Dirty White Coat
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Dirty White Coat
Vaccines in the ER: A Public Health Frontier
Dr. Rob Rodriguez, MD
Professor of Medicine
Associate Dean of Clinical & Population Health Research
University of California Riverside School of Medicine
Discusses his groundbreaking study examining vaccination screening in emergency departments across America. The research reveals a critical public health opportunity as 86% of ED patients aren't up-to-date on their vaccinations, yet nearly half would accept them if offered during their visit.
• Vaccination has saved more lives than any other public health intervention
• For 25-30% of Americans, emergency departments are their only healthcare access point
• Study conducted across 10 EDs in 8 cities focused on non-critically ill adult patients
• About half of patients were unaware of vaccines recommended for their age group
• Implementation could increase vaccination rates from 14% to potentially 48%
• Automating the screening process is the next step to avoid burdening ED staff
• Government funding for vaccines significantly increases uptake rates
• Recent political shifts have reduced emphasis and funding for vaccination research
If you're interested in joining this public health mission or have thoughts to share, please contact Dr. Rodriguez through the link in our show notes.
This is Rob Rodriguez. I'm an emergency medicine physician. I was at UCSF, on faculty there, for about 20 years, and now I am the Associate Dean of Clinical and Population Health Research at the UC Riverside School of Medicine, still practicing emergency medicine as well at our old stomping grounds at UCLA and at all of the that's right.
Speaker 2:And that is over 30 years ago. Oh boy, we got alt Really incredible time to train at UCLA with Jerry Hoffman there and so many other great faculty. It was an amazing time, particularly for me because I'd just gotten off the boat from Australia in the early 90s and Rob was one of the really fantastic senior residents that saved my ass many times. And I should say that Rob has actually triple boarded emergency medicine, internal medicine and critical care medicine. But now he is doing research at this new medical school in Riverside here in the Los Angeles sort of greater area and his focus is on underserved populations and vaccinations Quite topical right now.
Speaker 1:And one thing to know about Mel he's a surprisingly good basketball player.
Speaker 2:If you have not said that before, I personally have not said that I have not played basketball in years, and when he says surprising, he means for a not too tall Australian. But we did indeed have these epic basketball sessions after Grand Rounds at UCLA. It was some of the most fun I've ever had. It was just such a great bonding experience. You all know about it, who have done residency, those people that you go through residency with you've bonded to for the rest of your life because you've been terrified and you do terrible things and these are the people that know about them. But enough reminiscing. Let's talk about the study you just published in the MMWR.
Speaker 1:This study just came out about five days ago. It is a study that arose from really from three or four premises. The first one is that vaccines or vaccination have saved more lives than any other public health intervention, and that's really an undeniable fact. You can look it up in AI, google or whatever search engine you'd like, but vaccination has saved more lives than any other public health intervention.
Speaker 2:And I would just caveat that to say outside of the really basic public health stuff don't poop in the drinking water.
Speaker 1:The second premise behind this study screening for vaccines or screening for vaccination is a fundamental part of primary care. It's a fundamental part of public health care. It's a fundamental part of public health. And then the third premise is that we all know this is that there's a substantial portion of the US population and global population that lacks primary care and lacks public health. Their only health care access occurs in emergency departments and that's anywhere between 25 to 30 percent of the US population. We see that population every day in the ED and these are highly underserved groups, many of them either uninsured or underinsured, a lot of homeless persons or unhoused persons, a lot of immigrants and basically people that lack the funds to have a primary care physician. So the only place that these people can get primary care and public health interventions is during their ED visits. The ED is really their only healthcare access point.
Speaker 1:The thoughts behind this study, which we started about two years ago more or less we should do that. That is an important function of the emergency department. It's not as sexy as resuscitation or the pit, but it is just as important that public health function that providing public health to underserved populations. So we did this study at 10 EDs across the US, 10 EDs in eight cities, and what we did was basically perform a vaccination screening specifically only on adults. We didn't really want to get into the toddler and the childhood vaccination space, so we really looked at adults. And we looked at adults who were not critically ill. We weren't looking at those patients who were intubated or major trauma patients, but really the rest of the ED population that comes in and is able to participate in a short survey. And so what we did was we asked them adult patients demographic questions about themselves, how do they characterize themselves, and then we asked them a series of vaccine uptake, knowledge and uptake questions. And for every adult there and for different age groups, there are a series of vaccines that have been recommended by the CDC for that age group. And so we divided the adults into four age groups and we asked each patient, each participant, the vaccines, whether they knew about vaccine X, vaccine Y, vaccine Z that is indicated for them at their age group, and then we asked them if they had received those vaccines again, all the vaccines for their age group.
Speaker 1:Okay, and then we asked the people that were missing vaccines whether they would be willing to accept them. So the notable findings were that about half of people had not heard of or did not know about certain vaccines that were recommended for them. A whopping 86% of them had missed one or more of the vaccines that were recommended for them, or in other words, 86 percent were not up to date on their vaccines, and then about half basically 49 percent of those who were missing vaccines said they would accept them if they were offered to them in the emergency department that day. Overall, we performed that vaccination screening function for ED patients. We showed that it can be done, showed that there's a huge gap in both knowledge and, mostly, in receipt of vaccines and, finally, we've shown that a lot of people would accept them. A lot of people would accept them. A lot of people would accept the vaccines that they're missing, and that is the nutshell of our study.
Speaker 2:So back years ago, when Rob and I were even in residency, there was a lot of discussion about this, the role of public health in the emergency department, a lot of pushback then a lot of people saying this is not our job. Our job is acute care, medicine and public health should go to primary care. Well, my take on that now is that in the US, the horse has left the barn. 30% of the patients don't have primary care. You're primary care for them and we just have to accept that. We don't like that. It's the terrible system. But you have an opportunity to potentially significantly reduce morbidity, mortality in these patients that we're seeing. And if you just do the math on it, if we see 150 million patient visits a year, we're talking about tens of millions of patients who are not up to date on their vaccines and perhaps we can do something about that.
Speaker 1:And that's exactly how I feel and that's exactly where this space is moving. Many other notable public health provisions in the emergency department. We all do a number of things. Now I think the providers in the emergency department now are growing to become of that mindset Again.
Speaker 1:What we're talking about here we're not talking about bringing in people for these measures and it's not like we're advertising on the street hey, come get your vaccines. What we're talking about here is doing things when people have substantial waiting time in the ED. We're talking about the people that are already there. We all know the waiting times in the ED are huge, and so people offering services and offering public health interventions for that less critically ill group of patients who are basically sitting around in the ED, often bored Again. This is, in my view, as important, if not more important, than a lot of the other ED interventions, ed things that we do and can say. As I opened up with that statement, vaccination is the single most important public health intervention. It saved more lives than anything else and we should just be a part of that.
Speaker 2:So were my numbers about right when it comes to how many people this affects.
Speaker 1:We did a back of the envelope calculation and if we were to implement the vaccine screening, vaccination screening processes and, most importantly, referrals for vaccines, if that were to go through, we could potentially increase that up-to-date vaccination status from where it is now of 14% to as high as 48% is what our calculations determined and that would mean tens of millions of people becoming fully vaccinated and again preventing a number, probably millions, of cases of severe disease. And we're talking about. There are a lot of new vaccines that people simply do not know about, like the RSV vaccine. A lot of people still don't know about the shingles vaccine. I hope you've had yours, I had mine. There are a lot of adult vaccines that our patient populations, or underserved patient populations they simply don't know about it. When we interviewed them or when we surveyed them, I didn't know anything about that vaccine and I didn't know I'd seen or I've seen those, maybe that commercial, but I didn't know I was supposed to get it. So there's a lot of educational opportunity there.
Speaker 2:So again the pushback yeah, docs are working hard, they're working faster. I have to do more and more and more. You're asking them to do another thing. Is there a way we can simplify this process? I?
Speaker 1:completely agree and my team's next steps are to automate the process and take away that time-consuming burden on staff, the potentially time-consuming burden on staff, the potentially time-consuming burden on staff. We're looking at automating the process and hoping to implement that broadly across, especially safety net EDs. There are a lot of EDs over 70,. 80% of their ED census are people who black insurance and they perform that. All EDs perform a safety net function. But there are particular EDs, particular settings that are particularly have high underserved patient populations. We're looking to automate the process, move in that direction.
Speaker 2:So now we're a little politics. The current administration has quite explicitly very, very doubtful about vaccination. So where does this leave this kind of research, these kind of interventions?
Speaker 1:when we have people who really are questioning this basic fundamental public health principle. That's the trillion dollar question. We know from a couple of studies that we did during COVID in that when the government pays for vaccines there's much higher rates of uptake than when people have to pay for them. People often cannot afford them, and so there was a period in time the first three years basically of the COVID pandemic in which COVID vaccines were basically free, or at least vaccine portion of it was, and so a number of sites, ed sites across the country, including ours. We did a randomized trial of vaccine messaging for COVID vaccines and for influenza vaccines, and we found that during those times that a lot of people would take it Implementation studies. Both of those studies showed a tripling of the 30-day uptake of those vaccines COVID and influenza but at that time they were free.
Speaker 1:That is a quandary. Who is going to pay for these vaccines? It's my belief that the government really should pay for all vaccines. They have been shown to be cost-effective in terms of healthcare savings. They're one of the most cost-effective interventions that can be done, but there is a real challenge there getting it funded.
Speaker 2:What about at the most basic levels? We're seeing that funding is being removed for a lot of this research, for mRNA research. Where do you see this going? You've actually been a presidential advisor for this president during COVID.
Speaker 1:Yeah, I have deep concerns about the de-emphasis on vaccines since January of 2024. A number of people, including me, lost grant funding for that type of research, but fortunately we had finished most of this project and other projects and there's again a de-emphasis on vaccinations and that is highly concerning.
Speaker 2:There is a link in the show notes, and if you've got any comments, rob, we'd love to hear them and have more of a discussion around this, and we'll be talking much more about this in the future. There is now just an enormous amount of confusion about what vaccines are suggested by actual medical experts, and we're at a very difficult time now where we don't know exactly where to look for that information, the way we used to.
Speaker 1:Absolutely. I'd love to hear from anybody. This sounds sappy, but this could become my mission. I would say If anybody wants to join us in this endeavor, please contact me. Thank you.
