Placing Trust

Left to right: Dr. Laura Riley and Dr. Sallie Permar

Over the last 18 months, U.S. health officials recommended reducing the number of childhood vaccines from 17 to 11 and limiting who should receive annual flu and COVID shots. The messaging — including an emphasis on the idea that doctors and patients should practice “shared clinical decision-making” around vaccination — has created public confusion. Dr. Sallie Permar, who studies how to create new vaccines and improve existing ones, and Dr. Laura Riley, who previously served on the federal government’s Advisory Committee for Immunization Practices (ACIP), talk about the implications of a shift away from a public health mindset around vaccines to an individual one.

What does shared clinical decision-making look like?

Dr. Permar: Traditionally, shared clinical decision-making occurs when there is not evidence that physicians are relying on for the safety and benefit of an intervention for a specific patient population, so doctors and their patients have to make their own risk-benefit analysis.

We recommend vaccines during well-child visits because we already trust the processes our esteemed colleagues used in selecting, assessing and ensuring safety over time. We can confidently say to patients: “These are the vaccines that are best for your child’s health.” There is no vaccine mandate in the clinic. During visits, parents can always ask questions to make an informed decision about their child’s health.

The CDC’s recommendation gives the impression that something about this conversation between parents and their child’s pediatrician has changed when it really hasn’t. The recommendation also suggests that there is scientific evidence that these vaccines are not known to be the best action for your child’s health or that parents shouldn’t accept that what pediatricians say is the best course. That, too, is misleading.

We have always wanted higher vaccination uptake because we know it’s the most effective way to prevent illness, to prevent hospitalization, to prevent death in children, and things that we honestly can take off people’s plate of worries.

Dr. Riley: In shared clinical decision-making, you need two main things. First, you need a patient who has some knowledge about the benefits and risks of vaccines and can ask appropriate questions.

The second thing you need is time. There’s very little time during a visit, and we should resist rushing through decision-making. What’s happened now is the number of patients who are vaccine hesitant has blossomed. Although physician trust still exists, there are many more external forces like social media that are powerful and plentiful. It’s just harder to get the message across, even though we physicians haven’t changed our recommendations one bit.

Weill Cornell Medicine, along with states including New York, will continue to recommend to its patients the vaccine schedule backed by the American Academy of Pediatrics (which was the CDC’s schedule until early last year). But given a national landscape in which some states are less inclined to endorse or enforce that schedule, how has training for physicians and medical students pivoted?

Dr. Permar: People go into our profession to help people have healthier lives. And in polls, pediatricians are still among the most trusted professionals out there. But we have to train our pediatricians differently in how to talk with parents about vaccines when parents are faced with so many conflicting sources of information. Motivational interviewing has been the tested way to assess patients’ concerns. That means meeting your patients where they are in the examining room, listening to their questions, finding out what’s holding them back and getting to the root of the hesitation.

We now also need to train our new pediatricians to recognize what once were rare infections — like bacterial meningitis, measles — when previously these vaccine-preventable diseases had been so unusual that you might not think of them as part of a differential diagnosis.

What are other ways you are sharing the message about the importance of vaccination and vaccine safety?

Dr. Riley: I think one of the important pieces is to remind OBGYNs that our professional opinion is that nothing has changed. Our recommendations from the American College of Obstetricians and Gynecologists (ACOG) are the same as they have been: influenza, Tdap, Covid-19 and RSV vaccinations are efficacious, safe and important in pregnancy. We have to remind physicians and patients that we’re making decisions based on evidence. It’s a matter of consistent communication.

How might the loss of trust in “official” vaccine guidance and the resulting patchwork of state mandates change the public’s health?

Dr. Riley: Worst-case scenario, fewer people are going to get vaccinated, there’ll be a higher prevalence of these vaccine-preventable diseases and more people will be harmed or even die.

Dr. Permar: Doctors in the clinic face unprecedented levels of hesitation that take their time, effort and attention away from other well-child needs. And in our hospitals and care settings, we see patient illnesses and disability that could have been prevented and lives that could have been saved. The vaccine completion rate amongst 2-year-olds in New York City is 61 percent; other declines in vaccine uptake in this age group are occurring nationally. This group is important because they’re the ones entering preschool, when many of New York’s childhood vaccine requirements that have historically protected the population kick in.

We may end up seeing more protection against certain infectious diseases like measles or pertussis in states that still maintain mandates for entry into school and whose public health recommendations align with the evidence-based guidelines that are coming from medical professional organizations, like AAP or ACOG. You will start to see a divide in terms of numbers of outbreaks, of hospitalized children, of children who have a long-term disease from not being protected or their mom not being protected, and even in death rates. We already have disparities in infant mortality rates, and this will only exacerbate it.

What is the best-case scenario?

Dr. Riley: A positive result would be that more patients would feel empowered to ask questions of their doctors to get a better understanding and more confidence in the decisions being made. That’s the best-case scenario.

Dr. Permar: I think there’s an opportunity for health systems to take on more ownership of the childhood vaccine schedule because you rely on them to deliver the best care. If a child comes into a hospital for any reason, it is an opportunity to vaccinate.