The COVID-19 pandemic continues, and as front-line health care workers, we have directly witnessed the disease's adverse effects. Vaccination has proven to be our best tool to mitigate the spread of the virus, including highly contagious new variants. The Centers for Disease Control and Prevention (CDC) reports that as of January 8, 2022, only 73.1% of all adults ≥ 18 years in the United States are fully vaccinated, with less than 40% having received a recommended booster (asamonitor.pub/3CZSXhr).
Because there remains a sizeable number of unvaccinated patients, we argue that vaccination should expand beyond traditional efforts. One such approach should be the involvement of the perioperative teams that have borne much of the brunt of the effects of COVID-19 and yet have largely not been engaged in the broader vaccination effort. Importantly, the perioperative team may be a patient's rare point of contact for health care, as many of our patients do not have a regular primary care provider (PCP) (JAMA Intern Med 2020;180:463-6). Furthermore, low-vaccination groups like millennials and younger generations prefer convenient access and immediate and timely care without wait times, such as in the perioperative period (asamonitor.pub/3MSz5Tk). The perioperative period represents an untapped opportunity to reach this segment.
Routinely screening patients for public health measures, like smoking cessation, at every preoperative visit is already commonplace. Thus, it is reasonable to expect that perioperative teams should approach every patient at every visit about vaccination. Strategies should include discussing vaccination with every unvaccinated patient, offering vaccine registration, and even directly administering the vaccine. Perioperative physicians such as anesthesiologists would be well-suited to coordinate vaccination safely around surgery dates. This requires that the perioperative teams be knowledgeable about the available vaccines, their comparative benefits and side effects, and factors that lead to vaccine hesitancy and refusal. Here, we briefly present the information that would assist perioperative providers in engaging patients regarding COVID-19 vaccination.
First, patients should be informed that all team members have been vaccinated and thus are able to care for them more safely. Hospitals and clinics can assist perioperative providers by identifying unvaccinated patients and providing resources to administer vaccines during every patient encounter, using routine care pathways and easy-to-access orders through electronic health records. Perioperative clinical locations such as anesthesia preoperative and surgery clinics could coordinate vaccination prior to surgery. ASA currently recommends delaying surgery until at least two weeks after the patient has received their final vaccine dose, and the anesthesia team could assist in scheduling accordingly.
While ASA notes that the effects of vaccination and surgery are not fully understood, a postsurgical patient has the potential to be immunosuppressed, which could make an unvaccinated patient especially vulnerable to SARS-CoV-2 infection (asamonitor.pub/3i7a8pg). Vaccination in advance of surgery could greatly reduce that risk. Furthermore, providing vaccinations in clinic would address the concerns many vaccine-hesitant patients have in scheduling time off from work, as they could receive at least one dose of vaccine while already taking time off for their visit.
Detailed analysis of the unvaccinated population is provided by the Kaiser Family Foundation COVID-19 Vaccine Monitor project. By July 2021, 22% of unvaccinated adults claimed they would likely be vaccinated by the end of 2021 out of concern for new variants. Unvaccinated individuals comprise those that want to “wait and see” how the vaccines work (10% of population), those that will only get it if required (3%), and those that will definitely not get the vaccine (14%). The “wait and see” group and those who would get the vaccine only if required represent the next demographic that can be potentially persuaded. Targeted approaches can promote vaccine acceptance among this population, provided we address their concerns. Demographics also play a key role in vaccine hesitancy and refusal: unvaccinated individuals are younger, healthy, less educated, uninsured, and tend to be rural residents (asamonitor.pub/3CJ8p2I; asamonitor.pub/361Ph4b).
Vaccine hesitancy arises from misinformation, lack of trust, fear of shots, lack of accessibility, and personal preferences (asamonitor.pub/3CJ8p2I). Additionally, 34% of individuals in the “wait and see” group and 75% of the vaccine-refusal group believe the health risk from vaccination is higher than SARS-CoV-2 infection, and 57% of unvaccinated adults think the severity of COVID-19 is exaggerated (asamonitor.pub/3CJ8p2I). Vaccine effectiveness concerns may also deter vaccination, as only 17% of unvaccinated individuals believe vaccines help prevent severe illness, hospitalization, or death from infection (asamonitor.pub/3CJ8p2I). Here is where we can offer our own direct experience – from caring for critically ill patients, to the significant disruption the pandemic has made to our health care organizations.
Black and Hispanic adults represent a larger proportion of adults concerned about missing work (asamonitor.pub/3CJ8p2I). Thus, improving vaccine accessibility could help further reduce racial and ethnic disparities in vaccination rates. Among the “wait and see” group, 46% would accept vaccination if offered where they already go for care, underscoring both the importance of trust with a known medical provider and convenience (asamonitor.pub/361Ph4b).
One overlooked factor driving vaccine hesitancy is needle fear. Twelve percent of unvaccinated individuals list aversion to shots as one reason for vaccine hesitancy (asamonitor.pub/3CJ8p2I). Needle fear decreases with age. In adolescents, prevalence ranged from 20%-50%, and with adults aged 20-40 years it was 20%-30% (J Adv Nurs 2019;75:30-42). Offering vaccination concurrently with a scheduled procedure may be a solution to vaccine hesitancy due to needle fear, especially in younger, less vaccinated populations.
What about emergency surgeries in unvaccinated patients? While there may be too many confounding factors to allow for vaccination perioperatively, the inpatient period presents an additional opportunity to discuss vaccination. Discharge planning should include vaccine education as well as outpatient vaccination scheduling post-surgery. For patients without routine PCPs, hospital discharge may be one of the few points of contact for vaccination education by a knowledgeable health care provider. At our own institution, the obstetrics department has a system for identifying partially vaccinated inpatients and provides a nurse who locates and vaccinates those patients. These are patients who might otherwise miss a second dose due to hospitalization.
In summary, the perioperative team can contribute to vaccine acceptance by improving convenience and availability, by increasing trust in vaccines through education, and by demonstrating to the public that we have received the vaccine ourselves. The authors of this paper have found considerable success in discussing vaccination with vaccine-hesitant patients, using motivational interviewing practices endorsed by the CDC (asamonitor.pub/3q4F11J). Utilizing these techniques, we can further our aim to offer vaccination to every patient, from every provider, at every visit. In fact, every health care worker in every specialty should use every patient visit as an opportunity to discuss vaccination.
Disclosure: Dr. Hennessy is a consultant for Boston Scientific Corporation.
The authors wish to acknowledge the de Beaumont Foundation and NPR for their reporting and inspiration for “Every Physician, Every Visit,” Laura Brashear, Drs. Girish Joshi and Sara Hennessey for their expertise in editing, and Dr. Trousdale's late grandfather Bill Robertson for his tireless efforts in promoting the polio vaccine campaign.