Promote Trust, Avoid Fraud: Lessons in Public Health Messaging from the Booster Roll Out

By Carmel Shachar

Even in September 2021, it was fairly clear that boosters for all adults, regardless of risk factors or which vaccines they initially received, would be coming soon.

Indeed, within two months, the U.S. Centers for Disease Control and Prevention (CDC) revised its recommendations to say that all vaccinated adults should receive a COVID-19 booster.

Unfortunately, the discrepancy between past messaging, which restricted access to boosters to select groups, and the current, broad recommendation has spawned two, related public health communications problems.

The first problem is the whiplash and uncertainty caused by the quick revision in recommendations.

Months ago, the data from Israel suggested that virtually everyone could benefit from a booster.

But, in the U.S., the initial roll out of the COVID-19 boosters focused on groups that should get the COVID-19 booster (people over 65 years, those aged 50-64 with underlying medical conditions or those living in long-term care facilities) and that may receive the COVID-19 booster (people aged 18-49 with underlying medical conditions and adults with heighted risk factors due to occupational or institutional settings).

These September 2021 recommendations were also limited to those who received the Pfizer vaccine for their initial doses because, as noted by CDC Director Dr. Rochelle Walensky, “[the CDC Advisory Committee on Immunization Practices] only reviewed data for the Pfizer-BioNTech vaccine. We will address, with the same sense of urgency, recommendations for the Moderna and J&J vaccines as soon as those data are available.”

By issuing recommendations that left out many vaccinated adults, only to revise them shortly thereafter, the CDC may have undermined the public’s trust.

As one woman, who requested not to be named, told the Boston Globe, “I feel like we have to fend for ourselves… Who’s looking out for us? My doctor hasn’t called me. And the CDC keeps changing what we’re supposed to do.”

This is similar to the distrust sowed in the early days of the pandemic when federal leadership flip flopped over whether masking was recommended or necessary.

The importance of consistency in business leaders, such as CEOs, has been studied and touted repeatedly. It stands to reason that consistency would be important in public health leadership as well.

Second, many adults who did not fall into one of the groups covered by the September 2021 recommends were tempted to “cheat” to receive their boosters.

Some people crossed state lines and lied about their vaccination status to receive a “first dose” as a makeshift booster. Others lied about their health status, alleging an underlying medical condition, to get a booster as soon as they were six months out from their second dose.

Any system that encourages or rewards widespread, casual fraud is one that erodes trust, a cornerstone for healthy communities.

So, what have we learned from the experience of rolling out booster recommendations?

Public health leaders need to carefully thread the needle between following best scientific practices and achieving our ultimate public health aims. Tying booster recommendations to the best available data and revising the recommendations quickly in light of new data helped us avoid “getting ahead” of what we knew about the risks and benefits of boosters. But it meant not taking a holistic look at the public health picture, i.e., that even in September 2021 we already had a good sense that boosters would be necessary for most of the population. And it meant undermining some important public health goals, such as trust in our public health leadership and avoiding a system that rewards fraud.

Perhaps it would have been better to acknowledge the likelihood of a widespread booster campaign, with messaging along the lines of: “everyone will likely need the booster very soon, but we are going to prioritize those most at risk for the first few weeks.” Or perhaps we should have been more aggressive about the recommendations, to allow ourselves to get “a little ahead” of the data in the interest of clear, trustworthy messaging.

As the specter of omicron looms, we should think closely about the art of public health communication. How can we rebalance our public health messaging around omicron to maximize trust in our public health institutions, our medical practices, and each other?

Carmel Shachar

Carmel Shachar, JD, MPH, is Assistant Clinical Professor of Law and Faculty Director of the Health Law and Policy Clinic at the Center for Health Law and Policy Innovation of Harvard Law School (CHLPI). Previously, Shachar was the Executive Director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.

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