Defying Gravity: Championing Vaccination in a Time of Skepticism and Misinformation

[00:05:50]

Burden of Vaccine Preventable Diseases in the US

Let's see, I'm going to start here by just talking a little bit about the burden of vaccine-preventable diseases in the US, with focus on adults. Leave it to say that the majority of the burden is actually in adults.

For just 4 major adult vaccine-preventable diseases, flu, pneumococcal disease, shingles and pertussis, those costs of those vaccine preventable diseases is estimated about $26.5 billion annually in the United States. For influenza, we have about 120-710,000 hospitalizations per year from 2010 to 2024. 90% of those hospitalizations are in adults, and 45%-72% of those are in patients 65 and older.

And about 1 in 3 adults will get shingles, and there are about 1 million cases of shingles in the US every year, so lots of disease.

[00:06:51]

COVID-19 Disease Burden Remains High

In terms of COVID, this has been a bit of a moving target, right? We had a new virus that was introduced that underwent quite a bit of evolution in the human population.

Now we're starting to see a little bit more maybe predictive patterns in that we have about 2 outbreaks per year, 2 peaks per year, it looks like is now where we are. And we have the highest hospitalization rates in children younger than 2 years of age, particularly babies, and adults 15 and older, and particularly those 65 years of age and older.

[00:07:32]

Trends in US Adult Vaccine Coverage

So we have a lot of disease burden with diseases that are very common. And so, how are we doing getting patients vaccinated?

The answer is not great. We see around 70% vaccination rates for flu and pneumococcal disease for patients 65 and older, but we tend to not do as well vaccinating patients who have high-risk conditions who are younger than those age cutoffs for routine vaccination. And we are making progress on things like the shingles vaccination, but still well below where I think any of us would want to be.

And just to be clear, that pneumococcal vaccine vaccination rate averages based on the 65 and older, but as I'm sure you all know, that recommendation is now routine vaccination for all adults down to age 50. But this is data from the National Health Interview Survey through 2022, which was done prior to that recommendation. So I think the bottom line is that vaccination rates are relatively stagnant with some increases in shingles—but still that shingles vaccination, still not where we want it to be.

[00:08:50]

Vaccine Uptake Among Adults

So what are those factors that influence vaccine uptake? Well, we'll talk about a number of those, but certainly we know that age-based recommendations are easier to implement than risk-based recommendations. So it's much harder, I think, for us to make sure that those high-risk younger patients are getting vaccinated.

We also continue to see racial and ethnic disparities in adult vaccination, and this differs from pediatrics. So for pediatrics, there are some racial ethnic disparities, but they're substantially less. And that's because there is a Vaccine for Children's Program that provides vaccines for children who are uninsured or whose insurance doesn't cover vaccines, and we do not have that kind of a program yet for adults.

So being uninsured, again, a major predictor of not being vaccinated if you're an adult.

[00:09:49]

Selected US Vaccination Coverage Among Adults by Age and Risk Indications

So what are some other issues? One, again, this age vs risk condition-based.

Everyone up through age 60 is recommended to have a hepatitis B vaccine, but we know that coverage is not great, but we do see higher coverage in travelers since hepatitis B vaccination is also recommended for travelers. So we're going to want to really follow this hepatitis B vaccine coverage, given the universal hep B vaccine recommendation, which has been there now just for a few years.

For a COVID vaccine, we see higher rates in older vs younger populations. So the higher-risk people tend to have higher vaccine coverage. And same thing for influenza. Even though we know 19- to 64-year-olds are also recommended to get flu vaccine, even though they may not have a high-risk condition, we're still less than 40%.

For pneumococcal, again, the recommendation is everyone 50 and older now, but considering the older recommendation for 65 and older, we reached about 70% coverage, but high-risk 19- to 64-year-olds, we're just over 30% or so. So, long way to go, particularly with pneumococcus.

And shingles vaccine, also that vaccination is now recommended for 50 and older, not 60 and older. But we have a long way to go with improving shingles vaccine coverage.

[00:11:28]

Selected US Vaccination Coverage Among Adults by Vaccination Status and Usual Place of Care

So what about other factors that predict vaccination? We know that having a usual place of care is associated with higher vaccination coverage. And being insured, having health insurance also increases your chances of getting vaccination. And that was true even for COVID-19 vaccine when there was no out-of-pocket cost. So we have other issues to consider, not just the cost of vaccine, but access to healthcare and access to that recommendation.

So not just for COVID, but we also see for pneumococcal vaccine and shingles vaccines that having usual pace of care and having insurance make a big difference in whether you're getting vaccinated.

[00:12:17]

Racial and Ethnic Disparities in Vaccine Coverage

But what about racial and ethnic disparities? We continue to see in adult populations, large gaps in vaccine coverage by race and ethnicity.

This is just 1 example for pneumococcal vaccination, where in the 65 and older group, in the solid lines, you see substantial differences in coverage. When you look at the highest group, which were White, non-Hispanic compared to Hispanic populations, big gaps there. Smaller gaps for the high-risk 18-64, but also lower vaccination rates for everyone. So continued racial and ethnic disparities, and this is something that we need to continue to work on and try and understand these gaps and address them.

[00:13:11]

Racial and Ethnic Disparities n vaccine Coverage: COVID-19

So this is just 1 other example from COVID-19 vaccine. This is from the National Immunization Survey at CDC for 2024-25, and we see relatively low vaccination rates for everyone, but still significant differences by race and ethnicity, with the highest vaccination rates among White, non-Hispanic, and the lowest vaccination rates, in this example, among Alaska Native and Native American populations.

[00:13:42]

Up-to-Date Vaccination, Adults: 2022 NHIS Data

So when you look at multiple vaccines together, we do have this up-to-date measure, which is also a HEDIS measure, and it looks at the vaccination rates combining influenza, Td and Tdap, pneumococcus, and shingles, and the proportion of adults based on the age recommendation only. So not the risk-based, but just age-based. And if you look at 19 years of age and older, only 22.8% of people were up-to-date on just those 4 vaccines. So if we were to add additional vaccines that patients may be indicated for based on their risk condition or age, we would likely see even lower proportion of adults being up-to-date.

So this just tells us, again, a lot of room for improvement. If you are concerned that you may not have enough unvaccinated people to make it worthwhile in your practice, I think that the vast majority of practices are going to see a lot of need and a lot of gaps in vaccine coverage in their populations.

[00:14:51]

Factors Associated With Adult Vaccination

So we've talked about those things that are associated with lower vaccination rates, but I just want to highlight what is associated with higher vaccination rates, what works, and that you have control over.

So again, having a usual place of care, having higher numbers of medical visits in a year, and, most importantly, the provider recommendation. So, tons of studies out there showing that having your provider recommend a vaccine was a major predictor of you actually getting vaccinated.

[00:15:24]

Top Reasons for Vaccine Refusal

So why do people report that they decide not to get vaccinated?

I think really the main 1 often reported are safety concerns. And so we'll talk about a little bit about that later, but also trust. And I think that that's going to be an even more important consideration and something that we need to be ready to talk about with patients.

Again, that lack of a health care provider recommendation, low perceived risk, their personal out-of-pocket cost, and then competing priorities or just inconvenience, "I didn't have time."

[00:16:02]

Top Reasons for Vaccine Refusal by US Adults: COVID-19, Flu, RSV

But those reasons do differ by vaccine.

So this is again from a CDC survey looking at COVID-19, flu and RSV. And just highlighting that those reasons tend to differ why people don't get 1 vaccine compared to another. So if you look at the responses for COVID-19 vaccine, safety, that was the number 1 concern about why they chose not to get vaccinated. Also on that list was trust.

For flu vaccine, the number 1 concern was they weren't concerned about getting flu, and they just don't like getting vaccines, and they didn't have time. And there was some concern about effectiveness.

For RSV, those reasons are really different. They didn't know enough about it. They haven't talked to their doctor. "My doctor didn't recommend it." So those were the big things. So, really differs by vaccine. So, it's hard to make any sort of global recommendation for vaccination. You really have to tailor people's concerns to individual vaccines.

[00:17:10]

Poll 3: How confident are you in sharing information on vaccine safety to address patient concerns?

Tracey Piparo: So what are you guys thinking? How confident are you in sharing information on vaccine safety to address patient concerns?

Not confident at all;

Slightly confident

Somewhat confident;

Confident; or

I'm very confident.

Don't forget to hit that submit button.

[00:17:43]

Vaccine Safety Monitoring: Robust and Ongoing

Dr Bridges: Okay. Well, let's dive in a little bit to safety. I think 1 of the things that's important for patients and also for healthcare providers to be aware of, what does that vaccine safety monitoring look like?

And pointing out to patients that this is a really robust and ongoing system. So that safety monitoring starts in preclinical studies. It goes all the way through clinical trials, the FDA review of vaccine efficacy and safety, the review by CDC and the advisory committee on immunization practices.

And then that safety monitoring continues in post-licensure. So safety monitoring continues until that vaccine's no longer in the market. So ongoing safety monitoring, even after licensure, even after recommendations.

[00:18:37]

Example of Post Licensure Surveillance: Expanded Safety Monitoring Systems and Programs for COVID-19 Vaccines

So there are also multiple different studies that look at vaccine safety. So this is a really nice reference here by Julianne Gee in Vaccine last year, which describes these multiple systems. They look at different endpoints.

They help with different parts of that system. Some are really for signal detection, and others look at population-based risk to determine whether there's an association or not. I think there's been a lot of confusion, and particularly about the vaccine adverse events reporting system.

Anyone can report a vaccine adverse event or any event that occurs after vaccination. That does not help us understand causality. It does help provide some signal that then can be looked at in population-based systems so you can understand whether there is a difference in that outcome being reported in vaccinated vs unvaccinated populations. So you have to be able to look: What is the risk in vaccinated vs unvaccinated groups?

And there are systems like the Vaccine Safety Data Link, which is a population-based system that help look at that risk. And they've been able to identify risk down to the 1:1 million vaccine risk. So that's pretty rare. A very sensitive system. And there are other systems here that CDC works in collaboration with FDA, Department of Defense, the VA, and the Indian Health Service. And I would really encourage you to look at this paper in vaccine to give you even more information to help you feel comfortable as well about really the robustness of these vaccine surveillance systems for safety.

[00:20:33]

Evidence for Safety of Coadministration of Adult Vaccines

So I think the other question that we get a lot about is safety of coadministration.

So these same safety systems I just mentioned have also looked at vaccine coadministration. In addition, in clinical trials, many of these vaccine combinations are also looked at. But we do know that CDC has recommended for many years to give vaccines at the same visit when there are multiple vaccines that are needed.

Those vaccines should be separated by at least 1 inch if you need to give them in the same limb. Ideally, giving them in separate limbs is probably better or easier on the patient. But you can give 2 or 3 in the same deltoid muscle if you absolutely need to.

And this, again, has been a very longstanding recommendation. And that helps you avoid missed opportunities for vaccination because we know patients often don't come back or find it difficult to come back for additional visits if they don't absolutely need to. So avoiding missed opportunities is important.

But there are quite a number of studies done looking at different combinations of vaccines. And CDC states that most inactivated recombinant and live vaccines can be administered at the same visit at different anatomic sites without loss of effectiveness. There are very few exceptions to this rule.

One is you don't want to give the pneumococcal polysaccharide and pneumococcal conjugate vaccines at the same visit. And then also the other 1 is with yellow fever vaccine, obviously 1 that not a lot of people keep in their office, but that's another 1. Can't give that with MMR vaccine.

But again, these are very kind of rare, unusual circumstances where you cannot give more than 1 recommended vaccine at the same time. If you're talking about live vaccines, if they're not given on the same day, again, you need to separate those by at least 4 weeks. And that's 30 days if you're talking about yellow fever vaccine.

[00:22:52]

Vaccine Effectiveness: Practical Benefits of COVID-19 and Influenza Vaccinations

So what about vaccine effectiveness? This is 1 of the issues that was brought up in some of those surveys about benefits and reasons patients choose not to get vaccinated, particularly with COVID and flu vaccines. These vaccines don't have as high effectiveness as some other vaccines, but the disease burden both from COVID-19 and influenza is substantial.

So even with a vaccine that has somewhat lower vaccine effectiveness compared to some other vaccines, it really still can reduce large numbers of complications from these illnesses, hospitalizations, and medically attended illnesses.

[00:23:38]

Effectiveness of Other Common Vaccines

So what is the effectiveness for some other vaccines? You know, things like polio, MMR, hep B, varicella, shingles vaccine, very highly effective.

The tetanus and diphtheria part of the Tdap or DTaP vaccines, highly effective. A little bit less effective in preventing pertussis or whooping cough. But still, we do know that maternal vaccination with Tdap, highly effective at preventing whooping cough or pertussis in infants. So in the 90th percentile range.

Pneumococcal vaccine, more effective in preventing invasive pneumococcal disease than it is against preventing vaccine-type pneumonia. But still, you know, substantial benefits. And what we're really trying to do with all these vaccines is prevent the more serious endpoints.

[00:24:41]

New Challenges With US Vaccine Recommendations

So in addition to those issues, and I would say with really complex vaccine schedules, we have now new challenges. And that comes with this now disharmonization between vaccine recommendations from professional medical societies or organizations like the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, compared to some of the recommendations from the US Department of Health and Human Services or CDC. In addition to that, we now have some states and some groups of states that are now issuing their own recommendations.

And in part, they're doing that because some of their legislation about who can give which vaccines are tied to ACIP recommendations. So now where there's some disagreement about what should be recommended, some of these states have decided on their own then to, again, issue separate recommendations to be followed in their states.

So all of this disharmonization really is creating additional confusion among patients, and I would say also healthcare workers as well, regarding which recommendations to follow and what may be the implications of following different recommendations.

But I'll show here you have a couple of examples for recommendations where you can find those for American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, but also AAFP, ACP, or others that have also issued separate recommendations.

[00:26:29]

National Adult Influenza Immunization Summit: Tip Sheet Updated September 2025

So to help providers keep track of who's recommending what, the National Adult and Influenza Immunization Summit has developed a tip sheet. This is updated in early September.

It will be updated based on ACIP recommendations from the most recent meeting. Usually what we have to do is we have to wait until there's a sign-off by the CDC director, in this case, an acting director, on what those advisory recommendations were. So once we know what the recommendations are going to be from CDC, whether they adopt ACIP or have a different recommendation, we'll further update this tip sheet.

I'll just let you know that Common Health Coalition, which you will have the link in the resources slide, also has a summary of how these recommendations differ by professional society vs CDC/ACIP.

[00:27:40]

AHIP (America’s Health Insurance Plans): Vaccine Access

So I apologize, it looks like this slide did not get updated, but America's Health Insurance Plan is a trade organization for private insurers, and they have made statements both in June and again most recently in September, which talk about the recommendations for, or their group's recommendations for coverage. And what they said in September is that their plans will be covering with no-cost sharing vaccines as were recommended by September 1, 2025, and they'll be recommending those at no-cost sharing through 2026.

So these differences in recommendations certainly create a lot of concern about payment issues, but this is the latest statement from the AHIP trade organization.

[00:28:46]

What Can You Do to Support Science-Based Recommendations?

So what can you do to support science-based recommendations? You know, my recommendation is to continue to follow best practices medical care.

You know, we know that flu, COVID, RSV are happening now every year. I think we can count on flu season, RSV season, and a second wave of COVID coming, so patients need to be aware that really that has not changed. And really follow and support your professional societies.

State and local immunization coalitions can also be helpful in helping you stay up to date, and also educating your peers and the public about vaccine-preventable diseases and the importance of vaccination. I think it's also, given the uncertainties, important for all of us to understand what might be the payment implications where recommendations differ between medical societies vs the ACIP, and I would also recommend, you know, making sure that you stay alert regarding statements that are being made that may not follow accepted scientific, evidence-based decision-making processes.

[00:29:58]

Assessing the Strength of Scientific Evidence for Clinical Guidance

So the summit, as well as Common Health Coalition, as well as National Foundation for Infectious Diseases, and I'm sure many others, have come out with some, you know, brief overviews of, gosh, what is strength of scientific evidence, and what can people do to, you know, try and understand what's happening with some differences in how people are interpreting data?

So some of the core principles for developing evidence-based, trustworthy clinical considerations are, you know, really, what should that evidence-based guidance be? What are the core principles? Well, you want to make sure that those recommendations have been subject to a systematic review, that all relevant studies have been evaluated and weighted.

So those with, you know, the largest sample size, who have the least bias, randomized controls, obviously those would be weighted more heavily than, say, a case series. Was the risk-benefit weighted? So how have we looked at overall risk of the disease, the outcomes, risk of vaccination vs the benefits of preventing that disease? How has that been applied to different patient populations?

And we want to make sure that there's transparency in how those analyses are being done, which data are included, which are excluded, and why. The conflict of interest is clearly reviewed, that there's been a determination of the level of certainty of the evidence, how certain are we about the benefits and risks, how relevant are the benefits and risks to clinical practice and clinical illness, and then what is the strength of a recommendation? For example, is a strong recommendation or is it conditional?

Think about the study designs that are of those that are being cited and their strength, making sure that we are clear about causation vs association, and that correlation does not imply causation, particularly correlation in time. And then, you know, be alert to situations in which there's cherry-picking of data or misinterpretation of selected studies.

[00:32:24]

Vaccine Integrity Project

So, given many of the changes we've had recently, the Vaccine Integrity Project was developed under the banner of CIDRAP. You can find more information at the links below, but they did a lot of focus group testing to try and determine, you know, what are the biggest needs in our current environment.

They published a final report of that on their website. And then what they decided to do subsequently was to conduct systematic analyses of publicly available studies on the benefits and risks and epidemiology of influenza, COVID-19, and RSV vaccines. And those analyses were made publicly available and provided to both the public and professional medical societies.

Defying Gravity: Addressing Vaccination Concerns and Misinformation in the Primary Care Setting

[00:33:25]

So given our current situation, you know, how can we help our patients in primary care?

[00:33:36]

Poll 4: What are your patients’ most common reasons for not getting vaccinated?

Tracey Piparo: Yes, so here's a question for you guys. What are your patients' most common reasons for not getting vaccinated? Throw a short answer in there, and don't forget to hit the "Submit" button.

Dr Bridges: Yes, and I would also add, I'd love to hear what you're hearing about, you know, concerns that patients are asking you, you know, what questions are coming up in your practice.

[00:34:01]

4 Evidence-Based Strategies to Improve Immunization Practices

So what can you do in our current environment? Well, Dr Rick Zimmerman and his colleagues have developed this 4-pillar toolkit, and their recommendations are to use 4 basic strategies. One, make vaccine services as convenient and accessible as possible. Two, use effective communication strategies with your patients. Three, enhance your office systems to reduce missed opportunities, and then help motivate patients to get vaccinated.

[00:34:40]

Strategy 1: Make Vaccine Services Convenient and Accessible

So making strategy 1, make services convenient and accessible, you know, make sure you are asking about visits or vaccines at every visit, including during rooming, offer walk-in services if you can, or after-hours clinics, all those things can be helpful. And then making sure you use the tools that you have to communicate the importance of vaccines, including making sure your staff are trained so that they can talk about vaccines with patients and help you during patient rooming. Conducting outreach using your health portal or mobile devices, actually, text messaging has been shown to help improve vaccination rates as well.

[00:35:24]

Effective Patient Messaging

And then think about what that effective patient messaging is. You want to share – personalize it for them. You know, people really want a tailored message. What's – why is it right for me, for my age, for my risk condition, and, you know, make sure it's personalized.

[00:35:44]

The SHARE Approach

CDC has also recommended for some time the SHARE approach. I think this is really more for patients who have a lot of questions or need some additional information.

You know, why is it right for them? You can highlight positive experiences you've had with vaccination for yourself or other patients, and make sure to address their concerns. Remind patients that it can help protect their loved ones as well. Patients are often more motivated to protect their family than sometimes they're motivated to protect themselves. And then also explain the cost of actually getting disease. What does that illness look like vs, gosh, you might feel, you know, not great for a day or 2, have a sore arm, and maybe have low energy for a day or 2 after vaccination vs how might you feel if you, you know, for example, actually get shingles.

[00:36:36]

The Best Messages for Patients . . .

The best messages for patients are simple, concise, and direct. They stress prevention. They use a presumptive approach to vaccination.

And what I mean by that is you say, "Gosh, you know, Mr. Jones, today you're due for a, you know, a COVID flu and shingles vaccine." Instead of saying, "Gosh, you don't want to get vaccinated today, do you?" You know, really think about the language that you're using when you make that recommendation.

[00:37:04]

Strategy 3: Use Enhanced Office Systems to Reduce Missed Opportunities

And then strategy 3 is enhancing your office systems to reduce missed opportunities. Utilize your alerts on your electronic health record system. Utilize your immunization information system.

And ideally, we'd like people to stock vaccine in your office. We know that when you refer patients out for vaccination, you know, the vaccination rates really drop. So where possible, stocking vaccine, being able to offer it in your office are really important.

[00:37:35]

Vaccine Standing Orders

And then standing orders. We know that standing orders are associated with increased vaccination rates. Have been shown to improve coverage. And this really helps empower staff to go ahead and vaccinate. And it helps them with doing the screening for eligibility by chronic condition, age, and screen for contraindications to vaccination.

[00:38:05]

Evidence-Based Interventions to Increase Vaccination: The Community Guide

So the community guide has investigated and done analyses to look at what are the evidence-based strategies to improve vaccination coverage. And these include reducing out-of-pocket cost.

As we've talked about, remind your recall system, vaccine requirements. We've seen some decrease in vaccine requirements for schools. You know, I would just remind all of us that we may be seeing more adults, maybe who didn't get a vaccine in childhood that we need to, you know, think about what they may have missed early on.

And another 1 of those things that really works is provider assessment and feedback. So helping providers understand how well they're doing with vaccination of their patients can be very powerful. We know from lots of studies in general, providers tend to overestimate how well they're doing. And that provider assessment and feedback helps raise vaccination rates and raise awareness about how different practice is actually doing.

[00:39:10]

Strategy 4: Motivate Patients to Get Vaccinated by Leveraging Clinic Staff

So the fourth strategy is, you know, using your – leveraging your clinic staff. You know, make sure that they are on board with what your practice is recommending with vaccinations and why.

And really empower them with more information and, you know, making sure that their questions are also answered about vaccinations. And, of course, encouraging staff to be up-to-date on their vaccinations as well.

[00:39:43]

The Vaccine Confusion Continuum

So despite all of that, you know, we do know that there's a continuum with where people are about acceptance of vaccinations, going anywhere from actively seeking out vaccinations to refusing all vaccines.

But, you know, don't give up. In my clinical practice, I do see patients that initially are just not interested. It's not the want to talk about it. But I say, "Gosh, you know, it's my job to let you know about what's recommended for you and why these are recommended for you. I get that you don't want to talk about that today, but let me give you some information about, you know, why these vaccines maybe are recommended for you, why I would recommend them for you. We can talk about it in the next visit."

And, you know, this has often been a very successful strategy with, you know, the next visit getting patients interested. But it's about building that trust, understanding that sometimes refusing just means I don't have the information that I need, and making sure that patients feel heard about what their concerns are about, and making it an open conversation to, you know, bring back up again.

[00:41:04]

Transcultural Nursing

We also want to, you know, make sure that we're being culturally competent when we're talking with patients about their vaccination, considering where they are in terms of their needs, and taking a holistic approach to patients' needs and their concerns. So, remain open-minded.

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Reframing Patient Discussions on Vaccines

So, what are some of the stages to discussing vaccines with patients?

[00:41:40]

Step 1: Set the Stage

So, stage 1, really set the stage, let them know what's recommended and why.

But, you know, first it's important for the patients to know that you hear their concerns and you're going to address them. So, you want to acknowledge what those are, and it helps often to repeat those back to the patient. "What I heard you say is that you're concerned about, you know, situation X. You know, could I provide you with some information about that?"

So, use your motivational interviewing skills in addressing patients' concern, and making sure that they know that you've heard those.

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Step 2: Listen to Your Patient

So, we talked about this, you know, it's building trust. So, if you care about them, you're going to hear what they say, you're going to let them know that you've understood what they've said, and that over time will build trust.

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Step 3: Answer Their Questions

So, when answering the questions, make sure that your responses are evidence-based, they are context-specific, again, putting it into the patient's context for their age, the risk condition, their family situation, making sure it's culturally appropriate, clear, and simple. So, do make it personal. Patients really want to understand that tailored vaccine recommendation, why is it for them.

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Step 4: Follow Through

And then follow through.

As I mentioned before, if they choose not to get vaccinated, a no is not always a permanent no. Make sure they have information, that they can get additional information, and bring it up the next visit. "You know, we talked about that last time, and I know that you weren't interested then, but, you know, are you interested now, or do you have any additional questions about, you know, that flu vaccine that I recommended, or the shingles vaccine that I recommended?"

You know, I certainly have patients who just, "I don't have time today." "I don't want to talk about that." "I can't feel bad tomorrow." But maybe at that next visit, they'll have time, they'll be more open to getting those needed vaccines.

[00:44:00]

Additional Considerations

So, there are additional considerations. You know, you want to make sure that you use vocabulary that is not negative, or doesn't sort of blame the patient for not knowing about vaccines.

So, avoid terms like "hesitancy" and "misinformation." I think "concern" is a much better word to understand, you know, what may be reasons why they don't want to get vaccinated today.

Body language matters, use good eye contact, you know, palms up. And then, again, don't give up. It may take more than 1 visit to provide a good opportunity for vaccination. You know, you can give patients information to take home with them. I often provide the vaccine information statements and then continue to build trust.

[00:44:56]

No Time?

We know clinical practices are very busy, and so you may not have a lot of time, but, you know, do remember to work with other people in your practice, those who are rooming patients, and help take some of the load off of you as well. And do recognize that sometimes there is provider fatigue, you do have time constraints, and the patient may have different priorities for that visit. And then, you know, if you don't have time for that long conversation this time, you know, just open the door for next time.

[00:45:35]

Maximize Others in Your Clinic

And as I mentioned, maximize others in your clinic. Make sure your team is on board, that they're trained to be able to help answer questions, and that their concerns, personal concerns, about vaccination are also addressed.

[00:45:52]

How to Improve Immunization Practices: Summary

So, in conclusion, really, summary, how can you improve immunization practices?

You want to make vaccination as easy and convenient as possible for your patients. So, that includes stocking vaccines that you can, so that they don't have to go through the process to get them, and making sure that you have a good place to refer them to for vaccination, if you aren't going to be able to stock vaccine in your office.

You know, designate an immunization champion for your office. They can help train staff, monitor your vaccine coverage, give you that kind of provider feedback about how you're doing, and help empower other staff to help with that vaccine recommendations of your patients.

And then, work on your communication, communicating effectively with patients. Make that strong, presumptive recommendation, and then tailor that to why it's specific to them and their current situation. And then, if you're not successful, you know, use motivational interviewing, try and understand their specific concerns, and make sure that they hear that you acknowledge their concerns.

And then, use electronic health record and immunization registries and standing orders to help make it a little bit easier to track which vaccines patients need. And then, also recognize the long game of vaccine recommendations. So, if someone's not open to vaccine – getting vaccinated today, they may be their next visit, and make sure that they also know that that's an open conversation. Thanks so much.

[00:47:38]

Posttest 1: I have multiple effective counseling points for patients who express concerns about vaccine safety and efficacy.

Tracey Piparo: We're going to head right into our questions that you guys have been awesome at answering. So, our first one is, I have multiple effective counseling points for patients who express concerns about vaccine safety and efficacy.

Strongly disagree;

Disagree;

Neither agree nor disagree;

Agree; or

You strongly agree.

Take a few seconds. Looks like most of you agree with that, which is great.

[00:48:22]

Posttest 2: After a patient refuses a vaccine, how likely are you to discuss vaccination in future visits?

After a patient refuses a vaccine, how likely are you to discuss vaccination in future visits?

Extremely unlikely;

Unlikely;

Neither likely nor unlikely;

Likely; or

Extremely likely.

[00:49:02]

After, I think you guys answered that great. Look at that. They're all likely. Doc, that is awesome. That's what we like to see.

[00:49:14]

Posttest 3: What is the best approach to take with a patient who consistently refuses the influenza vaccine because they think it causes the flu?

Right. So, now let's look at what's the best approach to take with a patient who consistently refuses the influenza vaccine because they think it causes the flu?

Acknowledge the concern and explain how the vaccine works using simple, non-technical language;

Emphasize that declining vaccination puts others at risk for disease, especially those older than 65 or immunocompromised;

Explain that you have studied the data and your expert recommendation is that this vaccine is safe; or

Acknowledge the concern and explain that most people have received the vaccine with no issue.

[00:50:07]

Everyone did awesome there. I think we got some, we got 78% of people are agreeing with this rationale, which makes sense after listening to you.

[00:50:20]

Posttest 4: According to CDC/ACIP guidelines regarding the coadministration of vaccines in adults . . .

According to the CDC/ACIP guidelines regarding the coadministration of vaccines in adults.

Inactivated vaccines may be administered at the same visit; recombinant and live vaccines must be separated by at least four weeks;

Inactivated and live vaccines may be administered at the same visit; recombinant vaccines must be separated by at least two weeks;

Inactivated and recombinant vaccines may be administered at the same visit; live vaccines must be separated by at least six months; or

Inactivated recombinant and live vaccines may be administered at the same visit.

[00:51:23]

I think you guys are going to do great on this. This 1 is a tough 1, Dr Bridges. It looks like this is a little bit tough for people, but the correct answer is (D), they can all be administered at the same visit.

Dr Bridges: Yes, all of these can be administered at the same visit. Like I said, there are very few exceptions to not being able to administer the same needed vaccines at the same visit. Very rare. It's only a polysaccharide in the conjugate pneumococcal vaccines. You don't give those two at the same, and the issue with yellow fever vaccine. Those really are the exceptions.

D is the recommendation, and it's also the CDC recommendation to not miss opportunities for vaccination. You can get those vaccines at the same visit.

Tracey Piparo: Good to know. Good to know.

[00:52:23]

Poll 5: Do you plan to make any changes in your clinical practice based on what you learned in today’s program?

After all of this, guys, do you plan to make any changes in your clinical practice based on what you learned today?

Yes;

No;

Still uncertain.

[00:52:53]

Poll 6: Please take a moment to enter 1 key change you plan to make in your clinical practice based on this education.

Can you just take a moment and enter 1 key change that you plan to make in your clinical practice based on this education? This would be super helpful for us as well as Dr Bridges.

Q&A

Tracey Piparo: While you take your time to do that, I think there's been some great questions coming in, Dr Bridges, if we can start talking about some of them.

Dr Bridges: Yes.

Tracey Piparo: A lot of people are asking, what would be your suggestion for having conversations, maybe particularly with parents who are responding to misinformation that's been shared on social media or even these days through the government or things related to autism? Do you have any recommendations for how these things can be discussed?

Dr Bridges: Yes. I'm not going to pretend that this is an easy time. It's not.

But I do think, again, acknowledging that things are confusing out there and saying, "Here's what I know, and this is who I listen to. Here are my trusted sources of information."

I'm actually an internist, but I've been working on vaccines a long time. But if I'm talking to control medicine-type patients, "I'm listening to the American College of Physicians." Or I'm talking to a pregnant patient and say, "Gosh, the group that I'm listening to that I trust is the American College of Obstetricians and Gynecologists," when I'm thinking about vaccination of pregnant women. If I'm a pediatrician, "I'm listening to the American Academy of Pediatrics. This is why. I know how they evaluate vaccine safety. I know that they've looked at all of the data and have children's health in mind. So this is what they say, and this is who I trust."

So I think it's also helping them understand who you trust. Those patients are in your office. They trust you. We know that provider recommendation is super important and it has tremendous impact. So I would acknowledge, "Yes, this is a confusing time. I understand that this is something that's been – you're probably hearing about, but this is who I trust. And this is where I go for information to answer those kinds of difficult questions. And this is why I recommend this vaccine for you."

So when it's a matter of trust, talk about who you trust as well, and provide them with additional resources that they may not have of trusted places that you go to for information.

Tracey Piparo: I think that's super helpful because that was some of several other questions about, given some of the issues with the reconfigured ACIP, who to look to now to get that trusted information. And I think the organizations that you mentioned are super helpful, and folks can even look that up online themselves, and that can be shared with patients.

Dr Bridges: Yes. And provide them with websites. Like I said, when it comes to specific vaccines, I do provide patients who maybe aren't interested that day. I give them a vaccine information statement for that vaccine. "You know, here's some places you can go. Here's where I go." And I think that's been helpful. And most of the time I would say when patients come back, they're more open to getting vaccines. And sometimes we have to split those up.

We don't always do them at the same visit. "Gosh, I only want to get my shingles vaccine today." "Okay, that's fine. Let's do that today. And we'll talk about your COVID vaccine, your flu vaccine, or pneumococcal at your next visit." So take the wins where you can get them.

Tracey Piparo: Exactly. That's a great strategy. Someone brought up just the amount of vaccines that we have to think about speaking to patients about, and some are more confusing than others, particularly the pneumococcal vaccine.

That schedule can be confusing and challenging even for clinicians. Do you have any tips of how to keep that straight?

Dr Bridges: You know, I would really recommend there's an app that CDC has developed on pneumococcal vaccines to help you. And that would be my recommendation is to – hopefully, we can provide that resource. I think there's a talk on pneumococcal vaccination. But CDC has an app that's available on their website to help answering those questions about pneumococcal vaccine.

Tracey Piparo: That's awesome. Someone was also asking a question kind of specific to shingles. If there are people who have already had the shingles and there's some age recommendation for the vaccine itself. A) Can it be given earlier? And how long after infection should we be recommending it to people?

Dr Bridges: Yes, that's a really good question. And there's some information in the ACIP shingles vaccine recommendations. But bottom line, there's no specific interval.

I think clinically most people wait a year after having had shingles before someone gives the vaccine, but that's not a hard and fast. The vaccine can be given down to 19 years of age. For everyone, it's 15 or older is the recommendation, but you can give it down to 19 years of age for people who are immune compromised.

Tracey Piparo: And I think this could be our last question. And again, I think it speaks to that trust that you were talking about, building that with your patients. How do you advocate for vaccinations when maybe folks are coming from a prior clinician who did not do the same?

Maybe it was lack of time. Maybe it was because they didn't have that relationship, but they've never had these discussions before. So maybe this seems brand new to the patient. How do you fit that into a busy clinic visit?

Dr Bridges: Yes, I think that first of all, you want to use the staff that you have in your office during rooming. That brings it up in the first place. And they may say, "Gosh, I don't want to get anything." Okay, now I've opened the door. I've had the MA tell me what that conversation was, your nursing assistant tell me what that conversation was. I can go in there prepared and wanting to bring it up and talking about those concerns.

And again, I think tailoring it to the person. "Hey, I care about you. I'm worried about, you're someone who has, say, COPD. This is why I recommend these vaccines for you, because we already know you're at risk of getting severe illness. And that's much greater than your potential risk of having 1 of these really rare, 1-in-a-million adverse events from whatever flu vaccine," or whatever it is that your vaccine is that they need. So I think it's tailoring it to the patient, what their particular situation is, and stating why you're making that recommendation is really important.

Patients want to know that they've been heard and that you care about them personally. This is not a rote recommendation from you, but it's really for them, that patient sitting in front of you, and what's best for them and their health.

[END OF TRANSCRIPT]