COVID-19, Adverse drug events, COVID-19 vaccine, General practice
The SARS-CoV-2 virus, responsible for covid-19, had an animal origin and jumped to humans in 2019. In 2020 alone, COVID-19 infected almost 100 million people around the planet and ended with the lives of 2 million people. The development in a very short space of time, of vaccines against COVID-19, in response to the urgency of the pandemic, is a transcendental milestone in the history of medicine.
The widespread use of vaccination in recent centuries has been the intervention with the greatest impact on public health that effectively prevents morbidity and mortality from infectious diseases. Vaccination is generally well tolerated in the vast majority of the population, and its benefits far outweigh the risk of serious adverse events in most patients . Although vaccination, like any other medical intervention, can have adverse drug reactions (ADRs) .
All licensed vaccines are extremely effective in preventing severe cases of COVID-19. Importantly, the rates of hospitalizations and deaths associated with COVID-19 are substantially higher among unvaccinated adults than among those who have received a primary series and are up-to-date on recommended COVID-19 vaccination, particularly among adults age 65 and older. The protection provided by current vaccines against symptomatic infection and transmission is less than against severe disease and decreases over time, especially against currently circulating variants. For this reason, it is important to stay current, especially as new vaccines become available [3,4]. Mass vaccination is associated with a lower spread of the pandemic and a decrease in mortality [5-8]. COVID-19 vaccine is the hope for containment of disease outbreak. But, the post vaccination adverse effect is an important consideration.
While vaccine efficacy and effectiveness are of concern to public health authorities because they determine disease control, community and health care provider perceptions of vaccine safety are an important determinant of vaccination rates. This is more evident for the newer vaccines . On the other hand, currently, COVID-19 is an endemic infection that will remain with us for generations, and vaccination should be concentrated on the most vulnerable .
All health care providers play an important role in maintaining public confidence in vaccines because their attitude and knowledge are often critical to facilitating acceptance of a vaccine. Providers should have a thorough understanding of common and rare adverse effects of vaccination. The reason is that healthcare providers play a central and critical role in vaccine pharmacovigilance through post-licensing surveillance. The safety of the vaccine can only be inferred from the absence of ADRs .
The mass application of vaccines, as COVID-19 vaccination, requires robust pharmacovigilance systems and global coordination of post-licensing surveillance, both for governments to make the right decisions and to maintain or gain public confidence in vaccines. On the other hand, general medicine consultation is a good observatory of ADRs, including vaccines. The role of GP in the knowledge of ADRs is fundamental , and likewise in avoiding rejection of vaccination. Among the advantages of the GP are the continuous care that it entails in knowing the patients (and the correct assessment of ADRs, avoiding the difficulties of interpreting symptoms or diseases that are not due to medications but to psychosocial effects).
There are people who are more afraid of the vaccine than the coronavirus. While figures of hundreds of deaths per day from COVID-19 have been assumed, the focus is on the infrequent adverse effects of vaccines. The culture of knowing that medicines are not harmless, that everyone has a certain risk, is lacking. For example, with the oral polio vaccine (an attenuated virus), after administering it to 3,000 million children in the world, the World Health Organization recorded 760 cases of polio caused by the vaccine; But it is estimated that it prevented 13 million cases .
But not everyone is staunchly against vaccines, and many may be open to persuasion. It is important to keep in mind that unvaccinated people are not all anti-vaccines. As of June 2021, approximately 14% of US adults said they would "definitely not" receive the vaccine . But many others are in a "mobile field." About 16% want to get the vaccine as soon as possible, and they are waiting to see how the vaccine affects other people before getting it themselves, or will get it if needed (for example, for their job).
On the other hand, there are people who are especially vulnerable to COVID-19, such as patients of 65 years of age or older, pregnant, have asthma, COPD, heart failure, chronic kidney disease, chronic liver disease, chronic neurological conditions (Parkinson's disease, multiple sclerosis, learning disability, or cerebral palsy), diabetes, sickle cell disease or splenectomy, immunosuppression (AIDS, corticosteroid treatment or chemotherapy), and obesity.
Adherence to preventive behaviors plays a crucial role regarding the control of COVID-19. The psychological characteristics and risk perception of different individuals result in various forms of response to preventive behaviours. A key factor is perceived susceptibility. Although COVID-19 is highly contagious, it has a relatively low mortality rate and milder symptomatology with the latest variants . In general, a greater acceptance of the COVID-19 vaccine is found among women, older adults, those with more education and those who have greater confidence in the government . For example, in a study among college students who were hesitant to get vaccinated, 56% were men . Similarly, vaccination rates for the population with severe mental illness are substantially lower than those for the general population.
So, what should be the role of the GP in relation to COVID-19 vaccination? In the first place, he/she must be attentive to ADRs, and secondly, he/she must use his/her special place in health care (continuity of care, doctor-patient relationship, patient trust in his GP, knowledge of the context)  to target the most vulnerable people, and act to change the minds of people who are hesitant about vaccination. And so, how to intervene to change a patient's opinion regarding COVID-19 vaccination? Some suggestions would be [19-23]:
- Listen with empathy
- Review your biases; People are complicated and their reasons for not getting vaccinated are personal. Respect those reasons and you could have a more productive conversation.
- See if the person is open to conversation. If not, it might be a better use of your time and energy to simply back off.
- Be kind. The person you are trying to communicate with will immediately exclude you if you are disrespectful.
- Ask open questions
- Identify the obstacle. Explore the reasons for wanting to be vaccinated. Ask if there is anything you can do to ease your load or help remove any barriers.
- When you don't know the answer or aren't sure how to address people's concern, offer to help find information
- Adapt your argument to the person. Consider your specific concerns and try to address them. Do not use jargon or speak badly.
- Choose the educational intervention (informative, assertive, persuasive, and training) according to the characteristics of the person and their known health problems.
- Rely on people of influence for a certain target population. People who have had similar concerns but went ahead and got vaccinated are more likely to persuade others than someone eager to get vaccinated. Anyone in a person's social circle could act as an influencer: teachers, coaches, religious leaders, and even friends.
- Inform and prepare the person in relation to possible adverse effects. The public should be prepared because a subset of people may experience severe, albeit transient, side effects. Those transient reactions shouldn't deter people from getting vaccinated against a pandemic virus that kills at least one in 200 of those it infects.
In summary, the GP basically has two important tasks to perform regarding vaccination against COVID-19: 1) Detect, communicate and prevent the adverse effects of the vaccine; and 2) Promote the acceptance of the vaccine, especially in vulnerable populations, through informative, persuasive, assertive and empowering communication, focused on the characteristics of each person, based on the clinical interview, the doctor-patient relationship, trust of patients in their doctor, continuing care, and attention to the context.
2. Stein RA. Vaccination: A public health intervention that changed history & is changing with history. The American Biology Teacher. 2011 Nov;73(9):513-9.
3. CDC (2022) Stay Up to Date with COVID-19 Vaccines Including Boosters. Updated Sept. 8, 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fvaccines%2Fbooster-shot.html
4. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2022) Benefits of Getting A COVID-19 Vaccine. Last Updated Aug. 17, 2022. CDC. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html#:~:text=COVID%2D19%20vaccination%20helps%20protect,illness%20or%20post%2DCOVID%20conditions.&text=Getting%20sick%20with%20COVID%2D19%20can%20cause%20severe%20illness%20or,have%20mild%20or%20severe%20illness.
5. Carta MG, Orrù G, Cossu G, Velluzzi F, Atzori L, Aviles Gonzalez CI, et al. Covid-19 vaccines work but other factors play a relevant role: A data analysis on spread and mortality in 24 countries. Journal of Public Health Research. 2022 Feb;11(2):JPHR-2022.
6. Abu-Raddad LJ, Chemaitelly H, Ayoub HH, AlMukdad S, Yassine HM, Al-Khatib HA, et al. Effect of mRNA vaccine boosters against SARS-CoV-2 omicron infection in Qatar. New England Journal of Medicine. 2022 May 12;386(19):1804-16.
7. Pajon R, Doria-Rose NA, Shen X, Schmidt SD, O’Dell S, McDanal C, et al. SARS-CoV-2 Omicron variant neutralization after mRNA-1273 booster vaccination. New England Journal of Medicine. 2022 Mar 17;386(11):1088-91.
8. Munro AP, Janani L, Cornelius V, Aley PK, Babbage G, Baxter D, et al. Safety and immunogenicity of seven COVID-19 vaccines as a third dose (booster) following two doses of ChAdOx1 nCov-19 or BNT162b2 in the UK (COV-BOOST): a blinded, multicentre, randomised, controlled, phase 2 trial. The Lancet. 2021 Dec 18;398(10318):2258-76.
9. Joob B, Wiwanitkit V. Expected viscosity after COVID-19 vaccination, hyperviscosity and previous COVID-19. Clinical and Applied Thrombosis/Hemostasis. 2021 Jun 17;27:10760296211020833.
10. Loewy MA. COVID-19: The Weekly Roundup (October 28 to November 3, 2022). (2022) Medscape; November 4, 2022.
11. Turabian J. Strategies to increase opportunities to identify and communicate adverse drug reactions and drug related problems in general medicine. Journal of Family Medicine and Community Health. 2018;5:1165.
12. Llaneras K, Álvarez JA, Zafra M, Ansede M. Discover the risks and benefits of covid vaccines according to your age. El País; 2021; 18 ABR.
13. Kirzinger A, Sparks G, Brodie M. KFF COVID-19 vaccine monitor: in their own words, six months later. 2021; Jul 13.
14. Baek J, Kim KH, Choi JW. Determinants of adherence to personal preventive behaviours based on the health belief model: a cross-sectional study in South Korea during the initial stage of the COVID-19 pandemic. BMC Public Health. 2022 Dec;22(1):1.
15. Drouin O, Fontaine P, Arnaud Y, Montmarquette C, Prud’homme A, Da Silva RB. Parental decision and intent towards COVID-19 vaccination in children with asthma: an econometric analysis. BMC Public Health. 2022 Dec;22(1):1-2.
16. Xiong Y, Zhao Y, Zhang T, Wang Q, Liu JA. Factors Associated With The Vaccination Behavior Among COVID-19 Vaccine Hesitant College Students in Wuhan, China: A Survey Based on Social Psychological Dimension. Frontiers in Public Health. 2022:1259.
17. Hooper K, Hooper M, Nguyen J, Fukutomi A. Are you vaccinated? COVID-19 vaccination rates and the effect of a vaccination program in a metropolitan mental health inpatient population in Australia. Australasian Psychiatry. 2022 Nov 6:10398562221136756.
18. Turabian JL. Notebooks for family and community medicine: an introduction to the principles of family medicine. Madrid: Díaz de Santos. 1995.
19. WHO (2021) How to talk about vaccines. 19 May 2021. https://www.who.int/news-room/feature-stories/detail/how-to-talk-about-vaccines
20. Basu T. How to talk to vaccine-hesitant people, MIT Technology Review; 2021 August 16. https://www.technologyreview.com/2021/08/16/1032001/how-to-talk-to-unvaccinated-people/?truid=c5ce033f231235ecb64f4a6525782d31&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=&utm_content=11-06-2022&mc_cid=7534fca110&mc_eid=647a60bd64
21. Wadman M. Public needs to prep for vaccine side effects. Science; 2020; 370(6520): 1022. https://science.sciencemag.org/content/370/6520/1022?utm_campaign=toc_sci-mag_2020-11-25&et_rid=33551709&et_cid=3572793
22. Turabián JL, Pérez-Franco B. Usefulness and limits of health education. FMC 1988; 5:419-21.
23. Turabian JL. Strategies and methods to improve compliance in special patient groups and with specific health problems. Archives of Community Medicine and Public Health. 2020 Jun 22;6(1):104-9.