The COVID-19 pandemic has upended many aspects of family medicine practice. In some instances, telemedicine has replaced wellness checks, physical exams and other procedures that have historically been conducted face-to-face -- and the AAFP remains committed to ensuring members stay up to date on the latest developments in this area.
For all of the potential associated with virtual visits, however, some patient care services simply can't be performed online. Administering routine immunizations is an essential aspect of care that requires FPs and patients to be in close physical contact.
To help ensure that patients continue to receive needed vaccines while safeguarding clinicians and staff, the CDC has issued new interim guidance(www.cdc.gov) for immunization services during the pandemic.
Among specific topics covered are considerations for routine vaccination, advice regarding vaccination of people with suspected or confirmed COVID-19, infection prevention practices, use of alternative vaccine administration sites, and strategies for promoting catch-up immunizations.
For insight on the new guidance and tips for discussing the importance of immunizations with patients, AAFP News reached out to four family physicians:
- 2009-2010 AAFP Vaccine Science Fellow Jamie Loehr, M.D., is a former AAFP liaison to the CDC's Advisory Committee on Immunization Practices and founder/owner of Cayuga Family Medicine, a private practice in Ithaca, N.Y.
- Paul Hunter, M.D., is a 2010-2011 Vaccine Science Fellow and associate professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health in Madison.
- 2018-2019 Vaccine Science Fellow Mina Khan, M.D., is an attending physician and managing partner at Primary Care Services-Blount LLC in Oneonta, Ala.
- Laura Morris, M.D., is a 2018-2019 Vaccine Science Fellow and associate professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia.
Here's a recap of what they shared.
Regarding the importance of the CDC guidance in the current COVID-19 environment, Loehr pointed to evidence indicating(www.cdc.gov) that routine vaccinations for children fell significantly during the pandemic because offices had to limit in-person visits and patients were reluctant to come into the office for nonessential care. "This decrease in immunizations might leave some populations below the level of herd immunity necessary to prevent outbreaks," he noted.
"Efforts to reduce COVID-19 transmission, such as stay-at-home and shelter-in-place orders, have led to decreased use of routine preventive medical services, including immunization services," said Hunter. Maintaining or reinitiating routine vaccination during the pandemic is essential to protect individuals and communities from vaccine-preventable diseases and outbreaks, he noted.
"Timely immunizations are just as critical in the time of a global pandemic as when there is no such disease circulating in communities," agreed Khan.
Morris echoed the same sentiment: "COVID-19 took the health care system by storm. It is easy to forget in the chaos of the pandemic that we are still responsible for our patients' comprehensive health needs, including preventive care.
"This interim guidance reminds all of us that it is still beneficial to vaccinate children, adolescents and adults," she added.
To that end, Loehr suggested that FPs proactively assess the immunization status of their patients and make a point of catching up on necessary vaccinations during all visits, not just well visits.
FPs should identify patients who have missed well visits or vaccine follow-up visits and encourage them to make follow-up visits as soon as possible, Loehr added. "If you need to prioritize, focus on children under age 2, kindergarten visits, children ages 11-12 and adults who just turned 65," he advised.
Hunter suggested reaching out to pregnant women who missed Tdap vaccination because of deferred in-person prenatal care visits and schedule them for follow-up, including vaccination during their next in-person appointment. He also recommended that FPs identify adults with underlying medical conditions who have missed recommended vaccinations and contact them to schedule in-person catch-up appointments.
Hunter cautioned, however, that vaccination visits for those with suspected or confirmed COVID-19 should be postponed to avoid exposing health care personnel and other patients to the virus.
Although both Khan and Morris said routine vaccination of healthy patients should continue despite the pandemic, they also emphasized the need to safeguard patients' health. "The risk of contracting vaccine-preventable diseases in unimmunized patients outweighs the risk of contracting coronavirus at a medical office where precautions are being taken to protect patients, such as through use of personal protective equipment and good sanitizing practices," Khan observed.
"We have a responsibility to our patients to ensure our offices and clinics are safe places for preventive care," said Morris. "FPs should take the lead in community health efforts to coordinate vaccinations and consider alternative sites for vaccinations, as well as effective communication strategies with other stakeholders such as public health departments, pharmacies, schools and employers."
As for how the pandemic has affected these FPs' ability to provide immunizations to their patients, their responses reflected a range of challenges, as well as innovative solutions they've found to overcome them.
"My office stopped all in-office well visits from mid-March to June 1 except for children aged 2 years or younger," Loehr said. And although his practice initially experienced problems using telemedicine, with insurers rejecting their claims, "We negotiated an understanding that all telemedicine well visits would be followed by an add-on in-person visit within 90 days to ensure vitals were taken, a physical exam was done, and any necessary in-office testing and vaccinations were addressed," he explained.
Khan said her practice has continued to schedule adult preventive visits and well-child visits as they come due, and she has used these office visits to update immunizations. "Also, I check vaccine records at each visit, even if not scheduled as a preventive visit, to reduce the need for the patient to have to return for an additional office visit," she explained. "Patients are screened for symptoms associated with COVID-19 over the phone, and those with active respiratory symptoms are seen in their cars or via telemedicine instead of in the exam rooms. If sick patients are due for vaccines, they are immediately scheduled for follow-up visits or immunization-only visits at a later date."
Similarly, Morris' practice has focused on catching patients up on immunizations whenever they're in the office. "We have also reached out to local pharmacies to ensure they are alerting us if patients receive vaccines in a setting that is not office-based," she noted.
When it comes to getting the word out to patients about the importance of immunizations, the current COVID-19 pandemic offers a unique teachable moment.
"Use patients' concern for preventing one infectious disease -- COVID -- to focus their attention on how they can effectively prevent others with vaccinations," Hunter advised.
Khan agreed, pointing out that current conversations about the COVID-19 pandemic can segue into discussions about getting vaccinated against influenza for the upcoming fall, especially since the signs and symptoms of influenza and COVID-19 overlap. "Since one respiratory illness could make a patient more vulnerable to another, and the reality is that a vaccine against COVID-19 is still at least a year away, vaccinating against influenza may indirectly make patients less likely to become severely ill if they contract the illness," she said.
And when addressing vaccines with patients, it's essential that physicians use an authoritative voice and an all-hands-on-deck approach.
"Make a strong recommendation and take a presumptive approach," Loehr urged. "Don't offer the vaccine as an option, but rather present getting the vaccine as the default position. Involve the whole office. Have the front desk tell the patient the influenza vaccine is available, have the nurse or medical assistant offer the vaccine when rooming the patient. Use standing orders so the nurse can even give the vaccine before you walk into the room."
Morris echoed that message, saying, "It's very important to have a united front with your health care system. Vertical integration of all members of the health care team, from the staff member who makes their appointment and welcomes them in the door to the nurse who reconciles their medications to the physician who recommends vaccines -- all need to be on the same page."
Of course, projecting a robust vaccination message doesn't mean that patients' concerns should ever be ignored or glossed over.
"If the patient or parent objects, slow down and listen," Hunter cautioned. "Say, 'Most of my patients want the protection from serious infections. Please tell me what your concerns are.' Do not interrupt or offer information unless specifically asked. Instead, ask, 'What other concerns do you have?' At the end, strongly recommend the vaccines."
If patients or parents continue to object, ask them to reschedule for another discussion of vaccines and have parents sign the American Academy of Pediatrics' Refusal to Vaccinate form,(downloads.aap.org) he advised.
Overall, it's imperative that FPs use all the tools at their disposal to keep immunizations front and center in their practices and to leverage every opportunity to vaccinate.
Hunter recommended adding recorded messages to office phone systems, patients' access portals and websites to inform patients that in-person visits for vaccinations can be conducted safely.
"Include pending orders for needed vaccinations in huddles with nurses and medical assistants at the beginning of clinical sessions," he advised. "Meet with clinic managers to discuss procedures to identify and contact patients who need vaccination and to schedule them safely for in-person visits. Meet with clinic managers and physicians to review the Immunization Action Coalition's 10 Steps to Implementing Standing Orders for Immunization in Your Practice Setting."(www.immunize.org)
Since many practices are experiencing lower in-office patient volumes, this may be a good time to renew vaccine-related education for clinic staff, Khan suggested. "Also, many EMRs have a recall feature that can be used to notify parents and patients who are due for immunizations and preventive care," she said. "This may be a good time to enable such a feature if available.
"Opportunistic immunization is more important than ever," Morris observed. "Take advantage of all visits, including visits not typically designed for preventive care, to address vaccinations with your patients. Start counseling patients now about the upcoming influenza season and remind them of the importance of getting their flu vaccine this year.
Finally, there are many ways family physicians can get involved in promoting vaccines beyond the walls of their practices. For Loehr, that means advocating against nonmedical vaccination exemptions.
"Currently there are five states that only allow medical exemptions in order for children to attend school: California, Maine, Mississippi, New York and West Virginia," he stated. "About 30 states allow religious exemptions; the rest allow religious and philosophical exemptions. According to a JAMA study,(jamanetwork.com) after California removed personal and religious exemptions in 2015, the rate of kindergartners without up-to-date vaccination status decreased from 9.84% during 2013.to 4.87% during 2017."
For her part, Morris called on FPs to counter misinformation spread by so-called antivaxxers. "FPs should not underestimate the coordination and penetration of anti-vaccine groups," she advised. "Our patients are inundated with false and misleading pseudomedical information on social media, and it is our job to dispel these rumors and provide scientific and evidence-based facts that support the public health benefits of vaccines. This is a historic moment and if we do not approach with strong offensive tactics, public perceptions about vaccine development, vaccine safety and vaccine efficacy may be forever altered."
Hunter, meanwhile, focused on boosting vaccine uptake. "Work within your clinic, health care system, state AAFP chapter, and local or state immunization coalition to support local and state public health officials in efforts to raise vaccination rates. And in February-March 2021, consider applying for the AAFP Vaccine Science Fellowship."
To Khan, the COVID-19 outbreak is an unprecedented event that will force practicing physicians to think "outside the box" when it comes to health care delivery and immunizations. "What works for one small single-physician practice may not be feasible for another larger or group practice," she warned. "We need to utilize resources such as the AAFP (online) communities to share our ideas and learn for our cohorts."
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