Experts offer advice on vaccination decisions

To begin the latest ACP/Annals of Internal Medicine virtual forum, “Vaccines: Decision Making Amid Conflicting Recommendations,” Christine Laine, MD, MPH, FACP, painted a picture of the current state of vaccination in the United States, explaining its rapid transition from foundational element of public health to political lightning rod.

“Trusted scientific processes for developing vaccine recommendations have been dismantled and replaced with a process that appears to be designed to yield recommendations that align with the misinformed beliefs of the Secretary of Health and Human Services,” said Dr. Laine, Editor-in-Chief of Annals and a Senior Vice President at ACP. “Those with expertise are leaving the Centers for Disease Control, either by force or because the political climate has made it impossible for them to responsibly fulfill their roles.”

The U.S. has also seen a recent measles outbreak and halting of government funding of all mRNA research, Dr. Laine said. Professional organizations that previously relied on the CDC are developing their own vaccine recommendations, and states are developing policies that span a wide spectrum, from banning vaccine mandates to requiring vaccine coverage.

Against this chaotic background, the ACP/Annals forum aimed to provide practical information to enable well-informed decisions about vaccines, Dr. Laine said. Led by moderator and ACP President Jason M. Goldman, MD, MACP, three expert panelists responded to clinical vignettes and answered questions submitted in advance by attendees. A recording of the forum and an accompanying commentary were published Sept. 16 by Annals of Internal Medicine.

The first vignette asked attendees how they would advise a 60-year-old retiree with a body mass index of 30 kg/m² and well-controlled hypertension who is seen in early fall for routine follow-up. She has regularly received the flu vaccine, is vaccinated against hepatitis B, and had her last COVID-19 booster about a year ago. She hasn't been vaccinated for respiratory syncytial virus (RSV), pneumococcus, or shingles, and she's hesitant to receive multiple vaccinations at once.

Panelist Rochelle Walensky, MD, MPH, walked forum attendees through her thinking about how to prioritize vaccines for this patient, given her history and the fact that she's currently uninsured.

First, Dr. Walensky noted that it might be a little early in the season to consider vaccination for flu. “Especially for people with comorbidities, we're trying to push it a little bit later, into October … to make sure that we can get through the entire season,” said Dr. Walensky, who was director of the CDC from 2021 to 2023 and is a professor of medicine at Harvard Medical School in Boston.

COVID-19 and the flu vaccine can be coadministered safely, so Dr. Walensky said she would recommend that the patient receive them at the same time. For the shingles vaccine and the pneumonia vaccine, “I think it's a bit of a toss-up as to which one you want to do first,” Dr. Walensky said. “She should get them both, she should get them both relatively soon, she's eligible for both of them.”

The RSV vaccine, though, is approved for patients older than age 75 years and for people older than age 50 years with significant comorbidities, so this patient doesn't really qualify, Dr. Walensky said. “You layer on top of that that [the RSV] vaccine is the most expensive of all of those there, in the $320 to $360 range, and I might actually defer on the RSV vaccine for this respiratory virus season.”

Panelist Robert H. Hopkins Jr., MD, MACP, added that he would probably spend a few minutes asking the patient why she's hesitant to receive multiple vaccines at one visit and trying to address her concerns. “We know that if you have increased visits or increased barriers to getting vaccines, that's going to reduce vaccination uptake,” said Dr. Hopkins, a professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences in Little Rock and Chair of ACP's Immunization Committee.

The second vignette asked about measles vaccination for a 55-year-old man with well-controlled type 2 diabetes who does not know his measles or vaccine history. While 53% of the forum audience said they would check the patient's measles serology as a first step, Dr. Hopkins said he would go ahead and administer the MMR vaccine. “This gentleman is younger than I am, so I know he was born after 1957. He is much younger than the age at which he potentially has a reasonable chance of having immunity from measles due to childhood infection,” Dr. Hopkins said.

Dr. Hopkins based his decision primarily on the patient's lack of knowledge of his vaccination history and the safety and efficacy of the current MMR vaccine. He said it would also be reasonable to check serology, keeping in mind that the presence or absence of antibodies is a surrogate marker of protection.

“If he has serology done and it's negative, he would still need to receive the MMR vaccine,” Dr. Hopkins said. “If the serology is positive, then you could defer.”

The third vignette asked about vaccine recommendations for a healthy 36-year-old woman with a recent positive pregnancy test who presented in the fall for referral to an obstetrician. Eighty percent of forum attendees said they would recommend influenza and COVID-19 vaccines now, with only 1% recommending avoiding vaccinations during pregnancy.

“I think your audience, for the most part, got it right,” said panelist Fiona Havers, MD, MHS. She noted that both the COVID-19 and flu vaccines are recommended in pregnancy by the American College of Obstetricians and Gynecologists and had previously been recommended by the CDC as well.

“When talking to pregnant women that are considering vaccination, one of the things to emphasize is that those vaccines do protect them from severe complications from COVID and influenza, but also are really important for protecting infants,” said Dr. Havers, an infectious diseases expert and a former medical epidemiologist at the CDC. “Infants are at very high risk for hospitalization from both influenza and COVID, and maternal antibodies from vaccination during pregnancy are the best way to protect them.”

The panelists discussed whether physicians should turn to Canadian or European recommendations on vaccination, given the recent upheaval at the CDC and the replacement of the members of the Advisory Committee on Immunization Practices (ACIP). Dr. Walensky said that while it's helpful to look at other countries to see what they recommend, it won't necessarily be equivalent, since ACIP has traditionally considered U.S.-specific factors such as insurance coverage, access to care, out-of-pocket costs, and accessibility when developing its recommendations.

Both Dr. Walensky and Dr. Havers commended U.S. professional societies' recent efforts in developing their own vaccine recommendations, although Dr. Havers pointed out that federal recommendations are the only ones insurers are legally required to cover. Dr. Walensky also discussed her work with the Vaccine Integrity Project, an initiative that aims to ensure vaccine use in the U.S. remains grounded in the best available evidence. For the upcoming respiratory virus season, the group has reviewed and abstracted the literature on RSV, COVID-19, and influenza vaccination since the last time ACIP reviewed it and plans to make it publicly available along with an executive summary.

Dr. Goldman asked the panelists to outline the evidence supporting continued annual immunization against COVID-19, and Dr. Havers pointed out that these recommendations were most likely always going to become more targeted.

“People may not realize that CDC and ACIP were sort of moving towards more tailored recommendations for this upcoming season, even before ACIP was fired and we had this political interference,” she said. “I think coverage generally was pretty low, particularly in the pediatric population, and I think there was a thought that a more tailored recommendation of really kind of targeting high-risk children and high-risk younger adults may get coverage up in those groups.”

Dr. Havers stressed that even with more widespread immunity and lower rates of infection, “COVID is still a major public health problem, at least on par with influenza in older adults, and that's something to keep in mind when you're talking with patients about what [vaccines] to get.”

Also, Dr. Hopkins said, “We can't forget about long COVID, and there is some evidence that the vaccines reduce the incidence of long COVID, both in children as well as in adults.”

Physicians need to be sure that patients understand the definition of vaccine effectiveness, said Dr. Goldman, a private practice physician and a clinical affiliate professor at the Florida Atlantic University Charles E. Schmidt School of Medicine in Boca Raton. “What is our endpoint? It's not always prevention of infection, because that may not be possible, but it's prevention of hospitalization, it's prevention of death, it's prevention from being out of work, because you have to take care of sick family members, or bringing it home to those who are immunocompromised,” he said.

Another consideration when talking to patients is that most who express reluctance about vaccination may just need more information on which to base their decisions, Dr. Hopkins said. “In my practice, I approach any patient or family member who … raises questions about vaccines the same way. I say, ‘Can I ask you a couple of questions about why you have concerns, or what your concerns are?’”

For patients who don't want to answer questions or engage in discussion, Dr. Hopkins said he reiterates that his goal is to improve their and their families' health and that he recommends vaccines in that context, then closes by saying, “But we can address this again when you're in the office next.”

For those who are willing to have a conversation, Dr. Hopkins said he asks about their goals for their life and their family, using a brief motivational interviewing technique. He then reiterates that he wants to support their goals by using vaccination to preserve their health.

“I close with a vaccine recommendation, but also make it clear that the decision today is not mine, but the decision is theirs, and that if we decide not to vaccinate today, we're going come back to it the next time around,” he said. “I think having those respectful conversations, often one or two or three times, are really the best way to discuss and to help people get to our goal of getting them vaccinated and protected.”