Vaccine Hesitancy and Proposed Strategies

Podcast Transcript

Respiratory Exchange Podcast Series

Release Date: June 26, 2024

Expiration Date: June 25, 2026

Estimated Time of Completion: 40 minutes

Vaccine Hesitancy and Proposed Strategies

Aanchal Kapoor, MD

Tosin Goje, MD

Description

Welcome to a special series by the Respiratory Exchange Addressing the Impact of RSV and Vaccine Hesitancy. In this series, we explore the efficacy of RSV vaccines and discuss preventive strategies aimed at reducing the occurrence of severe RSV respiratory illness in infants, children and older adults. 

This episode will focus on the Vaccine Hesitancy and Proposed Strategies, where Dr. Tosin Goje and Dr. Aanchal Kapoor discuss vaccine acceptance, hesitancy, and resistance, as well as the challenges and opportunities for vaccination immunocompromised patients. Learn techniques used to communicate with patients and families include empathic listening, finding trusted sources, and addressing fears and myths.

Learning Objectives

• Appraise the difference between anti-vaccination and vaccine hesitation.
• Demonstrate understanding of various reasons for vaccine hesitancy.
• Apply evidence-based strategies to increase vaccine uptake.

Target Audience

Geriatricians, infection disease physicians, intensivists, nurse practitioners, nurses, obstetricians/gynecologists, pediatricians, pharmacists, physician assistants, primary care physicians, pulmonologists, and other prescribing and non-prescribing providers.

Accreditation

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this internet enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this internet enduring material for a maximum of 0.75 ANCC contact hours.

• American Academy of PAs (AAPA)

Cleveland Clinic Center for Continuing Education has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.75 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.

• Accreditation Council of Pharmacy Education (ACPE)

Cleveland Clinic Center for Continuing Education designates this knowledge-based activity for a maximum of 0.75 hours. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion. Universal Activity Number List:

- Pharmacist UAN: JA0000192-0000-24-514-H06-P

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

Cleveland Clinic Planning Committee for Addressing the Impact of RSV and Vaccine Hesitancy Series

Cecile Foshee, PhD
Co-Activity Director
Director, Office of Interprofessional Learning

Steven Gordon, MD
Co-Activity Director
Chairman, Infectious Disease Department

Kaitlyn Rivard, PharmD
Co-Activity Director
Department of Pharmacy

Nichole Brown, MSN, RN, CHSE-A, PhD(c )
Nursing Institute

Neal Chaisson, MD
Department of Critical Care Medicine
Department of Pulmonary Medicine

Frank Esper, MD
Pediatric Infectious Disease
Cleveland Clinic Children’s Hospital

Debra Kangisser, PA-C
Director of Education
Physician Assistant Services

Aanchal Kapoor, MD, Med
Department of Critical Care Medicine
Department of Pulmonary Medicine

Steven Kawczak, PhD, CHCP, FACEHP
Co-Medical Director, Center for Continuing Education

Neil Mehta, MBBS, MS
Center for Technology-Enhanced Knowledge and Instruction
Associate Dean of Curricular Affairs, Cleveland Clinic Lerner College of Medicine

Anne Vanderbilt, APRN
Senior Director, Advance Nursing Practices
Center for Geriatric Medicine

Hannah Wang, MD
Director, Molecular Microbiology & Virology

Faculty

Aanchal Kapoor, MD
Cleveland Clinic Medical Director, Intensive Liver Unit

Tosin Goje, MD
Cleveland Clinic Medical Director, Center for Infant and Maternal Health

Host

Steven Gordon, MD
Cleveland Clinic Chairman of Infectious Disease Department

Agenda

Vaccine Hesitancy and Proposed Strategies

Aanchal Kapoor, MD

Tosin Goje, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Nichole Brown, MSN, BSN,
Cecile M Foshee, PhD, Steven Mark Gordon, MD, Debra Kangisser, PA-C, Aanchal Kapoor, MD, Steven Kawczak, PhD, Neil Mehta, MD, and Anne Vanderbilt, APRN.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC, AAPA, ACPE Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: http://cce.ccf.org/ccecme/process?site_code=main&activity_session_code=EHCE05705

to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Acknowledgement:

The Cleveland Clinic Center for Continuing Education acknowledges an educational grant for support of this activity from ModernaTX, Inc.

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

PODCAST TRANSCRIPT

Dr. Raed Dweik:

Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for healthcare providers, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Dr. Steve Gordon:

Well, Hello. My name is Steve Gordon, I'm Chairman of the Department of Infectious Diseases, and I'm very excited to host this podcast today, where we're going to be focusing on an interesting topic, which is vaccine hesitancy and proposed strategies to combat that. I think it's extremely timely, and I've got two of my favorite people, colleagues at the clinic here. So, without further ado, let me first start with introducing Dr. Tosin Goje. So Tosin, can you just tell the audience a little bit about your background?

Dr. Tosin Goje

Hello guys. So, my name is Tosin Goje, and I am an obstetrician gynecologist and also an infectious disease specialist for women. And currently, I serve as the medical director for our Center for Infant and Maternal Health.

Dr. Steve Gordon:

Wow. Well, it is a pleasure, I know we are going to weigh in, and can't wait to hear some of your opinions. Also, we're blessed here to have Aanchal Kapoor. Dr. Kapoor has been a colleague for a long time. Aanchal, do you want to tell the audience a little bit about your background?

Dr. Aanchal Kapoor:

Sure. Hello everyone. Aanchal Kapoor. I'm one of the critical care staff physicians. Did my fellowship here and stayed here as a staff. Currently, I'm the director of Medical Intensive Liver Unit, and it's a pleasure to be here with Dr. Gordon and Dr. Goje.

Dr. Steve Gordon:

We will get right into it, but just a little bit of a background as we look at the headlines today, we are looking at measles resurgence a little bit in the United States, something that we declared defeated in 2000. And a lot of that has to do with, obviously, a little bit of vaccine hesitancy resistance in terms of some people. But I think I'd like to just frame this as we're coming off the pandemic, it was remarkable to note that about two thirds of the world population received a COVID vaccine. So, a relatively novel vaccine that was actually, I think, a tremendous lift. The WHO goals were obviously an effective, safe vaccine for everybody. And again, estimates that many lives were saved by the vaccine.

On the other hand, I think, all of us, maybe some more surprised than others, ran into what I would say, belief systems, which we all share. And I think for me, one of the lessons has been that people's beliefs are stubborn, and this goes beyond vaccines, or this can go to everything. We like to think that we hear something, then maybe we research it, we go back and vet it. But, in fact, most of us, we hear something, we believe it, and then maybe at a later time, we may or may not go back and consider why is it, is that really true. And so, I think this spins around nicely in terms of some of the distress or some of the conversations we may have had or seen in the public with the issue about vaccination, COVID in particular, but now beyond that. And I think that kind of sets up the conversation that we're going to have here in terms of some of the issues as we move forward.

So, Aanchal, if we could start with you, maybe just with definitions, when we talk about vaccine resistance, vaccine hesitancy, vaccine acceptance, can you just level set for what does that mean?

Dr. Aanchal Kapoor:

Sure. Dr. Gordon, you're absolutely right. We saw a big lift with the COVID vaccine, probably haven't seen it before. It was a multi-pronged approach to act on these definitions. Vaccine acceptance, in general, are people who have taken previous vaccines, they believe in vaccines, they believe diseases can be prevented by vaccination. In general, when you look at the history, they are the people who always take vaccines, whatever comes in the market because they're so scared of diseases, they take the risk of taking a vaccine as compared to taking a risk of getting a disease. So those are easy population to target with a new vaccine too.

Another extreme, we see are people who do not believe in vaccination, their vaccine resistance, anti-vaxxers, we call them, they don't want to take any vaccine, period. No matter what you explain to them, no matter what you hear, they read about it. They just feel it is the natural immunity which will take care of them. And they don't want to add any extra products into their body. They are more worried that the vaccine will give them the disease, in contrary to vaccine will prevent a disease.

The middle population, which is our target population, is vaccine hesitant. Those are the patients who do not have enough information about the vaccine. And they have some beliefs, some peer pressure, some social pressure or some misinformation from the media or social aspect of it, that they are hesitant to take the vaccine. That could be our target population, especially in a COVID era. We targeted that population by multi-prong approach to tell them, to educate them about the benefits of vaccine. And many people turned around and took the vaccine.

Dr. Steve Gordon:

Well, thank you for sharing that nice overview in definitions. I want to turn to you, Tosin, because when we talk about the pregnant women, this is a very special population, and I'm wondering if you can share some of your experiences even beyond the COVID vaccine in terms of the approach of vaccination in pregnancy in the pregnant women.

Dr. Tosin Goje:

Thank you so much, Steve. This is an excellent question, and also timely. Pregnant patients traditionally have not been included in clinical research. And that gap was emphasized and was really seen during the pandemic. So, we had a vaccine that was needed that was not trialed in pregnant patients. And because they are a vulnerable population, they have some immunosuppression going on with pregnancy, we wanted them to get the vaccine. And the world is a much, much savvy place. Patients read, and here they are reading that this vaccine was not trialed in pregnant patients. They don't know the safety; they don't know the efficacy in pregnancy; they did not know much about teratogenicity in pregnancy, words that some of them have heard before, and then you ask them to take the vaccine. So, there was a lot of hesitancy at the beginning, from misinformation, lack of awareness, and the fear that RNA vaccine will change their DNA, not just their DNA, but you have a DNA of an unborn child.

And then when you look at data, data also was showing during the pandemic that pregnant patients who got infected with the COVID infection did poorly. So, you have this cohort doing poorly with an infection, and the same cohort not receiving the vaccine. So, a lot of education had to be done. A lot of education, I call it a campaign, from all the birthing societies explaining what an RNA vaccine is, how it's so different from your DNA, in as much as there was no trial conducted in pregnancy, they had some animal models that they could speak to and reassure the patients. Also, they had to look at the benefit versus the efficacy and side effects. Pregnant patients were dying all over the world. We had a lot of papers from China, from Asia, from England showing the same thing we were seeing here in the United States, that pregnant patients who had the infection were doing poorly, and especially when they had other comorbidities like diabetes, obesity, hypertension added to pregnancy. So, a lot of campaign was done. And as we kept educating the providers, we saw this gradual uptake in the vaccine.

Now, let's go back to talk about vaccine in pregnancy. Vaccination in pregnancy is not new. The CDC recommends influenza vaccine in pregnancy, regardless of your trimester. They recommend Tdap, the tetanus, diphtheria vaccine with every pregnancy, even if you have 10 children. So, vaccination is not new. We also know that when the provider offers the vaccine to the pregnant patient, there was an increased uptake, versus if it was a non-provider or just their neighbor. So, vaccine is not new. I think for COVID, it was because of the initial fear that it was not trialed in pregnant patients. And I have seen a difference between the rollout of the COVID-19 vaccine in pregnancy, and the rollout of the maternal RSV vaccine in pregnancy, because we just completed that seizing, and we had less pushback from the patients. So, the pandemic, the COVID-19 pandemic was kind of helpful because these patients are reading, they're more savvy, and we know that the RSV vaccine was trialed in pregnant patients. So, we had more data to have the shared medical decision conversation with. So, I think we need to have more education in pregnant patients. We need to open clinical trials to pregnant patients so that downstream the uptake is what we want it to be, as close as 100% if we can.

Dr. Steve Gordon:

Well, I love how you present, especially with new vaccines, even if the technology is not new, that safety is first. And I think that's CDC, FDA, and even as a clinician, right? It's first do no harm. But also understanding that no we are not saying that there is absolutely no potential side effects to a vaccine like any medication. I mean, most may be local symptoms, but as we saw, even with the COVID vaccines and others, you can get a myopericarditis, although usually mild in usually young adolescent males was where that was. The adenoviral vector vaccine actually increased risk in certain patients of clots, so in terms of this. And so, I think it's important, and I think we all learn that too, is to say we are going to continue for post-surveillance as well and be able to take new information for shared decision-making, which I think is extremely important.

On the other hand, Aanchal, going back to those days in 2020 in the ICU where you where you saw and witnessed death or a lot of morbidity, can you explain how that affected you? And then the approach when now a vaccine is available that may not prevent infection, but certainly in certain populations could prevent hospitalizations or death.

Dr. Aanchal Kapoor:

You're right after seeing that there was a cure, or there could be a cure, going back to those populations and seeing how the family members are reacting to it. I personally made few phone calls once the vaccine came out to the people who actually died in the ICU saying to the family, “What do you think?" And those people who actually saw the death, they were more vulnerable, and they were more open to getting the vaccine, even if they haven't received vaccine before. And I go back to Dr. Goje's point, coming from the provider where they have a firsthand experience was helpful. People were more open after seeing the deaths. And particularly in ICU, the nurses, everybody was talking about it. And people who were not vaccinated before they were getting vaccination just by looking and seeing the other side of the disease.

I can share my examples, like my friends who were somehow anti-vaxxers, hearing those stories, looking at those, reading about it in the media, reading about it in Cleveland Clinic Journals or newsletters, they were asking questions and asking questions is the key factor. If you are not even open to learn about it, how can another person put it in your head? The more questioning, more webinars, more podcasts like this were opening many people's minds and they were becoming open to even hearing about it.

Dr. Steve Gordon:

It's interesting, as we talk about this, there's been a lot written in terms of beliefs. And, one of the interesting books I read about this in terms of the construct, it was something called misbelief. So, it was a psychologist and talked about, especially during COVID, right? There's an emotional component, there's a cognitive component, there's also a social component of this. And if you think about people who may be isolated during the pandemic, and then maybe not having great experiences in some way, how you can begin to get information, some of that information maybe be disinformation. So, there may be kernel of truth or interpretation there. Some may be what we call fake news where it's just more to confirm a belief already, not necessarily to persuade. But I'm wondering if we can explore your approach on how to have open dialogues with people who may be resistant or be very hesitant.

Dr. Tosin Goje:

Excellent question, this is one of my areas of campaign. Never dismiss a person's belief or concern, whether at the individual level, or at the community level, don't dismiss it. One, it's an opportunity to understand the root cause, and to understand where the belief system and information is coming from.

Secondly, is an opportunity for education, which is something the three of us are very, very pro, educating the patient, their family, and their community. For example, a patient tells me, "If I get the influenza vaccine, I'm going to get the flu." I smile. And once I smile, my patients know, "Oh, something is coming." And we talk about what a vaccine does. Or they say, "If I get the flu vaccine, then I have a double clinical symptom. It's, my clinical symptoms are even more severe." And then you must sit down. Don't dismiss them and say, "It doesn't happen." You have to explain what that means.

During the pandemic, I was fortunate to talk to special groups from pregnant patients to people living with disability to religious groups. Everyone had a different fear. "You guys call it an RNA vaccine. That means it's going to change my DNA.” Oh, no. You need to explain the difference. And we need to start understanding that patients are more educated than what they were in the '40s and '50s. Explain to them at an eighth-grade level how these vaccines work. Be transparent about the side affects you know about, whether short term, long term. And if you don't know, like at the beginning of the COVID pandemic, you tell them, "I don't know what the long term is." But we know as Dr. Kapoor said, people are dying, and I have seen them dying. And allow the patient to have that shared medical decision with you of what they want to do.

Understanding the root cause of vaccine hesitancy is very important at individual and community level. If it's religious, you might not be able to stop it, but if it's from experience, if it's from misinformation, disinformation, you should be able to, at a patient level, eighth grade level, separate facts from myth, respecting their view.

Dr. Steve Gordon:

That is so important in terms of how you approach that. And I love building rapport as you said. So, I think the wordsmiths would say, "Don't start with a version, don't start with no and but, start with understanding and then ands." So, you're trying to hopefully create a dialogue in terms of this. So, Aanchal can you show us some of your techniques to create that dialogue to either try to get to yes, or to try to get to a position where there's a potential for persuasion?

Dr. Aanchal Kapoor:

Sure. So I go, as we just heard, to the root cause analysis, to understand their fears. I was surprised when I was talking to one patient. The fear I was thinking was religious or environmental from a low socioeconomic status, the fear was the needles. So, unless we explore where the fear is, we do not know where to act on. I can educate thousand things, but it'll not come across if I haven't heard about, it's just the needle. So, my strategy in this scenario is, just listen. First 15 minutes, I'm just listening where it is coming from and trying to understand and confirm. So, this is what I heard, is that the fear you have, or is this what you have heard, or is this your friends are doing? It could be just the ingredients in the vaccine. They have a misinformation about it has animal products, or it has some allergens. And I'm already allergic, I have asthma; I don't want this vaccine with allergens. So, it could be multiple things which we, even as physicians, do not think of.

Once we have that information, it's easy to strategize where to act on. Is it just the person, is it vaccine related, or is it the social media impacting their decision, or is it just the misinformation. So, then I dive into different strategies. As a critical care physician, I'm not their primary physician. So, if they really get into trouble, I try to connect with the primary care physician whom they trust the most, and try to relay that information, say, "Let me schedule an appointment with So-and-so, and let's sit together and discuss together." Sometimes that's what it needs, that they need to hear it from a trusted person. It could be a political figure; it could be somebody from movies. So, during COVID, we saw all these campaigns where all these movie stars were propagating for COVID vaccine, and people heard them because they trust them, they like them. So, trying to find different strategies which will hit the particular niche would be helpful.

Dr. Steve Gordon:

That's very, very informative. And I love, as you said, the needle or that. Of course, that's one strategy in the future, looking for different ways of vaccine delivery, whether it's COVID or not, that doesn't involve a needle to try to get at that.

Tosin, as I'm listening to this, one of the things was, "Yes, go to your primary care provider." Then if you look at health equity issues, not everyone has a primary care provider or try to find one during COVID. So, I'm wondering if you can speak to some of the communities that you were reaching out to, which maybe were vulnerable communities in terms of what techniques that you saw that were effective. Whether it's using religious leaders, community activists or as Aanchal said, other people trusted in the community to get messages out.

Dr. Tosin Goje:

Another very important question. Not everybody has a primary care provider. So, during pandemics, what we call vaccine campaigns or vaccine programs are always put together to get to communities that traditionally have a mistrust of the healthcare system or do not engage with the healthcare system. And I can speak to what we did during the COVID-19 pandemic. We started by having town hall meetings, town hall meetings with different people of color, people living with disability. There are very small communities that I never ever knew existed in the northeast Ohio space that we wanted to reach out to. One of them was a Somali community, because I got an email, "Hey, Tosin, are you from Somalia? We need someone." I was honored because it means we are thinking about community and population medicine and respectful care and cultural competency. The things that are very important when you have a very diverse population. And we found someone who actually spoke the language to go talk with them.

So, we went to specific communities like immigrant communities like that. We spoke with the Padres, with the faith organizations, both Muslim and other faiths, Christians, just explaining what the vaccine does, effectiveness, efficacy, side effects that we knew. Because when you get the buy-in of community leaders, many times, they're able to discuss with the population that respects them, that trust their judgment, versus you going as a healthcare system to individuals, or just to families trying to convince them to come in. For example, there was a Black town hall meeting I had, and one of the questions that was raised is, "Why now? Why are you guys interested in us?" And, of course, cultural competency came in and we had to explain why it was important because the Cleveland Clinic went to many communities, and we had to explain why we were coming to them. If you don't have a primary care provider that you talk to, we need to come to you. We, as a system, are your provider right now. And then you talk about the benefits versus the risk and dispel all the misinformation as Dr. Kapoor said, you need to listen. And that's why those town hall meetings were very important at the beginning.

Dr. Steve Gordon:

Now, I think that's something that I need to get better with as well, the empathic listening. Because in such a hurry that becomes an issue for some clinicians that may not know, have done their talking points and are just used to either, hey, doc orders it, patient accepts it. And as you said I think it's good that people question in terms of what goes into their arms. That is an important thing. And that's something that even before the COVID vaccines made us reassess in terms of getting our messaging down. Not to deceive people, but to understand and then to try to convince.

Aanchal, I'm wondering what techniques you've found in terms of, “Well, I'm looking at the data, I'm young and healthy, so I don't need the vaccine, I'd rather give it to somebody else." or "I don't need the vaccine." I wonder if you can talk about household immunity as a different way of looking to try to convince others to pay it forward. Potentially, that you may protect others in your friend circle or in your household because you deal with a lot of immunocompromised patients.

Dr. Aanchal Kapoor:

Sure. Saying to that population, showing the data sometimes is helpful, that these are our stats, these many cases in immunocompromised patients, these many in young patients. Especially, we saw a lot of young population very, very sick. Showing them, not particularly sharing the details of the case, but saying, "This many percent of patients came at this age with the COVID, and the outcomes were not favorable.” It's not that you don't need it. You want to prevent the disease, you have to take care of healthy, and you have to provide immunity within your circle. If you are healthy, less chances of patients around you or people around you getting sick, because this spreads from one person to another. So that is why we are taking all these precautions in the hospital. If you get sick, I agree with you, you might be okay, but people around you will get sicker because they will catch it from you. So, it's equally important that we protect you as well as the circle around you.

And many people, I'm not saying 100% compliance will happen by saying that, but people will be open to hear. They don't want their grandfather to get sick who has melanoma. They don't want their grandmother to get sick. So, they might come around thinking, "Okay, I can spread this infection. My body is healthy, I might not get sick, but other people around me will get sick."

Dr. Steve Gordon:

Now, that's a very nice way of looking at that. Tosin, it reminds me too, of how we handle pertussis in the neonates, right? Because there is no treatment or vaccine that you can give until the six months. And so that's the cocooning, right?

Dr. Tosin Goje:

Correct.

Dr. Steve Gordon:

If you look, there's an estimated 9 million Americans that are immunosuppressive and will not mount an effective, prolonged T cell response to these vaccines. So that vaccine for them at the current way is probably not going to be a very efficacious. Therefore, looking at other ways, we still have 4 million new babies born each year that need to get some acquired immunity. I'm wondering other ways that we can adapt from how households look at their newborns, to maybe looking at others in our community that aren't newborns.

Dr. Tosin Goje:

Yes, I think exactly what Aanchal said is what we say, which is, you might be strong, you might be immunocompetent, but your newborn is vulnerable. And as you rightly said, newborns don't get their vaccines. They start maybe third month of life, six month of life, and then you show them data. We have data that shows that when it comes to pertussis is the very newborn under the age of three months or six months that get admitted into the hospital. Just the same thing as RSV, the very severe disease is in that little three-month-old that is not immunocompetent. People do things for their babies. And for Tdap, we encourage partners and grandparents to receive a Tdap for the newborn. And they do it. As you said, it's cocooning, and it's like everyone wrapping their arms around the most vulnerable person in the house. And I think we can translate that to families and communities, "Yes, you are immunocompetent, you have no comorbidity, but by receiving the vaccine, it's a way of you wrapping your arms around your grandmother or grandfather," as Aanchal said. And people tend to be good citizens, good children, good family members when they understand what cocooning is to the loved person in their life, and they tend to do it.

Dr. Steve Gordon:

It reminds me of two of the most memorable vaccines that I've received in my lifetime that I remember. One was obviously the first COVID vaccine that I got in December of 2019, but the second was my Tdap booster with the birth of my first grandchild. And so, as you said, I'm not a big needle person, truth be told, but I am a big vaccine person. So that was something that's understood, and gratefully proceeded doing, which is good. I think it also underscores that we don't have necessarily a monoclonal antibody for COVID anymore, and we do have antivirals. So, this is also about treatment options.

And I’m wondering now, as we look to the landscape, some of the other lessons that you learn, Aanchal, from this experience in terms of trying to educate healthcare workers. That was the other cohort that we saw at the clinic, as we had mandatory participation, not mandatory vaccine. But I'm wondering, do we use the same education of our own healthcare workers in terms of accepting vaccines for vaccine preventable illness that may transmit to patients?

Dr. Aanchal Kapoor:

Sure. I think as I hit on primary care physicians, educating the healthcare workers is very, very important. You cannot preach what you don't believe in. So, I think the very first hit, if you are treating an education campaign should start with the healthcare workers. And again, starting off with what fears you have, what are your concerns? Do you believe in it or not? If you don't, tell us the reasons. During COVID, when we started educating our residents and fellows, we very quickly, within 30 days, created multiple educational platforms on MyLearning modules. We had an app on our phone where we can go and look up the information and treatments. And as the more antiviral came into picture, those apps got updated right at the time so that people have the latest information. There were blast emails when there was new information. Let's say we have the modules, and the information doesn't hold true anymore. There was a blast of emails saying, "Please refer to this. This is new information we are uploading into MyLearning now." Also, in addition, we had a blog ongoing where people could show their concerns, ask questions, and then that created for the webinars based on those questions so that we can continue to educate these people.

Within the ICU, every single day, our ICU director had meetings with the whole cohort saying, "This is the latest and greatest, and we have created this checklist, this is what we have to follow." There was a buddy system in the ICU where that person's only responsibility was that everybody's taking the right precautions as even precautions were changing over time. So that person's job was to make sure those were the most updated precautions healthcare workers were taking.

And once they saw these patients, those beliefs, even if they were misbeliefs, they fell off when they were really seeing the sick patients. We saw all the real time burnout within our healthcare workers during that time. It was not easy, especially when we can only have Zoom meetings or Teams meetings with the healthcare workers to address their issues. But we tried our best in most level care, giving them time off to be with the family, rotating them. That holds true for medical school, to the nurses and other healthcare workers so that everybody takes some time off to recoup and be with their family members.

Dr. Steve Gordon:

No, thank you for sharing that. You know, as I reflect, there were many good things that also came out of the stress of the pandemic on healthcare delivery. And one of those was the realization that most Americans, live within five miles of a pharmacy. Looking at the vaccine delivery system is a post everyone has to come, for example, down to main campus is utilizing the retail pharmacy as a vaccine delivery in education. Now, I know when I talk to my cohorts generally, in OB-GYN, in pediatrics, the patients or the moms and dads want their kids vaccinated generally by their pediatrician or their OB-GYN. But we saw most vaccine aside from those groups, was delivered in retail pharmacy. I wonder, Tosin, do you mind commenting on the benefit from that in the durability now as we move out of the pandemic into other vaccine deliveries.

Dr. Tosin Goje:

I think we should be able to educate the pharmacists to administer vaccines. And currently, for COVID vaccines, some of our patients are getting it from either their working organizations, or school, or even from other campaigns or walk-ins. I think traditionally, pregnant patients, pediatric patients have always received it from whoever is their primary care, whether it's OB-GYN or the pediatrician because of the education.

But speaking to what Aanchal said, if we educate every provider, then everyone should have the same message, the same skillset, the same evidence to administer the vaccine to the pregnant patient just the way OB-GYN will administer it.

And this is very important when you talk about rural medicine. There are a lot of maternity deserts in the country, which is something we're trying to address. So, if we have the little pharmacist in rural America who has the evidence, the training, the skillset, then they can help get the vaccine to those hinterlands that don't have hospitals or clinicians.

Dr. Steve Gordon:

Well, thank you. I want to focus the last segment here on the newest kid in the block, which is the RSV vaccine. Tosin, I'm going to come back to you first and then Aanchal, but can you talk about what you've learned about RSV vaccine delivery in pregnancy now and for the neonates? Because I think this has been a fascinating experience in this first year.

Dr. Tosin Goje:

Yeah, I'm smiling because I'm happy we're going there. I don't have the data right now, but as someone who has been in the trenches from the H1N1 pandemic to the RSV vaccine, the uptake has been different. The RSV vaccine has had a different reception. The pregnant patients are happy to receive it. In fact, some of them were a bit sad that they were going to be outside the window of being vaccinated because it's from 32 to 36 weeks of pregnancy, and within that RSV season. So, they are more receptive. The uptake is much better. And I think it all stems back from the COVID pandemic. There were some good things and learning points from the COVID-19 pandemic, education of the patients, understanding what a vaccine is all about, understanding how it works, talking about side effects. So, I think it's distilled down to the RSV vaccine. They're more receptive to listening about what it does. They're more receptive to receiving the vaccine, and I can already imagine that with the next season, the uptake will even be higher.

Dr. Steve Gordon:

Wow. And for the adults, in terms of your approach, because now it's shared medical decision-making, at least currently, that may change. But can you talk about that and your experience, what you've seen in this first season for your adult patients that qualify for RSV?

Dr. Aanchal Kapoor:

I think I agree with Dr. Goje. This is what we are seeing. People are scared after COVID. They are accepting vaccine with both hands. We don't see as many cases of RSV, but the ones we see are coming as very severe ARDS. So, people are learning, and people are actually asking where to get the vaccine, when to get the vaccine. So, it's a completely different thing. Like, when I went for the flu vaccine this season, they were asking, "Do you want this? Do you want this?" So, I think the healthcare workers are more motivated to give more vaccines, and they're aware of it, and they are promoting it, and the patients are more open to it. We don't see as many cases because next question comes as, "Is there going to be RSV pandemic?" No, no, no. If you're vaccinating, we don't see it yet. So, people use the word pandemic for RSV and getting scared and getting vaccination.

Dr. Steve Gordon:

No, those are great points, I find. The other is we're beginning to test for it even in adults. So, I think it takes some of the stigma or unknown out, because a lot of people, it's RSV. “Respiratory central virus” or “that’s for kids.” I think testing for it, even outside the hospital now, is our standard for this season, right? We test for the Triplex in the adult’s flu, RSV, as well as SARS-CoV-2. Although we didn't see a lot of it, it's just another toolkit to reinforce. Oh, this is another vaccine preventable, because we don't actually have effective antivirals for the kids or adults for the RSV. So, I think it is interesting. As we evolve and as hopefully more vaccines will continue to be developed, it's all about preventing morbidity and mortality in our most vulnerable population. I'm wondering if just any closing thoughts Tosin that you may have for the listening audience.

Dr. Tosin Goje:

One thing that came to my mind as I was getting ready for this podcast is the world is a global village. So don't think you're insulated from infectious diseases or pandemics, because sometimes we have this this false security that my little community is protected. Think about the global village. Protect yourself, your community, and as many people as you come in contact with by getting vaccinated.

Dr. Steve Gordon:

Well, I like that. And, of course, as you said, it is not fortress America with global travel as we saw, aside from supply chains and things. And that is why cooperation is so important. That is why the US for our own security to set up capacity to identify novel viruses sequencing early for early detection, because we really do need to worry about it. If there are smallpox North Korea, that's our problem as well. This is not beyond political, so thank you for bringing that up.

Dr. Kapoor, any final notes for the audience that you want to summarize?

Dr. Aanchal Kapoor:

While you were talking, I was just thinking that every one of us think of us as a global citizen of this earth, and our job is to serve others. And that brings me to a metaphor of flight attendant. When they are announcing before the flight, "Put your mask on first before you put the mask on others." So, I think it's the same thing. If you have an intent to serve others, you have to protect yourself before you can serve others. So only way you can preach the vaccination is if you do your own vaccination. So, I think everybody should be on the same page.

Dr. Steve Gordon:

In conclusion, I want to thank our guests here today for a wonderful podcast, Dr. Tosin Goje and Dr. Aanchal Kapoor. This has been a wonderful discussion on vaccine hesitancy, vaccine resistance and persuasion. So, thank you both so very much.

Dr. Tosin Goje:

Thank you for having us.

Dr. Aanchal Kapoor:

Thank you.

Dr. Raed Dweik:

Thank you for listening to this episode of Respiratory Exchange Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter at RaedDweikMD.