Overcoming COVID-19 Vaccine Hesitancy

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare, committed to advancing effective evidence- based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety risk and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent trusted authority to improve the safety, quality, and cost- effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. We're recording this podcast from our respective home offices as we practice, and certainly all of you to continue to practice a good social distancing practices to help limit the spread of COVID. With access to COVID- 19 vaccines now more widespread throughout the United States, but still only available under emergency use authorization. Employers are wrestling with questions about whether to mandate that their staff received the vaccine. Perhaps, no industry has a more fraught decision than Aging Services, where there remains a significant gap between vaccination rates among staff and residents, and older adults remain one of the most vulnerable populations to COVID- 19. So, to get us started in that conversation, I'll ask our guests to introduce himself.

Vic Rose: Hi, Paul. Thanks so much. My name is Vic Rose and I serve here at ECRI as the Director of Aging Services.

Paul Anderson: Vic, I thought we could start by doing a quick review of our understanding of the current state of COVID vaccination in Aging Services, given the vulnerability of residents, Aging Services, residents and providers were really a top priority for vaccination when the first emergency authorizations happened late in 2020. We're six months later, where... What do we know about where we stand now?

Vic Rose: Well, we have seen significant achievements in regards to vaccination acceptance within the resident staff populations in Aging Services. There's still a lot of work to be done. Overall, the data shows that there is a statistically significant difference in between vaccination, acceptance rates and the resident population versus lower rates in the Aging Services workforce. Recently, published Abbott in Pennsylvania identified that acceptance rates in the resident population in nursing homes is as high as 87%, whereas staff is as low as 58%. And we're also seeing similar findings mirrored nationwide. From a public health and infection prevention perspective. We find this to be a care critical issue, given the interdependency between these two populations, when it comes to preventing the spread of infection within any provider organization, which directly contributes to outbreaks and the potential for real harm for persons served the staff caring for them, and of course the organization itself. I find these lagging acceptance rates and the Aging Services workforce to be really important, and for no other reason than the fact that the residents and staff alike have together lived through some of the worst that the pandemic and COVID-19 has to offer. And yet one has to surmise that there are some very real reasons that drive a greater level of hesitancy in one population over the other. And this is in spite of the fact that both have faced very real harm and dangers throughout the pandemic and they've faced them together.

Paul Anderson: Okay. So, Vic, we'll talk in a minute about strategies for increasing vaccination rates among staff, but before we get there, I guess my question is, if there's such a large majority of residents are vaccinated, I think you said 87% in Pennsylvania, right? Does it matter that much if vaccination is lower among staff, if the residents are protected anyway?

Vic Rose: That's an important question, too. While there may be a temptation for people to reason. Well, if residents are vaccinated, and therefore protected, does it really matter if the workforce receives a vaccine as well? ECRI and many other organizations are here to say that it most certainly does matter. It is important for us to remember that COVID- 19 vaccines are not antidotes to COVID- 19, but instead our prevention efforts that-

Paul Anderson: Mm- hmm(affirmative).

Vic Rose: ...encourages one's body to build antibodies to the illness, and therefore, helps to reduce the seriousness of the effects of an infection. So, this said vaccination does not always prevent outbreaks, but there is an increasing body of evidence- based medicine that does illustrate the vaccine's efficacy on reducing the severity of an infection, if it does occur. This is especially important for keeping our older adults safe, especially those who live in congregate settings when they are already considerable risk for severe illness and even death from COVID- 19. In addition, and as we have learned through this pandemic, outbreaks within the staff population have serious consequences on so many aspects of a provider organizations carrying service delivery as well. Continuity of care is near impossible without continuity of staffing and scheduling. Anything that disrupts staffing and scheduling, limits the provider organization's ability to meet the resident care workload of person served and it poses a significant threat to all. If the staff become infected, they pose a risk of spreading an infection to others when they leave the organization or carrying it into an organization when they report to work. Ultimately, more of our overall population who become vaccinated, the better chance we have to end this pandemic and prevent harm.

Paul Anderson: That's an interesting perspective. I really hadn't thought that much about, Vic, but this idea that the risk is not exclusively that I might transmit COVID, or it's just that if it's... If it... If there's an outbreak only... Even if it's only among the staff, if there's a huge outbreak among the staff and there's that interruption in care, that in itself is a safety risk.

Vic Rose: Exactly, Paul, that's actually some of the worst situations we've seen through the pandemic and Aging Services where the infection settles in both the resident population and the staff population at the same time, because when it settles in the resident population, it creates such a spike in workload. And at the same time when it's active in the staffing population, our ability to meet that workload diminishes greatly.

Paul Anderson: Let's talk some more about staff vaccination. Obviously, provider organizations have a huge interest in driving up vaccination rates as high as possible and you just laid out a lot of those reasons. And we have a community interest in driving up those vaccination rates as high as possible. So, one of the things that we're going to talk about is whether organizations should mandate that vaccination. But before we talk about whether they should, let's talk about whether they can. Now, stipulate, neither of us is an attorney, but if... Can an organization, to the best that we know, mandate that its employees take the COVID vaccine?

Vic Rose: This is a really important risk, quality and safety issue. And it's one that has been debated nationwide here over the past months. Legally and technically in many jurisdictions, an organization can mandate the COVID- 19 vaccine. I think it's important to note there they can. And that really is jurisdictional dependent. It's one of those issues and you said it well, this is a legal issue before any organization ever looks at mandating the vaccine, they really should make sure they talk to their local legal counsel, understand state and federal laws and regulations that influences decisions, and really treat that with all the respect that such a big risk management issue involves. So, when it comes to the COVID 19 vaccination campaign, it does carry with it certain issues unique to this campaign and this particular infection, since all of the vaccines have received the Emergency Use Authorization or AUA, as it's often referred to rather than the normal FDA approval, it really is only natural that many people from all groups and populations within societies worldwide might feel certain concerns about receiving these vaccines. There are those who have offered arguments that because of EUA, for these vaccines, it's really not permissible to mandate them. However, as I mentioned earlier, we do see an increasing number of organizations doing just that. Again, we strongly recommend at any time, you work with our local legal counsel when developing these and procedures. And of course, as you pointed out in your question, there's often a difference between what one is permitted to do and what one should do. So, from our perspective, we do believe there's other options that can be employed before mandating, and in truth, if some of those other processes are used first, it could actually pave the way to mandating the COVID- 19 vaccine in the future, like we've done with other vaccines such as influenza.

Paul Anderson: Yeah. No, I mean, I think, I mean, I have teenagers, right? So, I think at least once a day, I'm trying to point out the difference between can and should. It's just part of my vocabulary. But let's do... I want to talk about some of those other strategies, but one more question about mandates, and I just sort of think I know where we're going to go with this, but if most of the time mandates are probably an option, and are they the best option. And I know it's kind of a blunt force tool, but it seems to me that maybe it would get the job done?

Vic Rose: Again. And we've seen this many times in other vaccination campaigns where they've been mandated. Absolutely. And when the right understanding about a vaccine and a disease process and the evidence is there, you can employ different strategies to get it done. And there are some really important obligations to consider both for and against mandating vaccines. There are many who believe that as healthcare professionals, and this is not just direct care workers, clinicians, practitioners, but also everyone who works in the healthcare setting in any role. Now, we have somewhat of a moral obligation to get vaccinated since a failure to do so can actually cause harm to the very people we have promised to care for and protect. I suppose there is truth to this argument, undoubtedly, it could help to drive- up vaccination acceptance rates, but it all... It could also have some unintended consequences.

Paul Anderson: What are some of those unintended consequences?

Vic Rose: One consequence to mandating is that it could add to existing stressors that are already affecting staffing, and scheduling, and Aging Services. And that could actually be added to, depending on what the outcomes are for employees who actually declined the vaccine, with pandemic related turnover and burnout already a concern, terminations for not getting vaccinated could make a bad situation worse. In addition, where lack of trust is an underlying driver for hesitancy, mandating the vaccine could actually work to make those types of issues worse, and not just for the COVID- 19 vaccination campaign, but potentially for other campaigns as well. Ultimately, each vaccination campaign is different and should be treated as such, factors like the lack of evidence- based science regarding COVID- 19, the use of new vaccine platforms for the COVID- 19, like the mRNA platform, the newness of the vaccines themselves, and the fact that they are available through EUAs rather than the standard FDA process can all contribute to hesitancy. With factors like these for this campaign, it really isn't hard to understand that hesitancy exists and in different levels within different groups.

Paul Anderson: I know that you've given a lot of thought to some other strategies, some other ways that we want to approach this topic. Because again, I think we're not really arguing the goal of, we want to drive up vaccination rates. So, what are some other strategies that you've been thinking about that might help us get there?

Vic Rose: There really are some other options that organizations can consider, a QAPI approach can be taken which actively gathers data on the reasons that persons declined any vaccine. That declination data can then be used to drive improvements in the vaccination campaign and be used to inform education communication efforts. Secondly, we must remember that if a person has reasons that they choose to decline the vaccine, whether we believe the reason is valid or not, it is really a reality. Furthermore, education, science, or reasoning may not help a person to overcome their particular fear, concern, or reason for declining. So, it is not just about educating. It is also about seeking to understand the reason for individual declination and helping that person to overcome it. This often takes a trusted messenger which can differ between groups of individuals, cultures, and so on. Therefore, it is important to remember that it isn't just about the message, it is about how the message is delivered.

Paul Anderson: Now, that we're six months into this idea that the people who were chomping at the bit to get the vaccine, they've probably gotten it at this point. And now it's how do we... There's access issues, of course, there's always questions of access, but then there are questions of how do we help those who have... I think it's important to frame the distinction between hesitancy and just outright refusal. And to sort of say," Okay. Patiently, respectfully, thoughtfully, what are your questions? What are your concerns?" And to sort of work through that. And that's painstaking because it's person by person, but it seems to me that that's a much more healthy way to get from here to there.

Vic Rose: That's really well said, Paul.

Paul Anderson: So, we always like to close the podcast by asking guests to describe something that listeners can do today to start to advance patient safety. So, if I'm in an organization that, again, is looking to drive a vaccination rates among my staff. What's my first move?

Vic Rose: Sure thing. That's a great question. I would offer this, Paul, take the time to listen both the people who accept the vaccine and those who declined it. Letting both inform your vaccination campaign efforts. Trust is a care critical issue when it comes to many things in healthcare, and that includes campaigns. Creating an open and learning environment that respects the individual, the residents and staff alike lays the foundation for trust, with trust, meaningful and purposeful conversations can be had where those who experienced hesitancy are more likely to open up and honestly discuss their reasons for that hesitancy. And it provides the information necessary to help individuals overcome reasons for declination.

Paul Anderson: And I'm willing to bet that building that trust in this context will have positive spillover effects to other aspects of the organization.

Vic Rose: That is definitely a process-

Paul Anderson: Okay.

Vic Rose: ...not an event, Paul.

Paul Anderson: Very true. Well, Vic, thanks so much for joining us.

Vic Rose: And thank you.

Paul Anderson: You could learn more on COVID- 19 vaccination among Aging Services staff in two recent blog posts available at blog. ecri.org. As well as in the March, April 2021 ECRI Insights column in Annals of Long- Term Care, Clinical Care, and Aging. Be sure to subscribe to Smart healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes. We welcome your feedback. Visit us @ ecri. org or email us at ecri- podcasts at ecri. org.