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Welcome to this expert podcast episode from ACIP to practice, turning guidelines into a living, breathing, immunization workflow. Before starting this podcast, please review the faculty information, disclosure statements, and learning objectives using the link in the episode description. To claim your CME credit, complete the evaluation using the link in the description. This podcast is a continuing education activity managed and accredited by partners for advancing clinical education in collaboration with Medall. This activity is supported by an independent medical education grant from GSK. Today, we're diving into how multiprofessional care teams can translate the Advisory Committee on Immunization Practices or ACIP adult recommendations into a highly practical daily workflow. We're joined by primary care physician, Doctor William Callaghan and infectious diseases specialist, Doctor Monica Gandhi. Thank you both for being here. Let's start with the sheer scale of the issue. Doctor Gandhi, data shows us that adult vaccination rates in the United States remain chronically low, leaving patients highly vulnerable. Why do we see such a high volume of missed vaccination opportunities across our health systems? So, you know, there are a variety of reasons, but you're completely right that anywhere between 38 to 95% of primary care encounters represent, Documentable medical opportunities for vaccinating people, and it doesn't always happen. And there are two major reasons. One is not because we don't have scientific data on the incredible importance of vaccine preventable diseases and vaccination, but one is that the clinician Um, is not always focused on vaccination. There's so much going on in a medical visit, highly crowded adult schedules, and, um, the providers so, uh, can be overwhelmed and not think about the primary prevention, um, of vaccination. And then the second is we are in a time that there is a certain degree of vaccine hesitancy. I think it's time to Um, mention that and, um, and really, really important to say that right now, this is an incredible time for us to talk about this as physicians because even coming in for BP medication or a BP check or a laboratory test, something really quick that could be used as an opportunity to look at the immunization schedule and to get that vaccination done. So this is a good time to make that happen. Doctor Callahan, looking at this from a primary care perspective, how can a clinician realistically screen for these gaps quickly without having to memorize the entire complex adult immunization schedule? Do you have a practical mental framework or a decision model that you apply? You are absolutely correct, it is a lot of vaccines and parameters to remember, so breaking it down can be really helpful. Uh, usually I consider age, uh, underlying conditions. That the patient may have, and then also I consider the clinical context of the encounter. So, looking at the age of the patient. Generally, I'm seeing adults. I sometimes I'll see children, but generally I'm seeing adults. And so for adults, the big ages are gonna be 50 and 65, right? That's where new vaccines are gonna become recommended for those patients. So, just in my mind, I think, OK, 50, 65, where do they fall within that? Star. Thinking along that, that frame, you know, which vaccines are they due for at 65, which are they due for at 50. Um, then I also think what chronic conditions do they have, right? So someone with COPD or with heart disease is going to need certain vaccines that someone without those conditions won't need. You know, the type 2 diabetic, we should be offering certain vaccines, you know, at earlier, at an earlier age rather than, you know, someone without that condition. So, again, you know, I look at age, look at like, look at the underlying condition. Um, clinical context is really why is the person coming in. So, at a routine physical, you know, their, their annual visit. That is something that I'm doing at every, every uh annual visit. But when it comes to someone who's coming in, you know, maybe they're coming in because, you know, they have a cough or, or, you know, maybe they're having, you know, and maybe they stub their toe, they want to be seen, you know, something acute, you know, that's the clinical context of the visit, you know, am I going to consider giving the vaccine at that visit? We should, right? But I also then I'm going to be relying a little more on prompts. At that visit, because physical, I'm thinking of that at that visit, whereas, you know, at more of the acute visit, while I should be thinking the vaccines, it is really helpful to have, you know, an electronic health record really prompting me to do it, you know, what is it saying about that patient. So perhaps we can look at that in a little bit more detail, how it plays out in real life. Can you give us an example of how this mental model intercepts a patient who would otherwise perhaps slip through the cracks of a busy clinic layout? You know, we can have a patient come in, uh, you know, we'll call the patient Mr. Smith, a non-English speaking patient comes in, we'll say he's 58 years old, comes in, past medical history of type 2 diabetes, uh, and is coming in with acute foot pain. Um, it's a very busy day. This person was squeezed in. Uh, to a visit, maybe someone else canceled. They were squeezed in. So I'm really not having a lot of time to review the chart, you know, I'm running from room to room. I see, you know, this new patient, Mr. Smith, on, on the docket to be seen, and I, I'm not really having the time to go through. Um, you know, when I do get into the room, if I'm running straight from one room to his room, right, I'm probably realistically going through his chart as I'm walking into the room, so I'm not really delving through. And as I do look, you know, I might see, you know, that he's missing vaccines, or I might see that it's just not clear what his, uh, you know, what his vaccines are, and that's actually really common, right? I'll, I'll say to a patient, You know, for instance, regarding a tetanus shot, I'll say, hey, it looks like, you know, you're due for a tetanus shot. I, I don't see that you've gotten one in the past 10 years. And then they'll say to me, oh, I think I have. I, I think I cut myself and got it at urgent care, or got it in the emergency room, right? So that unverified history is actually really common that we do face, and in, in this case, you know, if they're non-English speaking, and I don't speak their tongue, Um, you know, that only adds a layer to it because not only am I not hearing it directly from the patient, but I'm hearing it through a translator. So I have that extra level, you know, that's going on with this patient. Um, this is where, you know, I really, really rely on, uh, having a system, right? So, when the patient is roomed, it is really helpful for whether it be the EHR or even my nurse, screen the patient. Have you had this vaccine? And are you interested in this vaccine? Ideally, yes, right? Ideally, they have not had it, uh, and they're interested, or ideally they have had it and we just put it in because we can get that information. Um, whether, you know, to break them apart, right? The patient who hasn't had the vaccine, we flag as, OK, let's have that discussion about getting the vaccine, even if it's just 5 minutes during the visit, right, where we prime that patient to get them the vaccine, you know, we Discuss what they should be aware of and go from there. Uh, alternatively, maybe we flag it as, oh, they did get the vaccine, here's where they got it. We're going to reach out and get that information because it is important for us to have a complete medical record, you know, again, I don't. I don't want to rely on someone telling me, oh, I think I got this. I'm really not sure because I don't know if that's true as far as our, you know, should they be getting an updated vaccine, right? I trust that they got it, but what I don't necessarily trust is the timing, right? Because with something like tetanus or if we're talking about, you know, pneumonia, right, the timing does matter, and so I really do need to know the specifics of that. Doctor Gandhi, what about the hospital setting? When a patient's admitted to an inpatient ward, the team's obviously completely focused on the acute reason for their admission, how can the inpatient team capitalize on that multi-day window to protect a patient before discharge? So, you know, the inpatient ward is a very high yield clinical opportunity because this is often where the gaps are most severe, especially if someone came in with pneumonia and they've never gotten a pneumococcal shot. So, Published data shows that adults over 50 face a 4 times higher 3 day or 30-day mortality rate from vaccine preventable diseases. And actually, if you have a very severe pneumonia or influenza, up to 41% of survivors can have long-term symptoms. So, shockingly, only 1.9% of adults admitted with community acquired pneumonia. Or even given an influenza vaccine by the inpatient team by, um, the time they leave. So, um, I will say that I do see patients in the hospital as an infectious disease doctor. I'll give an example, Mr. Carter, a 64-year-old gentleman from a rural area, type 2 diabetes and high BP. He had two separate hospital admissions over the last year for COPD and heart failure exacerbations, and different hospitalists, not one person in both time, they, the team.