be, I think, some lag just generally.

But you're right.

I mean -- And certainly over the past year, you know, with the pandemic, there was a major dropoff in vaccines, for example measles-containing vaccines, polio vaccine.

That clearly happened.

But I do think what's happened is, to some level, vaccines are a victim of their own success.

Not only have we largely eliminated measles, we've eliminated the memory of measles.

I mean, measles made you sick.

Anybody who lived through measles -- and I'm of an age where I had measles -- knows how sick that virus can make you.

I mean, 50,000 children would get hospitalized every year with measles.

500 children would die every year from measles when measles infected the lungs or measles infected the brain.

I think it's that we've eliminated the memory of these diseases is probably what we suffer from the most in some ways.

>> So, take us back.

What happened with that MMR vaccine so that parents are still to this day thinking that that original study that was done, which has never been able to be replicated, is still meaningful?

>> Right.

So, this was a British researcher named Andrew Wakefield, who, in 1990, published a study -- It wasn't really a study.

It was a case series.

Nothing was studied.

It was just 12 children, 8 of whom had developed autism within a month of receiving the vaccine.

I mean, that's not a study.

I mean, you might as well have published something saying that, "Here's eight children who developed leukemia within a month of eating a peanut-butter sandwich."

I mean, that's no sense of proof.

And, so, what happened was, subsequent to that, about 18 studies were done in seven different countries on three different continents, looking at children at who did or didn't get the MMR vaccine to show that there was no greater risk of autism in a vaccinated or unvaccinated group.

But he held sway.

I mean, what he had done was, he stepped forward and he had said, "Look, here's this disorder, autism, which is -- It's difficult, and we don't know what causes it.

It's financially burdensome.

It's emotionally burdensome.

I have the reason for it.

It's that vaccine.

So if you don't get the vaccine" -- or, he argued, "If you separate the vaccine into its three component parts, you can avoid autism."

You know, he was well-spoken.

He was handsome.

He was charismatic.

He had a British accent.

I think, you know, he came to the United States, where we love that British accent.

I think we're willing to give ourselves back to the queen at this point.

So, he was on every major news program.

There was actually a biopic about him starring Hugh Bonneville, you know, the Earl of Grantham from "Downton Abbey."

I mean, you know, as scientists, we are way too boring and unattractive to ever have biopics made about us.

But he had a biopic made about him.

So, we just have been dealing with the fallout from that ever since.

It's very hard to un-scare people.

For all the studies that you do, it's hard to un-ring the bell.

>> So, Dr. Limaye, fast-forward.

Now here we are, COVID-19.

You have that association with the MMR, you know, with the autism.

What are we -- Is there a similar -- any kind of similarity to what we're seeing now with COVID-19?

>> I think, in that same way, what we're seeing is that we've been living in an uncertain time for a long period of time.

People want to reduce that uncertainty in any way they know how, so what we're seeing within the context of COVID is that individuals are really linking and liking conspiracy theories in the same way that individuals believe this fraudulent study.

And that's simply because people are uncertain.

They feel as though their governments might not have been transparent with them.

They feel as though recommendations are changing.

And so it's a congruence of all of these factors that really lead people to search for things like conspiracy theories and other misinformation as a way in which to make decisions about vaccines.

>> So, I think part of the issue, too, is people's hesitancy to understand how vaccines are developed.

And help us understand how vaccines are developed.

>> Right.

So, there's a number of different strategies you can use to make a vaccine.

You can take a virus, for example, and weaken it so that it can reproduce itself in the body enough to induce an immune response which is protective, but not enough to cause the disease.

So you can have the immunity induced by natural infection without having to pay the price of natural infection.

So that's sort of that approach.

A live, weakened viral approach is how the measles vaccine is made, the mumps vaccine is made, the rubella, or German measles, vaccine is made, the chicken-pox vaccine is made, one of the Rotavirus vaccines is made.

Or you can take a virus, a whole virus, and completely inactivate it with a chemical.

That's the way the polio vaccine is made or the hepatitis A vaccine is made.

Or you can take just one protein from the virus.

Just one protein that typically sits on the surface of the virus.

That's the way the hepatitis B vaccine is made or the human papillomavirus vaccine is made.

What's different about this vaccine, what's novel about this vaccine is, none of those approaches were used.

The so-called messenger RNA approach was novel.

It's the so-called -- It's the first in the era of genetic vaccines.

So, now what you do is, you take a small piece of genetic material called messenger RNA, which is the blueprint for how to make a protein.

In this case, it's the SARS-CoV-2 surface protein, or spike protein.

So, then that gene enters the cytoplasm of your cell, not the nucleus.

It then enters the so-called ribosomal system, where it's translated to a protein.

And, so, your body makes the viral protein, and then your body makes antibody responses.

But I can see how -- and Dr. Limaye alluded to this -- how that could be worrisome to people, right?

It's a genetic vaccine.

And people hear that and they think, "It's gonna alter my genes.

It's gonna change my DNA."

So I think it's been a little scarier in that sense.

>> But they have to go through many, many studies, and a lot of people think this happened so fast, but correct me if I'm wrong.

This new technology with the MMRA -- it's been going on -- These studies have been going on for years, right?

So that they were in a good place to put it into action with this particular virus.

>> No, that's exactly right.

So, if you look at sort of the Pfizer-BioNTech vaccine, that was based on work done by Drew Weissman and Katalin Karikó, actually, at the University of Pennsylvania starting more than 15 years ago.

So there's a lot of experience with this technology.

But you're right.

I think it was -- This vaccine was developed quickly.

I mean, it was certainly the fastest vaccine ever made.

We had this virus sequenced and in hand last January, and within 11 months, we had two large clinical trials.

No vaccine has ever been made that quickly, and I think that did scare people.

Plus, some of the language that surrounded it, like Operation Warp Speed, scared people that made maybe timelines were being truncated or, worse, that vaccine safety guidelines were being ignored, which wasn't true.

But you can see where people might have felt that.

>> Sure, because those are the words that get used in the headlines, as opposed to the fact that this has been years in the making.

And, Dr. Limaye, once it goes through -- I mean, all vaccines have to go through all of these, you know, series of different studies.

Then comes the time for the public-health decision to be made and how you can get compliance.

So talk to us about that part of the bringing it to the public.

>> Yeah, and I think Dr. Offit makes a very, I think, strong and important point here, is that simply because it's going through -- And at this point, it went through an EUA, which is the Emergency Use Authorization mechanism.

That's simply because we're in the middle of a pandemic.

There's no steps that are missed.

They essentially overlap some of the phases with regards to the development process.

And with regards to looking at and examining the safety data, as well as the efficacy data, that is done by an independent board of scientists.

So those are people in your community that people likely know.

They are not individuals that were involved in the development of the product itself.

And they are the ones that make the recommendation, based off of the data that they have in front of them, whether or not this vaccine should be brought to market.

That then goes through another committee, and, essentially, it's a number of regulatory steps is what I would say, but it's all done by independent individuals, again, looking out for the best interests of the community of, "How do we reduce morbidity and mortality and protect the health of the public?"

>> Now, if that had been, Lou, exactly what everybody would have heard... >> Right.

>> ...maybe they would have felt differently.

I mean, you're listening to all of the studies and the controversy and the debates.

It's easy to understand how a lot of people are just completely -- >> Absolutely.

>> They just don't understand all this, and, therefore, they become hesitant.

What do you think is the best way to try to advise individual citizens so that they make the decisions that would be in their best interest?

>> Well, that is exactly the role of a primary-care doctor.

>> I knew you were gonna say it.

I led you right to it.

>> And it's interesting, because there was a survey that was done.

CVS did a survey, and they found that what got people to decide to get the vaccine was public-health information was important.

Direct information from Dr. Fauci was even more important.

But the most important -- and this was the quote from one of the lead surveyors -- the most important individual to help them make that decision was the primary-care doctor.

And part of that is, when I sit down with patients that are hesitant or even resistant or an anti-vaxxer, I'll explain to them, they've been coming to me for years trusting the science, and this is all about trusting the science.

You know, the vaccine -- The thread to get to a vaccine is really the same biology.

We're just at a different point.

And there was just a study that came out that showed that each iteration of our vaccines over the -- Just in the last 5, 10 years, each iteration is safer and more effective.

It's one of the most important public-health interventions we've ever had was vaccines.

>> And we never expected the efficacy that we got, even with the -- >> No.

And I think that was one of the other things that was, you know, a victim of its own success is that we were really hoping for 60%, maybe, and it was wildly more successful.

>> But it begs the question, I mean, in order to immunize people on such a mass level, we kind of cut out the primary-care physician.

>> Yeah.

>> Is this, like, a lesson that we might learn going forward?

I don't know how you would have done it that way, but it might have been more effective.

>> I think you're right.

I think that level of trust with the primary-care physician was very important.

I think part of the rollout and the need to get it done quickly, a lot of primary-care doctors just didn't have the manpower or the person-power to be able to do that.

But, in retrospect, that trusted individual -- I've had several patients that I have convinced that were vaccine-hesitant and even a couple of anti-vaxxers that agreed to get the vaccine, once I had a one-on-one and basically said, "Why is my information all of a sudden not valid?"

>> Yeah.

>> "Why is, all of a sudden, the science not valid?"

>> Is it just us, Dr. Limaye, or -- I mean, you've worked in 20 countries or more -- or do you see this same kind of hesitancy in other countries?

Or is it an American phenomenon?

>> I would say what's happening here in the U.S. is exceptional.

I think we are seeing pockets of hesitancy in other countries.

But, for the most part, I think, here, it's very much tied to underlying values related to liberty, autonomy, essentially this idea that, you know, I have control over my body and what I want to do.

And so I think there is a higher level of distrust.

And there was a study that essentially looked at trust in government and willingness to get a vaccine, and those were highly correlated.

And so I think it's been a tumultuous time here in the U.S. You know, we've had an administration that left.

Obviously, there was a changing of power.

So I think all of that, I think, has really led to these issues, I think these stronger issues, of autonomy and making sure tyranny -- "You can't tell me what to do."

That has really led to, also, a lot of vaccine hesitancy.

>> And we can't forget that you add into the mix to make the perfect storm social media.

>> Yeah.

>> I mean, Lou, we've talked about this, how it just amplified a lot of misinformation.

>> It did.

And, actually, that's almost to a person where the conversation starts with the patient is, "I saw it on..." whatever social-media platform of the day they were talking about.

And the problem with -- You know, ironically, the social media was its own form of a virus that spread this very rapidly, you know, to individuals that were susceptible.

And I think that rapid spread of misinformation desperately added to this.

>> And we can't forget traditional media, as well.

Dr. Offit, I mean, in one day, it was pointed out to me, there was a headline, based on published medical information from a scientific community -- Three different headlines.

One said, "Everyone needs a COVID vaccine booster."

The other one said, "No one needs one."

And the third one said, "Only immunocompromised people need one."

>> Yeah, I think the beauty of science, in many ways, is that it's circumspect.

As more and more data become available, then recommendations can change.

But I think for the general population, they see that fluidity as disconcerting.

>> We live in a sound-bite world, and part of the problem with each of those headlines -- what they really should have included was, "Discussion is ongoing.

Research is ongoing."

And they -- Most people don't read beyond the headline or a few lines into it and they don't get the details.

>> That's true.

>> And I think, you know, the scientific community has to get to the point where we're battling on the same front that -- Some of the information that's being spread out, it gets out before us most of the time.

And, you know, very often, once the water is poisoned, it's very hard to get people to drink from it.

>> Yeah.

Yeah, Dr. Limaye, I mean, once, you know, all the discussion that was going on in the scientific community really got shared in real time with the public.

>> Absolutely.

And I think that is what is so unique about this pandemic, is because of social media, because individuals who are essentially locked at home, they'd also turned to social media much more for their news than they did pre-COVID.

And, so, I think having this come out in real time, people looking at data, at sort of preliminary data from Pfizer, as well as Moderna, that really -- I think this is the first time we've seen this.

It's become a much more sort of sharable world, I would say.

But I think, as a result, as Dr. Offit also mentioned, I think the issue there is that because it is in real time, you are getting these little sound bites and you're not getting the whole picture.

The booster is an exact great example of really poor messaging.

And I think many of us are public-health scientists have tried really hard to work with journalists to make sure that headlines are not sensational, that they are essentially telling people what they need to do, and they're being transparent with what they have learned.

And I think that's a huge lesson learned through all of this.

>> Dr. Offit, you work on both ends of it, of the childhood vaccinations and now the COVID vaccination.

Are these two different demographic groups, the people who are hesitant to take the childhood vaccines and those who are hesitant to take the COVID or -- And maybe also a question is, are we concerned that the hesitancy overtaking the current COVID vaccine might have any spill-over into a hesitancy to really take those childhood vaccines?

>> Well, people tend to see their children as especially vulnerable.

So, I mean, we have a vaccine that is available for 12-to-15-year-olds.

We've had it available for a while.

Yet, only about 40% to 50% of parents have chosen to vaccinate their children.

It will be interesting to look to see whether or not they chose to vaccinate themselves, in other words, that while they would vaccinate themselves, they would be less likely to vaccinate their children, 'cause that, in part, answers your question, which is, they'd see the children as more vulnerable.

I just think people sort of -- you know, sort of just -- They say to themselves, "This is not for me," for whatever reason -- 'cause they don't trust the pharmaceutical industry or they don't trust the government or they don't trust the medical establishment.

They have just sort of dug in.

And I'm amazed by -- We had one child who was greater than 12 years of age who wasn't vaccinated, and I had a long talk with the mother about vaccinating herself.

And it was a -- You would think, at this point, she would have seen that -- she had other children at home -- that she can protect those children who were younger than 12 by making sure she was vaccinated, her husband was vaccinated, but it was a hard conversation.

And this conversation is happening in the intensive-care unit with her son, who was on a ventilator.

Still, it was hard getting her to understand the importance of vaccination.

So, I don't know.

It's very, very frustrating for me, though, to watch the way this plays out.

>> Well, Lou, on that note, though, there are those who are very vocal about not wanting to get it because they say, "Look, this person and this person -- they got the vaccine.

They still got COVID."

>> Yeah, and that is a -- I will echo what Dr. Offit said.

It is very frustrating, because nothing is 100%, right?

I mean, the flu vaccine is only about 40% effective on a given year, in a good year.

You can't get out of bed with 100% guarantee that you're not gonna fall down.

Nothing's guaranteed.

I just explain to them that these vaccines are important not only for controlling their health, but controlling others, and that it reduces the risk.

And the more people that get it -- It really is a public-health responsibility in addition to protecting yourself, but protecting others.

And I think it gets lost.

We talk about this being a war.

This is a war.

And the situation changes on the ground.

We got one weapon.

One weapon -- that's it.

And we're not using it effectively.

>> And, Dr. Limaye, you know, thinking about how the health agencies and the government looks at this, and we heard so much talk about herd immunity.

If we could get up to 70, then 80 -- Recently, I think I've heard from some of the doctors here, we'd have to be into the 90s -- 90 percentile -- to really reach herd immunity.

But is it pretty likely that we're going to see this become an endemic, where you just don't eradicate it or might we just look -- I mean, I know that if you look at the dropoffs and the same flow of the 1918 flu, that it's pretty much the same.

And can you think that we're gonna just see it kind of eventually wane after three years or so?

>> I think it will be endemic.

I mean, we're starting to see this.

We know that it has been mutating.

It's been mutating -- It has already mutated a number of times since we first, you know, discovered it.

I think that will continue to happen.

We're gonna continue to see pockets of individuals that do not want to get the vaccine, and, as a result, there will be susceptible hosts, i.e.

the virus will continue to replicate.

And so I do think it will be endemic.

And I think this idea of herd immunity -- I think there were a lot of issues with messaging around this, as well.

I think that that also confused individuals in the general public.

Individuals felt as though, "Okay, if we can get to 70% in this country, we'll be able to then make sure that we can really, you know, have, I think, community transmission in check," but we have seen that is not the case.

And, again, that has led to more distrust in science.

It's the same issue when, at first, the CDC said, "You don't need to wear masks," and then, later on, they changed that.

We see that as a way that science is making progress.

We're getting data.

We're updating recommendations.

But the public sees that as, "Scientists don't know what they're doing," and it leads to a larger amount of distrust, in my opinion.

>> And a tough question, but I'll ask you anyway.

When should individual choice be overruled by public health?

>> [ Chuckles ] It's a really great question, and I think one thing that we have tried to do from a public-health perspective is that we have this balance, we have this tension that we need to try to really uphold, and that's the idea of preserving individual self-choice, self-freedom, liberty, but also protecting the health of the public.

And if you think about this from a bioethical lens, with regards to the types of interventions that we can apply -- so I'm speaking mandates, for example -- it's important to think about how we can apply these so that they're least restrictive, but yield the biggest benefit from a public-health perspective.

>> Thank you, Doctor, and thank you, all doctors, because this is such an important conversation right now and a challenging one.

So I thank you all for being here.

I also want to thank all of our medical advisers, who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And, of course, to all of you at home, thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your healthcare.

I'm Joan Lunden.

Be well.

♪ Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion," with Joan Lunden, is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.