• Better Public Health With Vaccines: A Family Physician’s Role

    August 17, 2022, 12:30 p.m. John Epling, M.D., M.S.Ed. — By now, you have surely heard of the first case of polio to have occurred in the United States in nearly a decade. While the individual affected is no longer contagious, health officials are still worried about potential further spread after the virus was isolated from wastewater monitoring in a neighboring county; it has also been detected in wastewater in New York City.  The individual had not been vaccinated but was exposed to a strain of poliovirus from abroad. This poliovirus strain was likely descended from the type used in oral polio vaccination programs in other countries. Unlike our currently used injectable polio vaccine, OPV can result in rare cases of vaccine-associated polio. Because of this risk, in the United States, we stopped giving OPV in favor of IPV in 2000.

    headshot of John Epling, M.D., M.S.Ed.

    In the setting of a recent uptick in vaccine hesitancy and a decrease in some community vaccination rates, there is concern that poliovirus may get into a vulnerable community and spread. In fact, there is concern now that there may already be potentially hundreds of individuals in New York who have been infected and may be spreading the virus.

    In addition, monkeypox continues to make its presence known in the United States. This current outbreak predominantly affects people who have sex with multiple partners without barrier protection, but as the number of cases grows, the concern is that household and other close contacts of those initially affected are now at risk of acquiring the disease. Unfortunately, while we have treatments and vaccines available to fight monkeypox, supplies are limited, raising concern that the people at highest risk will not be able to receive a vaccine when needed. Because supplies of monkeypox vaccine are limited, the FDA recently issued an emergency use authorization (which the Academy has since endorsed) that allows health care professionals to use an alternative form of administration of the Jynneos vaccine, extending the amount of existing vaccine doses considerably.

    And all this is unfolding as the COVID-19 pandemic brings several immunization-related concerns to light. Diminished access to routine medical care and health maintenance visits during the highest-risk period of the pandemic meant that adult and child vaccinations were delayed or missed. In addition, the misinformation that surrounded what should have been a celebrated success of the safe and effective COVID-19 vaccinations has caused our response to be fragmented and has had negative ripple effects on all immunization rates.

    We are presented with these lessons over and over again in health care. The diseases discussed above have joined pertussis, measles and hepatitis A as examples of what happens when society lets down its vaccination guard. A small drop in vaccination rates in an area can leave that community vulnerable to a previously quiescent threat introduced through travel or an unvaccinated individual.

    What is a family physician to do about all this?

    A bright spot in some of the vaccination services research performed during the COVID-19 pandemic is a reinforcement of family physicians’ role in protecting the public through vaccinations in primary care. Surveys of vaccination intent and barriers have again demonstrated what we have long known: no matter the variety of barriers to vaccination, primary care physicians remain the most trusted source of vaccine information for their patients, and most people prefer to get vaccinations in their primary care physician’s office.

    So, to be most effective for our patients now at the midpoint of National Immunization Awareness Month, we must continue to do what we have always done:

    • keep abreast of the latest information about circulating vaccine-preventable diseases;
    • have frank discussions with our patients about their risks and the effective prevention measures for these diseases; and
    • when vaccines are indicated, give strong personal recommendations for the vaccines based on your knowledge and your relationship with your patients.

    Keeping up with vaccine and vaccine-preventable disease information is not easy — we have recently seen, for example, a series of rapidly-changing and complex recommendations for pneumococcal vaccinations, an overall increase in the number of vaccinations recommended, and a multiplicity of condition-based (in addition to age-based) vaccine recommendations. Using just a few sources, you can stay up to date on the latest changes.

    The AAFP Immunizations and Vaccines webpage  is a one-stop shop for a variety of helpful vaccine information. The Advisory Committee on Immunization Practices webpage has a wealth of authoritative information about each vaccine on the schedule. And immunize.org (formerly the Immunization Action Coalition) is a great site for standing order templates, brochures and handouts, frequently asked question documents and other useful practice resources to promote vaccination.

    Understanding and discussing our patients’ risk factors for disease is our strength in family medicine. Sometimes these conversations can be awkward or difficult, but the lifelong relationships we have with our patients allow these discussions about community exposures, underlying conditions and sexual exposures to occur in an open and frank manner that is hard to replicate in other settings. Our patients deserve these conversations to keep them healthy.

    Finally, we must leverage our relationship advantage to keep our patients healthy by making strong personal recommendations for vaccination. Our patients are bombarded by misinformation — intentional or not — about vaccinations and the diseases they prevent. I frequently share with my patients the story of the Haemophilus influenzae type B vaccination, which in the span of my career has caused a dramatic reduction in severe childhood infections such as meningitis, periorbital cellulitis and pneumonia. When you have the opportunity, share your expertise in favor of vaccines at a larger scale — in your local news media, and at community organization meetings and similar events. Your voice is important.

    A popular political aphorism — “all politics is local” — applies similarly to health care. Family physicians’ greatest contribution to public health is our commitment to prevention for our patients. By providing high-quality information and strong recommendations for vaccines, we can positively and consistently influence public health one patient at a time.

    John Epling, M.D., M.S.Ed., is a professor and vice chair of research and population health in the Department of Family and Community Medicine at Virginia Tech Carilion School of Medicine and Carilion Clinic in Roanoke. He also is the AAFP’s liaison to the CDC/ACIP Combined Immunization Schedule Work Group.