National Immunization Awareness Month (NIAM) is an observance annually in August that highlights the importance of vaccination for people of all ages. It is very important for patients with some health conditions to be up to date on recommended vaccinations since they are at a higher risk for complications from certain vaccine-preventable diseases.
Any primary care provider has had the following experience. You are advising a vaccination (or another recommendation), and the patient refuses. This exam room experience when I was just starting out many moons ago would surprise me. Here I was, the so-called “expert” that the patient was coming in to see, to get advice, or treatment…and they sometimes say, “no thanks.”
COVID-19 vaccine refusal is not a new phenomenon. We have all had patients decline screening for a condition like colorectal cancer, a vaccine like HPV (human papillomavirus), or other. I thought I would share how most doctors or providers approach these situations. I heard a wonderful talk by Jerome Abraham, MD, MPH that resonated with many of us in the audience.
There is a reason
We never assume a vaccine-hesitant person does so out of willful ignorance. There is usually a reason. There is also a broad spectrum between outright refusal and reluctance. Reasons can include lack of education or information, cultural or inherited medical trauma, inability to get to the clinic, inability to take time off from work, or pressure from family and friends to not comply.
It often comes down to shared view of safety. You as a provider want the safest thing for your patient and your patient wants the safest thing for them. Bottom line for some, they believe the harm from the vaccine is greater than the harm of the disease. To fulfill our duty as care providers we must:
- Take time to understand our community and why they might be hesitant.
- All of us need to know how to start a productive discussion and have hard conversations.
- Providers need to reach out to communities in need and build partnerships.
- Remember to fight for those in need of better medical care.
Yes, we have heard it all: “mark of the beast,” microchips, alter your DNA, magnets, etc. So, how do most providers approach this?
- Ask the question. “Would you be interested in receiving the vaccine?”
- Patiently listen. Ask a follow-up question, “why do you feel that way?”
- Align with the patient over safety. This is your common goal.
- Ask about other goals: “what motivates you to want to get life back to normal?” Listen.
- We as providers need to stick to information we know. If we do not know the answer to a question, we should say so. Many times, I would respond with “let me find out for you.”
Culture is key. We must remember for some communities, there was a legacy of medical trauma that involved dangerous or involuntary experimentation. Today, many patients still struggle to get access to a doctor. Even when they do find a doctor, there may be a feeling their concerns are ignored or undermined. And yes, some fear giving personal information. Therefore, even with higher death rates in some communities from illnesses like COVID-19, there is still higher hesitancy. We must not forget that many still have financial barriers, lack of transportation, no internet access, or fear symptoms from the vaccine may cause them to miss work.
Monkeypox is a “zoonotic” virus. This means that it transfers from animals to humans. Some animals which can spread it include various species of monkeys, giant-pouched rats, African dormice, and certain types of squirrels. As of this writing, there were 109 confirmed cases in Colorado. Most cases are in New York, California, Texas, and Chicago.
The illness belongs to the same family of viruses as smallpox. Its symptoms are generally similar, but not as severe as smallpox. The first cases of monkeypox were found by medical clinicians in 1958 during two outbreaks in monkeys being kept for research.
Most people who get infected with monkeypox virus have a mild, self-limiting disease even with no specific therapy. The outlook depends on the patient’s health status and vaccination status.
There are some that should be treated, including those with severe outbreaks, immune compromised and those younger than eight years old. Some authorities recommend those that are pregnant, or breastfeeding should be treated. There currently is no approved treatment specifically for monkeypox virus infections, but antivirals developed for use in patients with smallpox may be effective against monkeypox.
There is debate as to whether monkeypox is a sexually transmitted infection, probably more precisely, it is an infection that can be transmitted with sexual contact. In some ways it is like herpes with spread through skin-to-skin contact.
Most people experience two sets of monkeypox symptoms. The first set occurs for about five days and includes fever, headache or back pain, swollen lymph nodes and low energy.
A few days after having a fever, a rash normally appears on the person infected with monkeypox. The rash looks like pimples or blisters and can appear on many parts of the body, including the face, chest, palms of the hands and soles of the feet. This may last two to four weeks.
The FDA approved the JYNNEOS vaccine — also known as Imvanex — for preventing smallpox and monkeypox. Additional doses have been ordered. The JYNNEOS vaccine includes two shots, with people considered fully vaccinated about two weeks after the second shot. A second vaccine, ACAM2000T, has been given expanded access for monkeypox. This is only one shot. It is recommended for pregnant individuals, infants younger than one year old, people with weakened immune systems, those with heart disease, and those with HIV. You are considered vaccinated four weeks after getting the shot. These vaccines are in short supply and your provider will need to work with Colorado Department of Health and Environment (CDPHE) to coordinate.
Medical professionals suggest people take the following steps to help prevent the spread of monkeypox:
- Avoid intimate and skin-to-skin contact with a person who has a rash like that of monkeypox. A person is considered contagious until the rash is completely healed.
- Try not to touch bedding, clothing, or other materials that may have touched a person with monkeypox
- Wash hands frequently with soap and water
I have found that if we as providers and doctors keep to five key messages, this is our best approach:
- The vaccine is to keep you safe. Our goal is for you to have your best life.
- Side effects are normal and manageable.
- The vaccines are highly effective in keeping you out of the hospital and alive.
- These recommendations are built on years of reliable, publicly available research.
- Do not be afraid of questions.
No person is a lost cause
It is particularly important that nobody is ever demonized for refusing a medical recommendation. All patients want to be safe. Our goal as caregivers is to keep the door open, because as time goes on, more will consider. Across the country, the “definitely not” group with regards to COVID-19 vaccination fell from 20% to 15% over the last three months of 2021. Our goal is to educate and be patient, with our patients. We know that all patients are motivated differently and uniquely. Sometimes my best response when I hear reluctance or belief in an unfamiliar perspective is to simply say “that is not consistent with my experience.”
Finally, as an aside, more than 96% of physicians across the country are vaccinated against COVID-19. This includes me.