Encouraging Vaccine Compliance During COVID-19
August is National Immunization Awareness Month (NIAM). This annual observance highlights the efforts of physicians to protect patients of all ages against vaccine-preventable diseases through on-time vaccination. Participating in NIAM and promoting immunizations is more important than ever during COVID-19.
This article will provide an overview of NIAM resources for medical practices, a summary of the CDC’s vaccine guidance during COVID-19, a Q&A for physicians about COVID-19 and routine vaccinations from the Immunization Action Coalition, and an opportunity to sign-up for a list-serv on flu clinics during COVID-19.
National Immunization Awareness Month
During NIAM, MCMS encourages you to ensure your patients are up to date on recommended vaccines. Research has consistently shown that healthcare professionals are the most trusted source of vaccine information for parents and patients.
Use NIAM as an opportunity to access CDC educational resources like the #HowIRecommend Video Series, which offers simple and practical guidance for having successful vaccine conversations with parents and patients. These short videos demonstrate how to make effective vaccine recommendations, address common vaccine questions, and take a team-based approach to vaccination.
CDC has developed CME activities to help healthcare professionals have successful conversations with parents about vaccines, available below:
The Public Health Foundation and CDC have developed a digital communication toolkit with messages and graphics tailored to your role as a healthcare professional emphasizing the importance of vaccination for your patients. Show your practice’s support of vaccination throughout the month by using this content on your website and on social media. During NIAM and beyond, you can engage with CDC and other healthcare professionals on social media by using #ivax2protect in your posts. You may also find MCMS’s general campaign encouraging patients to seek medical care, #CallYourPhysician helpful. Learn more.
Reminder: ImmuNet Compliance
As of October 1, 2019, all vaccinations administered in the State of Maryland are required to be reported to Maryland’s Immunization Information System, ImmuNet. This new requirement was passed into law during the 2019 legislative session, and is codified in State Statute §18–109(d)(6)(I)3.
ImmuNet is Maryland’s Immunization Information System; it is a secure web-based registry operated by the Maryland Department of Health. Information stored on ImmuNet is confidential and available only to authorized users. Learn more.
From the CDC: Vaccination Guidance During a Pandemic
The COVID-19 pandemic has caused physicians to change how they operate to continue to provide essential services to patients. Ensuring immunization services are maintained or reinitiated is essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks and reducing the burden of respiratory illness during the upcoming influenza season.
Key Takeaways from the CDC’s Guidance
- Administration of vaccines is an essential medical service.
- Assess the vaccination status of all patients across the life span at every health care visit.
- Administer routinely recommended vaccines to children, adolescents, and adults (including pregnant women).
- Delay vaccination for persons with suspected or confirmed COVID-19.
- Follow guidance to prevent the spread of COVID-19 in health care settings.
- Encourage vaccination at the patient’s medical home.
- Implement effective strategies for catch-up vaccination.
- Communicate with patients/families about how they can be safely vaccinated during the pandemic.
The following are key section’s of the CDC’s guidance on considerations for routine vaccination, influenza, vaccination of patients with COVID-19, and practices for safe delivery of vaccination services. To view the full guidance, visit the CDC’s resource base.
Considerations for Routine Vaccination
- Children and adolescents: Healthcare providers should identify children who have missed well-child visits and/or recommended vaccinations and contact parents to schedule in-person appointments, starting with newborns, infants and children up to 24 months, young children, and extending through adolescence. Additional guidance is available for the prevention of mother-to-child transmission of hepatitis B during COVID-19-related disruptions.
- Pregnant women: If administration of the recommended maternal vaccines (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and influenza) has been delayed because of reduced or deferred in-person prenatal care visits, pregnant women should be scheduled for follow-up and receive vaccination during the next in-person appointment.
- Adults: Healthcare providers, whether they administer vaccines or not, should take steps to ensure that their patients continue to receive vaccines according to the Standards for Adult Immunization Practice. Older adults and adults with underlying medical conditions are particularly at increased risk for preventable disease and complications if vaccination is deferred.
Additional Considerations for Influenza Vaccination
Annual influenza vaccination is recommended for all persons age 6 months and older to decrease morbidity and mortality caused by influenza. Healthcare providers should consult current influenza vaccine recommendations for guidance around the timing of administration and use of specific vaccines.
During the COVID-19 pandemic, reducing the overall burden of respiratory illnesses is important to protect vulnerable populations at risk for severe illness, the healthcare system, and other critical infrastructure. Thus, healthcare providers should use every opportunity during the influenza vaccination season to administer influenza vaccines to all eligible persons, including:
- Essential workers: Healthcare personnel, including nursing home, long-term care facility, and pharmacy staff, and other critical infrastructure workforce
- Persons at increased risk for severe illness from COVID-19: Including adults age 65 years and older, residents in a nursing home or long-term care facility, persons of all ages with certain underlying medical conditions. Severe illness from COVID-19 has been observed to disproportionately affect members of certain racial/ethnic minority groups
- Persons at high risk for influenza complications: Including infants and young children, children with neurologic conditions, pregnant women, adults age 65 years and older, and other persons with certain underlying medical conditions
Vaccination of Persons with Suspected or Confirmed COVID-19
Routine vaccination should be deferred for persons with suspected or confirmed COVID-19, regardless of symptoms, until criteria have been met for them to discontinue isolation. While mild illness is not a contraindication to vaccination, vaccination visits for these individuals should be postponed to avoid exposing healthcare personnel and other patients to the virus that causes COVID-19. When scheduling or confirming appointments for vaccination, patients should be instructed to notify the provider’s office in advance if they currently have or develop any symptoms of COVID-19.
Practices for Safe Delivery of Vaccination Services
The potential for asymptomatic transmission of the virus that causes COVID-19 underscores the importance of applying infection prevention practices to encounters with all patients, including physical distancing, respiratory and hand hygiene, surface decontamination, and source control while in a healthcare facility. Immunization providers should refer to the guidance developed to prevent the spread of COVID-19 in healthcare settings.
To help ensure the safe delivery of care during vaccination visits, providers should:
- Minimize chances for exposures, including:
- Screen for symptoms of COVID-19 and contact with persons with possible COVID-19 prior to and upon arrival at the facility and isolate symptomatic patients as soon as possible.
- Limit and monitor points of entry to the facility and install barriers, such as clear plastic sneeze guards, to limit physical contact with patients at triage.
- Implement policies for the use of a cloth face covering in persons over the age of 2 years (if tolerated).
- Ensure adherence to respiratory hygiene, cough etiquette, and hand hygiene.
- Ensure all staff adhere to the following infection prevention and control procedures:
- Follow Standard Precautions, which includes guidance for hand hygiene and cleaning the environment between patients.
- Wear a medical facemask at all times.
- Use eye protection based on level of community transmission:
- Moderate to substantial: Healthcare providers should wear eye protection given the increased likelihood of encountering asymptomatic COVID-19 patients.
- Minimal to none: Universal eye protection is considered optional, unless otherwise indicated as a part of Standard Precautions.
- Additional considerations for vaccine administration:
- Intranasal or oral vaccines:
- Healthcare providers should wear gloves when administering intranasal or oral vaccines because of the increased likelihood of coming into contact with a patient’s mucous membranes and body fluids. Gloves should be changed between patients in addition to performing hand hygiene.
- Administration of these vaccines is not considered an aerosol-generating procedure and thus, the use of an N95 or higher-level respirator is not recommended.
- Intramuscular or subcutaneous vaccines:
- If gloves are worn during vaccine administration, they should be changed between patients in addition to performing hand hygiene.
- Ensure physical distancing by implementing strategies, such as:
- Separating sick from well patients by scheduling these visits during different times of the day (e.g., well visits in the morning and sick visits in the afternoon), placing patients with sick visits in different areas of the facility, or scheduling patients with sick visits in a different location from well visits (when available).
- Reduce crowding in waiting areas by asking patients to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment.
- Ensure that physical distancing measures, with separation of at least 6 feet between patients and visitors, are maintained during all aspects of the visit, including check-in, checkout, screening procedures, and postvaccination monitoring using strategies such as physical barriers, signs, ropes, and floor markings.
- Utilize electronic communications as much as possible (e.g., filling out needed paperwork online in advance) to minimize time in the office as well as reuse of materials (e.g., clipboards, pens).
FAQ: COVID-19 and Routine Vaccination
The following FAQ is courtesy of the Immunization Action Coalition (IAC), and is updated by IAC on a rolling basis. For the latest edition, visit IAC online.
What does CDC advise about routine immunization services during the COVID-19 pandemic?
CDC is clear: Routine vaccination is an essential preventive care service for children, adolescents, and adults (including pregnant women) that should not be delayed because of the COVID-19 pandemic. The complete CDC Interim Guidance for Immunization Services During the COVID-19 Pandemic is at this link: www.cdc.gov/vaccines/pandemic-guidance/index.html.
What does CDC advise about administering recommended immunizations to children and teens when COVID-19 is circulating?
It is important to assess the vaccination status of all children and adolescents at each patient visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up. All vaccines due or overdue should be administered according to the recommended CDC immunization schedules during that visit, unless a specific contraindication exists, to provide protection as soon as possible and minimize the number of healthcare visits needed to complete vaccination.
Due to COVID-19 in my community, many children in my practice missed well-child visits or were seen only on a telemedicine visit and need to be caught up on recommended vaccinations. How do we tackle this problem?
Begin by identifying children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in person appointments. Consider starting with newborns, infants up to 24 months, young children and extending through adolescence. Consider the following strategies:
- Use a reminder/recall system or other vaccination assessment tools in your state immunization information system (IIS) or electronic health record to identify and notify children in need of catch-up vaccination
- Assess immunization status at every visit and provide all vaccinations due or overdue
- Consider standing orders to simplify the process of vaccination. Templates are available here: www.immunize.org/standing-orders
- Follow the CDC catch-up schedule to get children up to date on vaccination as efficiently as possible: www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html#guidance
Should infants born to women with hepatitis B virus infection (hepatitis B surface antigen-positive [HBsAg+]) be treated differently during the COVID-19 pandemic?
No. The prevention of mother-to-child transmission of hepatitis B virus infection requires timely vaccination and administration of hepatitis B immune globulin (HBIG) at birth, followed by completion of the hepatitis B vaccine series and post-vaccination serologic testing.
Prenatal care providers should ensure that HBsAg-positive pregnant women are able to advocate for the proper care of their infants in case labor and delivery occurs at an unplanned facility or is attended by staff that are not knowledgeable about managing HBV-exposed infants. HBsAg-positive mothers should be educated about the importance of proper preventive care for their infant, supplied with documentation of their HBsAg laboratory results and instructed to provide this documentation to labor and delivery staff at the time of delivery.
Every effort should be made to ensure HBV-exposed infants complete the hepatitis B vaccine series following the ACIP recommendations (see www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). CDC has posted additional information here: www.cdc.gov/vaccines/pandemic-guidance/index.html.
An infant in my practice is due for vaccinations but just tested positive for SARS-CoV-2 infection (the virus that causes COVID-19). She has no symptoms. Should we keep her vaccination appointment?
No. CDC recommends deferring vaccination of people while infected with SARS-CoV-2, regardless of symptoms, until they meet the criteria to discontinue isolation. Although mild illness is not a contraindication to vaccination, vaccination is deferred to avoid exposing healthcare personnel or other patients to SARS-CoV-2.
What does CDC advise about administering immunizations to adults when COVID-19 is circulating?
Healthcare providers, whether they administer vaccines or not, should take steps to ensure that their patients continue to receive all recommended vaccines. All providers should assess, recommend, administer (or refer) and document vaccination or vaccine counseling. Older adults and adults with underlying medical conditions are particularly at risk for preventable disease and complications if vaccination is deferred.
Vaccination of pregnant women with recommended maternal vaccines (tetanus toxoid, diphtheria toxoid, and acellular pertussis (Tdap) and influenza) is important for maternal and infant health. If vaccination has been delayed because of reduced or deferred in-person prenatal care visits, pregnant women should be scheduled for follow-up and vaccination during the next in-person appointment.
When COVID-19 is circulating, if I have the opportunity to vaccinate a child, teen, or an adult, should I administer only high priority vaccines, or should I administer all vaccines that are due at that visit?
You should continue to follow CDC’s best practice guidelines and administer all recommended vaccines simultaneously when no specific contraindications exist at the time of the visit. By administering all vaccines due at the visit, you will reduce the total number of healthcare encounters necessary for the patient to be fully vaccinated.
How do I safely deliver vaccination services during the COVID-19 pandemic?
People infected with the virus that causes COVID-19 can transmit the infection even if they show no signs of illness. For this reason, it is important to apply good infection prevention practices to encounters with all patients. You should review carefully the detailed guidance on safe vaccination practices here: www.cdc.gov/vaccines/pandemic-guidance/index.html.
In general, vaccination in a medical home is preferred, but may not always be feasible. Primary care practices in communities affected by COVID-19 should continue to use strategies to separate well visits from sick visits.
Examples could include:
- Scheduling sick visits and well visits during different times of the day
- Reducing crowding in waiting rooms, by asking patients to remain outside (e.g., stay in their vehicles) until they are called in, or setting up triage booths to screen patients safely
- Collaborating with other healthcare providers in the community to identify separate locations for providing routine well visits for children
How should we approach influenza vaccination when COVID-19 is or may be circulating during influenza season?
During the COVID-19 pandemic, reducing the overall burden of respiratory illnesses is important to protect vulnerable populations at risk for severe illness, the healthcare system, and other critical infrastructure. It is more critical than ever to use every opportunity during the influenza vaccination season to administer influenza vaccines to everyone who needs it. Influenza vaccination is recommended for all people age 6 months and older.
Some patients develop flu-like symptoms or fever after vaccination with recombinant zoster vaccine (RZV, Shingrix; GSK). Should I defer Shingrix vaccination because such a reaction might be confused with COVID-19?
No. If you have an opportunity to vaccinate a patient age 50 years or older who is due for dose 1 or dose 2 of Shingrix, proceed with vaccination as usual. It is important to counsel the patient about the risk of self-limited side effects, including local reactions, such as redness, pain, or swelling at the injection site, and systemic reactions, which include fever, chills, headache, and body aches. If they occur, such side effects normally resolve within 72 hours after vaccination.
Because of concerns about COVID-19, if a vaccine recipient develops fever after vaccination, they should stay home until it resolves. Shingrix vaccination does not cause respiratory symptoms common in COVID-19, such as cough or shortness of breath. If the vaccine recipient develops new symptoms of cough or shortness of breath, or if fever does not resolve within 72 hours of vaccination, the recipient should contact their healthcare provider.
Due to COVID-19 circulation in my community, I am delivering more patient care via telemedicine. Does that mean I can do nothing about vaccinations?
No. You can consider conducting your immunization assessment and counseling during the telemedicine visit and scheduling the patient for a brief vaccination-only encounter at an appropriate time and location.
References & Resources
References for this article:
- National Immunization Awareness Month (NIAM). U.S. Centers for Disease Control and Prevention. (2020, July 13). Retrieved July 31, 2020, from https://www.cdc.gov/vaccines/events/niam/index.html.
- Vaccination Guidance During a Pandemic. U.S. Centers for Disease Control and Prevention. (2020, June 09). Retrieved July 31, 2020, from https://www.cdc.gov/vaccines/pandemic-guidance/index.html.
- COVID-19 and Routine Vaccination. Immunization Action Coalition. (2020, June 11). Retrieved July 31, 2020, from https://www.immunize.org/askexperts/experts_covid19.asp.
- MCMS Flu Busters Campaign
- Interim CDC Guidance on Handling Non-COVID-19 Public Health Activities that Require Face-to-Face Interaction with Clients in the Clinic and Field in the Current COVID-19 Pandemic
- Repository of Resources for Maintaining Immunization during the COVID-19 Pandemic
- Resources for Hosting a Vaccination Clinic
- Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic
- Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission
- Vaccine Recommendations and Guidelines of the ACIP
- Community Preventive Services Task Force – Findings for Increasing Vaccination
- Vaccine Finder
- Vaccines for Children program
- Vaccine information statements
- Vaccinate with Confidence
- Immunization Information Systems
- Epidemiologyand Prevention of Vaccine-Preventable Diseases, 13th ed
- Vaccine administration Resource Library