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Pharmacists are poised to address selective vaccination and counsel patients contemplating delaying, skipping, or seeking an alternate vaccine schedule.
The global COVID-19 pandemic has brought the subject of vaccine confidence to the forefront, along with new interest and debate about vaccination relating to individual choice vs population health. The impact of vaccination as a milestone achievement in public health is irrefutable; nonetheless, hesitancy and skepticism regarding vaccine safety and efficacy, coupled with false or misleading health information, have rendered persisting vulnerabilities to vaccine-preventable diseases in communities and among individuals throughout the United States. The recent reemergence of polio in New York highlights the susceptibility to communicable diseases of unimmunized individuals living in communities and areas with low vaccination rates.1 Research indicates that low uptake, acceptance, and confidence in vaccines influence personal health decisions, manifesting both in parents with young children opting to follow alternative vaccination schedules and in adults opting to receive some, but not all, recommended vaccinations according to age and comorbidities. This article describes ways that pharmacists can address selective vaccination and support confidence in vaccines.
The Scope of the Issue: Vaccine Hesitancy
Vaccine hesitancy, as defined by the Strategic Advisory Group of Experts’ Working Group on Vaccine Hesitancy, is a “delay in acceptance or refusal of vaccination despite availability of vaccination services.”2 Vaccine hesitancy is as old as immunization practices themselves and certainly predates the COVID-19 pandemic; in 2019, the World Health Organization (WHO) declared vaccine hesitancy one of the top 10 threats to global health because of its potential to reverse public health gains achieved in vaccine-preventable diseases.3,4 During the COVID-19 pandemic, however, skepticism surrounding vaccines was exacerbated by social isolation and the so-called “infodemic”—the “overabundance of information, both online and offline,” resulting from viral conspiracy theories and misinformation shared across social media platforms about the SARS-CoV-2 virus and associated vaccines during the height of the pandemic in 2020.5-7
Hesitancy to receive a vaccine has been described as a “complex and context-specific” phenomenon, with time, setting, and the vaccine itself as potential variables influencing one’s decision to become immunized with a particular vaccine.2 Vaccine hesitancy and acceptance exist on a continuum of intent, with individuals often expressing varying degrees of certainty and action (Figure 1).2,8
Despite the recognition of vaccines as one of the most cost-effective preventive health care interventions,3 recent statistics related to vaccine hesitancy are striking. According to data from the Kaiser Family Foundation, more than 4 in 10 parents of children aged 6 months to 4 years (43%) indicated they will “definitely not” vaccinate their child against COVID-19. Among parents who are not vaccinated against COVID-19, 64% indicated that they will “definitely not” vaccinate their youngest children (<age 5 years). When asked for the primary reason why they will not vaccinate children under age 5 years “right away,” parents cited concerns about vaccine development (eg, newness of the vaccine, not enough testing or research), adverse events, and the overall safety of the vaccines. Survey results revealed that approximately 1 in 10 parents felt their child did not need the vaccine, or they were not worried about COVID-19.9
According to that same report, although more than three-quarters of adults in the United States have received at least 1 dose of a COVID-19 vaccine,9,10 approximately 20% indicate that they will “definitely not” receive a COVID-19 vaccine.9 Very few adults (about 4%) stated that they still might get vaccinated at some point.9 Similar to the COVID-19 vaccine experience, some communities across the United States remain vulnerable to outbreaks of vaccine-preventable diseases due to suboptimal childhood and adult vaccination rates.11,12
Pharmacists should recognize that vaccine hesitancy often is multifactorial; determining the reason for an individual’s hesitancy to receive a vaccine necessitates an evaluation of contributing factors and exploration of beliefs through motivational interviewing and probing, open-ended questions. The WHO 3 C’s model highlights the effects of confidence, complacency, and convenience as they relate to vaccine acceptance (Figure 2).2
Importantly, it has been recognized that vaccine hesitancy and acceptance of vaccines—for COVID-19 and other diseases—may be based on contextual, vaccine- specific, or vaccination-specific issues, and individual and group influences (Figure 3).2
Misinformation About Delaying or Pursuing Alternative Scheduling for Immunizations
When patients ask questions about altering or delaying receipt of recommended vaccinations, pharmacists should be prepared to share information, and to direct and encourage patients to seek additional guidance from other reputable sources, including the CDC and the Advisory Committee on Immunization Practices. Some key considerations pharmacists should be prepared to address include questions and concerns related to the necessity of recommended vaccines, the need to delay or separate vaccine administration because of vaccine ingredients, or skepticism related to evidence of vaccine safety and efficacy.13
Each of these misperceptions is discussed below13,14:
Reasons to Follow the Recommended Vaccine Schedule
Whether for routine childhood immunizations or for adult preventive health care, pharmacists can advocate for following the recommended vaccination schedules whenever the opportunity arises. There are several reasons why adhering to the recommended vaccination schedule is appropriate, as depicted in Figure 4.16
Questions to Ask of Those Considering Modified Vaccination Schedules or Refusing Recommended Vaccinations
Pharmacists can play an important role in helping patients understand vaccination recommendations and addressing hesitancies or concerns related to a specific vaccine or vaccines. In discussing recommendations with individuals who may be contemplating delaying vaccination, seeking an alternate schedule, or refusing a particular vaccine, reasonable areas of concern to explore may include the following13,14:
Approaches to Overcoming Barriers to Vaccine Uptake
Selective vaccination and hesitancy to receive any vaccine represent barriers to achieving population-level protection against vaccine-preventable diseases. A review article by Bach et al elegantly summarized the different perceived barriers to vaccine acceptance and offered strategies for overcoming these concerns. These are included in the Table.17
Conclusions
Pharmacists are poised to address selective vaccination and counsel patients contemplating delaying, skipping, or seeking an alternate vaccine schedule. By listening to individual concerns and exploring hesitancies with compassion, pharmacists can continue to support efforts to eradicate vaccine-preventable diseases, championing greater public health for all.
About The Author
Mary Barna Bridgeman, PharmD, FCCP, BCPS, BCGP, is a clinical professor at the Ernest Mario School of Pharmacy at Rutgers University and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, both in New Brunswick, New Jersey.
References
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Poliovirus Response Team. Public health response to a case of paralytic poliomyelitis in an unvaccinated person and detection of poliovirus in wastewater — New York, June-August 2022. MMWR Morb Mortal Wkly Rep. 2022;71(33):1065-1068. doi:10.15585/mmwr.mm7133e2
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13. When individual doctors make their own immunization schedules: what you should know. Children’s Hospital of Philadelphia Vaccine Education Center. Fall 2017. Accessed August 20, 2022. https://media.chop.edu/data/files/pdfs/vec-individual-doctors-vaccine-schedule.pdf
14. Vaccine schedule: altering the schedule. Children’s Hospital of Philadelphia. Updated September 6, 2022. Accessed September 16, 2022. https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-schedule/altering-the-schedule
15. Explaining Operation Warp Speed. U.S. Department of Health & Human Services. Accessed September 16, 2022. https://www.nihb.org/covid-19/wp- content/uploads/2020/08/Fact-sheet-operation-warp-speed.pdf
16. Reasons to follow CDC’s recommended immunization schedule. CDC. Updated February 25, 2020. Accessed August 20, 2022. https://www.cdc.gov/vaccines/parents/schedules/reasons-follow-schedule.html
17. Bach AT, Kang AY, Lewis J, Xavioer S, Portillo I, Goad JA. Addressing common barriers in adult immunizations: a review of interventions. Expert Rev Vaccines. 2019;18(11):1167-1185. doi:10.1080/14760584.2019.1698955