So my question for the – for our panelists. What makes adult vaccination especially important right now? And what makes those conversations so important right now?

Dr. Laura Hurley (University of Colorado Anschutz Medical Campus): I – I would just share that current federal vaccine policy has become unpredictable and increasingly politicized. Programs that have protected Americans for decades are now being disrupted. Most people who get a vaccine preventable disease are adults. And we need you, our clinicians, to be positioned to continue to vaccinate adults in this current environment.

Dr. Limaye: Just to add on to what Laura was – was mentioning. I think the other piece we can think about, I study trust in vaccination, and one of the things that we have really noticed is that there has been a study that looks at trust in healthcare providers as a source of health information. And this has been going on for at least 30 years, and we are seeing declines in trust towards healthcare providers.

So I think this time, more than anything, making sure that you can think about the ways in which you can talk to your adult patients so that they trust you and that they trust you for a vaccine recommendation when you give one and actually get vaccinated.

Dr. Humiston: In meeting some of you before the program, several of you are from outside the United States. Raise your hand if you're from outside the United States? So a handful. And my understanding is that the trust issues are not just a US issue. Is that true? Holler out, say yes. Anybody? I'm not hearing anything. Okay.

When you say that – like we know that the provider recommendation for a long time has been the most consistently proven reason that people get vaccinated. Do you have any feeling for why trust in providers is declining?

Dr. Limaye: Yeah, it's a – it's a great question. And I think one of the things that we're really facing is that some of it is the after effects from COVID. There was a lot of concerns and the ways in which the – the pandemic was really managed, not only in terms of recommendations, but in terms of policies. And so I think there has been a backsliding of trust specifically related to science broadly, but then specifically related to vaccination due to what Dr. Hurley was just talking about the politicization of vaccines, the confusing vaccine policy that is happening.

I work primarily overseas, and this is not something that is just domestic. This is an issue that we are now facing everywhere. And while people still go to their healthcare provider for information, can you guess where they go to next to confirm? Any guesses? Social media. There you go.

And so while they might hear from a doctor, this is what you're supposed to do. They generally then check their social networks to determine if they're actually going to take the recommendation forward or not.

Dr. Humiston: In terms of – like we were talking about the importance of vaccination. Well, maybe we should just give up and not vaccinate. So can you talk a little bit, Laura, about what's – what's the point? Why is this – why is this worth doing?

Dr. Hurley: Yeah.

Dr. Humiston: Oh, I – oh, I keep thinking that my screen is everybody's screen.

Effectiveness of Key Adult Vaccines

Dr. Hurley: Yeah. Exactly. So on this slide, we just highlight some of the advantages of using vaccines to present – prevent disease. This past influenza season, the 2025-2026 season, where we had moderate alignment between the vaccines and the circulating influenza antigens, the vaccine was 30% effective at preventing needs for outpatient visits as well as influenza-associated hospitalization.

While 30% doesn't seem great, I would very much like to be in that group that was avoiding having to go in to see the doctor and missing work and – and events with my family, and certainly want to be in that group to avoid being hospitalized.

Pneumococcal vaccination can prevent the majority of invasive pneumococcal disease, so that means central nervous system infection or a bloodstream infection. It also is about 50% effective at preventing pneumococcal pneumonia. And then shingles vaccine. You just – my – my patients that most – are most interested in receiving a shingles vaccine have known somebody who has had shingles and that if they received both doses of the current recombinant zoster vaccine is, you know, 76% effective at preventing that.

So – so we can manage vaccine-preventable disease by using these products that are readily available in the US.

Dr. Humiston: Do you think that there are so – okay, when I was a resident, it was flu and pneumococcal vaccine, and it was PCV23. That was it. And you know, there – there weren't the more sophisticated vaccines that we have now. Now we have vaccines, you know, as you said, against shingles, against RSV, Mpox. You know, like that we have so many more vaccines that are relevant for adults, and it's so much harder on providers. Adult – adult providers have a ton to talk about other than vaccination.

And so it seems to me that that's one of the things that makes it harder too is there's so much to talk about in the vaccine world. And there's so much, you know, talking about obesity and who wants a GLP-1 inhibitor, you know. And so can you talk a little bit about how can – how can a – an adult provider prioritize this?

Dr. Hurley: Well, I'm – I'm a huge advocate of using your electronic health record to your advantage and having clinical decision support. And for those of you living in jurisdictions where your medical assistants or whoever, whatever type of provider you use in your practice could take some of the burden of providing the vaccines before you even end up seeing the patient. I'm a – a huge advocate of that.

Obviously, if there's issues and you guys are attending here to find out ways to communicate about vaccines, sometimes people are going to have some questions about the vaccines, and you can be drawn into them. But I really think we – we can be using our electronic health record to our advantage. There are now 16 vaccines that adults are potentially eligible for on the adult immunization schedule. So we need technology to support us in delivering the vaccines.

Dr. Humiston: Keeping track of all of that. I'm not trying to cut anybody off. Do you have anything to add?

Dr. Limaye: No, no. I think we can go to the next – the next slide, I think.

Faculty Discussion

Okay. Oh, okay. How are we doing with vaccine uptake in the United States? Do you want to talk a little bit about the facts on this one?

Recent Trends in MMR Vaccine Uptake in the US Set to Lose Measles Elimination Status

Dr. Hurley: Yeah. No, I'm happy to. I – I wanted to share with the group because I think it's top of mind what's happening with measles in our country. We are actually at risk for losing measles elimination status. And that's largely because our patients aren't getting their children vaccinated. And so I wanted to put a plug in here and – and draw attention for you all to the fact that we are now – our – our MMR coverage among our children has declined from 95%, which is felt to be what we need to maintain community immunity to 92.5%.

And as you see in the map here, we are seeing outbreaks of measles across our country. Among those who have experienced measles are some of our adult patients. So we are having to become aware of how to recognize measles, a condition that, you know, I, as an adult provider have not had to recognize necessarily. And I – I just wanted to – to really highlight that. Can we go to the next slide?

Trends in Adult US Vaccine Uptake

In terms of vaccinations that – you know, we – we do give some MMR vaccines in our adult practice, but in terms of vaccinations, I would say, overall, we – we don't perform well, particularly compared to our pediatric colleagues in – in terms of delivering adult vaccines.

In terms of influenza, our older patients are more likely to accept an influenza vaccine at 69%. But the younger age groups – and you've probably experienced this in their – in your practice, they – younger folks don't think they're susceptible and don't want to bother with getting it.

COVID is more accepted in the older populations and very much not being accepted in the younger populations at 11%.

Pneumococcal vaccine. This is relatively old data in addition to affecting vaccine policy. Our surveillance systems have also been affected in the current environment. So relatively old data shows that we're even slipping with administering pneumococcal vaccine to older populations. However, that younger group, which I would say, you know, only about 23% of the younger individuals at risk for pneumococcal disease are receiving that vaccine. That's staying relatively stable but stably low.

Importance of Adult Immunization Standards

Dr. Humiston: So do you want to talk a little bit about NVAC, the National Vaccine Advisory Committee standards?

Dr. Hurley: I – I do just because I think it sort of level sets for the group of things that we can do to encourage vaccination. These were guidelines that were published over a decade ago, but remain very salient currently. And their recommendations are that we should be assessing vaccination status at every visit and that seems kind of daunting. But again, if you have your electronic health record, do it – it's – you know, it – it's not a burden for you.

And then we know, as Sharon has already shared, that our recommendation is – is tantamount to people receiving vaccines. So you need to strongly recommend and either administer or have a referral in place for the patient to get the vaccine. It might be need to be given at the pharmacy because of Medicare Part D.

And then last – the last standard is to upload your vaccinations to an immunization information system, because that is an excellent way to track a centralized database to track vaccinations from a variety of different providers. And so before we even talk about messaging about vaccines, those are the standards that everyone should have in place to encourage vaccination in their practice.

Dr. Humiston: I think that one of the things about being at a session like this that's so important, and other sessions by Decera and other groups this week, is that you need to know enough about vaccination to be able to give a heartfelt recommendation.

And so, for example, the thing about flu. I think that there's so much vaccine hesitancy around flu because, “Oh, I got the flu vaccine, but I still got a cold.” You know, like, we didn't say that the flu vaccine was going to stop all upper viral illnesses. We said it was going to keep you out of the hospital for flu, you know.

And so I think that knowing enough to make an accurate recommendation too is an important piece of this.

Okay. That's – I'm going to get off my soapbox for a second and – and say, we are open to your questions as we go through, as they said at the beginning. You can type your questions into your tablet. For those who are virtual today and not in this beautiful San Francisco weather, you can send us your questions as well and that we get both the virtual questions and the questions from the people in the room.

Audience Q&A

So I'm going to go ahead and look at what questions do we have so far. What is one thing I can do to reverse the low rate of vaccination in adults? Anybody want to take that one?

Dr. Limaye: Maybe I'll start really quickly. I think – so I work primarily with providers. I've studied vaccine hesitancy for about 15 years. Before it was actually a thing, and no one wanted it to fund us when we were working on this work, one of the things that I have very much noticed is, I think the one thing I suggest to everyone, and I suggest this actually in every single patient encounter that you might have as a provider is to start the conversation through empathy.

I think that there is this sort of desire to go in and dismiss concerns. And I know me, when I was pregnant with my second child, I felt very dismissed about concerns I had about vaccines. I'm pro vaccines. We're up-to-date. My kids are up-to-date. But I really felt as though my clinician wasn't listening. And so I think the one thing you can do in every encounter is approach it with empathy. People are coming to you with their concerns. They have uncertainty in their lives. Your job is to reduce that uncertainty. In a way you can do that is through empathy.

Dr. Hurley: Another question that was posed was about why people are hesitating about seasonal vaccination. I have definitely noticed more hesitation about COVID seasonal vaccination than influenza. And I – my experience has been that people feel like they've just had too many COVID vaccinations and they don't understand why we're continuing to vaccinate.

And so if you can make the case that the virus mutates and similar to influenza, we need to revaccinate every year to maximally protect. That – that's where I – where I focus my discussion.

Dr. Humiston: I have to tell you a bad story about myself, about empathy. I was in the emergency department, and a mother brought a kid in and, you know, what's the problem? And she said, his eyebrows are pink. And it was a little blonde kid. And it was like, well, you know, he's got a rich vascular bed in his eyebrows. And I laughed. And that moment she wrote me up, you know, that – that – like, I laughed and she was so offended.

So like, even – it's not just even what we say. It's like that one little moment of a giggle. Like you brought him into the emergency department because of pink eyebrows and that one moment of giggle and she was mad. So yeah, that empathy thing is really important.

Okay. Not that I'm not empathetic, but I can be. Okay. Okay. We're moving on to understanding barriers to vaccination. I think we have to click this one.

Understanding Barriers to Vaccination

Poll 4

Okay. So for the audience, what is the most common barrier to vaccination that you face in adult patients?

1. Safety concerns;
2. Misinformation/politicalization;
3. Apathy/lack of urgency. Like, I don't need this today. Can I come back?
4. Patients saying they're too busy;
5. Access issues. Whether that's, you know, that they live in a vaccine desert; or
6. Insurance issues. They don't know if they're covered.

Which is it for you?

Dr. Hurley: So misinformation and politicalization, about 60%. So that's the by far the biggest. Rather than specific questions about vaccine safety or that it doesn't work – you know. That's interesting. So.

Dr. Humiston: Oh that's sad. Okay. All right.

Faculty Discussion

Oops. I got to go back. So okay. Now for you guys. So how do you address misinformation?

Dr. Limaye: Yeah.

Dr. Humiston: What do you do with that?

Dr. Limaye: It's a great question. And I think the default might be to refute. Right? It's an easy way. So during COVID, I spoke to about 2,000 vaccine-hesitant people and they were all older adults. And it was really trying to figure out what was the root cause, what was the concern? And a lot of people, the number one thing people told me is that how can you tell me that there's not a microchip in the vaccine, right? That was literally the number one question they got.

Dr. Humiston: Okay, you guys just laughed.

Dr. Limaye: So I think it's easy to refute, right? The way that I address this and the way when I train providers, I always say there's a lot of information out there. It is really hard to decipher what is based in evidence and what isn't. Let me talk to you and tell you how I think about this vaccine. Right? So you're not refuting it. You're acknowledging they have a concern, but then you are shifting or you're pivoting the conversation to talk about what you know about the vaccine and why you would recommend it.

There's been a ton of evidence on this. There's something called the backfire effect if – if folks are interested and have learned about this before. Whereas if you refute, people just dig their heels in more, right? Then you sort of lose. And – and we'll talk about vaccine hesitancy in a moment. But the people we want to talk to are those that are movable, that are in that movable middle where they might have some concerns, but they can be persuaded, right?

So personally, what I would suggest is you don't refute, you acknowledge the concern. You acknowledge that there's a lot of misinformation out there. And then you say, “Can I tell you what I know based off of, you know, working with vaccines and working with adults for how many ever years?”

Dr. Humiston: Do you find that it works to say, I got my mother vaccinated or I got vaccinated or I got my – my kids, which are now adults vaccinated?

Dr. Limaye: 100%. When I think Dr. Hurley was talking about what does it mean to have a strong provider recommendation? So one of it is to first recommend the vaccine strongly, right? Don't just say, “Oh, you know what? You could get it today.” Recommend it, recommend the same day, which is another part of that recommendation, but then end that conversation with some sort of a personal story if you're comfortable doing that. Right?

So you can say, “I understand you might have concerns. This is what I've done for my family. And these are the reasons why”, because that just helps normalize it and it also helps build trust again between you and the patient.

Dr. Humiston: Okay. How about the access issues? Laura, do you want to take this one? How do you address access issues in people who are uncertain about – like, are the – in the United States, the payment for vaccination is so complicated to me for adults. And so I think a lot of people may be worried about, although we didn't see that this was a big barrier, but...

Dr. Hurley: I – I mean, I think you have to have a system in place because of some vaccines being covered by the drug benefit or Medicare Part D so you don't want – and I – I still – even though I published papers about this, I get slipped up sometimes asking my MA, “Now, why didn't you give them the RSV vaccine?” And she looks at me and she's like, because they have to go to the pharmacy to get it. So that doesn't feel good. You need to have your systems in place and we subsequently have created a – a pharmacy referral within our electronic health record for those vaccines, so we can give the ones that they can get in the office there, but also simultaneously place a referral to the pharmacy to kind of streamline it.

And then have the conversation with the patient that this is why we're referring you out for this particular vaccine, because it won't be reimbursed if it's not given in a pharmacy setting.

The Vaccine Hesitancy Continuum

Dr. Humiston: Okay. All right. My next slide is about the vaccine hesitancy continuum. Do you want – do you want to talk about this one?

Dr. Limaye: Yeah, I can take this. So this refers to what I was just speaking about is that we want to really focus on those patients that are in the movable middle. And what I mean by that is that we have these extremes, right? But one thing that I do try to focus on is that vaccination behavior is not a binary. It's not a yes/no, right? There is a continuum. You have folks that will actively come to you and say, “When can my son get the HPV vaccine, for example, here in the United States?”

But then you have people that accept – accept some and delay some and refuse some. And this is typically in the adult population as – as Dr. Hurley was mentioning, there's lower uptake specifically related to the influenza, the seasonal vaccine. And that's pretty common over years.

And then you have those that refuse all vaccines. And what we really want to focus on and spend time on are those that you think can be moved, can be persuaded. And so I think – I think that's it on the – on the hesitancy slide. But I think it's important to understand that there are ways in which that you can segment this population and think about how do you nudge them is what I call it, towards the right end of this.

Audience Q&A

Dr. Humiston: Okay. I do have one question from the audience. I work with residents. What suggestions do you have if a patient continues to say no to vaccines? Do we respect after a few times and stop, or do you keep going? How do you deal with that?

Dr. Hurley: Something Rupali and I were talking about before this started is kind of understanding where people are on the spectrum. And so I do want to give you license. If you ask somebody, on a scale of one to 10, what is your chance of getting this vaccine? And if – if they say zero, at least in that moment, I think it's appropriate to move on. You have to address their diabetes, their heart failure, their chronic pain. Like don't – don't – don't waste the time during the visit.

But if they're anywhere, you know, above, you know, one, I – I would try to engage and – and I would ask for permission, just like with smoking cessation. How many times have we seen somebody who says they don't want to quit? But you bring it up at every visit because you know how important it is for somebody to stop smoking?

Well, I feel like vaccines are just as important. So ask permission. Okay. You're not going to get the vaccines today. But you know what? I am going to bring it up the next visit. I have had patients who know what my background is. I've taken care of them for over 20 years who kindly ask me not to bring it up anymore, and I'm respectful. If they don't – you know, it – it is about their autonomy. And if they don't want me to bring it up, I won't bring it up. But most people, I would say as to coin Rupali’s term, are in the movable middle. And – and you – you need to recognize that.

I have one audience question that came in. What's one vaccine myth that you wish would disappear permanently?

Dr. Hurley: Only one.

Dr. Limaye: Only one. I feel like there's a lot, but I think the biggest one that I have is that really related to the microchip, because that's what I heard over and over and over again. And people do believe that a vaccine is injecting a microchip, right? That is hard to get out of someone's head if that's really what they feel and fear in terms of – of getting a vaccine.

But I think internationally, the one that I deal with most is that, will this vaccine make me infertile? That comes up a lot specifically with maternal vaccines that are given during pregnancy, but that also comes up a lot, unfortunately, with HPV.

Dr. Humiston: And the interesting thing about the HPV vaccine is that it actually prevents some causes of infertility.

Dr. Limaye: Yeah.

Dr. Humiston: And so bizarrely enough, it's the opposite.

Addressing Questions About Vaccination

All right. Our next section is on addressing questions about vaccination. Again, if as we're going you think of questions, put them in as we go rather than waiting so that I'll see them on my screen.

Poll 5

Here's our polling question for you. How would you respond when a patient is uncertain about receiving a vaccine due to concerns about its safety? For example, you can write a phrase like provide a strong endorsement. Ask them if you can explain vaccine safety. Ask them what their – you can put in a whole phrase, is what I'm saying. You don't have to just do one word.

I know this one is hard to type. There's some. I see. Concerns is a big word. Specific. That's interesting. Concern, ask, address, show, benefits. We'll get there. Provide, understand, talk. So it turned into a word cloud. That's very cool.

Faculty Discussion

Okay. All right. For you guys, how do you explain vaccine safety and monitoring? I know that it's a complicated topic, but how do you explain it in a way that's accurate but not overwhelming?

Dr. Hurley: I just want to share the next slide.

Dr. Humiston: Okay.

How Vaccine Safety Is Assessed

Dr. Hurley: Yeah. Not that I'm going to go through – this obviously would not – it would backfire in the – the clinical setting. But I emphasize to patients who have concerns about vaccine safety, that safety is paramount to any preventive measure. We don't want to make people sick with something we're trying – trying to prevent.

I explained that the – the development process for vaccines is multi-staged and safety is a priority throughout the process. I also share with my patients, by the time I'm giving a vaccine in the clinic, tens of thousands of people have already received this vaccine without event. So it's not that we're experimenting on them. Others have had it and it's been deemed safe for the population. That's – that's what I go through.

Dr. Humiston: I think one of the things that you brought up – like how vaccine safety is assessed in the United States, is such a complicated process that I don't think that most doctors know, like could explain it. I'm a – a big vaccine nerd, and I've gone through this a lot of times, and I think I would stumble over some of the steps. And so I think that one of the things is remembering that there is a slide like this that shows all the steps and that the – between – okay, when people say that they think that there's a conspiracy, when you think about how many people between the FDA, the CDC – like it would have to be the most coordinated government effort that has ever happened in the United States. We're just not that coordinated.

Dr. Hurley: Before we move on, I just – I do want to draw attention where you see on this slide organization review, we specifically took off Advisory Committee on immunization practice. And now, even though – well, they're on a hiatus right now until things get sorted out. But right now we're leaning on national organizations like the American College of Physicians, like the American Academy of Pediatrics, like the American Association of Family Physicians for Guidance of Vaccines, which, you know, in my tenure as a vaccine researcher, never thought that we would get to that point. But I want to highlight for you that this is incredibly disruptive to our process of studying vaccine safety.

So even though the – the issue is people are having concerns about safety of vaccines, when you take these organizations and dismantle them, vaccine safety can potentially be compromised.

Dr. Humiston: I think that what you're saying is really true. And California, for example, now is going with a – a state based. There's the – the West – the Western States Coalition that's going to make its own separate recommendations that there – instead of a centralized recommendation, we're going to have, you know, the West Coast, the East Coast, you know, that we're dividing up, which duplicative, unfortunately.

Types of Vaccine Safety Surveillance

All right. Rupali, do you want to talk a little bit about types of vaccine safety surveillance that we have in the United States?

Dr. Limaye: Sure. So the great news is, and as Laura mentioned, this is a really rigorous process, right? This is not something that happens quickly. There's a number of organizations involved. There's a number of safety monitoring boards involved in terms of before a vaccine actually makes it to market, right, after phase III trials.

The great news is, is that even after they have been marketed and they're on the market and they're regulated and they're licensed is there's really a lot of ways in which vaccine safety is continuously being assessed, right? So on the left side, when we talk about passive surveillance, we do know there's a couple of different ways in which there's reports that healthcare providers themselves can send, whether that's to your state or whether that's to a more national level.

Vaccine Adverse Event Reporting System (VAERS)

But then there's also VAERS, which people are probably familiar with and have heard about. That's a way in which individuals can input and talk about concerns that they may have had related to possible vaccine safety problems, for example. And this is something that, you know, by law, not only can HCPs or healthcare providers submit, but so can patients and caregivers. And it's important to have this opportunity for patients and caregivers to talk about any concerns that they think could be related.

One thing that I will just say very broadly about – about VAERS is, right, that this is – anyone can access it, anyone can input it. Doesn't mean it's necessarily caused by a vaccine event. But again, it gives an opportunity for the public to be able to provide feedback if they think there could be some sort of link between vaccine and some sort of an adverse event. And so I do think it's really important. But further investigation typically is what follows if something comes up in VAERS.

Dr. Humiston: And the real danger of VAERS is the misunderstanding that the Vaccine Adverse Event Reporting System actually shows the side effects of vaccination. I can drive out of the park – you know, get a vaccine in my doctor's office, drive out into the Street and be in a car crash, and I can report that car crash because it shortly followed after vaccination. It doesn't even have to shortly follow after vaccination. You can report anything. Any patient, physician, any healthcare provider, anybody in the public can report anything to the Vaccine Adverse Event Reporting System.

So it does not mean that it was caused by the vaccine, but it's a jumping off place for studies to look at if – you know, if there were a lot of incidents – intussusception after a vaccine. Then it's – it's – and that's all reported to VAERS. That's a hypothesis-generating approach.

And – and so it's an important piece in the United States, but it should never be misinterpreted by anyone in the government as being an actual report on side effects of vaccination. There's another one of my soapboxes.

Vaccine Safety Datalink (VSD)

Okay. I think we talked about VAERS. We talked – VS. Now, Vaccine Safety Datalink is different.

Dr. Limaye: Yes. And I'll talk very briefly about this one just in the interest of – of – of time. So this is another opportunity again to think about safety once a vaccine is on the market and is being used by the intended target population. This piece really focuses on population-based vaccine monitoring, right? And so essentially this is something that was stood up by the CDC. 13 US healthcare organizations collaborate together, and essentially they're really looking for any potential serious or rare adverse events.

And so again, these are sort of two options for surveillance that we have. But just to show you that there is a lot that goes into surveilling vaccines after they're administered.

Posttest 1

Dr. Humiston: Okay. So we have a post – this is a post-test question. You've already seen this once, but your answer may have changed after this little discussion. How should you explain vaccine safety to a patient who says, “What worries me most are rare, long-term side effects?”

1. So you could just talk about pre-approval trials. They're designed to detect rare, long-term side effects;
2. After approval, VAERS reports show whether rare, long-term side effects are caused by the vaccine;
3. After approval, active surveillance continues to detect rare, long-term side effects; or
4. Just saying the risk of the disease is generally higher than any rare, long-term side effects.

Which would you choose now?

Okay. Let's see. Yay! We – yeah, okay. So we improved. The first one about pre-approval trials. Well, the question was about long-term safety. And so the pre-approval trials wouldn't help. After approval, talking about VAERS reports. Again, we talked about how VAERS reports are hypothesis generating, but don't really tell us about long-term side.

Posttest 1: Rationale

The C is correct. And – and D, the risk of disease. Well, it doesn't really answer the person's question.

Faculty Discussion

Okay. Faculty discussion. Move now to, when a patient raises a vaccine concern, what communication approach is most likely to move the conversation forward?

Dr. Limaye: I can start and I'll – again, I'll try to keep this short because I know we're a little bit tight on time. And so some of the – the work that we use is we use motivational interviewing. And again, I don't think it's applicable just for vaccination. I think it's applicable for any type of encounter. So it's thinking about active listening. It's reflecting back. It's asking questions. It's allowing for permission to provide more information.

This is typically a way that you can really think about the shared decision-making and the ways in which you can also start. And I suggest starting every conversation with saying we have the same goal. Our goal is to make sure that you can live your healthiest life, right? And then moving forward. That would be my quick – quick suggestion on that.

Dr. Hurley: And I would just acknowledge. As a practicing internist, I – I think there won't be time for motivational interviewing for every patient, and so would reserve it for those patients that are in the middle. And – and hopefully you can set up a system where you – you can recognize the people that you need to have a more nuanced discussion.

And a – a quick way to turn somebody off is to be condescending, laugh at them. And so always – those hesitant patients always start with an open-ended question.

Audience Q&A

Dr. Humiston: One of the questions that came in virtually and keep sending me your questions. One of them is, how do you deal with it when somebody says, “Oh, I think the vaccines are just a big push from pharma because they're making money. You know, it’s – it's just a money making effort.”

And we've also – you know, I know that pediatricians have been accused of being, you know, oh, it's just – pediatricians are pushing it because it's a money making thing.

Dr. Humiston: I'll let you take that one.

Dr. Limaye: Okay. So very quickly, the way that I talk about this is that I think I say usually vaccines are like any other product. And so typically when you're having an adult patient, they're probably on some other medication. And so I usually talk about it like, you know, the blood pressure medication you take. That is to help you lower your blood pressure, right?

There is – there is a way in which again, we need pharmaceutical companies. That's what it comes down to, right? A lot of the medications and therapies that either their family is taking or that they themselves are taking were developed by pharma. So I try to reframe the conversation just a little bit. And I think if patients dig in, I usually say, “Well, you know, actually most pharmaceutical companies make very, very, very little money, pennies essentially on vaccines.” That is not a lucrative – it's not a lucrative product for them. Right? They make a lot more money off toe fungus, for example.

And so I try to – I try to remind folks about that, right, that really that it's not really a money making machine here in the United States or even globally.

Promoting Vaccine Benefits

Dr. Humiston: All right. Moving on to promoting vaccine benefits.

Poll 6

Which aspect – so this is the question for the audience. Which aspect of vaccine benefits do you emphasize – we're going to do one of those word clouds again. When you're recommending vaccines, what do you talk about, like the individual health benefits. Something about, you know, it'll help you make it so that you can keep going to work. The – the cost benefit is more of a societal thing than it is an individual thing for somebody who's insured. But – so what do you emphasize? Write me a note.

So are individual, hospitalization, benefits, prevention, health, benefit, decreased, protection. So those are the big words that are coming up. Are there anything that you guys want to add to that?

Faculty Discussion

I would say – okay. I think that the autonomy issue is huge like that. I want to keep you healthy so that you can keep going on with your daily activities. This isn't some vague, I want you to keep healthy for healthiness sake. This is so that because ageing isn't a slow, gradual. It's a stepwise thing. You want to tell your story?

Dr. Hurley: Yeah. So I – I had a patient this year who – he did not get an influenza vaccine, which I – I don't actually think he was seeing me during that time. But his wife had said we didn't get them this year because we don't go anywhere. Well, it turns out these octogenarians actually still teach ballroom dancing. And I'm sure he was exposed there.

So the issue for them is he is immunocompromised with rheumatoid arthritis. He gets hospitalized. And then after that hospitalization, they tried to send him home. Well, my – his wife, who's also my patient couldn't manage him at home. So I'm getting all these crisis calls, like, I can't do this. And so when they eventually came into the clinic and he ended up getting readmitted. So two hospitalizations for one episode of influenza.

When they came in to see me, I just made the point that if you had had an influenza vaccination, I think you could have avoided these two hospitalizations. And so it's not only the acute illness, but it's the debilitation after the illness that has a huge impact on our elderly patients.

Dr. Humiston: And one of the things that this story brings up, too, is that the wife might get the vaccine because she's in the household with somebody who's immunocompromised, or I know that a lot of people have gotten RSV vaccine because they – not because they want to protect themselves as adults, but because they don't want to bring RSV into the household with a baby.

Conclusions

All right. I'm going to skip the next slide and just move to our conclusions. Invite patients to share their concerns so that they feel heard. Feeling heard is such an important piece of that trust issue. Address patient concerns about vaccine safety by developing trust, trusting relationships, and providing accurate information. Accurate information puts a big burden on you because you need to know enough about all these vaccines to make accurate recommendations.

And this also brings up the talking about the vaccines in advance of the next visit. So it's called pre-bunking where you're the first person to be talking about the vaccine. So when they hear about it on social media, they say, “Hey, the doctor already told me that I really should get the whatever vaccine.”

Use evidence-based communication strategies to promote shifts toward acceptance in vaccine-hesitant Individuals. I skipped over the SHARE model, but that's in your slides that if you want it. The advice of a trusted personal healthcare provider is key to vaccine uptake. And – and you have such an advantage because you have the – their chart in front of you. So, you know, if they have diabetes or, you know, an – an immunocompromising condition and you can make a personalized recommendation, consistently recommend vaccines during clinical encounters so that they can get them while they're there and educate patients about vaccine benefits for them, their close contacts, including their spouse, their grandchildren and their communities.

Posttest 2

So post-test question number two. Your patient says, “I've heard mixed things about vaccine safety on social media, and I'm not sure what to believe.” Which of these answers.

1. If you'd like, I can give you a few minutes to review an information sheet about the vaccine, and then we can revisit whether or not you want to vaccinate it;
2. Since you're unsure, how about I walk you through how vaccine safety is studied and monitored during development and other – and after approval;
3. I recommend staying away from social media, good luck, for a vaccine information since there is a lot of misleading information online; or
4. I understand that you feel confused.

Tell me what you've heard and what concerns you most and we can walk through those concerns together.

Posttest 2: Rationale

All right. The answer is D, I understand that you feel confused. Tell me what you've heard. So I understand. There's that empathy moment. Tell me what you've heard. Because I'm not going to answer questions you don't ask, there's no way to waste time more than answering questions they don't have. Tell me what you heard and what concerns you most, and we can work through those concerns together.

Posttest 3

All right. The next one. Post-test three. After participating in this activity, I will use evidence-based messaging to tailor vaccine recommendations to individual patients.

1. Strongly disagree;
2. Disagree; or down at the bottom
3. Agree;
4. Strongly agree.

Okay. We have a big preponderance of agree. Okay.

Poll 7

I want to move on to poll seven because in case people need to leave for your next session. I want to make sure I catch you before you leave. So poll seven. Do you plan to make any changes in your clinical practice based on what you learned in today's program? Is there anything that you can change in your practice? And that means you or your staff.

Poll 8

All right. Eight. Please take a moment to enter a key change you plan to make in your clinical practice based on this education. And I won't see this as a word cloud.

Q&A

Okay, while you're typing, I'm going to go through some of the questions we got. Is there any good patient website for vaccine information for low literacy patients. Vaccine info – there's actually a website called vaccine information. If you go to immunize.org and you scroll to the bottom of the home page, you can link on to vaccineinformation.org. And there's another one called Let's Get Real About Vaccines. And if you just type in Let's Get Real, that's enough to take you to that website.

How many vaccines can be administered safely in one visit? Is there a maximum number?

Dr. Humiston: I – I love the question because it's a question I have, and I am actually hoping to study that. Right now, the – the party line is, you know, with – with a few exceptions, that you can give a number of vaccines together. And that's – that's what is currently recommended. But I – I do agree that we need to study this more specifically among adults, because now we're getting to an era where we can potentially be giving an adult five vaccines at once.

Still, right now we believe it to be safe. There's some literature from the – the travel vaccine. Folks that have looked at multiple vaccines being given at once. But I think we – we need more information.

Dr. Humiston: How many times do you document that you have recommended, like this – a patient comes in, they don't – they refuse the vaccine you recommended. They come in another time, you recommend it. How many times do you document that you have recommended it?

Dr. Humiston: Every time if they decline it. That's my practice.

Dr. Humiston: I think that that's because, God forbid, they get a disease and it looks like you didn't recommend the vaccine when the standard of care is vaccination.

Dr. Hurley: Well, and with these electronic health records, what happens – and I want to document it. I don't want it to be documented in the electronic health record, because if you do that, then the prompt doesn't come up. And so you're not offering it anymore. So it's better to just be in the note and not something that you put into the EHR, because then you potentially are not recommending the vaccine in the future.

Dr. Humiston: How long – how long are vaccines studied before they're in use? I think that there's some variety there like…

Dr. Hurley: Like usually 15 to 20 years. So they're – they’re studied for decades before they ever make it to your clinical practice.

Dr. Humiston: I know that with HPV, it was 40,000 people were vaccinated. You know, like when you compare that – and I – I always think about comparison with GLP-1 inhibitors, where a quarter of every household in the United States has somebody who's using, you know, and how much are we hearing about, oh, you know, how long have they been studied? There's just no comparison.

Okay. Thinking about lengthy safety process – process, typically, how do you address concerns that the COVID vaccine was available so quickly during the pandemic?

Dr. Limaye: I’ll – I'll quickly take that one. I think just as – as Laura mentioned, the mRNA products and the platform had been in development for decades. And that's usually how I explain it, that this was not something that was done in a year. We happened to be able to stand on the shoulders of giants, really, honestly, in other technology platforms that allowed us to get a market – a COVID vaccine, excuse me, to the market in such an efficient time frame. And that's because there was a pandemic. So.

Dr. Humiston: How do you explain the different mechanisms of vaccines available if questions or concerns come up? Like some vaccines are live, some vaccines are inactivated, some vaccines have mRNA in them. How do you deal with those questions? Because they can get technical fast.

Dr. Hurley: Yeah, I mean, I – I have to say that that is not something that I – I mean, certainly the MRA – mRNA question has come up. There's very few live vaccines on the adult immunization schedule with measles, mumps and rubella being one of the – the only ones. And you know, I do talk about adjuvants in the vaccines, which I think is something we all should be familiar talking to our patients about because not all adjuvants are created equal.

If you all aren't familiar with that term, that's something that is put into the vaccine to make it more immunogenic, to have more of immune response. And that tends to be what makes people so symptomatic with the vaccines, like the RSV vaccine, like the recombinant zoster vaccine.

So I do bring up that component, but I don't find getting into the mix of what types of vaccines they are. Is that relevant in my clinical discussions?

Dr. Humiston: I'm going to do one more question. How – what's the role of schools, you know, colleges and workplaces in doing recommendation for vaccination? What should it be?

Dr. Limaye: Yeah, I think that for me, it goes back to the accessibility issue, right? If – if there is on site vaccination offered, especially in employment settings, you're removing a barrier. So I do think it's really important. Same with the school level. If there's a flu clinic, which happens, like at my kids schools, for example, it just takes the burden off the parents. And so I just think of it as an access issue, why we should be promoting employment-based vaccine programs. But also church-based, for example, is another really great one. And churches play an important role not only here but also globally with regards to administering vaccination.

Dr. Humiston: And I would just bring up kind of – I'm from Colorado. We've just had an outbreak of measles at one of our high schools, and there were 12 cases, and they had to isolate 80 individuals who were un – unvaccinated. And when I was hearing the person from the Adams Public Health Department discuss this, she said, I am so thankful that we had an affluent, highly vaccinated community, or this could have been like a wildfire. So – so important that I don't know that the MMR vaccine was being given at that school, but the relevance to vaccination within the school.