Available languages :::warning If you would like to help translate the handbook into your native language, please contact us. ::: The COVID-19 Vaccine Communication Handbook is being translated into the following languages: Croatian (complete) Handbook Summary

[name=Stefan Herzog] We should try to link to John Cook's video on reasoning fallacies --> Argument quality and fallacies Arguments can be good or bad, and that difference is not just a matter of subjective preference. Rather, argumentation research has spent centuries identifying how and why some arguments are stronger than others. This includes understanding why some arguments (so-called ‘fallacies’) can fool the unwary into thinking they provide good reasons for believing or doing something when, in fact, they do not. In thinking about argument quality, we are interested not just in what someone might subjectively find persuasive or convincing, but also in what ought to be convincing to a rational critic. As a result, rational argument involves ‘norms’ or ‘standards’ against which actual arguments can be compared. These standards provide a yardstick for argument quality and allow us to make statements about when particular arguments are weak or strong. As we typically don’t want the wool pulled over our eyes we should care about whether an argument genuinely provides a good reason or not, at least when we are the recipient. At the same time, though, decades of research on persuasion and attitude change suggests that one of the, if not the biggest, factor in persuasive success is the actual quality of the argument put forward in a persuasive message (see e.g., Hoekens et al., 2020). Thinking about argument quality in the context of the vaccination debate is consequently of direct practical relevance. However, it is also clear from the research literature that individuals vary in their ability to distinguish good arguments from bad (see e.g., Kuhn, 1991). Educational psychologists, in particular, have developed and tested wider programs for improving argument skills (e.g., Kuhn & Moore, 2015), and useful textbooks for improving skills exist at every level.

Vaccine deniers From acceptance to hesitancy and beyond Attitudes towards vaccines span a whole range, from full endorsement to complete rejection: _{Source: UNICEF} People who are hesitant about certain vaccines because they have safety concerns or are lacking information should not be called "deniers." That does not mean, however, that deniers do not exist. On the contrary, there is a large and growing literature on people who deny science---and why they do it---and criteria to identify denial have been developed: _{Source: SkepticalScience}

The politics of misinformation related to COVID-19 In many countries, COVID-19 and measures to address it, including vaccination, have become heavily politicized with important negative effects in the public's willingness to be vaccinated and follow the WHO and government relevant guidelines. In this unit, we present findings that illustrate the politicization of Covid-19 and its disastrous effects (vaccine hesitancy, disobedience in measures like mask wearing etc.), as documented in research from all around the world. Then, we discuss the most significant factors that have contributed to this phenomenon (psychological characteristics of people, motivated misinformation by malevolent agents, conflicts of interest between countries and companies etc.). The politicization of COVID-19: evidence and effects A clear factor that affects beliefs and attitudes regarding Covid-19 is political ideology and partisanship. In a multi-country study conducted before Covid-19 vaccines were available, significant differences were found between countries, indicating that trust in government was a strong predictor of vaccine acceptance (Lazarus et al., 2021): people who trust their government are much more likely to accept getting vaccinated than those who do not. Many more studies have investigated the effect of partisan differences and epistemological attitudes on vaccine hesitancy in specific countries. After more than two years since the pandemic struck, a clear consensus has been formed: political partisanship significantly affects people's beliefs regarding Covid-19 and their attitudes towards vaccine and behavioral measures, often leading to science denialism and believing in conspiracy theories. America Beliefs In the United States, a worrisome partisan gap in perceptions regarding COVID-19 and responses to relevant government measures emerged between conservatives / republicans and progressives / democrats. For example, an analysis of over 1.1 million survey responses collected daily between April and September of 2020 found that levels of concern have come to deviate sharply between Republicans and Democrats over time, regardless of the incidence of the disease in respondents' local areas, as has individuals’ willingness to stay-at-home and reduce mobility in order to help contain the pandemic (Clinton et al., 2020). Similarly, Calvillo et al. (2020) found that U.S. conservatives tended to view the virus as less severe, and often believed that the spread of the virus was a conspiracy. Similarly, a longitudinal study on COVID attitudes identified a decrease in the willingness to vaccinate among Republicans, while Democrats attitudes remained stable (Fridman et al., 2021).

COVID-19 conspiracy theories Pandemics and conspiracy theories Pandemics have always been a fertile breeding ground for conspiracy theories, and the COVID-19 pandemic is no exception. When people suffer a loss of control or feel threatened, they become more vulnerable to believing conspiracies. For example, the Black Death in the 14th century inspired anti-Semitic hysteria and when cholera broke out in Russia in 1892, blame fell on doctors and crowds hunted down anybody in a white coat. 19th century Russia does not seem terribly far away in light of recent reports from Italy, the US and the UK of doctors and nurses being accused of being "terrorists" or being trolled by people who claim that hospitals are empty and the pandemic is a hoax. Conspiracy theories have also frequently proliferated around vaccines, recurring often in a long history of "anti-vaccine tropes" described by the Anti-Vaxx Playbook (recently published by the Center for Countering Digital Hate).

Common anti-vaccination misinformation :::warning This page is about common misinformation about vaccines in general. For misinformation specific to COVID-19 vaccines, visit this page. ::: Notwithstanding broad public acceptance of vaccinations generally, anti-vaccination activists have sought to undermine vaccinations since their invention more than 200 years ago. Although they ultimately rarely prevail, when activist movements find temporary traction in a society, vaccination rates decline, leading to a resurgence of preventable diseases. This has occurred with the polio vaccine, the pertussis vaccine, and the measles-mumps-rubella vaccine programs, among others. The perpetuation of misinformation around vaccines can therefore present a danger to public health. Since vaccines were first developed, opponents have made many different claims about them. Broadly, the claims centre on the need for vaccines, how they work, their safety, their components, their moral or religious acceptability, and their development and testing. In anti-vaccination writings, vaccines have been linked to anything from Gulf War Syndrome through to cancer and even violence and crime.

Fallout from COVID-19 misinformation <span style="color:green">Beliefs in COVID-19 misinformation have been associated with reduced trust in public health guidelines and readiness to get vaccinated in multiple countries (Roozenbeek et al., 2020). </span>As such, COVID-19 misinformation has a wide range of negative consequences for individuals and society overall: People who are misled often fail to engage in health-protective behaviours. People who are misinformed are less likely to get vaccinated. Misinformation has been directly linked to increased mortality rates. Misinformation and conspiracy theories have been linked to violence. Reduced health-protective behavior A study by Allington, Duffy, Wessely, Dhavan, & Rubin, (2020) found a strong negative relationship between COVID-19 conspiracy beliefs and COVID-19 health-protective behaviours. That is, the more people endorsed conspiracy theories, the less likely they were to look after themselves and others. For example, instead of staying home and social distancing, believers in conspiracy theories tended to disregard those precautions. This is potentially problematic because these are behaviours known to reduce the risk of catching and spreading COVID-19 (CDC, 2021).

Myths about COVID-19 vaccination :::warning This page is about misinformation specific to the COVID-19 vaccines. For misinformation about vaccines in general, visit this page. ::: Where does misinformation come from? YouTube has been a significant source of misleading information during previous public health crises, including the Ebola and Zika outbreaks (Li et al., 2020). In March of 2020, a search of YouTube revealed that more than one quarter of the most-viewed videos contained misinformation, whereas videos from reputable sources remained underrepresented (Li et al., 2020). :::info An in-depth scholarly analysis of how misinformation and other attributes of the online environment, and how it challenges citizens in a democracy can be found in Kozyreva et al. (2020).

Muslim History and Contributions to Science and Why it Matters :::success This piece by Dr Shamaila Anwar looks at vaccine hesitancy among ethnic minority communities from the lens of systemic discrimination that has led to the historical scientific achievements of these communities being obscured. It highlights the importance of education as key to breaking this cycle of discrimination. Empowerment of communities through their histories is an important part of this. As we become more aware of inequalities as a society, we should also recognise that names of Muslim scholars like Ibn Sina and Al Razi should be synonymous with Edward Jenner and James Lynd. Scientific knowledge that enables medical progress such as vaccination has a long history in many communities and this should celebrated. For more about cultural differences in vaccine uptake, see our page here. ::: Introduction: 2020 - An Eye Opener of a Year for Inequalities in Health The pandemic has opened our eyes to health inequalities, their causes and how much our race, ethnicity, religion, socioeconomic status and the sources of information we access shape our experiences of and attitudes to health. The evidence was clear from the outset, in the UK Black, Asian and minority ethnic groups had higher rates of infection, serious disease, and deaths from COVID-19. But there was also a clear disconnect: the communities most at risk from COVID-19 were the same communities where vaccination rates were and in some cases still are low.

The potential side effects of COVID-19 vaccines Efficacy vs. side effects Our facts page about the COVID-19 vaccines highlights the efficacy of the three main vaccines available to date (Pfixer-BioNTech, Moderna, and Oxford-AstraZeneca) and explains how those data were obtained. All trials involved the same basic design: participants were randomly assigned to a control (placebo) group or to the vaccination group. The Pfizer-BioNtech trial involved 43,448 individuals; the Moderna trial involved 30,420 participants; and the Oxford-AstraZeneca trial recruited 23,848 participants of whom 11,636 were included in the interim analysis that has been published. Altogether more than 80,000 people were enrolled in those trials, and so there was considerable opportunity to observe side effects. A useful summary of the known side-effects of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines --- the two which are authorised for use in the UK as of 1st Jan 2021--- can be found in the “Green Book”, which is a U.K. manual for healthcare workers who administer vaccines: Local reactions at the injection site are fairly common after Pfizer BioNTech COVID-19 mRNA Vaccine BNT162b2, primarily pain at the injection site, usually without redness and swelling. Systemic events reported were generally mild and short lived (Walsh et al, 2020). In the final safety analysis of over 21,000 participants 16 years and older, the most common events were injection site pain (>80%), fatigue (>60%), and headache (>50%). Myalgia, arthralgia and chills were also common with fever in 10-20%, mainly after the second dose. Most were classified as mild or moderate. Lymphadenopathy was reported in less than 1%. (Polack et al, 2020). Four cases of Bell's palsy were reported in vaccine recipients in the trial. Although within the expected background rate, this will be monitored closely post-implementation. Side effects were less common in those aged over 55 than those aged 16 to 55 years. Severe systemic effects, defined as those that interfere with daily activity, included fatigue in 4% and headache in 2%. There was no signal to suggest that prior vaccination led to enhanced disease with only 1 case of severe COVID-19 in the 8 vaccine failures. (Polack et al, 2020). From early phase trials, mild pain and tenderness at the injection site was common with AstraZeneca COVID- 19 vaccine occurring in 88% of 18-55 year olds, 73% of 56-69 year olds and 61% of people aged 70 years or over; similar levels were reported after each dose. Short lived systemic symptoms including fatigue and headache were also common but decreased with age, being reported in 86%, 77%, and 65% of those aged 18-55, 56-69 and 70 years or over respectively; most of these were classified as mild or moderate. These reactions were unusual after the second dose (Ramasamy et al, 2020). Mild fever (>38 ̊C) was recorded in the first 48 hours for around a quarter of younger participants and but was not reported in those over 55 years of age or in any age group after the second dose (Ramasamy et al, 2020). Fever can be modified by the prophylactic use of paracetamol, which does not affect the immune response to this vaccine (Folegatti et al, 2020). In the phase 3 study, injection site reactions, mild fever, headache, myalgia and arthralgia occurred in more than 10% of vaccinees. Less than 1% reported lymphadenopathy or an itchy rash. Only one serious adverse event was reported as possibly linked to the vaccine; this was a case of transverse myelitis which occurred 14 days after dose 2. There was no signal to suggest that prior vaccination led to enhanced disease. (Voysey et al, 2020).

The COVID-19 Vaccine Development Process ..and why you should not worry about it Many people understand the need for a COVID-19 vaccine but have concerns about its safety and effectiveness due to the rapid development of the vaccine and the use of relatively novel mRNA technology. ::: info You can read more about mRNA technology and why it is safe on our dedicated COVID-19 vaccine fact page. ::: Here we summarise the current state of vaccines, explain the standard vaccine development process and the obstacles that are faced under normal circumstances. We then explain how and why it was possible to accelerate this process for the development of the COVID-19 vaccines.

<span style="color:green">Success of COVID-19 Vaccines :::warning <span style="color:green">This section is about the success of COVID-19 vaccines in tackling the pandemic. The speedy development of the COVID-19 vaccinations is of course also great success for vaccines. Visit our pages on the COVID-19 Development Process and Facts About COVID-19 Vaccines for more about this. ::: <span style="color:green">Since the first vaccine was administered outside of a clinical trial in the UK, over 6.5 billion vaccine doses have been administered globally. There are a range of sources publicly available that have tracked reports of global cases, deaths and total vaccines administered --- showing clearly that the vaccines are reducing deaths, hospitalisations and infection rates. <span style="color:green">Finding the data <span style="color:green"> Whilst both the World Health Organisation and CDC publish data, a collaboration led by Johns Hopkins University provides updates in real time and includes data from China at Province level and at a city level in the USA, Australia and Canada.

COVID-19 Vaccines and Pregnancy Impact of COVID-19 on pregnant women During pregnancy, one’s immune system has to accommodate the developing fetus and the organs supporting it (e.g., the placenta). The adaptations to develop immune tolerance to the fetus mean that pregnant women are more susceptible to severe disease---including COVID-19 (Ovie et al., 2021). There is now evidence that getting infected during pregnancy yield to higher risks of developing a severe form of COVID-19 (Zambrano et al. 2020; Kadiwar et al., 2021), especially with the Delta variant (Vousden et al., 2021). COVID-19 can result in pregnancy complications for the mother, and there is a possibility of transmitting the disease to the child. The WHO has reviewed three possible ways transmission could occur (WHO, 2021): In utero (i.e., in the womb)

COVID-19 Vaccines and Children Impact of COVID-19 on children Children can and do become infected with COVID-19. In the US in October 2021, up to 25% of weekly reported cases were among children. A study looking at transmission rates in primary school children in Belgium found that children tested positive for COVID-19 at similar rates to adults (Meuris et al., 2021). However, for most children and young people COVID-19 is usually a milder illness that rarely leads to complications---children also tend to be symptomatic for shorter period of time than adults (Meuris et al., 2021). For a very few the symptoms may last for longer than the usual 2 to 3 weeks (see our section below on long-term consequences of COVID-19) (Bhopal & Absoud, 2021). Monitoring case rates among children is nonetheless important. While the percentage of children who suffer severe or long-term outcomes from COVID is small, if case rates are high, this still translates into large numbers of children being affected. For example, in England, case rates for children rose in September 2021 following the opening of schools. The age group that comprised likely parents of schoolchildren also saw an uptick in case rates at the same time. This matched a trend observed in Scotland slightly earlier (corresponding with earlier school start times in that country).

Facts about COVID-19 vaccines Vaccines provide a possible path out of the COVID-19 pandemic, and it is therefore fortunate that scientists have now developed several vaccines against COVID-19. Those vaccines have been found to be highly effective against the disease, and some provide a protection level of around 95% in controlled trials. For facts about the disease COVID-19 see our page here. Find out how successful vaccines have been in the past at our page here. Find out more about how the COVID-19 vaccines were developed at our page here. Find out more about COVID-19 vaccines for children at our page here. How do the vaccines work?

Facts about COVID-19 COVID-19 is a serious disease that has infected over 17 million people across the world, killing 1.6 million in only 10 months. It is more contagious and more deadly than the flu. Unfortunately, some people have been disseminating misinformation about the disease which we rebut here. We address people's risk perceptions about COVID-19 here. Facts about the COVID-19 vaccines can be found here. Facts about how the pandemic can be controlled by government policy can be found here. A superb site that debunks many common myths about COVID-19 is Anti-Virus: The Covid-19 FAQ See also this piece debunking 8 common COVID-19 myths.

Nudging Flattening the curve of the "infodemic" Although it is possible to correct misinformation, as we have shown in the COVID-19 Vaccine Communication Handbook, the Debunking Handbook 2020, and the Conspiracy Theory Handbook, this may not be sufficient to stop disinformation from gathering speed, particularly if it is disseminated by highly motivated people for political reasons. (Our page on the politics of COVID-19 disinformation explains this is in more detail.) We must therefore look for additional ways in which we can “flatten the curve of the infodemic, so that bad information can’t spread as far and as fast” (Ball and Maxmen, 2020). Two of those options are nudges and boosts. What are nudges? Nudges are ways to use the context in which a decision takes place to systematically affect these decisions. For example, employees at Google have access to free food and drink at work. Healthy options, such as sparkling water, are more visible and easier to access than less healthy options, such as sugary drinks. Together with a number of other nudges, Google successfully shifted employees' consumption towards healthier options. Many nudges have been successfully explored in a variety of settings.

The role of vaccination mandates What are vaccination mandates? Vaccination Mandates refer to various ways in which people are legally compelled to be vaccinated. In the extreme case, mandates can be backed by criminal sanctions (people who refuse to vaccinate are subject to prosecution) or by limiting access to schools, services, and jobs (either by law or at the employers' discretion). Historically, vaccination mandates are not a new concept, though it can be difficult to determine what counts exactly as a mandate (Wynia, 2007). It is therefore important to understand when are vaccines mandated, whether mandates can be successful, whether the public accepts them, and whether they are ethical. What about "Vaccine Passports"? At the height of the pandemic, many governments, organisations, and companies worldwide required some form of vaccine passport for a range of circumstances.

Equity of vaccine allocation What is vaccine equity? The WHO defines vaccine equity as equal allocation of vaccines across all countries, regardless of their developmental or economic status. They highlight that allocation of vaccines should be based on the fundamental human right of everyone to have access to the highest standard of healthcare regardless of race, religion, political belief, and economic or other socal conditions. To achieve this, vaccines need to be both accessible and affordable to everyone. The WHO set a target for all countries to vaccinate 10% of their population against COVID-19 by the end of September 2021. 56 countries, most of them in Africa, have been unable to reach this target. Whilst the UK administered its first vaccine dose outside of a clinical trial in December 2020, and had vaccinated more than two thirds of its adult population by October 2021, Senegal only received its first supply of vaccines in October 2021. Most countries are at risk of missing the WHO target of vaccinating 40% of their population by the end of 2021 and 70% by the middle of 2022. Inequalities in COVID-19 Vaccine Accessibility High income countries started vaccinating their populations on average two months earlier than low-income countries. A slower and delayed vaccine rollout in low and middle-income countries has left them vulnerable to the spread of COVID-19, emerging new variants of the virus, and a slower recovery from the social and economic crises. (See our Facts about COVID-19 page for more on the impacts of COVID-19).

Successful strategic communication measures Setting up a successful vaccine communication strategy requires much advanced planning and consideration. In a nutshell, the following steps are recommended for policy makers: Monitor social media to identify messages and "memes" that gain traction using social listening tools. It is important to look for measures of sharing and engagement, rather than mere volume of messages because it is possible to generate large volumess of misinformation that are rarely seen by others (Dunn et al., 2020) Conduct regular pulse surveys of the target populations to identify emerging misinformation beliefs. Identify trusted local members of the community to disseminate key information (e.g. employers, headteachers, religious leaders, student union body) Highlight positive social norms and challenge media that exaggerate or sensationalise prevalence of vaccine opposition in populations. Fund both broadcast communications and two-way engagement. Put communications and behavioural experts at the decision making table and consult with them.