Stories of the “Good Vaccines” - Lessons Learned in Public Health Communications

Dr. Chavalin Svetanant

Dr. Dragana Stosic

Macquarie University, Australia

 

After a year of round-the-clock research and countless clinical trials of potential COVID-19 vaccines, a number of vaccines obtained approval in different parts of the world within a rather short time frame. In December 2020, for instance, China approved the Sinopharm COVID-19 vaccine for general use[1] while the UK issued emergency-use approvals for the Pfizer–BioNTech and Oxford/AstraZeneca Covid-19 vaccines[2]. Additionally, between December 2020 and June 2021, the World Health Organisation (WHO) granted emergency-use approvals for six different vaccines.[3]While the appearance of Covid-19 vaccines allowed many across the medical community to breathe a sigh of relief, the existence of multiple vaccines had also brought about a sense of confusion among the general public as to whether there are “good/better” or ‘bad/worse” vaccines. Therefore, a clear communication of a vaccine’s risks and benefits seems to be key for any government when it comes to devising an effective pandemic response. Otherwise, the initial confusion can grow into larger issues threatening public health such as the over-/under-supply of particular vaccines or even vaccine hesitancy in general.

Expressing and adjusting attitudes in verbal communication

To explore the language of evaluation used in the official communication surrounding Covid-19 vaccines, this article draws on the ‘appraisal’ framework developed by functional linguists James R. Martin and Peter R. R. White.[4] Within this framework, language can be used to express three kinds of positive or negative attitude – ‘affect’ (i.e., emotions such as scared or confident), ‘appreciation’ of things or activities (e.g., good/bad vaccine), or ‘judgement’ of people’s characteristics or behaviours (e.g., responsible/reckless individuals). Furthermore, the expressed attitudes are seen as inherently gradable, which means they can be (re-)adjusted using a range of graduating expressions. For example, when talking about a “good vaccine”, we may decide to amplify/downplay the intensity of our positive ‘appreciation’ by stating that the vaccine is “highly/somewhat beneficial” or “often/sometimes effective”. Alternatively, we may opt to graduate our positive assessment through expressions that indicate amount (e.g., “multiple/few benefits”) or extent (e.g., “long-/short-term benefits” or “beneficial to the entire/60+ population”).

To explore the language of evaluation used in the official communication surrounding Covid-19 vaccines, this article draws on the ‘appraisal’ framework developed by functional linguists James R. Martin and Peter R. R. White. Within this framework, language can be used to express three kinds of positive or negative attitude

When communicating their advice on the use of particular COVID-19 vaccines, governments necessarily draw on evaluative language that ‘appreciates’ the vaccine either positively (e.g., “benefits”, “protection”) or negatively (e.g., “risks”, “side effects”). To convey the delicate risk-benefit balance and specify the scope of their recommendations under the ever-changing pandemic conditions, they often adjust their ‘appreciations’ through graduating expressions. In this article, the authors present a comparative study of COVID-19 vaccine ‘appreciations’ in several instances of public discourse in Thailand and Australia. Within the Thai context, we will look closely at the health advice provided by the government and the health authorities between February and September 2021. Within the Australian context, we will discuss the summaries of public statements made by the Australian Technical Advisory Group on Immunisation (ATAGI) on the use of the Oxford/AstraZeneca and Pfizer Covid-19 vaccines in the period between April and July 2021.[5] These summaries preview the main content of public health discourses such as official authoritative announcements or guidelines, which are often referred to by politicians and the media outlets.



The Story of the “good vaccines” in Thailand

Thai people became aware of COVID-19 after the first case in the country, a traveller from China’s Wuhan, was reported on 12 January 2020.[6] Mr. Anutin Charnvirakul, the Minister of Public Health, assured the public on 25 January 2020 that COVID-19 was “just another type of flu.”[7] However, the epic of the initial COVID-19 outbreak in Thailand started only a few days later, on 31 January 2020, with the detection of the first domestically infected patient followed by several incidents of infections among large population clusters.

Mr. Anutin Charnvirakul, the Minister of Public Health, assured the public on 25 January 2020 that COVID-19 was “just another type of flu.

During the first year of the outbreak, when Thailand had no vaccines, members of the government and authoritative public health officers tried to ease public anxiety over the novel virus. They employed the communication strategy set by the public health minister, who re-assured the public on 5 December 2020 that Thailand was well prepared to deal with the outbreak because “COVID was just a minor disease.”[8] Meanwhile, the government’s communication played with the word “vaccine” by using it in a figurative sense to refer to “protective tools” that are better than an actual vaccine. The tools included mask-wearing, handwashing, and use of serving spoons. The term was also used in an abstract sense (e.g., “mental health community vaccines”), encouraging community members to work together to deal with the outbreak.[9]

Mask-wearing is the best COVID-19 vaccine. (COVID-19 Information Centre, 28 September 2020)

The best vaccine in Thailand now is mask-wearing, handwashing, use of serving spoons, and eating newly cooked food.  (Department of Health, 20 December 2020)

The discourses illustrated above were delivered amidst a severe outbreak of COVID-19 and a global crisis during which the governments of different countries were trying to mobilise all resources, including budgets and diplomatic negotiations, to procure effective vaccines for their people. The Thai government’s words led people to believe that COVID-19 was not a severe disease and that there was no urgent need for a vaccine. The government’s strategy of minimising negative ‘appreciations’ of COVID-19 (e.g., “a minor disease”) and amplifying positive ‘appreciations’ of non-vaccine measures (i.e., “the best vaccine”) met some serious opposition among Thai people. Bearing this dissatisfaction, a great number of people believed that the Thai government had never been sincere in its efforts to procure suitable vaccines.  

In its efforts to prevent further COVID-19 outbreaks, the Thai government moved towards supporting COVID-19 vaccination in its literal sense after the first lot of 200,000 Sinovac doses had arrived in Thailand on 24 February 2021.[10] The government then made announcements emphasising the safety of inactivated vaccines such as Sinovac to motivate people to get vaccinated. Several prominent medical community leaders, including Dr Nakhorn Premsri, Director of the National Vaccine Institute, Dr Taweesin Visanuyothin, Spokesperson for the Centre for the COVID-19 Situation Administration (CCSA), and Prof Yong Poovorawan, MD, Head of the Centre for Clinical Virology, Faculty of Medicine, Chulalongkorn University, issued statements to support the Ministry of Public Health in their assurances regarding the safety of inactivated vaccines. In these statements, the evaluative language used to convince the public to get vaccinated was all highly positive of Sinovac, a vaccine freshly imported from China. The commonly used expressions included wordings that maximise vaccine efficacy (i.e., amplify positive ‘appreciation’) while highlighting one’s confidence (i.e., positive ‘affect’) in making such a positive assessment.

“You will find that the vaccines used in Europe, the USA or Thailand are 100% effective at preventing death, including Sinovac and AstraZeneca. These two vaccines are as efficacious as Moderna or Pfizer, which are used in the USA. So, you can be confident in the efficacy of the vaccines used in Thailand”[11]

As the media was reporting on numerous deaths caused by both COVID-19 and COVID-19 vaccination side effects nearly every day, the abovementioned expressions of high confidence surrounding the vaccines’ efficacy cast doubts in people’s mind about the said medical information. These doubts led to a decrease in trust toward the information from the government and medical officials. The doubts greatly increased when the effectiveness of different vaccines started to be noticeable in the global community.      

The government’s (or the medical officials’) use of imprecise graduation expressions when gauging vaccine efficacy (i.e., positive ‘appreciation’) resulted in interpretation issues and confusion among people. A representative example can be found in Dr Nakorn Premsri’s statement to the public arguing that both Sinovac and AstraZeneca “are considered good vaccines that are fine to use” and are “reasonably efficacious”. Describing the vaccines’ efficacy levels through inherently ambiguous expressions such as “fine” or “reasonable” without specifying the involved benefits and risks led people to interpret that both vaccines were just “passable” – or even “not good enough” – when compared to other vaccines.

“The best vaccine now is the one that you can get the soonest. The registered vaccines approved by the Food and Drug Administration are considered safe and efficacious and are fine to use”. [12]

The public's confusion and concerns over the government's messaging and sincerity were further exacerbated by the Ministry of Public Health's announcements made from February to October 2021, which labelled Sinovac as the main vaccine for Thailand. The COVID-19 Situation Administration (CCSA), the Department of Disease Control, and government media outlets all presented to the public negative information on mRNA vaccines (i.e., negative ‘appreciation’) even though the government was yet to procure the said vaccines for public use due to procurement issues. As a result, the government was widely mocked with statements such as “Good vaccines are the ones that (Thailand does not) have”.

The confusion caused by the official communication on COVID-19 vaccination in Thailand as well as the rapid changes in the medical advice brought about by the results of various COVID-19 vaccine efficacy assessments worldwide continuously contributed to grave communication issues with the public. The government’s poor choices of evaluative expressions when assessing the severity of COVID-19 and the efficacy of COVID-19 vaccination led to a loss of public confidence in Thailand’s COVID-19 crisis management and procurement of appropriate vaccines. Furthermore, the fact that the government media outlets emphasised the negative ‘appreciation’ of mRNA vaccines during the time when Thailand was yet to procure the vaccines was another reason for mRNA vaccine hesitancy among some people even though the test results in other countries had clearly shown that mRNA vaccines were more efficacious than inactivated vaccines.       

 

The confusion caused by the official communication on COVID-19 vaccination in Thailand as well as the rapid changes in the medical advice brought about by the results of various COVID-19 vaccine efficacy assessments worldwide continuously contributed to grave communication issues with the public

 

At different stages of the pandemic, the often-ambiguous information on the benefits/risks of COVID-19 vaccination, together with the government’s inability to procure particular vaccines in time to address the outbreaks appropriately, resulted in the public’s tendency to rank the existing COVID-19 vaccines as either “the best”, “passable”, or “poor”. In addition, the periodical mix-and-match strategy to ensure that people got “the best vaccines” inadvertently triggered a phenomenon called “arm filled with vaccines.”[13]

The story of Oxford/AstraZeneca versus Pfizer in Australia

In the period between April and July 2021, ATAGI released three statements regarding the use of the AstraZeneca and Pfizer Covid-19 vaccines. In April, the first statement recommended the AstraZeneca and Pfizer be used for the 50+ and 18-50 age groups, respectively; in June, the second statement revised the initial advice to recommend the AstraZeneca only for those that are aged 60+; in July, yet another statement reworked the previous advice to recommend both the AstraZeneca and Pfizer vaccines for all adults New South Wales due to a COVID-19 outbreak.

           

To encourage the uptake of the AstraZeneca vaccine in the 50+ population, the initial ATAGI statement upscales the negative ‘appreciation’ of Covid-19 infection in the older population while amplifying the positive ‘appreciation’ of Covid-19 vaccination:

This recommendation is based on the increasing risk of severe outcomes from COVID-19 in older adults (and hence a higher benefit from vaccination) …

Conversely, the risks of the AstraZeneca vaccination are upscaled for those aged 18-50, indicating a negative ‘appreciation’ of the AstraZeneca for this age group:

… and a potentially increased risk of thrombosis with thrombocytopenia following Astrazeneca vaccine in those under 50 years

Interestingly, the summary makes no mention of the potential future AstraZeneca benefits extending to the 18-50 population or its side effects extending to the 50+ population. Arguably, this may have contributed to a part of the general public believing that the positive or negative ‘appreciations’ of the AstraZeneca vaccine with reference to the specified age groups are not susceptible to change. It is therefore advised that future pandemic responses emphasise and reiterate the changing nature of circumstances at every stage of a public announcement. A good example of such communication can be found much later within the same ATAGI statement, which notes that “advice may be revised as more information may become available”.   

In the second statement summary, ATAGI continues adding to a positive ‘appreciation’ of COVID-19 vaccination in the older population. To justify its revised recommendation regarding the use of the AstraZeneca vaccine, however, this text puts a strong focus on establishing a negative ‘appreciation’ of the AstraZeneca for those aged 50-59. In the text, this is evident in the upscaled the amount of the newly found AstraZeneca vaccination risks:

The recommendation is revised due to a higher risk and observed severity of thrombosis and thrombocytopenia syndrome (TTS) related to the use of Astrazeneca COVID-19 vaccine observed in Australia in the 50-59 year old age group than reported internationally and initially estimated in Australia.

There is no comment on the AstraZeneca vaccination risks for adults younger under 50, likely because its purpose seems to be to discourage the 50-59 age group from choosing AstraZeneca (as previously recommended). Be that as it may, the use of the AstraZeneca vaccine as the second dose is encouraged for anyone who did not suffer any side effects the first time. This is achieved by downscaling the risk of AstraZeneca vaccination regardless of age:

This is supported by data indicating a substantially lower rate of TTS following a second COVID-19 Vaccine Astrazeneca dose in the United Kingdom (UK).

The use of imprecise measure expressions such as “higher” or “substantially lower rate” when up-/downscaling the updated AstraZeneca vaccination risks can be seen as one of the key culprits for the confusion and the increasing AstraZeneca vaccine hesitancy. Specifically, imprecise measurements are inherently subjective and open to interpretation – for instance, the concept of a “lower/higher risk” may be interpreted differently depending on an individual’s risk tolerance.  Thus, future pandemic responses may benefit from putting more emphasis on providing some statistical information to better define what is meant by different degrees of risk. Although some of this information can be found in the later sections of the ATAGI statement detailing the rationale behind the revised advice, this unfortunately appeared to be rarely reiterated in the resulting media announcements.

Thus, future pandemic responses may benefit from putting more emphasis on providing some statistical information to better define what is meant by different degrees of risk.

As far as the summary of the third ATAGI statement is concerned, there are several notable evaluative patterns that separate this outbreak-related announcement from the previous statements. To begin with, there is a sole focus on the benefits of vaccination (i.e., positive ‘appreciation’) during an outbreak, without discussing any potential side effects (i.e., negative ‘appreciation’). In other words, any vaccine – including the AstraZeneca – is now considered to be an undoubtedly “good vaccine”, with time (i.e., “bringing forward optimal protection”) becoming an important factor:

…consider getting vaccinated with any available vaccine including COVID-19 Vaccine Astrazeneca (…) can receive the second dose of the Astrazeneca vaccine 4 to 8 weeks after the first dose (...) to bring forward optimal protection.

Furthermore, when it comes to the benefits of vaccination, the extent of ‘appreciation’ has shifted from an adult’s age to their place of living:

All individuals aged 18 years and above in greater Sydney, including adults under 60 years of age, should strongly consider…

Finally, in addition to the risks of COVID-19 infection, the vaccine supply has now been introduced for the first time as a criterion influencing the risk-benefit assessment regarding the use of the AstraZeneca:

This is on the basis of the increasing risk of COVID-19 and ongoing constraints of Comirnaty (Pfizer) supplies.

The above differences between the final and the preceding two ATAGI statements might have been too great for the general population to re-shape their perception of AstraZeneca from being a potentially “bad vaccine” to an overwhelmingly “good vaccine”. Specifically, people appear to have been asked to abruptly shift their focus from the “rare but serious” side effects of the AstraZeneca vaccination, which were featured in the first two summaries, to the benefits of “earlier protection” with AstraZeneca. In addition, they were suddenly advised to take into account the dwindling supply of Pfizer into their risk-benefit assessment, which was probably more likely to cause their frustration with the government’s approach to procuring vaccines than provoke a change in their attitude towards the AstraZeneca vaccine.

The moral of the “good vaccine” stories

Public health communication may seem like a simple matter of providing medical information. Our case study of Thai and Australian public discourses about the COVID-19 vaccination, however, has shown the incredible impact that the choices of evaluative expressions in public announcements can have on the success or failure of pandemic responses. Therefore, future communications on vaccination may benefit from a more balanced overview of the perceived risks and benefits of particular vaccines. Whenever possible, it is also important to illustrate what is meant by different degrees (i.e., lower/higher amounts) of the said risks and benefits. Finally, there should be a constant reminder of the fact that the recommendations during a pandemic are inherently temporary and susceptible to change due to a range of factors.

 

Public health communication may seem like a simple matter of providing medical information. Our case study of Thai and Australian public discourses about the COVID-19 vaccination, however, has shown the incredible impact that the choices of evaluative expressions in public announcements can have on the success or failure of pandemic responses

 

After all, in a pandemic crisis, the quest for protecting our community – both locally and globally – does not end with the invention of a cure or a vaccine; rather, finding the cure or vaccine is only the beginning. Specifically, what we have learned from our research is that “good vaccines” must be born out of “good science” and then fostered by “good communication”.

This article is part of the Comparative Assessment of the Pandemic Responses in Australia and Thailand, supported by the Australia-ASEAN Council under Australia-ASEAN Council COVID-19 Special Grants Round, the Australian Department of Foreign Affairs and Trade.


References


[1] https://www.reuters.com/article/us-health-coronavirus-vaccine-china-idUSKBN29505P

[2] https://www.nature.com/articles/d41586-020-03441-8, https://www.gov.uk/government/news/one-year-anniversary-of-uk-approving-oxfordastrazeneca-covid-19-vaccine

[3]  https://www.nature.com/articles/d41586-021-01497-8

[4] Martin, J. R., & White, P. R. R. (2005). The Language of Evaluation: Appraisal in English. Palgrave.

[5] Links to the three ATAGI Statements: [1] Links to the three ATAGI Statements:

https://www.health.gov.au/news/atagi-statement-on-astrazeneca-vaccine-in-response-to-new-vaccine-safety-concerns

https://www.health.gov.au/news/atagi-statement-on-revised-recommendations-on-the-use-of-covid-19-vaccine-astrazeneca-17-june-2021

https://www.health.gov.au/news/atagi-statement-response-to-nsw-covid-19-outbreak-24th-july-2021#:~:text=Detail,be%20significant%20over%20coming%20weeks.

[6]  https://he01.tci-thaijo.org/index.php/bamrasjournal/article/view/241494/164620

[7] https://waymagแอสตร้าเซเนก้าine.org/the-best-of-anutin-charnvirakul/

[8] https://www.matichon.co.th/politics/news_2473021

[9] https://dmh-elibrary.org/items/show/424#?c=&m=&s=&cv=

[10] https://www.hfocus.org/content/2021/02/21115

[11] Prof Yong Poovorawan, MD, Head of the Centre for Clinical Virology, Faculty of Medicine, Chulalongkorn University, said in the Ministry of Public Health statement on 11 April 2021.

[12] Dr. Nakorn Premsri, Director of the National Vaccine Institute, said in the Ministry of Public Health statement on 12 April 2021.

 [13] https://cimjournal.com/public-health-news/%E0%B8%A7%E0%B8%B1%E0%B8%84%E0%B8%8B%E0%B8%B5%E0%B8%99%E0%B8%AA%E0%B8%B9%E0%B8%95%E0%B8%A3%E0%B9%84%E0%B8%82%E0%B8%A7%E0%B9%89-astrแอสตร้าเซเนก้าeneca-pfizer/

[14] https://m.facebook.com/Sumnakkaow.PRD/posts/6743035225721940/