Expert: Addressing Vaccine Hesitancy Takes Patience, Trust

In an interview with Pharmacy Times, Susan Koletar, MD, FACP, FIDSA, director of the Division of Infectious Diseases at the Ohio State University College of Medicine, discussed pharmacists’ role in addressing vaccine hesitancy and improving global vaccine rates. With recent outbreaks of measles and other vaccine-preventable diseases, vaccinations are more important than ever.

Q: With such a huge focus on vaccines in recent years, it can be easy to forget or overlook that global vaccination rates are low. Where do vaccination rates stand and what does this mean?

Susan Koletar, MD, FACP, FIDSA: I was trying to look up some global facts. I don't know how low you think things are. I mean, certainly in the United States, we continue to do better. In fact, the CDC publishes every year, national surveys on immunizations. And for the—I think there are 14 childhood vaccines in the first 2 years of life—actually, the United States is doing a little bit better. From 2016 to ’17, kids born then versus kids born in 2018, ’19, actually, there was a little bit of an increase. Like, only a percentage point, but a little bit of increase. I had it up in front of me here, but I think I might have lost it. The rates are a little bit different, again, based on socio economics. That's always true, right? I think that's part of the worldwide issue is that countries may not have access to vaccines or the newest vaccines, access to health care. We were having a discussion the other day about how important it is to stock vaccines in your clinic, because once you have someone there, at least in the adult world, you would like to vaccinate them. Right. So, I think pediatricians are particularly good about that. I think there's lots of issues about vaccines in general now, which in reality is ironic, right? Because some of the sentiments against vaccines are proposed by people who have actually, themselves, benefited from vaccines, right?

I mean, I will tell you, and I guess I'll tell the world now, I am old enough to have had many of the childhood illnesses. I remember having measles, and mumps, and rubella, and chickenpox. And there are now entire generations who are not exposed to those diseases or have those diseases because of widespread vaccine practices. And so, you may have heard that recently, there's been some measles outbreak—a big measles outbreak here in Columbus, Ohio, actually. That started in a child who was presumably not vaccinated, who had some international travel and exposure. So, I think that's the other thing that we always need to keep into context. The world is a small place. You can get on a plane and be anywhere, essentially within 24 hours, and bring with you any of those germs. I mean, I think that's what we saw with the COVID pandemic, right? Started in China, it seemed really far away. And I remember sitting around talking with some of my colleagues, going , this, this could be bad. Or not. But, I mean, just to know that things happen so quickly.

So, I don't think I'm actually answering your questions, but I do think healthcare delivery is different in different parts of the world. And a lot of it is economics. A lot of it is having access, not just to vaccines but to health care. And I think that's true in the United States, too. If you look at, again, the surveys, racial and ethnic minorities have lower vaccine rates in some populations because of socio demographics, and poli-socioeconomics in terms of access to health care. So, I think that's sort of the underlying theme: how do you distribute healthcare to the population at large? That's probably public enemy number one. How do we get things? How do we get things out there? And how do you train a workforce? And so, pharmacists have been particularly important in the immunization efforts, notably with flu shots and with COVID-19. That also includes education, right? How do you educate people about the value of these vaccines?

And I’ll go back to my statement about irony. If you’ve never seen someone, or had someone you know, your child or somebody, get really sick from one of these vaccine preventable diseases, it doesn't quite stick in your mind as much. And you know, I don't think anyone really thinks about tetanus, what a horrible disease tetanus is, because you just get a tetanus shot, and that's it, right? But if you're part of a culture, religious or otherwise, that don't believe in vaccinations and your child or somebody gets exposed to tetanus without ever having any tetanus shots, that's horrible. And as a physician, that still ranks up there in horrible things I've seen, where you're standing at the bedside and just hoping that some time will let someone get through something that's really not treatable by an antibiotic or by a toxin. And even things like chickenpox—most kids do well with chickenpox, but some of them can get really sick and secondary complications. Same thing with measles.

And I guess that's the other thing I would say about vaccinations in general, particularly childhood vaccines. A lot of those diseases, while they can be moderately severe in kids, tend to be much worse in adults. So, if you're a woman who was never, if you're a girl who never had chickenpox, never got the chickenpox vaccine, and then as you get more into your childbearing years, and you get primary chickenpox—again, horrible disease. And so, how do we address the disparities in health care delivery at the very basic level of childhood and then continue that through?

Q: What are the key causes for low vaccination rates?

Susan Koletar, MD, FACP, FIDSA: Part of that is just access, right? Having access to health care providers—whether they be doctors or nurses or pharmacists—just having that access, I think is important. This might sound self-serving, but I also think health care providers are an important part of the educational process. Why do you get these things? I think there should be—sometimes it seems mysterious, right? The delivery of healthcare is a mysterious thing, like, you should do this without talking to people. So, I think certainly, we all have the obligation to explain why these things work or how these things work and what the outcomes can be. You know, and I think COVID certainly taught us that people don't like to be told what to do. But I think there's some basic human things and people don't like being told what to do and particularly if there's not explanation and thought behind it. So, I think that's an important part of the of the disparities there. If you don't have access to health care providers, or health care in general, you also don't have access to that, hopefully, focused educational processes, too.

You know, I always like to tell the story about how my grandmother used to say things that a lot of people say, but she said them to me. Like, in response to “you should get a flu shot,” I don't want to get a flu shot because the last time I got a flu shot, I got the flu. It's like, Grandma, first of all, who do you think you're talking to? And second of all, that's just not true. But when myths begin and are perpetuated, that's where I think it's really key for us to address that. And that's just, that's not just social determinants of health type, that's health in general.

Q: Are there specific vaccines or disease areas where these rates are low, or is it across the board?

Susan Koletar, MD, FACP, FIDSA: Yeah, I know, you asked that question and I don't know if I have a really good answer, because it seems to come in waves. Again, if something's not directly affecting you, people don't necessarily think about it. But so here in Columbus, around, I guess it was Thanksgiving—I think the last case here was Christmas Eve—but like for the month, six weeks before that, all of a sudden, all these cases of measles, and I was like, Oh my God, measles. A handful years ago, it was mumps on the university campus. I mean, it seems to go in waves a lot. A lot of the outbreaks that we have seen, though, have been related to vaccine preventable diseases and kids who have no—you know, in adults, there may be some opportunity to have at least some exposure and some immunity. And then it depends on the process itself.

So, I have not heard of any recent outbreaks of hepatitis A but that has come in waves over time. And that’s a completely preventable disease. The vaccine efficacy is really, really good for hepatitis A, but if you have pockets of people who haven’t gotten it for whatever reason—not even because they were against it—just, say, their provider didn’t think about it, they were in an age range where it was not common, then you could have—you know, it doesn’t take much. All it takes is someone infected and someone exposed, someone not immune, exposed. So, I think it’s variable. You know, obviously, influenza changes every year. There are some years that the protective efficacy of the vaccines are really good. Some years, it’s not so good.

Q: How can pharmacists educate patients and encourage them to get recommended vaccines?

Susan Koletar, MD, FACP, FIDSA: Yeah, I think that's a great question. I don't—I wish I had the magic answer, but I think the real answer is that health care providers, in general, need to take the time, which is a precious commodity in rapid fire health care where I’m actually talking to people and asking them and trying to address any concerns. Right. So, it's easy when, like, do you want a flu shot? And someone says, yeah. You know, some of my patients, one of my patients, like clockwork, on the first day of fall every year, he schedules his flu shot, because that's what he believes, right? And it doesn't matter what I say. I can say, oh, you don't get it then, get it two weeks from now, and he wouldn't listen to me. But I think it's talking to people where they are and seeing what kind of concerns they are, and then re-emphasizing that vaccines have made a world of difference in terms of health care.

And I feel like I'm sort of an old fart now, but I think people who haven't experienced any of these illnesses or had someone they love experience some of these illnesses don't actually appreciate how successful we've been with vaccines. That is one of the things that actually really intrigued me about the whole COVID vaccine dilemmas and anxieties, because often what will happen is someone, they’ll say, I don't believe in vaccines, and then something will happen—they’ll get sick and then, oh, they work. That wasn't exactly true with COVID, and I still haven't quite figured out what drove that. I mean, people who definitely had someone they love die of COVID still wouldn't get vaccines, and that still intrigues me.

So, I think that goes back to education, talking to people and trying to assess people where they are in their thinking. What drives you not to want to get something as opposed to getting something? My grandmother: I get the flu when I get a flu shot. But you don't. That's biologically impossible. And that was some of the early things with COVID, right? The COVID vaccines—you’re gonna get COVID from the COVID vaccine. You can't. It's not a live virus. And so, I think one is talking to people and sort of assessing their understanding, assessing what they think they know. And then either confirming or redirecting, I think is one thing.

And sometimes it’s timing, too. I mean, I take care of a lot of people who are living with HIV. And again, the list of vaccines for that population is pretty long. And people who don’t like shots, I sometimes say, okay, let’s pick things in order, right? This is like—so during flu season, I would say, if you could just pick one shot today, get a flu shot. Okay. If, in different populations that may be exposed to things like hepatitis B, I would say, let’s start that now. Let’s sort of help—I think it’s also our job to help prioritize what people need, especially when, you know, I just told you, there are 14 vaccines that are recommended before the age of 2. That’s a lot. And then, as a parent, you go, oh, I don’t want to give, oh, I don’t want to. Kids don’t like it and stuff. I think, yeah, I think meeting people where they are, and then engaging people in the process.

We did one of the COVID vaccine studies here. And I was very proud of my group that we had a really high percentage of minority populations who participated. And I talked to a lot of these people and said, well, you know, what got you interested? And I was struck and touched, quite honestly, by the fact that many of those who were either foreign born living in this country or Black or Hispanic, that they said, I want to do this because my community is so distrustful. And so, I think that’s the other important thing: really engaging people to help us. I mean, because in the end, it doesn't matter a whole hell of beans what I say, right? It’s a matter of what people and their communities say. So, I think that's the important thing. That takes time. And if you're a busy pharmacist, you may not have time to spend half an hour talking to someone. So, I think we’ve got to do what we can. But, we have to keep the lines of communication open.

Q: These conversations may be particularly challenging for patients who have serious fears or anxieties about vaccines, or who are entirely against them. Are there strategies to approach these conversations?

Susan Koletar, MD, FACP, FIDSA: Yeah, I think those are hard. And for right or wrong, I—first of all—I always, if people are hesitant, I always say, I'm not going to talk you into this, right. I'm not. That's not my job. My job is to give you the best information as I know it, help maybe put into perspective. But in the end, I'm not going to assault you with an immunization needle. And it's been interesting that that is, as well, received as just pushing. And sometimes I just say, okay, I don't understand your view. I don't agree with what you're saying. But in the end, you have to think about this. But I always—and this was probably more true with COVID, probably always a little bit true with flu—I always do try to put in perspective that, I know you're making a personal decision, but I just want you to stop and think for a minute about the impact that you not doing this may have on your family.

Again, that's a value judgment that I'm not going to make for an individual person, but I like to put it out there. And I've probably, I guess if I were a baseball player, I’d be batting maybe 350 for people coming back and saying, okay, I'll do it. Which is not great, but it's not bad. But I honestly believe that healthcare is such an individual, personalized thing, you have to you have to talk to people where they are. And, I'm not going to hold someone down and give them a shot if they don't want it. But I hope that we bring perspective to the process.

I did get my grandmother to get a flu shot, by the way, eventually. But I think those are really hard conversations. And I think it's—I know, we have a training program here, and I know it's frustrating when people don't want to agree with you. But I think we shouldn't compromise our principles in terms of what we deliver, but in the end, you’ve got to, sort of, respect the process. And that's hard. And then you hope that enough people have participated in vaccine activities and that’s okay. And I think COVID showed us that, too. It is amazing, the rapidity of the impact. And I think we were all astounded by that.