The Role of the Pharmacist in Overcoming Vaccine Hesitancy

US Pharm. 2021;45(4)28-31.

ABSTRACT: Although vaccines are considered to be one of the most cost-effective means of preventing illness and death from certain diseases, some individuals are still reluctant to obtain vaccines recommended by the Advisory Committee on Immunization Practices. As frontline healthcare providers, pharmacists can act as patient educators and vaccine administrators and address vaccine hesitancy. By implementing effective communication strategies, pharmacists can inform patients about the safety and efficacy of available vaccines, address their concerns and fears, and dispel common myths and misconceptions, allowing patients to make informed decisions.  

According to the World Health Organization (WHO), vaccination has substantially decreased the burden of certain infectious diseases, and the CDC has declared vaccinations to be one of the top 10 public-health achievements of the 20th century.^1-4 The CDC also notes that vaccines are responsible for preventing nearly 2.5 million deaths annually. The incidence, prevalence, morbidity, and mortality associated with vaccine-preventable diseases have considerably diminished since vaccinations became available.^3,4

Despite the fact that vaccines are considered to be a safe, cost-effective, and efficient means of preventing illness, disability, and death from certain infectious diseases, an estimated 40,000 to 50,000 adults die annually in United States from vaccine-preventable diseases.^5-8 According to the National Foundation for Infectious Diseases, vaccine-preventable diseases kill more Americans annually than either breast cancer, HIV/AIDS, or traffic accidents.⁹ Although they are not 100% effective, vaccinations offer vital protection against certain illnesses and potentially serious disease-related complications.

The Advisory Committee on Immunization Practices (ACIP) annually reviews and continually updates vaccination standards, vaccine schedules, and recommended immunizations in the U.S. The ACIP vaccination recommendations are based primarily on factors such as age, health status, immunization history, lifestyle, occupation, and whether an individual is immunocompromised or planning to travel.^10,11 Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases is still an issue, and the potential health benefits of pediatric, adolescent, and adult vaccination are not being achieved due to suboptimal vaccine-coverage rates.¹²

Examples of available vaccines for vaccine-preventable diseases can be found in TABLE 1.¹³

Vaccine Hesitancy

The recent approvals of several COVID-19 vaccines have brought the idea of vaccine hesitancy to the forefront, and many individuals still express concerns about the safety and efficacy of the COVID-19 vaccines. However, in January 2019—before the COVID-19 pandemic began—the WHO declared that vaccine hesitancy was among the top 10 threats to global health.¹⁴ Despite the availability of safe and effective vaccines, many adults lack awareness of their need for vaccines and the current CDC recommendations. The vaccination rates for many of the recommended vaccines for adults still fall below the target levels. Pharmacists are well positioned to improve vaccination rates and can act as patient educator, advocate, identifier, and immunizer. The CDC encourages all healthcare providers to educate their patients about diseases that can be prevented with vaccines and to strongly recommend immunization, because data have shown that provider recommendation is one of the greatest predictors of patients deciding to obtain a vaccination.¹⁵

Defining and Addressing Vaccine Hesitancy

Various myths, misconceptions, and fears of adverse effects are often barriers to obtaining vaccines.¹⁶ Vaccine hesitancy is defined as the reluctance or refusal to obtain a vaccination despite its availability.^17,18 The reasons individuals decide not to vaccinate can be complex and multifactorial, but lack of confidence in vaccine safety, driven by apprehensions about adverse events, has been recognized as one of the main factors.^17,18 Hesitancy to vaccinate has been connected to some vaccine-preventable disease outbreaks in the past 2 decades, such as the resurgence of measles in various parts of the U.S., with 16 measles outbreaks occurring in 2011.^19,20 In addition, a report released in 2016 stated that the number of mumps cases had reached a 10-year high in the U.S. and was especially common on college campuses.²¹

Healthcare workers, especially those in primary care, remain significant influencers on vaccine decisions, and many patients consider vaccination after a recommendation from a healthcare provider. Therefore, it is imperative that healthcare providers, including pharmacists, are up-to-date on the clinical data on currently recommended vaccines.²²

Vaccine research indicates that vaccine hesitancy falls into three major categories: 1) lack of confidence (in effectiveness, safety, the system, or policy makers), 2) complacency (perceived low risk of acquiring vaccine-preventable diseases), and 3) lack of convenience (in the availability, accessibility, and appeal of immunization services, including time, place, language, and cultural contexts).²³ According to the Immunization Action Coalition (IAC), only 25% of adults are up-to-date on routinely recommended adult vaccines, leaving many adults at risk for illnesses, hospitalizations, disability, and deaths from vaccine-preventable diseases.²⁴ The IAC also indicates that low rates of vaccinations among adults may be due to lack of awareness of the vaccines recommended for them and, in some cases, absence of a provider recommendation or offer for vaccination.²⁴

According to the American Pharmacists Association, there are two models that influence vaccine hesitancy.¹⁴ They are referred to as the 3Cs Model and the 5As Model (TABLES 2, 3).^14,25,26

Barriers to Vaccination

Barriers to vaccination may be classified as personal, provider-related, or health-system related. According to a report by the CDC, factors that may contribute to low vaccination rates in adults include the following:²⁷

• Inadequate public awareness about adult vaccinations

• Misinformation about vaccines

• Absence of vaccine requirements for adults

• Disparities in integration of routine evaluation to assess vaccine needs and recommendations for adults during routine healthcare visits

• The expense of stocking vaccines in offices

• Providing vaccination services, inadequate and/or varying payment for vaccines, and vaccine administration

• Complications in how adult vaccinations are compensated by private as well as public insurers, lack of health insurance and limited funding for programs to vaccinate uninsured adults, and acute medical care taking priority over preventive services

Results from a recently published study added several reasons for hesitancy about vaccines. Although parents and patients had several concerns about vaccine safety, worries about adjuvants like aluminum, preservatives like mercury, and inactivating agents like formaldehyde were common.²² The results also indicated that patients/parents often have concerns about manufacturing residuals, such as human or animal DNA fragments, and also that the large number of vaccines administered might be overpowering or disturbing the immune system.²² As a result of these concerns, some parents/caregivers fear that vaccines may contribute to the development of autism, diabetes, developmental delays, hyperactivity, and attention-deficit disorders as well as other complications.²² The authors indicated that it is important for healthcare providers to address patient concerns and to assure patients that vaccines are a safe and effective means of preventing certain diseases.²² 

Measures to Overcome Vaccine Hesitancy

Pharmacists can overcome vaccine hesitancy by providing them with the facts about vaccines, including efficacy and safety data. They can also help to dispel common myths and misconceptions about vaccines and address patient concerns and fears.

When counseling patients about vaccines, pharmacists can engage them in conversation and use open-ended questions to obtain more information. For example:^14,17,22,23

• Find out the patient’s concerns and fears about vaccines and address them with safety and efficacy information when applicable

• Listen to the patient and acknowledge their fears or concerns and make them feel at ease by providing them with pertinent facts

• Provide patients with information about how vaccines work and how the immune system responds to vaccines to build immunity

• Provide patients with information on the clinical benefits of vaccines and the importance of staying up- to-date with ACIP-recommended vaccinations. Review the health implications associated with not obtaining vaccines for vaccine-preventable diseases

• Discuss the potential adverse effects and how they are addressed. Use the fact sheets available from the CDC or other reputable health organizations such as the IAC

• Share personal experiences with vaccines to build a level of trust

• Answer patient questions and make recommendations accordingly

• Instruct patients to discuss any further concerns with their primary healthcare provider and obtain the provider’s recommendations based on their medical and medication history

The Pharmacist’s Role

Pharmacists play a fundamental role in dispelling common concerns about vaccine-related adverse effects and in improving vaccination rates, and they can act as advocates and educators, as well as vaccine administrators. While there has been some progress in increasing vaccination rates, especially among adults, there are still many factors that contribute to the low rates of vaccination. Through increasing awareness, discussing the benefits versus risks of vaccination, and dispelling the common myths associated with vaccinations, pharmacists can seize every opportunity to discuss vaccination with their patients and motivate patients to obtain the recommended vaccines while also decreasing the incidence of preventable diseases. Unfortunately, some individuals shy away from vaccines due to myths and misconceptions, and pharmacists should encourage open dialogues with patients to identify and address any concerns. Additional patient-education resources for pharmacists are available at:

• Immunization Action Coalition vaccine hesitancy summary resource list: www.immunize.org/catg.d/p2070.pdf

• CDC website: Provider Resources for Vaccine Conversations with Parents. www.cdc.gov/vaccines/hcp/conversations/index.html

Conclusion

Vaccinations are critical to protecting patients from developing and dying from vaccine-preventable diseases. In order to be successful, a team effort is required of all healthcare professionals to boost rates of vaccination. Although vaccination is still a patient’s choice, pharmacists can be instrumental in providing patients with pertinent clinical information to help them make informed choices regarding immunizations, discussing their benefits as well as their risks. Pharmacists are also in a unique position to identify those patients who are in target groups for certain vaccinations and can make recommendations accordingly.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

REFERENCES

1. Andre FE, Booy R, Bock HL, et al. World Health Organization. Vaccination greatly reduces disease, disability, death and inequity worldwide. www.who.int/bulletin/volumes/86/2/07-040089/en/. Accessed March 11, 2021.
2. Violette R, Pullagura GR. Vaccine hesitancy: moving practice beyond binary vaccination outcomes in community pharmacy. Can Pharm J (Ott). 2019;152(6):391-394.
3. CDC. Ten great public health achievements–worldwide, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60:814.
4. Poudel A, Lau ETL, Deldot M, et al. Pharmacist role in vaccination: evidence and challenges. Vaccine. 2019;37(40):5939-5945.
5. Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract. 2015;4:67-77.
6. Poland GA, Schaffner W, Hopkins RH Jr., U.S. Department of Health & Human Services. Immunization guidelines in the United States: new vaccines and new recommendations for children, adolescents, and adults. Vaccine. 2013;31(42):4689-4693.
7. Esposito S, Durando P, Bosis S, et al. ESCMID Vaccine Study Group (EVASG). Vaccine-preventable diseases: from paediatric to adult targets. Eur J Intern Med. 2014;25(3):203-212.
8. Rémy V, Zöllner Y, Heckmann U. Vaccination: the cornerstone of an efficient healthcare system. J Mark Access Health Policy. 2015;3.
9. National Foundation for Infectious Diseases. Top 10 reasons to get vaccinated. www.nfid.org/immunization/10-reasons-to-get-vaccinated/. Accessed March 10, 2021.
10. CDC. Adult vaccination information for healthcare and public health professionals. www.cdc.gov/vaccines/hcp/adults/index.html. Accessed March 17, 2021.
11. Oldfield BJ, Stewart RW. Common misconceptions, advancements, and updates in pediatric vaccine administration. South Med J. 2016;109(1):38-41.
12. Ecarnot F, Crepaldi G, Juvin P, et al. Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting. BMC Public Health. 2019;19(1):1698.
13. CDC. Vaccines by disease. www.cdc.gov/vaccines/vpd/vaccines-diseases.html. Accessed March 11, 2021.
14. American Pharmacists Association. Vaccine hesitancy. Updated November 30, 2020. www.pharmacist.com/sites/default/files/audience/APhACOVID-19VaccineHesitancy_1120_web.pdf. Accessed March 11, 2021.
15. Tanzi MG. Adult vaccination rates show modest, but far from optimal, gains. Pharm Today. 2017;23(8):43.
16. Ventola CL. Immunization in the United States: recommendations, barriers, and measures to improve compliance: part 1: childhood vaccinations. P.T. 2016;41(7):426-436.
17. Lisenby KM, Patel KN, Uichanco MT. The role of pharmacists in addressing vaccine hesitancy and the measles outbreak. J Pharm Pract. 2021;34(1):127-132.
18. World Health Organization. Ten threats to global health in 2019 [Internet]. Geneva, Switzerland: World Health Organization Headquarters; 2019. www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. Accessed March 11, 2021.
19. Arede M, Bravo-Araya M, Bouchard É, et al. Combating vaccine hesitancy: teaching the next generation to navigate through the post truth era. Front Public Health. 2019;6:381.
20. Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. JAMA. 2016;315:1149-1158.
21. Latner DR, Hickman CJ. Remembering mumps. PLoS Pathog. 2015;11:e1004791.
22. Geoghegan S, O’Callaghan KP, Offit PA. Vaccine safety: myths and misinformation. Front Microbiol. 2020;11:372.
23. Shen SC, Dubey V. Addressing vaccine hesitancy: clinical guidance for primary care physicians working with parents. Can Fam Physician. 2019;65(3):175-181.
24. Immunization Action Coalition. Strategies to improve adult vaccination coverage. Updated October 2020. www.immunize.org/catg.d/p2050.pdf. Accessed March 11, 2021.
25. MacDonald NE. SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161-4164.
26. Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: a practical taxonomy for the determinants of vaccine uptake. Vaccine. 2016;34(8):1018-1024.
27. Williams WW, Lu PJ, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations — United States, 2014. MMWR Surveill Summ. 2016;65:1-36.

To comment on this article, contact rdavidson@uspharmacist.com.