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Hello. This is Dr. Russell Kohl, Chief Medical Officer and Chief Operating Officer at TMF Health Quality Institute. Today we'll be bringing you a brief conversation regarding immunizations and immunity. I'm joined today by Dr. Clifford Moy, TMF Behavioral Health Medical Director and Melinda Quinn, a Health Care Quality Improvement Specialist at TMF. In today's podcast, we'll talk about some of the benefits and risks of immunizations while understanding how they lead to increased immunity from illness. Thanks, Dr. Kohl. Let's start with a brief overview of vaccines. Vaccines are one of the most effective medical interventions over the last 200 years. Over the years, the products have evolved from live bacteria to inactivated microbes to immunologic stimulants using leading edge technologies such as recombinant DNA, and over the last few years, have even come to include messenger RNA vaccines. Vaccines stimulate the immune system to rapidly respond to and fight germs, most commonly viruses. Developing this degree of immunity prior to infection diminishes-- despite the fact that it may not entirely prevent-- the effects of an acute infection. And it decreases the circulating pool of germs in the community.
Of course, unvaccinated people who are infected and recover can have what is known as "natural immunity." Some of us may remember chicken pox and measles parties for kids, so that a group of people would be infected and develop immunity or resistance to the germs. Unfortunately, these natural infections led to far more bad outcomes than did vaccinations, With some of the party participants developing severe illnesses or long-lasting effects from the infections. The primary difference between modern vaccines and natural infection is how much of the germ is actually present to cause the immunity. In a natural infection, the entire germ along with the risk associated with it present, while vaccines typically include only a portion of the germ to allow your body to recognize and fight a future illness without the full risk of infection. That is why the old saying about catching the flu from the flu vaccine is actually wrong. The vaccine doesn't have the entire virus in it to actually trigger an infection, Although your immune system is definitely working to begin developing antibodies.
This podcast focuses on COVID-19, a type of coronavirus. Coronaviruses are constantly in the environment and ordinarily lead to common colds. However, the COVID-19 virus caused more severe illness, particularly in those with additional risk factors such as old age, chronic illness, or a history of lung damage. It is now understood that the COVID-19 infection caused immune system dysfunction at a much higher degree than previous strains and that it was highly transmissible.
Doctors, thank you for that information. I'd like to ask you some questions related to vaccines. As you know, my team here at TMF has been tasked with offering assistance to nursing facilities in providing the COVID-19 vaccines for residents, staff, and sometimes families. After so many different vaccine formulas have been developed and made available to the public, we are hearing concerns from some about whether continuing to get new COVID vaccinations is actually useful.
And we are seeing smaller portions of the population choosing to keep up with their vaccinations, even if they were accepting of the original primary vaccine series authorized by the FDA in 2020. In August of 2022, a newly formulated bivalent vaccine was made available to combat multiple strains of the virus. And we were still seeing success with acceptance, however not as high as with the original vaccine series. About the same time that the mandate for health care staff to receive the vaccine was lifted, beginning in June of 2023, we were starting to see less transmission of the virus and decreasing severity of symptoms, hospitalizations, and deaths. It's thought that this was largely as a result of increased immunity within the community from either vaccination, having survived a natural infection, or both.
Recognizing that, I'd like to discuss some of the obstacles we are currently hearing from facility leadership about what might be contributing to low vaccination rates for both residents and staff. While working with various facilities around the country, we have found in several instances cases of vaccine fatigue. Facility leadership may not have the time to talk to residents or staff about the importance of vaccination and herd immunity. What do you feel is the best way to counteract and change this outlook?
Thanks, that's a great question. Receiving a medical intervention is a personal choice and does require a level of informed consent. It really is essential that people receive objective information about COVID-19 and the vaccines and that they have an opportunity to discuss that information with a health care provider familiar with their specific circumstances.
Some people may opt to be vaccinated early on, while others may choose to see more experience in the population with the vaccine. In that case, it's important to discuss with the individual what specifically they are watching for in the population and what information they actually need to see in order to make a decision regarding their own vaccination. Part of informed consent is to continue to provide information about how the individual and the nursing home residents will benefit while acknowledging possible adverse effects.
This process will differ for each individual. So it's important to keep in mind that a single flyer or a recorded discussion alone is unlikely to fulfill every need. The COVID-19 as well as the flu vaccines are a bit like using gloves during patient care, the goal to protect the health of both the individual but also to protect the residents they're caring for.
Thank you, Dr. Kohl. I like the point you made regarding that the education process will differ for each individual. We must be prepared to address these differences in the approach to providing education. Another concern we have encountered in some facilities is apathetic leadership. With the ending of the public health emergency and relaxed regulatory mandates, it seems that people simply want to forget COVID-19 is still with us and in some cases, still causing severe illness, hospitalizations, and death. Can you give us your best advice to combat this kind of outlook?
We are fortunate that current COVID-19 variants are not causing as much severe illness, debility, and straining the health care system as it did in 2020 and 2021. Just like other viral illnesses such as the flu, we can expect that there will be continued mutations over the years that will sometimes lead to lighter or heavier health impacts in different years. It's likely that COVID-19 and other coronaviruses will continue to circulate in the community and cause variable if not unpredictable levels of illness.
Wastewater monitoring of the COVID-19 viruses provides community-level measures of virus activity and may allow us to predict larger outbreaks within the population earlier, as well as to identify what strains are circulating and to target our vaccination schedules to the specific community you are living in. Being aware of and monitoring this sort of data can help folks move from a general thought that COVID is gone to a realistic understanding of how much COVID is in their area, which direction it's trending, and what strains are they most likely to encounter. All of these are important factors to consider when thinking about vaccination.
Thank you, Dr. Moy. That is an excellent point. I am in complete agreement that we must monitor levels and outbreaks within our area. It's important to make sure that facilities are aware of where to access this information.
Speaking of information sources, misinformation has led to doubts being expressed about the efficacy of the vaccine due to multiple vaccine formula changes over time. Even when comparisons are made to changes in the annual flu vaccine formula, the mistaken belief that the COVID-19 vaccine does no good continues. What advice can you give to help with facility leadership who say no one believes in the vaccine because if it worked they wouldn't keep having to change it?
The most important aspect of vaccination is to remember that it will almost never fully prevent infection from the virus. It just gives your body basically a cheat code to fight the virus earlier and reduce your risk of severe illness or death from the community infection. Forgetting this truth can cause individuals to look at catching COVID-19 after vaccination as a failure of the vaccine. When in reality, success is keeping that infection from causing severe, lasting consequences or death.
If you think about how the vaccine works, , by showing your immune system a piece of the virus, it makes sense that the viruses that would survive are the ones that don't have that specific piece. Locking the front door means the only viruses that can get into the house are the ones with a different key. The new formula of the vaccine is like changing the locks on the door to stop that different key from working. But changing the locks once doesn't work forever when the viruses are constantly trying new keys.
Dr. Kohl, I love the analogy of changing those locks so the virus can't get in. That is a great way to simply explain vaccinations. We have a lot of excellent resources to offer. But even so, some facility staff feel that it is unethical and are reluctant to continue to ask about COVID-19 vaccination over and over again when resident staff and resident representatives have already said they do not want the vaccine. What do you feel is the best way to approach anyone who has already expressed extreme reluctance to accept the vaccination multiple times?
Melinda, there are many things that change throughout our lives, and a person's circumstances may have changed since the last discussion about the vaccine. We take vitals each time we see a patient even though they were fine the last time we checked.
Asking about whether they would like to receive a vaccination or if there is any additional information they would like to receive in order to make that decision is the same thing as rechecking vitals and should be rechecked just as routinely. We're not browbeating. We just want to be sure the individuals are getting the care they need and they desire.
Thank you, Dr. Moy. But would your approach be the same for anyone who becomes angry or hostile when asked about the vaccine more than once?
I think it's important to evaluate why the individual is actually angry about repeated requests to be vaccinated. Most often, this is someone who feels like their decision isn't being respected or that their reasons for making the decision are being treated as invalid. It's important in these cases not to focus on the anger or hostility, aside from making sure to keep yourself and your co-workers and residents safe, but really to understand what is driving it.
A better way to phrase the original question might be, I see that you've declined the COVID-19 vaccine in the past. Is there any change in your thoughts about it or any additional information that you'd like to have about the vaccine itself?
Thank, you, Dr. Kohl. Thank you so much for all of these amazing tips. I would like to ask, finally, can you give us some advice for talking with residents or resident representatives who refuse vaccines or immunizations of any kind?
Melinda, it's really important to acknowledge their autonomy. Too often, folks try to jump to herd immunity or protecting others, but vaccination is inherently about the individual. Seek to understand their concerns. Is it the potential for harm from the unknown, mistaken understanding of information about the risks and benefits? Or is it just a challenge to get the vaccine and potentially have a day or two of feeling crummy afterward?
With the reduction in a lot of our communicable diseases over the years, people frequently don't have an understanding about the impacts of these diseases, like measles, mumps, or polio. However, it's really important to not try to scare someone into getting a vaccine by being overly dramatic about the incidence or severity of those illnesses. Keep the discussion factual and focus on understanding what is really driving their refusal and if there is anything we can offer that might answer those specific concerns. Change is rarely immediate, so take a longer-term perspective on vaccination. One vaccine at a time, spread out over months may not be the recommendation for childhood vaccinations. But it is still better than not accepting any vaccinations at all.
I want to thank you both, Dr. Kohl and Dr. Moy, for this great discussion and these great suggestions. Listeners, for more resources and information on immunizations, COVID-19, and nursing home quality improvement, visit tmfnetworks.org.
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