Monthly Archives: September 2021

Yours, Mine or Ours?

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Work is hard. Distractions are plentiful. And time is short.”

-Adam Hochschild (Writer, historian)

The approval of COVID boosters this week, and the expected expansion of vaccination to school aged children in the next 2 months, will lead to a surge in demand for vaccination. Counties, pharmacies, hospitals, and medical providers are planning on how to respond to this demand, which could distract us from something all public health experts agree on: most hospitalizations and deaths are occurring in the unvaccinated. The unvaccinated deserve continued focus and attention.

Additionally, the energy and resources to provide boosters and pediatric vaccinations this fall will distract from other important healthcare needs of the populations we serve: increased levels of depression, substance use and obesity are combined with worsening control of hypertension and diabetes. Children are falling behind on well-child visits and routine childhood vaccinations.

What should be the role of Primary Care Providers (PCPs) in providing boosters and pediatric vaccines, during the fall of 2021? Planning with county stakeholders is key, with each stakeholder asking themselves, “What are YOU best equipped to do, what is MY responsibility, what do we need to do TOGETHER to be successful? What is yours, what is mine, what is ours?”

Yours. Consider directing motivated patients to register for vaccinations at community pharmacies, which are currently providing about 2/3 of vaccinations in the state.

Mine. How can we integrate COVID vaccination in our practices as efficiently as possible to avoid negatively impacting other preventive activities, including efforts to vaccinate those without prior doses of vaccine? Can we vaccinate our patients during regular hours and use the leftover doses at the end of the day to provide non-urgent boosters to those previously vaccinated?

Ours. Work with counties to develop a plan to vaccinate school-aged children rapidly, ideally in the school setting. How can we mobilize volunteers to take the pressure off practicing clinicians?

The work remains hard. The new vaccine policy distractions are plentiful. Although the fall Delta wave is subsiding, time is short before a winter wave begins. Nonetheless, it is worth the time to plan now.

A way for the Vaccine Hesitant to Save Face

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Difficulties mastered are opportunities won.“

-Winston Churchill

While we like to believe that we generally weigh different sides of a controversy before coming to an objective conclusion, the reality is that this is very rare. Studies show that humans generally decide first what they believe to be true and then search for supporting evidence and ignore evidence that casts doubt on their beliefs. Behavioral economists call this confirmation bias.

In a fascinating exercise, economist Angela Duckworth and author Steven Dubner (co-author of Freakonomics) debated if they would take a vaccine that prevented them from having any confirmation bias. One conclusion: the result of widespread use of such a vaccine would be economic paralysis. For everyday life to proceed efficiently, we rely on the confirmation bias. However, innovation, justice, and good policy depend on having at least a few individuals who are able, at least some of the time, to more carefully weigh different options before drawing a final conclusion. The most flexible will be willing to change their initial views in the face of evidence to the contrary.

Many individuals who are still refusing COVID vaccination initially felt that they did not want to be vaccinated, but those views solidified under the effect of confirmation bias: they latched onto any concerns, no matter how far-fetched, and actively wrote off evidence of the benefits of vaccination as tainted by a profit motive or a government drive to control citizens. These individuals need a way to allow them to change their view without feeling like they are “selling out” in some way. They need a way to save face.

One option may be to promote the coming Novavax COVID vaccine, likely to be approved for Emergency Use in adults in the next two months. Here is the narrative:

  • This two-dose series uses tried and true purified protein technology, used for decades in Hepatitis B and Tdap vaccines.
  • No fetal cell lines were used in any stage of its research or production.
  • The vaccine uses completely different adjuvants, so there is not a risk of cross-anaphylaxis.
  • The early reports of effectiveness show it comparable to the Pfizer and Moderna vaccines, but with less fatigue and local side effects.

This will not resonate with everyone opposed to COVID vaccination, but it does address several common stated concerns around current vaccine options. It may allow them to change their mind and accept COVID vaccination, in a way that is congruent with their earlier negative views.

A key is for early impressions of the Novavax vaccine to be positive, in your conversations with patients and your social media, leveraging the confirmation bias to increase support of vaccination.

 

Delta-conflagration

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I have no idea what’s awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.”

-Dr. Bernard Rieux in The Plague, by Albert Camus

August has not been a good month in our PHC counties.

Another summer of massive wildfires and poor air quality.  Another surge of COVID, this time hitting the rural northern counties with particular severity.  For several hospitals, their ICUs and Emergency Departments are full.  Patients are being transferred hundreds of miles south, to hospitals that still have capacity.  Many hospitals report they have no open mammogram or colonoscopy appointments for the rest of the year.

PCP offices are short staffed, as the sheer number of COVID cases leads to illness, but also to quarantines affecting a larger proportion of staff.  Telephone and video visits are on the rise again.  A state requirement that all health care providers require their staff to be vaccinated will lead to additional staffing stress for many of you.  The staff that are able to work are exhausted; you are working so hard to keep them from burning out.

In the midst of all this, we at PHC are impressed with your dedication to take care of your populations, with testing and vaccination efforts both in your offices and in your larger communities.  You are partnering with our public health colleagues, your local hospitals, and with trusted community-based-organizations to respond in an organized, professional and compassionate way to the many simultaneous stresses you are facing.

PHC is here to support you with advocacy and resources to support these efforts.  In the coming weeks we will be offering incentive opportunities for primary care providers to increase the vaccination rate in the PHC population, and to capture vaccination information missing from state registry databases.  In the coming week, PHC will also be offering grants to community organizations in every one of our counties to increase vaccinations among the most vulnerable populations.  We will be making calls, handing out gift cards to members as they get vaccinated, funding local media campaigns, and asking pharmacies to remind their customers of the option of getting vaccinated while picking up their prescriptions.  The September monthly newsletter will have more details.

Balancing Boosters
As the federal government has signaled an intention to approve a booster dose of COVID vaccination for those at least eight months post-vaccination, many of you are worried about this overwhelming your capacity.  Remember, those vaccinated early, especially health care workers, have more agency than more vulnerable patients. Community pharmacies have a large amount of untapped vaccination capacity: where possible, you may want to steer those who know how to make on-line reservations and keep appointments to pharmacies for their boosters, and save your in-office capacity for those who are actually in your offices at the moment, or for specific outreach events.