Primary care's role in COVID-19 vaccination

Did you know you're an influencer?

In a recent CVS survey of about 5,000 patients, most agreed that their primary care doctor was the most influential person regarding their choice to get the COVID-19 vaccine, reported David Fairchild, MD, MPH, FACP, medical officer for MinuteClinic and professor of medicine at University of Massachusetts Medical School in Worcester.

“Messages from the CDC were important. Messages from Anthony Fauci himself were even more important. But who was … the most important person in an individual's decision to get vaccinated? It was the primary care provider,” he said, adding that this finding was similar across racial and ethnic backgrounds.

In survey after survey, patients report that they trust their primary care practitioner the most, said ACP's Executive Vice President and Chief Executive Officer, Darilyn V. Moyer, MD, FACP. “It's the person who has that longitudinal relationship and knows how to meet people where they are, understands what hesitations they might have, and can address them in a real, personal way,” she said.

At a webinar hosted in February by the Primary Care Collaborative (PCC), Drs. Fairchild and Moyer served on an expert panel that discussed the role of primary care and other sectors in combating vaccine hesitancy and ensuring equitable distribution. Other panelists included Lloyd Michener, MD, professor emeritus of family medicine and community health at Duke University School of Medicine in Durham, N.C., and Angelica Geter, DrPH, MPH, chief strategy officer of the Black Women's Health Imperative, based in Atlanta and Washington, D.C.

Encouraging vaccine uptake

There has been a slow but steady rise in the public's intent to receive the vaccine.

From September to December 2020, the proportion of U.S. adults who said they were absolutely certain or very likely to receive a COVID-19 vaccine increased from 39% to 49%, while the proportion reporting no intent to receive it decreased from 38% to 32%, according to results published in the Feb. 12 MMWR. In the study, vaccine nonintent was highest among younger adults, women, Black adults, adults living in nonmetropolitan areas, and adults with lower educational attainment, with lower income, and without health insurance.

State-level factors also play a role in who's getting vaccinated, said Dr. Moyer, who is also chair of the PCC board of directors. For instance, the states that have the largest wealth gaps are also the ones that have the highest inequities in distribution of the vaccine, she said.

“We've seen a lot of different distribution systems, and the states have handled it all very differently. In fact, some states aren't even allowing primary care physicians to vaccinate yet,” she said. “I think that we need a more standardized, equitable approach.”

In the effort to vaccinate more Americans, instilling trust in the process is critical, said Dr. Geter. “Trust right now, especially for those who have experienced the greatest disparity as it relates to COVID-19 care, it can make or break what we're trying to do across the country,” she said.

To help combat vaccine hesitancy, Dr. Moyer recommended meeting patients where they are, understanding their concerns in a human way, and being persistent. She said her colleagues have reported being able to change people's minds over time.

“You may not have a successful conversation the first time, but … I think that as we see more and more critical mass of people getting vaccinated [and] people recognizing that it is the responsibility to their loved ones and to the people around them to do this, that we will start to overcome that,” she said.

In these educational conversations, physicians shouldn't assume the problem is ignorance, added Dr. Michener. “Sometimes it is, sometimes it's misinformation, and sometimes it's just a different view of the world,” he said. “Remember, we had anti-vaxxers before we had COVID. … There are folks who just don't put the same value on science as we do.”

Primary care clinicians were already hard at work on earning patient trust before the pandemic, added Dr. Michener. “It's not that we assume trust in primary care; we really work hard at it. Training helps, and practice helps even more. … There's a responsibility that comes with having that trust,” he said.

That responsibility involves reaching out to the community beyond the office walls as well, Dr. Michener said. “It's to be present and to answer questions and to help, at this moment of need, to heal some of those historic wounds that go back centuries,” he said. “I think we have critical roles in our offices, but also I think we have critical roles to help, with our communities, as trusted members” at local gatherings like community meetings and church groups.

Primary care clinicians can also bring their expertise to the state and local level. In Atlanta, primary care physicians contacted the mayor's office directly to figure out how they could help during COVID-19, which led to the opportunity for them to share the most update-to-date public health messaging for mass communications, Dr. Geter said.

“We had so many physicians reach out to us directly to say, ‘I have the training, I have a team, and I want to be able to provide those services,’” she said. “Don't underestimate the access and the resources you can provide to local policy and even state leaders.”

Reaching vulnerable communities

As of March 19, more than 77 million (nearly 30%) of U.S. adults had received at least one dose of coronavirus vaccine. About 16% had received both vaccine doses.

Having visited vaccination sites, Dr. Fairchild said he has felt patients' sense of relief and gratitude. “I think our job [in] primary care is to think about how to advocate for those patients who haven't gotten their vaccine yet and make it possible for them,” he said.

While the rollout has been historic, it's also been frustrating, Dr. Fairchild added. “It's frustrating both to patients who are ready to get the vaccine and they can't get it, and it's also frustrating to some providers due to the fact that every state has their own plan and, in some cases, the states have delegated it down to the counties,” he said.

Dr. Moyer agreed. While vaccine distribution “could definitely be better,” states are beginning to learn from each other's experiences and develop best practices, she said.

Like many states, North Carolina started off by offering vaccines at central sites for everyone. Then it became clear that those sites were in mostly White communities, and the data confirmed vaccines were mostly going to White people, Dr. Michener noted.

“It was actually the primary care groups working with the communities that pointed it out, and the state, to its enormous credit, pivoted to actually work with the primary care groups and the community partners and the health department to start vaccinating in those communities. … So we've seen our vaccination rates in our minority communities increase,” he said, adding that the vaccination sites also work to meet community-reported needs, from food to housing to transportation.

There have also been efforts to make it easier for at-risk populations in Philadelphia to get vaccinated. In March, city partners and FEMA opened a by-appointment community vaccination site at the Pennsylvania Convention Center, “which is the hub where all the mass transportation meets: the subway, the rails, the buses,” said Dr. Moyer. In addition, the city's Black Doctors COVID-19 Consortium in February hosted a 24-hour, walk-up vaccination marathon at the Liacouras Center on the Temple University campus in North Philadelphia.

“They were able to vaccinate a lot of folks in a short period of time, so we're really seeing these best practices start to pop up,” she said. “People [are] really recognizing and pushing the need to make sure that the most at-risk folks are the ones that are prioritized and getting vaccinated first.”

As the fight against COVID-19 continues, Dr. Moyer called for all hands on deck in primary care. “Get your sleeves rolled up,” she said. “We need to get as much vaccine into arms as possible, and we need to be equitable about it.”