April 2021 - Vaccine Hesitancy & the AstraZeneca COVID-19 Vaccine A Case Study
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Vaccine Hesitancy & the
AstraZeneca COVID-19
Vaccine
A Case Study
April 2021
Created By: Clinical Standards and Professional Practice
For: COVID-19 Immunizers
CV-19 LM0011 – April 12, 2021VACCINE HESITANCY AND THE ASTRAZENECA COVID-19 VACCINE
The latest National Advisory Committee on Immunization (NACI) recommendations about the use of
AstraZeneca COVID-19 vaccine may impact Canada’s vaccine confidence. The scientific community regards
changing recommendations as precautionary - contributing to safety by rapidly responding to new data and
protecting the public. An already hesitant public however can perceive these changes as signs of incompetence,
uncertainty and even dishonesty leading to an increase in mistrust and fear.
The risks are real, and no scientist or health care practitioner should minimize that. There are risks to all
medications, medical procedures, and activities or behaviours affecting health. The conversation has to evolve
from an understanding that decisions are often based on weighing risk against benefit. The job of health care
providers is to understand the perceived and real risks that people are faced with and help them make a
decision that will bring them the most benefit.
In the case of AstraZeneca, the manufacturer information, Health Canada’s initial approval, and NACI’s
subsequent recommendations have caused a public-confidence problem. The mixed messages that have
resulted from global data on efficacy, effectiveness and safety are confusing. This particular vaccine was initially
approved for adults over the age of 18. The NACI recommendation to not offer it to people over the age of 65
came simply from a lack of data regarding efficacy in that population – this was not an issue related to safety,
but many people concerned with receiving a new vaccine considered this to be evidence of a problem.
Interestingly, more recent data has shown that the AstraZeneca vaccine is very effective in the over age 65
population in limiting COVID-19 disease and preventing serious illness and hospitalization.
GUIDANCE FOR ASTRAZENECA VACCINE VARIES
WATCH this CBC News
This latest recommendation won’t be the last, and the AstraZeneca vaccine may video (4 minutes 47
continue to lose the confidence of Canadians despite the best intentions of Health seconds)
Canada and NACI. As the vaccine landscape continues to change, Health Care
Providers will have to communicate exceptionally well to overcome what may
erode Canadian’s COVID-19 vaccine acceptance. At a briefing in early March, NOTE: Use Chrome or
Canada’s chief public health officer Dr. Theresa Tam said the NACI is prepared to Firefox for best results
update its guidance as it “sees more and more … real-world data accumulating.
Don't read their recommendations as sort of static,” Tam said, “But this is what
they've recommended at this point.” https://www.cbc.ca/playe
r/play/1867860035783
AstraZeneca's COVID-19 vaccine and seniors: Where Canada and other countries stand
The case study below represents the current climate of vaccine availability,
confidence and hesitancy. Although our overwhelmed healthcare system and
COVID fatigued society are ready to be done with this pandemic, there will still be disagreement, mistrust, and
speculation about how to end it. Vaccine is the only option for a medical end that excludes unacceptable rates
of disease and death.
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 1 of 7CASE STUDY
Beverly is a 61 year old female. She works in a laundry facility where hospital linens are cleaned. Her husband
died in a motor vehicle collision a few years ago and now she lives alone. She doesn’t drive, so she relies on the
city bus service for transportation.
She quit smoking 15 years ago after smoking a half pack a day for over 25 years. She is slightly overweight; she
has an active job but does not exercise. She is on prescription medications including oral diabetes medications,
and an anti-depressant. She had cholecystectomy surgery 10 years ago. She has no known allergies.
Her eldest son lives nearby with his wife and 2 young children, aged 1 and 3. Beverly sometimes babysits her
grandchildren when their daycare is closed. Her other son is a farmer and lives rurally with his wife and their
children and do not visit regularly.
Beverly’s elderly father has dementia. He lives in a local nursing home and had a significant decline in his
condition last year; Beverly typically went to see him 2-3 times per week before visitor restrictions were in
place.
Today Beverly is your patient at the immunization clinic. She is accompanied by her daughter–in-law who has
brought her to the drive-thru clinic. Although Beverly has been eligible to receive her first dose COVID-19
vaccine for several weeks already, she has been reluctant to book an appointment. The drive-thru clinic is
administering AstraZeneca COVID-19 vaccine.
You approach the vehicle to determine which occupants are getting vaccinated today. Beverly’s daughter-in-
law states “I’ve brought my mother-in-law to get her immunized”. You look to Beverly for confirmation and she
is shaking her head, no. You know that you must have Beverly’s consent to administer the vaccine, so you move
to Beverly’s window to talk with her. You ask her what her concerns are and assure her that you are happy to
answer any of her questions.
Beverly states “My father’s dementia got worse after he got his Shingles vaccine last year. I don’t know why
they insisted on giving that vaccine to him. He was already frail and on so much mediation and he wasn’t likely
to get shingles anyway. And then this year I let them give him a COVID shot, because he could actually die of
COVID, but I haven’t been able to go visit him to see what it’s done to him.”
What does this initial statement tell you about Beverly’s vaccine hesitancy?
a) That she is a hard core anti-vaxxer and you will never change her mind
b) That she is being negatively influenced by recent personal experience where she felt that a vaccine
caused her father’s dementia to worsen
c) That she recognizes the importance of the COVID-19 vaccines, but remains mistrustful
d) B and C
The correct answer is D. Beverly is being influenced by her father’s experience as there was likely poor
clarification from her father’s care providers about cause and effect. There may have been other contributing
factors into her father’s decline.
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 2 of 7What is the best way to respond to Beverly’s initial reaction?
a) Ignore it and move on to the screening questions
b) Assume she is not going to want the vaccine and have them drive out immediately
c) Tell her she is being paranoid and that she must get the vaccine
d) Ask her to tell you how she feels about receiving the vaccine herself
The correct answer is D. By asking Beverly to clarify her feelings, we can help dispel myths and provide
accurate information where required. The goal here is to understand Beverly’s perspective and where she is
making her decision from. Understanding will go a long way to help resolve hesitancy.
Beverly states she thinks all the COVID-19 vaccines are too new and were developed too fast. She’d be willing
to get one of the “safer vaccines”, but she doesn’t want the AstraZeneca. She states “I don’t want that one that
they keep changing their minds on. It’s so suspicious that one minute it’s not safe for over 65, next minute it’s
not safe for under age 55 – how am I supposed to believe that it’s safe for me at age 61?”
Your best response:
a) You have nothing to worry about, all the vaccines are safe and they’re all the same
b) You should consider yourself lucky to be getting any vaccine; there are lots of people waiting
c) I understand why you would wonder about that. It may be reassuring to know that the
recommendation for not giving AstraZeneca to those over 65 had nothing to do with the safety of the
vaccine, but was actually made because it wasn’t clear that the vaccine would give enough immunity to
people over 65. There were not many people over 65 in the clinical trials, so it wasn’t certain that the
vaccine would boost their immunity as well as it did in younger people. The AstraZeneca vaccine it has
always been considered safe as well as effective for your age-group.
d) You’re probably right, and you’re unlikely to COVID-19 anyway.
The correct answer is c.
Beverly replies: “Well okay, but if it’s not safe for people under age 55 why should I take it? I read that the
government just doesn’t want to waste it and admit that they made a mistake.”
You’re best response:
a) I’m sure you’re trying to stay informed by doing lots of reading, just like I am. There haven’t been any
reports of anyone in Canada getting blood clots from the AstraZeneca vaccine. And the AstraZeneca
vaccine is recommended for people over 55 due to the lower risk of older populations developing this
rare blood clot condition and the increased risk of severe COVID-19 infections among these age groups.
b) I’m sure you’re trying to stay informed by doing lots of reading, just like I am. But you should probably
try reading something other than Facebook posts or conspiracy websites.
c) I’m sure you’re trying to stay informed by doing lots of reading, just like I am. I’m not sure you would
understand all the science though, so why don’t you just let your doctor decide for you.
d) I’m sure you’re trying to stay informed by doing lots of reading, just like I am. You just have to trust that
we know what is best for you.
The correct answer is a.
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 3 of 7Beverly replies: “I don’t know. I’m scared of getting a blood clot. Why shouldn’t I just wait until I can get one of
the other brands of vaccine?”
Your best response(s):
a) I understand that it can be scary. I’ve looked after many COVID patients, and complications from blood
clots are not uncommon. Blood clots can form in patients who are sick with COVID, causing restricted
blood flow to the lungs and cutting off blood supply to vital organs and limbs.
b) Getting the AstraZeneca vaccine reduces your overall risk of hospitalization or dying. It is
recommended that you accept the first vaccine that is offered to you. Your risk of becoming severely ill
from COVID-19 is much higher than the risk of a rare clotting disorder. Babysitting your grandchildren
would also be much safer for you and them if you are vaccinated.
c) These vaccine-related clots are rare, but serious and concerning. But, your eligibility for the
AstraZeneca vaccine is our health care community saying that you are at risk for COVID-19 and that you
need to be protected. So the extremely rare risk of a vaccine-related clot is outweighed by the real and
common risks of COVID-19 – an illness that itself gives you a less than one in 100 risk of blood clots.
d) All of the above
The correct answer is d.
DATA TO SUPPORT THESE FINDINGS, TO DATE:
According to a recent article by the BBC (British Broadcasting Corporation), risk of harm was compared to
someone who is 25 and someone who is 55. These include:
25 year old 55 year old
Serious harm due to vaccine side
11 people per million 4 people per million
effects
Dying from COVID-19 23 people per million 800 people per million
Dying due to accident or injury 110 people per million 180 people per million
Dying from a motor vehicle
38 people per million 23 people per million
collision
Being hit by lightening this year 1 in a million 1 in a million
The risk of death from the AstraZeneca vaccine, related to blood clots is 1 in 1 million.
The risk of a blood clot (without vaccination) is 4 men and 10 women per 1 million.
There are measurements out of the UK where the numbers of cases of rare blood clots reported by the end of
March, 2021 was 79 cases in total. This means that roughly 1 in ever 250,000 people who have received the
AstraZeneca COVID-19 vaccine have had a blood clot complication. As a measure of comparison, a significant
number of women utilize the birth control pill that also holds risks of blood clots. On average in the UK, 1 in
1000 women are affected every year from blood clots related to use of birth control pills.
Cambridge University is also examining the frequency of blood clots in the UK. They are examining potential
benefits and harms of the AstraZeneca COVID-19 vaccine for people with low, medium and high risk of
exposure to COVID-19. In all groups (low, medium and high risk), the risks of ICU admission are significantly
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 4 of 7higher without the vaccine. Cambridge University is estimating the number of ICU admissions PREVENTED with
uptake of the AstraZeneca COVID-19 vaccine, compared to the number of blood clots that have occurred, in a 4
month period.
These numbers are reflective of LOW exposure risks.
ICU Admissions PREVENTED Age Group Blood Clots due to COVID-19
PER 100,000 people Vaccine
0.8 people per 100,000 20-29 1.1
2.7 people per 100,000 30-39 0.8
5.7 people per 100,000 40-49 0.5
10.5 people per 100,000 50-59 0.4
14.1 people per 100,000 60-69 0.2
Measures for with medium exposure risk and high exposure risk are much HIGHER in the ICU Admissions
prevented with the use of the AstraZeneca COVID-19 vaccine.
Beverly agrees to receive the AstraZeneca Covid-19 vaccine and you immunize her right away. Your post-
immunization teaching must include which statement(s)?
a) You may notice some tenderness, pain, warmth, redness, itching, swelling or bruising where the
injection was given. You can put a warm or cold compress on your arm for comfort.
b) You may feel generally unwell or tired and experience chills, fever, headache, nausea, joint pain or
muscle aches for a couple days. You can take pain relievers like acetaminophen for these reactions.
Less common reactions may include decreased appetite, enlarged lymph nodes, itchy skin or rash.
These are all signs of your immune system responding to the vaccine and are expected reactions.
c) You should seek immediate medical attention if you develop symptoms such as shortness of breath,
chest pain, leg swelling, persistent abdominal pain or neurological symptoms including sudden onset of
severe or persistent worsening headaches or blurred vision several days (approximately 4-20 days)
after vaccination. These are not normal reactions and could be a sign of blood clot. Although this is
extremely rare, it is still important to monitor for signs and symptoms.
d) All of the above
The correct answer is d.
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 5 of 7SUMMARY
Covid-19 is an opportunity to rethink our approach to vaccine uptake writes Heidi Larson, anthropologist and
director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine. Larson
observed that “Vaccine reluctance and refusal are not issues that can be addressed by merely
changing the message or giving ‘more’ or ‘better’ information,” The reasons for skepticism may vary
among communities, but Larson’s approach to vaccine hesitancy is universally relevant: “before you
attempt to persuade, try to understand.”
In the scientific rush to develop, manufacture and deliver vaccines more rapidly than ever in history, countries
around the world have failed to engage the public.
“We need to restart immediately and bring vaccine confidence into the heart of our global Covid-19
recovery efforts. This is a global crisis at multiple levels. Training vaccinators and building their
confidence is essential. They are the ones interacting directly with the public, calming anxieties and
answering questions. Their training needs to go beyond the logistics of how to administer the shot and
prepare them for questions, including ones about the vaccines’ safety.”
While it’s important to provide up-to-date facts about Covid-19 vaccines, providing people with the
opportunity to ask their questions and get prompt answers is crucial. COVID-19 has already isolated us in so
many ways, providing the opportunity to just talk through vaccine concerns and be reassured is invaluable.
Heidi J. Larson
Want to Restore Trust in the AstraZeneca Vaccine? Start Here.
Covid-19 vaccine acceptance won’t occur because the government says so, but because vaccination will have
impact and meaning in people’s lives. Regulators must do their best to maintain calm, perspective, and
transparency. Reacting more conservatively may mean more people immunized, but if that results in a higher
incidence of adverse reactions, then loss of trust in the monitoring system for vaccines would be guaranteed.
“Addressing concerns about vaccines is a long game, and the biggest challenges will come much later on, when
all the eager people have been immunized and it’s time to persuade the holdouts.”
Hilda Bastian
We Need to Talk About the AstraZeneca Vaccine
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 6 of 7REFERENCES
AstraZeneca’s COVID-19 vaccine and seniors: Where Canada and other countries stand. CBC.ca; March 3,
2021. Retrieved from: https://www.cbc.ca/news/canada/astrazeneca-covid-vaccine-seniors-different-
countries-1.5934032
AstraZeneca COVID shots could test Canadians’ vaccine hesitancy: ‘There is no way they can downplay that
risk.’. The Telegram; March 31, 2021. Retrieved from:
https://www.thetelegram.com/lifestyles/health/astrazeneca-covid-shots-could-test-canadians-vaccine-
hesitancy-there-is-no-way-they-can-downplay-that-risk-570553/
Astra-Zeneca Vaccine: How do you weight up the risks and benefits? BBC News; April 8, 2021. Retrieved from:
https://www.bbc.com/news/explainers-56665396
Blood clot risks: comparing the AstraZeneca vaccine and the contraceptive pill. The Conversation; April 9, 2021.
Retrieved from: https://theconversation.com/blood-clot-risks-comparing-the-astrazeneca-vaccine-and-the-
contraceptive-pill-158652
Communicating the potential benefits and harms of the AstraZeneca COVID-19 vaccine. University of
Cambridge. Winton Centre for Risk and Evidence Communication (2021). Retrieved from:
https://wintoncentre.maths.cam.ac.uk/news/communicating-potential-benefits-and-harms-astra-zeneca-
covid-19-vaccine/
Education Program for Immunization. Canadian Pediatric Society. Retrieved from:
https://pedagogy.cps.ca/#/public-dashboard
Escaping Catch-22 – Overcoming Covid Vaccine Hesitancy. Rosenbaum, L. The New England Journal of
Medicine; April 8, 2021. 384:1367-1371. DOI: 10.1056/NEJMms2101220. Retrieved from:
https://www.nejm.org/doi/full/10.1056/NEJMms2101220
Guidance for AstraZeneca Vaccine Varies. CBC.ca; March, 2021. Retrieved from:
https://www.cbc.ca/player/play/1867860035783
Our best shot at beating COVID-19: Overcoming vaccine hesitancy in 2021. Canadian Pediatric Society.
Retrieved from: https://pedagogy.cps.ca/#/public-dashboard
Statement on AstraZeneca Vaccine Hesitancy. Hamilton Health Sciences; March 22, 2021. Retrieved from:
https://www.hamiltonhealthsciences.ca/share/statement-on-astrazeneca-vaccine-hesitancy-by-hhs-
hematologist-and-thrombosis-medicine-physician/
Tam insists health officials working in ‘lockstep’ despite discrepancy in AstraZeneca guidelines. CTV.ca; March
30, 2021. Retrieved from: https://www.ctvnews.ca/health/coronavirus/tam-insists-health-officials-working-in-
lockstep-despite-discrepancy-in-astrazeneca-guidelines-1.5368299
Want to Restore Trust in the AstraZeneca Vaccine? Start Here. The New York Times; March 22, 2021.
Retrieved from: https://www.nytimes.com/2021/03/22/opinion/astrazeneca-vaccine-trust.html
We Need to Talk about the AstraZeneca Vaccine. The Atlantic; March 30, 2021. Retrieved from:
https://www.theatlantic.com/health/archive/2021/03/astrazeneca-vaccine-blood-clot-issue-wont-go-
away/618451/
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
Page 7 of 7CV-19 LM0011
April 12, 2021
clinicalstandards@saskhealthauthority.ca
CV-19 LM0011 – Vaccine Hesitancy and the AstraZeneca
COVID-19 Vaccine – April 12, 2021
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