Trust Is a Potential Hole in the Emerging COVID-19 Mass Immunization Strategy

Regularly scheduled vaccinations have been around for as long as many of us can remember.

Save for recent measles outbreaks that can be laid at the feet of antivaxxers, most Americans do not think twice about the ubiquitous administration of universal vaccination efforts. Aside from influenza vaccinations, which are necessarily seasonal but predictable, age and condition usually determine who gets which vaccinations and when they get them, based on Advisory Committee on Immunization Practices (ACIP) guidelines. Most vaccines end up being administered year-round at a steady pace, giving us incremental retention of protection and herd immunity over time. On balance, vaccine production, transport, and administration are orderly and rather void of drama in the United States. Yet, we are soon likely to encounter a mass immunization effort significantly bigger and broader than the one for the 2009 H1N1 influenza pandemic.¹

LIKELY EVERYONE, ALL AT ONCE

With a high transmission rate between those who are affected and unaffected (asymptomatic) and a much higher complication and fatality rate than that of seasonal influenza, coronavirus disease 2019 (COVID-19) vaccination participation rates will need to be substantial to be meaningful. (During the 2018-2019 flu season, about 35 million people in the United States contracted the flu, and about 34,000 died, according to the Centers for Disease Control and Prevention.² COVID-19 is likely to hit more than 250,000 deaths in 2020. Unlike typical vaccination efforts, COVID-19 vaccinations will likely be recommended for everyone when available in sufficient supply, and per CDC recommendations will prioritize essential personnel, health care workers, and vulnerable Americans, such as the elderly and those with underlying health conditions.³ Because it is increasingly apparent that a successful universal COVID-19 vaccination effort also stands between all of us and a hopeful “return to normalcy,” health care providers will play a critical role in encouraging patients to receive the vaccination.

WHAT MIGHT THIS LOOK LIKE?

We have seen what impromptu mass testing feels and looks like—or, at least, attempts at it. Not unlike a trip to the theme park, patients get in a line at fixed and limited-in-number locations with high traffic capacity and wait for paperwork and a short injection procedure from a health care professional they have likely never met but will rather “encounter” if the immunizer is robed up with enough personal protective equipment. Most everyone in line will be like me: willing and wanting the injection, and trusting in science and the proper execution and interpretation of the phase 3 trials by long-experienced experts in the field. But not everyone who should be in line will get in line.

STAGGERING PERCENTAGE WILL AVOID THE EFFORT

The most recent Yahoo News/YouGov poll on COVID-19 vaccine perceptions provided jaw-dropping findings.⁴ Just 40% of Americans polled by YouGov in early August said they plan to get the COVID-19 vaccination when it becomes available, dropping from 55% in early May.⁴ These trends cut across political affiliation, with some dismissing the threat and others worried about rushed safety testing. More than a quarter (27%) do not plan to get the vaccination, and 33% are unsure if they will. Helping educate and reassure that 33% is critical to attempts at population-level prevention and herd immunity.

Along with clean water, testing, and tracing, regular vaccinations against infectious disease is public health 101. There are potentially enormous community protection differences between a 40% rate and a 73% rate of vaccination, especially when considering emerging cases of suspected reinfection.⁵

TRUST IS DETERMINING FACTOR OF SUCCESS

Mass immunization strategies should not focus solely on mechanics, such as manufacturing, distribution, and parking lot drive-through stations. There are millions of capable Americans who can safely put a needle into a shoulder and press with their thumb. These mechanical considerations are necessary but unlikely to be determining factors of success. Rather, we need to pay more attention to a skeptical populous, particularly in rural and underserved areas. Other challenges are likely to come from COVID-19 vaccinations specifically regarding special handling and the need for follow-up for repeat vaccinations, fear of government-run databases of patient information, and a greatly accelerated development and trials process, alongside copious amounts of disinformation, misinformation, and outright malicious obfuscation. That means trust becomes the determining factor in the upcoming mass-vaccination effort.

ROLE OF COMMUNITY-BASED, PRIVATE-SECTOR CARE DELIVERY

Primary care providers (PCPs) are the frontline diagnosticians for disease, both acute and chronic. They are also some of the most highly educated and trusted residents in rural areas.

Notably, PCPs also make up the plurality of health care providers in tightly woven block-level neighborhoods in some major cities. The online Yellow Pages for Brooklyn, New York, list thousands of small, neighborhood-based PCPs who look and speak like many other people in the neighborhoods in which they practice. Community-based care is about relating to and serving the community one is in.

COMMUNITY PHARMACISTS, PHARMACIES: CAPABLE, EFFICIENT, AND TRUSTED

Community pharmacists consistently rank as some of the most trusted professionals in surveys, alongside PCPs, especially in rural and underserved areas and among COVID-19 pandemic and vaccination skeptics. PCPs and pharmacists will play a crucial role in education and affirmation of the presence and seriousness of this pandemic and the need to vaccinate against it.

DO NOT LOCK OUT COMMUNITY-BASED PRIMARY CARE AND PHARMACY

Yes, many people will do fine receiving their vaccinations in unfamiliar care settings and locations, but many will not. Federal and state public health officials are beginning to plan for COVID-19 vaccinations, and it is critical that they actively engage all health care providers on all corners and intersections of both life and transportation in the United States. Trust has been accrued by PCPs and pharmacists over many decades in their local communities. These relationships are not easily replicated and are especially important for those who are not sure whether they will seek out the vaccine when it becomes available. The COVID-19 vaccination effort will not be “one and done.” It will likely require a second dose (2-dose series), along with continued vigilance for the foreseeable future. Using all willing, able, and available community pharmacies and primary care practices is a prudent public health strategy. In addition to the necessarily extraordinary efforts, let’s continue to use the community- based systems already in place.

WHAT CAN BE DONE NOW?

Now that the influenza vaccine is available, pharmacists can do their parts by having a strong flu campaign for the 2020 through 2021 flu season.⁶ Receiving the influenza vaccine can reduce the prevalence of illness caused by influenza, in which symptoms might be confused with those of COVID- 19. By preventing and reducing the severity of influenza, pharmacists can reduce outpatient illnesses, hospitalizations, and intensive care unit admissions, alleviating stress on the health care system. It is also an opportunity to start talking to patients about what to expect with the COVID-19 vaccine.

Pharmacists also can do their part by stepping up to the challenge of ensuring that adults and children in their communities are up-to-date with ACIP-recommended vaccines.⁷ This may call for innovative solutions and partnerships with care team members to expand immunization sites. It might also require working with state immunization programs as a result of expanded scope of practice in a state.⁸ Community pharmacies are also welcome to use the messages and graphics provided by the US Department of Health and Human Services to help spread awareness about catching up on childhood immunizations.⁸

Troy Trygstad, PharmD, PhD, MBA, is the vice president of pharmacy provider partnerships for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and his PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.Pamela Schweitzer, PharmD, RADM (retired), is the former assistant surgeon general of the US Public Health Service Commissioned Corps. Since retiring in 2018, she has been supporting the pharmacy profession’s and the US Department Health & Human Services efforts to increase pharmacy access to clinical and public health services, especially in ambulatory and community pharmacy settings in rural communities.

REFERENCES

• Operational framework for partnering with pharmacies for administration of 2009 H1N1 vaccine. Association of State and Territorial Health Officials. Updated September 28, 2009. Accessed September 1, 2020. https://www.astho.org/Infectious-Disease/Operational-Framework-for-Partnering-with-Pharmacies-for-Administration-of-2009-H1N1-Vaccine/
• Dooling K. COVID-19 vaccine prioritization: work group considerations. CDC. August 26, 2020. Accessed September 1, 2020. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-08/COVID-08-Dooling.pdf
• Estimated influenza illnesses, medical visits, hospitalizations, and deaths in the United States — 2018—2019 influenza season. CDC. Updated January 8, 2018. Accessed September 2, 2020. https://www.cdc.gov/flu/about/burden/2018-2019.html
• Romano A. Yahoo News/YouGov coronavirus poll: number of Americans who plan to get vaccinated falls to 42% — a new low. Yahoo! News. August 4, 2020. Accessed September 2, 2020. https://news.yahoo.com/yahoo-news-you-gov-coronavirus-poll-number-of-americans-who-plan-to-get-vaccinated-falls-to-42-percent-a-new-low-162000936.html
• Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices — United States, 2020—21 influenza season. CDC. August 21, 2020. Accessed September 2, 2020. https://www.cdc.gov/mmwr/volumes/69/rr/rr6908a1.htm
• Giroir BP. Now is the time: catch-up to get ahead on childhood immunizations. US Department of Health & Human Services. August 13, 2020. Accessed September 2, 2020. https://www.hhs.gov/blog/2020/08/13/now-is-the-time-catch-up-get-ahead-childhood-immunizations.html
• HHS expands access to childhood vaccines during COVID-19 pandemic. News release. US Department of Health & Human Services. August 19, 2020. Accessed September 2, 2020. https://www.hhs.gov/about/news/2020/08/19/hhs-expands-access-childhood-vaccines-during-covid-19-pandemic.html
• Catch-up to get ahead toolkit. Vaccines.gov. Accessed September 2, 2020. https://www.vaccines.gov/catch-up