MedBoard Matters

Covid-19 vaccination push: A conversation with NC DHHS's Dr. Betsey Tilson

August 18, 2021 North Carolina Medical Board Season 1 Episode 13
MedBoard Matters
Covid-19 vaccination push: A conversation with NC DHHS's Dr. Betsey Tilson
Show Notes Transcript

In this episode, you are going to hear straight from State Health Director and NC DHHS Chief Medical Officer Dr. Elizabeth “Betsey” Tilson about why it’s so important to get vaccination rates up in North Carolina and how pivotal our healthcare providers are to this effort. Dr. Tilson also shares information about several tools that have been developed to help shape conversations for patients who have been reluctant to get vaccinated.

Check out those resources on our website.

Host: Jean Fisher Brinkley
Guest: Dr. Elizabeth “Betsey” Tilson
Producer: Sylvia French-Hodges

Episode 13 – Covid Vaccine Push

Intro music: 0:00  

Podcast introduction: 0:10

If you’re watching the state’s COVID-19 dashboard, you know things aren’t looking good. So not good that leaders of the North Carolina Department of Health and Human Services are making an urgent push to increase COVID vaccination rates in our state. And they say support from community medical providers is critical. 

I’m Jean Fisher Brinkley, Communications Director for the North Carolina Medical Board, and this is MedBoard Matters. Thank you for joining me. 

On this episode, you are going to hear straight from State Health Director and NC DHHS Chief Medical Officer Dr. Elizabeth “Betsey” Tilson about why it’s so important to get vaccination rates up now. I had the opportunity to catch up with Dr. Tilson just last week. She was clear that North Carolina has no time to waste.  

Interview with Dr. Betsey Tilson: 1:00

JFB: Doctor Tilson, first off I just want to thank you for being here with me today.

BT: , thank you so much for having me. This is just incredibly important information and very, very grateful for the North Carolina Medical Board to be supporting getting new messages out and communicating with our providers. So, thank you.

JFB: Of course. Now this is not the first time someone from NCDHS has been on the podcast. Back in January when the state was still in the early days of the initial rollout of the COVID-19 vaccine, Secretary Cohen was good enough to come on MedBoard Matters and explain how medical professionals could help. Back then, her main request was for our licensees and other clinicians to help patients, you know, who might have concerns about the vaccine by talking about the importance of getting that protection. Now DHS is renewing and maybe even strengthening that request. Asking clinicians to help the state reach its goal of getting the maximum possible number of eligible residents vaccinated. I'd like to ask you to begin by explaining the context. Why is NC DHHS asking this now?

BT: So, a couple things that are changing in this landscape right now, especially when it comes to our… our providers. So, first is as probably many people know, although we were seeing some decreasing cases over the summer, and we thought maybe…maybe we were getting to the back end of this pandemic. We are surging once again more quickly than we've ever been surging in the pandemic. Really likely to the emergence of Delta, the Delta variance which is far more transmissible then the prior variant, which was far more transmissible than the original variants. So, we are seeing surges of cases and another surge of our hospitalizations, so we are not through this pandemic yet. We are seeing surges. The other piece is that are, vaccination rates statewide are not where they need to be. They are not high enough and that is allowing than this increased viral transmission. And as the viruses move, it also means that the viruses can continue to have variants. And right now, the vaccines are still very, very effective. However, the concern is if this virus continues to transmit, continues to vary, then we may be in a place where the vaccines are no longer effective and none of us want that. So that's one piece. OK, so the context of the viral spread going on in North Carolina. 

JFB: OK, so it's important to really act now that we have this good tool? 

BT: It is critical to act now. I am actually worried that our window to control this pandemic is closing quickly because I'm very worried that the variance that come down the pike will not be susceptible to our current vaccines and that worries me a lot.

JFB: Gotcha, you know I…I think I saw a national number fairly recently that 67% of Americans who are eligible for vaccination have been vaccinated. Where are we in North Carolina?

BT: In North Carolina, our overall population, 51% of our overall population have had at least one dose. Amongst our adults 18 and up, 62% of our adults 18 and up have had at least one dose.

JFB: So, Dr. Tilson I mentioned that the state has set a goal of getting the maximum possible number of North Carolinians vaccinated against COVID-19, but is there a more specific target? For example, what percentage of state residents would need to be vaccinated for North Carolina to get that magical state of herd immunity that I've heard about where community transmission is no longer a serious concern?

BT:  Yeah, I wish I knew what that magic number was, but boy  'cause I would love for us to be there that magic number. Um…it’s not really known, but it is most likely to be much, much higher than we are now,

and there's two different concepts. One is a high enough vaccination level that we're really suppressing any transmission. Think about polio, mumps, measles. We really don't see it circulating. You need very high rates of vaccination, probably in the high 90s percent, and especially with this delta being so transmissible, we probably gotta need like 97% to really suppress it. Our goal is to control it, and have it be circulating more like flu, where we're able to live with it. It's…it's controlled enough that we can live with, but to truly suppress this magical herd immunity, where it’s no longer circulating, we're going to need really, really high rates.

JFB:  Ok, well these trends are very worrying and it it's clear that there's still a lot of work to do, so I…I know that our licensees who are listening, would like to know what they can do to help. So, let's talk about how community providers can help with the state's vaccination efforts? 

BT:  Yeah, it's a couple things that we're asking providers right now. One, that same message in the beginning, our providers are trusted health care providers. They are the most trusted source of information, and that's what we've always heard it, and we're hearing it more and more, especially people who are not vaccinated now. They really want to get vaccinated and talk to their trusted health care providers. So, that is critically important for our providers to talk to their patients, answer their questions, make sure they have all of the facts, but be that trusted health care voice. And we have lots of tools and lots of  informations to help providers with those conversations. We have all sorts of fact-based vaccine information on our website. We have great provider tools, communication discussion tools based in motivational interviewing. We have lots of ways that we can help providers have that conversation. In addition, in our Medicaid program we have a new code, a vaccine counseling code so that providers can actually be paid for that counseling time 'cause we know those people now, they're going to need some more time. They're going to need counseling. There's going to be time spent to talk and that is such a valuable piece that our providers bring us to be compensated. So, there is a, we have a vaccine counseling code that you can bill to Medicaid.

JFB: That is fantastic. And that's just for Medicaid then? 

BT: That is just for Medicaid. We have been piloting it. We've…it's been live for about five or six weeks. We've had more than 6500 claims already, and now we're work…we're talking with our private payers to see if they might want to do that as well, because that…that…that vaccine counseling is so high value. So that's one piece for sure that we want our providers to know that they remain the most trusted  healthcare voice. We want them to be doing that as to be valuing that and reimbursing for that. 

JFB: And as I recall, that is very much what Dr. Cohen and I talked about when she was with us in January was that piece about community providers being the most trusted source of information. That people don't just want to hear from a doctor,  but they want to hear it from their doctor. What is this vaccine? Why should I get it? That's risks and benefits. So yes, OK.

BT: And we do have again, we have lots of tools so that if providers need that tools, they need the facts that 'cause the…the information changes rapidly. We have all that and then we’re happy to do that. So, that’s the first piece…really important. Second pieces right then. In the beginning we really were pushing the vaccines out in these much…much bigger mass vaccination clinics. Now really the vaccinations are going to happen in those primary care medical homes, in the specialty homes, in those trusted medical practices. So, this is now when having our providers come on board to actually be COVID vaccinating providers. And we've had lots of lots of increasing success in that we have more than 750 of our…of our medical providers on boarded and COVID vaccinators. So, that is that is really great and we have in the beginning it was pretty cumbersome and I may be of some of our providers had tried to do it in the beginning, it was a little bit more cumbersome but we have really done a lot of policy changes, a lot of system changes, a lot more TA and support to make it a lot easier for our providers to be able to to on board and CDM, mass to get that TA we've really made a lot of policy changes to make it easier for them. So, if they tried before and it seemed hard, try again. We've made a lot of a lot of changes. And the big thing for our providers, is that we just want you to have vaccine in your office, so that when that patient comes in, when you're talking to them and they say, “yes”, there's the opportunity and you have it there sitting on your shelf, ready to go when a patient is ready. And…um there were some more logistical barriers with the subzero freezer and storage and handling a lot of those have really eased and got a lot easier. We have lots of that information, but a lot of those logistics have eased.

JFB: OK. Could you say a little bit more about what specific types would specialists or what types of medical professionals you're most interested in encouraging to sign up to be vaccine providers? You mentioned medical homes, so that makes me think primary care, but could you elaborate a little bit?

BT: Yeah, so for sure any medical provider were happy with of course, but those primary care medical homes, our family medicine, our internal medicine, our pediatricians that have that ongoing longitudinal relationship with their patients. Our primary care really, really key. They are very trusted sources, but a lot of our specialists are also have that long term relationship with those patients. So, any of our specialists as well would be just fine that have that ongoing relationship. You know,  many of our many of our nephrologists, many of our sickle cell providers, many of our cardiologists, many of our OB GYN's, they really work as that primary care. So, any of our providers, especially those that have long standing relationship with patients, would be great.

JFB: Great and I just wanted to pause and say you've mentioned a couple of times the resources that DHS has developed, and they really are excellent and comprehensive. We will post selected resources including the Vaccine Provider Toolkit and I think you've got a one pager that talks about how to get started as a vaccine provider. We will post those on the MedBoard Matters show page so that people will be able to access them very quickly.

BT: That's great. That's great. Yeah, and that the vaccine counseling code. Yeah, a lot of people don't know that. That's live, so we want to make sure we go.

JFB: I think that's big news, definitely because that that's a real concern. I think it's very sensitive of DHS to recognize that you know that is unfortunately a barrier potentially to people having these extended conversations with patients is that you know they've got to get in and out in 15 minutes just like everybody else. And if they're adding on this complicated, sensitive conversation, it…it helps that they can be compensated. So, I think that's really great.

BT: Well, if we say the high value piece of our providers is that trusted relationship, then we should be compensating and paying for what that value is. Is that relationship and that conversation with that patient? That's incredibly high value thing that there our providers bring, so we want to be reimbursing for that.

JFB: Great. Well,  I think that's great leadership. It probably goes without saying, but I do want to note that pretty much anyone who wants to get the COVID vaccine and can get the COVID vaccine has already gotten it. So, that means that the physicians and PA's who take up your challenge are going to be attempting to persuade people who may be reluctant for a wide variety of reasons. And I imagine those are not easy conversations to have. So, I wanted to ask  if you have any guidance or even specific talking points that might help clinicians have constructive discussions with patients who may have a wide range of sincerely held concerns.

BT: I do, but first I'm going to push back on your assumption if I may.

JFB: OK.

BT: So, we said that about you about 62% of our adults have had at least one dose. When we've looked at surveys, there still is a percentage of people that are still undecided or still want to have a vaccine. There's maybe about maybe 15% of people that are…that have said “no”. But there is a delta between that 60% and that about 80% of people who are just not quite sure. So, I'm not sure that all those conversations would have to be completely persuading someone who's dead set against it.  A lot of people are that I'm…I'm just waiting a little bit. I have…I still have questions. I want a trusted person to talk through my questions. I want to make sure that it's convenient, a place where I can go that I have barriers, you know that there aren't barriers. So, there is a big chunk of people who just need a little tip in overall right person and easy, trusted, convenient. And for some people, a confidential place to get the vaccine. Because for some people they don't want other people to know they have gotten the vaccine in a confidential place. They can do it in private is a really important piece for some people, so I think there's a lot of people that come, that, uh, may be quite easy to vaccinate in the context of a trusted medical home.

JFB: OK, well that's an excellent point. I I think I I would still include those people in the reluctant slash hesitant, but but you raised some excellent points that it may not be that they are truly resistant to it. And of course, that's another strong point for why community providers you know, should be vaccine providers, because they can offer that confidentiality if you're going to your family doctor, you might be going there for any number of reasons and people don't have to know that you're going to get your COVID-19 vaccination if that's something that is is a concern for you.

BT: That's right. But to answer your direct question is what are those tips so and we as part of our provider tools that I mentioned, we do have this discussion guide that is rooted in motivational interviewing, right? And so really understanding understanding from the patient, “What are their concerns?” What are there questions coming in? Coming to that conversation with a sense of of compassion and respect, answering those questions, and we have a lot of really good tips on how to navigate those pieces. Other things that we've been hearing from providers is sharing their own personal experience. Maybe a provider themselves was a little bit nervous. Then they learn more and then they went ahead and got vaccinated. So sharing their own personal personal stories and the other thing that I would also counsel against doing with learning is there is a lot of misinformation. Out there, there's a lot of myths making sure people aren't repeating the myths and reinforcing the myths is really important, so just talking about the facts and not and not repeating that misinformation is really important. 

JFB: OK, ok. Great. And again, if there are any resources that we can link to, we're happy to put those on our show page so we can get those in in clinicians hands quickly. Now, one concern that I have heard raised is it people are concerned that you know the vaccine is approved but under on an emergency basis. So, at some point in the future the COVID vaccination, maybe as soon as the end of this month, according to Doctor Anthony Fauci, they will receive full and final approval from the FDA. How soon do you think that this will be and what are your thoughts about how this might impact vaccine acceptance?

BT:  Yes, let me answer that in a couple different ways. So, one it obviously it is correct that these vaccines are authorized under emergency use authorization. However, I do want to point out that the amount of people and data and safety surveillance as part of the EUA is enormous, so it's not that this EUA reflects not many people, not much research, not much data. Oh…my…goodness. So, more than 350 million people have received one of these vaccines. In North Carolina we’re just about to tip over to 10 million doses just in North Carolina.

JFB: Wow! 

BT: We have a huge amount of experience and the most robust safety surveillance system that has put into place as part of this EUA, so sensitive that we're finding literally the one in the 1,000,000, right? So, we're finding that Thrombocytopenia thrombosis immune. You're finding the very rare myocarditis. We're finding the very rare Guillain-Barré. So,  we are finding the one in the 1,000,000 because of so many people and this very intense safety surveillance. So, I just don't want to equate the EUA status as it's not tested, there's no data, there's no experience. That is not lately, so that is why we I feel very comfortable saying that that even under this EUA, we have incredible…credible data on efficacy and safety. So, I don't have any…any great insight into the FDA more than you, but what I am also hearing is that in September and maybe the full approval for Pfizer, which would be great and I think for some people, that may be enough to tip them over. I'm not sure what more data we're gonna get in a couple weeks that would change it. I feel like we've been the federal government, the CDC,  the FDA has been incredibly transparent with the data. I don't expect there to be any other data, but I think for some people it will give them assurance, that, OK, there's a full approval, but I I just want to be sure people are not equating the EUA with a lack of experience, safety data. There is so much data currently on these vaccines 

JFB: Absolutely. Is there anything else that I have not asked about our state's current efforts to increase COVID-19 vaccination that you would like to add?

BT: Uhm, I think again…just really wanting to reiterate that right now that trusted medical voice is the most important voice. Wanna be sure that our providers have all the information they need so as they’re counseling their patients, they know that they have everything that need and whatever we can do to support our providers, we stand ready to do that. I don't think there's anything more critically important right now than getting our vaccination rates up. And as I said at the beginning of this podcast, I am really worried that our window to control this pandemic may be closing because although currently our vaccines are effective against these variants, if we don't act now and really work to decrease viral spread then I can see a future not too far off that our vaccines won't be effective for those circulating variants and that is really, really scary. So there's an incredible sense of urgency right now in what we do in our state…in our country.

JFB: Wow…well, Dr. Tilson I really greatly appreciate your time and all that you're doing to protect public health in North Carolina. Thank you again for taking the time to appear on Med board matters.

BT: Thank you so much. Really…really appreciate the partnership. 

Relative risk of vaccination vs. risk from COVID-19: 19:19

I want to take a little time to elaborate on some of Dr. Tilson’s comments about adverse effects associated with the three COVID-19 vaccines. 

First, some basics for listeners who, like me, are not medical professionals.  The US Food and Drug Administration requires vaccine providers to report all serious adverse effects to the Vaccine Adverse Events Reporting System, or VAERS. Furthermore, all cases of COVID-19 that occur after vaccination and result in hospitalization or death must be reported. For good measure, the US Centers for Disease Control and Prevention – the CDC – encourages vaccine providers to report any clinically significant adverse event, even if it’s not clear that it was caused by the vaccine. 

So what have we learned?

Well, we’ve learned that serious adverse events don’t happen very often at all after COVID-19 vaccination. But there have been three main ones documented.

One side effect that received quite a bit of attention is Thrombosis with thrombocytopenia syndrome or TTS. Basically this is when a person has blood clots and low platelet counts.  TTS can cause long term disability or even death. This side effect is associated specifically with the COVID-19 vaccine developed by Johnson & Johnson. Federal regulators temporarily paused administration of the J & J vaccine this spring until they could better understand the risk of TTS. Inoculation resumed in April after it was determined that the clotting syndrome occurred in about 3 out of every one million individuals vaccinated. In a Morbidity and Mortality Weekly Report released August 10, the CDC estimated that there have been 26 confirmed cases of TTS associated with COVID-19 vaccination, including 4 cases that resulted in death.

Another side effect associated with the Johnson & Johnson COVID vaccine is Guillain-Barre Syndrome, a rare neurological disorder that causes pain, numbness, and muscle weakness. In the most severe cases, patients can become paralyzed. However, most people eventually recover fully from Guillain-Barre. VAERS data suggest that Guillain-Barre or GBS develops in about 8 out of every 1 million individuals who receive the J & J COVID vaccine. To date there have been 61 confirmed cases.

The third serious side effect associated with COVID-19 vaccination has been seen in people who received either the Moderna vaccine or the Pfizer vaccine. It is myocarditis, or inflammation of the heart muscle. This condition can reduce the heart’s ability to pump or cause rapid or abnormal heart rhythms. In the most serious cases, blood clots can form and cause heart attack or stroke. Myocarditis developed in 3.5 out of every 1 million individuals inoculated with either the Moderna or the Pfizer vaccine. And to date, there have been as many as 43 confirmed cases. 

As of late July about 187 million people had been vaccinated with one of the three vaccines. If you add up all the serious side effects I just mentioned, there have been 130 documented cases of serious side effects. That means just .000069 percent of all individuals who have been vaccinated have experienced a serious side effect. And that is why Dr. Tilson and others says that adverse effects are very, very rare indeed. 

I feel that I’d be remiss if I didn’t mention another data point available from the vaccine reporting system. And that is that more than 6,000 deaths have been reported among individuals who have been vaccinated against COVID-19. However – and this is critically important – deaths must be reported even if there is no information to suggest that the vaccine had anything to do with the patient death. Someone gets the COVID vaccine and dies in a car crash, it gets reported to VAERS. Someone gets the vaccine and then drowns while swimming, it gets reported. To date the only deaths that have been confirmed as having been caused by a vaccine are the four deaths associated with the blood clotting syndrome. 

If you’d like to look at the data yourself, we have posted a link to the MMWR report these numbers came from on the MedBoard Matters show page. You can find it at www.ncmedboard.org/podcast.

Podcast wrap-up: 23:56

Well, that brings us to the end of another episode of MedBoard Matters. 

If you feel the information discussed on this episode is useful, I’d like to ask you to share it with your friends and colleagues. If our state is going to be successful at meeting its goal of raising vaccination rates, we’re going to need all hands on deck. 

If you have comments or questions about this podcast, please email them to me at podcast@ncmedboard.org. Thank you for listening. I hope you will join me again.