Viral hepatitis is an ongoing public health threat, despite the long-standing availability of effective vaccines for hepatitis A and B. Tune in as experts Paul Kwo, MD, Jewel Mullen, MD, MPH, MPA, FACP, and Su Wang, MD, MPH, FACP, discuss the burden of hepatitis A and B in the United States, risk factors for infection, and current evidence-based recommendations for hepatitis A and B vaccination.
Viral hepatitis is an ongoing public health threat, despite the long-standing availability of effective vaccines for hepatitis A and B. Here, experts Paul Kwo, MD, Jewel Mullen, MD, MPH, MPA, FACP, and Su Wang, MD, MPH, FACP, discuss how to incorporate knowledge of hepatitis A and B risk factors and disease burden into patient counseling to enhance uptake of hepatitis A and B vaccines. Topics covered include:
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Presenters:
Paul Y. Kwo, MD
Professor of Medicine
Director of Hepatology
Stanford University School of Medicine
Stanford, California
Jewel Mullen, MD, MPH, MPA, FACP
Associate Professor of Population Health and Internal Medicine
University of Texas at Austin Dell Medical School
Austin, Texas
Su Wang, MD, MPH, FACP
Medical Director, Center for Asian Health & Viral Hepatitis Programs
Cooperman Barnabas Medical Center/RWJBarnabas-Rutgers Medical Group
Assistant Clinical Professor, Rutgers New Jersey Medical Group
Florham Park, New Jersey
This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
DeLIVERing Prevention Podcast: Optimizing Uptake of Hepatitis A and B Vaccination
Ongoing Threats: Hepatitis A Virus and Hepatitis B Virus
Dr. Kwo: Okay. So, thank you very much. So, let's now discuss some of the ongoing threats, and we're going to discuss Hepatitis A and Hepatitis B.
Global Death From Viral Hepatitis Exceeds HIV Infection, Tuberculosis, or Malaria
I think what we can really take from recent data are that viral hepatitis, despite some of the enormous advances that we've made, still contributes substantially to global deaths. And in fact, global deaths from viral hepatitis now exceed other major public health infectious diseases, including HIV, tuberculosis, and malaria.
But viral hepatitis continues to be a major health threat. And we obviously require interventions to mitigate these outcomes with viruses that can be and should be treated.
Hepatitis B Risk Factors and Vulnerable Populations
And so, just risk factors for Hepatitis B, the dominant risk factor is the age at infection. And the chronicity levels are dramatically higher if you are infected as an infant. Again, highlighting the importance of vaccination. With chronicity rates above 90% in infants, yet chronicity rates in adults are very low, less than 5%. Most acute hepatitis B infections result in elimination of the virus, particularly in adults, through development of hepatitis B surface antibodies, which provides protection against future infections with the hepatitis B virus.
CHB Prevalence Among Foreign-Born and US-Born Adults in the U.S.
When we look at the epidemiology in the United States, the prevalence really comes from foreign-born and U.S.-born adults in the U.S. Foreign-born hepatitis B prevalence is highest and drives the total prevalence of chronic hepatitis B. U.S.-born, again, is a small representation of this group, and it's typically in younger age, in non-Hispanic Asian adults.
And if we look at, non‑Hispanic Black adults, you can see slightly different patterns here, where you have both U.S.-born and foreign-born, both substantially contributing to the total burden of those who have chronic hepatitis B. And again, with increasing age, the number of people who are U.S.-born does increase over time.
Dr. Mullen: And Paul, this is part statement and part question. And looking at the data on non‑Hispanic Black adults, the younger age distribution, you make me wonder whether or not there are opportunities for us to increase our surveillance around people who might have other diseases, such as HIV, who should also be screened for hepatitis, and whether or not, the underlying risks in those groups, you know, is different enough that we need to remind ourselves as we care for adult patients to also consider their other risk factors for hepatitis B.
Dr. Kwo: Yes, I agree with you. None of these diseases occurs in a vacuum. And I think that we should take, therefore, a holistic approach to screening, right? If we're going to screen at-risk populations, we are screening across a variety of diseases, particularly because we have effective therapies for many of the diseases that we are now screening for. But I agree with you. This data does suggest that we need to step up our surveillance efforts here in these groups.
Importance of Vaccination in Hepatitis B Elimination Efforts
And let's just briefly talk about the importance of vaccination in hepatitis B elimination efforts. And so, just like with almost all infectious diseases, vaccination is the most effective intervention for controlling and eliminating hepatitis B infection.
The WHO now had set really ambitious targets to try to eliminate hepatitis, viral hepatitis, as a threat to public health, and had targeted a 90% reduction in hepatitis B incidents and a 65% reduction in hepatitis B mortality by 2030. To achieve this target, this is going to require 90% vaccine coverage, because elimination requires prevention of disease, and treatment alone is not going to eliminate hepatitis B as a threat that leads to and contributes to worldwide mortality. Again, when it comes to vaccination, the birth dose vaccination, especially when given within 24 hours, has the greatest impact on this particular goal.
Example from Taiwan: Benefits of Universal Vaccination
And also, what has been demonstrated now in well-controlled studies are that hepatitis B vaccine, or what has been demonstrated is that the Hepatitis B vaccine really does generate tangible benefits. And here's an example from Taiwan showing the benefits of universal vaccination. And this was a study of records from two national cancer registries from Taiwan after universal hepatitis B immunization that was initiated in July of 1984.
And what was found was that there were reductions in hepatitis B surface antigen prevalence, acute hepatitis B, chronic hepatitis B, and importantly, HCC incidents. As we've said, hepatitis B is the driver worldwide of hepatocellular carcinoma.
The incidence rates declined substantially amongst all of these in the period from July 1984 to June 1998 compared to prior eras where hepatitis B vaccination was not available. And again, as the cohorts got older, the reductions persisted throughout the various age groups.
Key Points
So the key points really are that despite the availability of vaccinations, viral hepatitis remains a serious health threat.
Disparities for incidence exist, and vulnerable populations are at higher risk of infection. These are populations that we must seek out for vaccination.
And while most infections are self-limiting, hepatitis B and hepatitis A can lead to significant complications ranging from chronicity of hepatitis B to severe presentations with viral hepatitis B, as well as viral hepatitis A that could include acute liver failure.
And again, as we've said, Hepatitis B is associated with chronic infection, particularly in the perinatal period and infant stage. But even in adults, there's a risk of chronic infection. And happily, we have interventions, which can reduce and mitigate these risks substantially.
Navigating the Recommendations: Current Evidence-Based Recommendations for Hepatitis A and B Vaccination
Dr. Wang: Thanks, Paul. That was really great. It's great to see such – the data and especially on such a broad scale in terms of interventions and how they've really made a difference.
So now, we want to move over to navigating recommendations. And I'm going to present current evidence-based recommendations for both hepatitis A and B vaccination.
ACOG Recommendations for Vaccinating Pregnant Women
So, let's start off with vaccinations for pregnant women. And these are the recommendations from ACOG. So for hepatitis A, it's recommended that we minister the vaccine to pregnant women if risk factors are present.
So if the woman's traveling to an endemic area, if there's close contact with infected individuals, or if there's been consumption of contaminated food and water. And you can also use it as a post-exposure prophylaxis if post-exposure prophylaxis is indicated but unavailable.
And for hepatitis B, it is recommended all pregnant women should be tested for hepatitis B. And the CDC recommendation for testing is a triple panel, which includes the surface antigen, the anti-HBC or the core antibody. It should be a total, not the IgM. And then the anti-HBS or the surface antibody to the hepatitis B surface antigen, if it's not documented. But it's important to note that for pregnant women, it should be for every pregnancy. So, even if they had a testing in a previous pregnancy, they will be retested in the first visit generally of their next pregnancy.
So and then for those who test positive, surface antigen-positive, and have hepatitis B, it's important to then assess the viral load. So that's the HPV DNA, which should be tested. And if it's over 200,000 IUs per ml, then it's recommended to start antiviral therapy, which could be TDF or TAF at this point, and it's recommended to start it per the latest ASLD guidelines to start at the 28th week. And it can be stopped right after birth, or it can be continued for various reasons, either wanting to complete vaccination or if the mother wants to continue on antiviral therapy. And importantly for infants of those women with hepatitis B, it's important to administer the HBIG, immunoglobulin and the Hep B vaccine, within 12 hours of birth.
So, important message is that both of these hepatitis vaccines are considered very safe and efficacious during pregnancy. So if a woman is found to be non-immune to hepatitis B, so, the surface antibody is negative and they've not been vaccinated, then it is safe to give them the hepatitis B vaccine during pregnancy as well.
AAP Hepatitis B Pediatric Vaccine Recommendations: Unchanged
All right. So this is the vaccine recommendation for infants. And this has actually been in change by the American Academy of Pediatrics.
And so, the AAP continues to recommend that the first dose of hepatitis B, which is the birth dose we call it, that it would be actually administered within 24 hours for every newborn in the U.S. And the goal is to really prevent mother-infant transmission. It's done amazing – it's had an amazing impact in the U.S. actually in terms of preventing 70-95% of transmission of infants born to hepatitis B surface antigen woman. And it's not just to mother to child.
It's really helpful for preventing household transmission too. So, a lot of times we may know the mother's status, but the father may not have been tested. The grandmother may not have been tested. The caregiver may not have been tested. And so, by giving a baby a birth dose, you blanket protection that baby from any kind of exposure that may exist. And very commonly infants can get hepatitis B transmitted from caregivers, just from innocent things like they may have a cut on their hand, or there may just be some exposure, maybe from nail clipping or something that, you know, it's just, we don't think about this microscopic blood. And so, that vaccine protects the infant from any infected caregivers or family members.
And then thirdly, it can protect the baby in case of medical errors. This is very unlikely, but you know, we've heard of cases of this as well. So, it provides a safety net to prevent perinatal transmissions when medical errors do occur. And it may be something in the hospital, maybe something outside, people are doing ear piercing. Sometimes babies get their ears pierced really, really early after birth. And this will also protect them from any injection-related infections.
Infants of HBsAg+ mothers: HepB Vaccine and HBIG First Dose Schedule for Newborns
All right. So this is the schedule for infants of Hepatitis B surface antigen mothers, where they don't just get the birth dose, but they also get the immunoglobulin. And that's the HBIG. So the HBIG gives the baby instant protection, whereas the vaccine takes a little while before the baby's immune system begins developing antibodies.
And so, if they're over 2,000 grams, then you would give the vaccine and the birth dose within 12 hours. And if they're not full term, then you would wait until the baby is at term. And some may not get it until after they're discharged. And so basically treat as if they're infected, if the mother status is unknown. And if they're negative, you would give the vaccine within 24 hours of birth, but there's not a need for the birth dose.
Pediatric Vaccine Recommendations: Hepatitis A
All right. And what about hepatitis A vaccines? So the AAP recommends that we give all babies two doses of hepatitis A vaccine. So the first dose is between 12-23 months of age. Second dose is 6-18 months after the first one. And the rationale is that hepatitis A causes acute viral hepatitis. And young children are often asymptomatic.
But what's interesting is that while they're asymptomatic, they can still infect other people. So a young infant or a child may have hepatitis A. They may not have any symptoms, but they could actually give it to adults around them. And depending on those adults, they may have more severe disease. So, it's also a way to kind of prevent ongoing spread of hepatitis A.
And for infants that did not get their vaccine, then there's recommendations for catch-up vaccines. So, up to 18 years of age, and you might prioritize them based on risk. So, people who are traveling to endemic areas, children in outbreak settings, or anybody with chronic liver disease or immunocompromising conditions, you might give vaccine even if they're after the infant age.
Childhood Vaccination: Shared Clinical Decision-Making
And as of January 2026, the federal recommendation shifted from recommending routine administrations for all children to immunizations based on shared clinical decision-making.
And so, some of the key elements, which I believe are important in all of us physicians are very aware of these elements, is to provide information on vaccine benefits and risks to the patient and family, and create an opportunity for the patient and families to ask questions. So, I think some of the conversations that have come up is like, "Oh, is this something new?" And I think a lot of us physicians are having these conversations with patients, explaining to them this has always been there. We always present the data about the vaccines and discuss kind of like patient preferences and look at the clinical scenario, because every patient is different in terms of risks and benefits. And I think it's almost like two things can be true, right? We can do clinical shared decision-making and follow data.
And one thing that the AAP has continued to kind of put out there is like, it's important for people to know and let families know that even the vaccines listed under shared decision-making are very important and that the science behind this has not changed.
Conversations with Families: How to Navigate?
All right, so how do we navigate this? I think listening and acknowledging concerns, questions that families have, clarifying any misconceptions, kind of explaining where some of this information, misinformation is coming from, obviously personalizing vaccine information. I think families really appreciate when we kind of bring it down to them and why it's relevant to them as patients or their children.
And also, reminding people and encouraging them to see vaccination as protection, especially for kids. You know, we want kids to be healthy and have all the opportunities in life and not end up being sick a lot or in the hospital. And so, kind of reminding them of how vaccines allow their kids to be healthy.
And then providing, connecting them with resources. So, AAP has a ton of great resources in different languages. The Hepatitis B Foundation has created a lot of really great materials for parents as well. So those are really important, I think. We do want our patients and our families to be educated. So, it's a good reminder for us to connect people to those.
So, I want to see if my colleagues have anything they want to add to this and how they've kind of tried to navigate some of these newer changes in the federal guidelines and recommendations from before.
Dr. Mullen: Well, Su, I think you outlined things really nicely. And as a primary care doc who's a doctor for adults, I'm an internist, I'm not a pediatrician, but I've actually liked to stand up for our profession in a way that you subtly said, we already do talk to our patients and remind ourselves that part of what we do in our professionalism is also offer the evidence-based guidance that you already listen to.
So, I never want to think that, one, a recommendation for shared clinical decision-making, even though hepatitis B vaccine for children has been put into that category, I never want that to be construed as some idea that suddenly the vaccine is less important because if it were less important, we wouldn't be having this conversation in the first place or if the risks were lower. But I also wouldn't want to send a message that doctors haven't already been talking to our patients, or I wouldn't want to send a message that patients don't value what we think is good for them, which is why, as I've read what the AAP has written over the years around strategies for discussing vaccines with patients, because many parents have questions, it's often acknowledged that strong recommendations actually help lead to more confidence in receiving a vaccine. So, it's more that balancing act along the way without abandoning the science, which is really important.
And just to dovetail on Jewel's very insightful comments, I'd just like to add that there are rigorous shared decision-making recommendations that the ACIP has put out that are, I just want to say are data-driven.
And we've already discussed one, the hepatitis B vaccination above the age of 60. That's a shared decision-making opportunity for our patients and physicians and care providers to get together to decide what is correct. But again, this is because this has been carefully vetted, and I think that patients and providers, as they discuss these vaccinations and the opportunities to move forward with them, should know that there's now been, because of the success of the policies, substantial data that supports that this reduces morbidity and mortality from chronic liver diseases, as well as chronic liver disease complications.
Hepatitis Vaccine Recommendations: Adults
So, moving from pregnant women, children, now we're going to move into adults.
So, for hepatitis A, it's recommended for adults at risk. So, those who are traveling internationally, and what often happens, and Jewel, you probably see this as a primary care provider, they come before their trip, we give them the Hep A, and then they forget to do the second one, right? They forget to come back six months later.
So, it's a good reminder, it's a two-dose vaccine, and you should come back for the second one. Even if you've missed the six months, still come back, we can still vaccinate you, or you can go to the pharmacy to have it done. Other people at risk are men who have sex with men, people who use or inject drugs, people whose jobs increase the risk of exposure, and people who are experiencing homelessness.
And now, for hepatitis B, and you can kind of see the contrast here, right? So, Hep A routine for adults at risk, it's not a universal recommendation, although it is for children, but not for adults. But for adults for Hep B, as Paul had said, we have the data now to say that we should be giving all adults ages 19-59 a universal hepatitis B vaccine.
And as Paul also mentioned, for those over 60, it's for people with risk factors in this list, but those without risk factors, it is under that shared decision-making framework. But the recommendation still stands that the benefits far exceed any of the risks for universal vaccination.
So this is the list for those risk factors for hepatitis B, many of them similar to hepatitis A, but additional ones, people with HIV, Hep C, elevated liver enzymes, diabetes, I think is often forgotten, but that's a reason to vaccinate everybody with – vaccinate with hepatitis B if you have diabetes, anybody on dialysis, any history of injection drug use, or sexual, or household contact. So if it's somebody you're living with, or your partner has hepatitis B, definitely want to get vaccinated, and then also history of incarceration.
Hepatitis A Vaccine Uptake in the U.S.
So, now we're going to talk about how we are doing in the U.S. and what the uptake has been. First, we'll start off with hepatitis A.
So in pediatrics, we have had some gaps in coverage, especially amongst adolescents who missed their childhood vaccination. And our coverage for two doses amongst adolescents ages 13-17 was 87.1% in 2024. In terms of our adult population, we've got a larger gap here, where unfortunately, in 2024, only a quarter, 24.8% of adults have had one dose. And in 2018, only 11.9% of adults have received the complete series. And I think partially this is a reflection that it's been a – it's not a universal recommendation, it's an at-risk recommendation. But I think as Paul mentioned, we've had a recent increase in hepatitis A due to some outbreaks, that's been actually an impetus for a lot of us pushing for more hepatitis A vaccination. And what I often tell patients is why not get vaccinated? Once you're vaccinated, you're protected for life. And even regionally, where I am in New Jersey, we had a number of outbreaks, not just in, like, where you might think of, like, people are at risk, like homeless situations or incarcerated, but actually in restaurants, in a couple of grocery store delis, and there was one at a country club. So what I tell people, it doesn't matter what your background is, there is always some possibility of being exposed.
Hepatitis B Vaccine Uptake in the U.S.: Newborns
So, let's talk hepatitis B vaccine in the U.S. in terms of newborns.
Looking at the vaccine uptake within 30 days of birth. And this is actually a really important one because this is part of us getting to hepatitis B elimination, universal birth dose. And generally we've been kind of hovering up to around 80%. The goal, if you remember, was 90%. We've actually had a little bit of a decline since 2024. And so, this is alarming. We really need to catch up. Otherwise, the more gaps we have, the more cases of chronic infection and potential liver disease we're going to see in this population.
Hepatitis B Vaccine Uptake in the U.S.: Adults
So we're going to look at hepatitis B vaccine update in the U.S. in adults now. So amongst people 32-59 years of age, 43.1% do believe that the Hep B vaccine is recommended for someone their age and with their health history. So, this is good. We feel almost 50% believe that it's recommended for somebody like them.
But only 30% had said that their healthcare provider actually ever recommended it. So we've got some work to do on our end as physicians kind of recommending it. So the big gap is people with risk factors are often vaccinated, but a lot of times it's the people without risk factors that don't get the vaccine. So, we want to make sure everybody gets the opportunity to get the hepatitis B vaccine.
So, now I'm going to switch it over to Jewel to talk about a vaccine uptake.
DeLIVERing Prevention: Strategies to Increase Hepatitis Vaccine Uptake in Clinical Practice
Dr. Mullen: Thanks, Su. And yeah, that point about making sure that everybody can get it continues to be, I would say, an imperative. And I think you and Paul really laid out nicely why a conversation like this is so important.
And as a primary care doc and public health practitioner, that combination oftentimes takes me back to sort of fundamental recognition of vaccines having been recognized as one of the 10 greatest public health achievements of the 20th century. And so, even as we highlighted and underscored the AAP and ACOG recommendations, and if we were talking longer and about different vaccines, we could add the American College of Physicians and others, then we would know that so many of the improvements in morbidity and mortality that you all have shown already are those that we don't want to see become declines in progress in the 21st century. And so, ongoing efforts to identify the best prevention strategies, I would call an all of medicine, all-public-health, all-of-pharmacy approach.
And sometimes we start with, well, how do you do that when people talk about how many barriers there are to vaccinating people or having the conversations now further perhaps compounded with where do we put in shared decision-making, which you covered so nicely.
Overcoming Logistical Barriers
So there have been various reports on how healthcare practitioners look at potential barriers.
Dr. Wang: I think it's interesting some of the biggest barriers are like the physician, the practitioner not knowing the patient's vaccine history and how many doses they've gotten, right? That is often the logistical thing where the patient's like, "Oh, I think I got vaccinated maybe once, maybe twice. I'm not sure." And then you're stuck like, do we just give you the next one or do we wait?
And so, I think it's helpful to really encourage patients to get all their health records together. And while pharmacies now do often have interface with our EMRs, it's not a 100%, but it's important for patients when they show up to try to document somewhere. I tell people just try to put it in your phone, right? Everybody keeps track of stuff on their phone, but that often is. And then I think what's helpful is knowing that it is okay to go ahead and vaccinate even if you're not sure, right? These are safe. And I tell people it's okay if we get an extra dose, it's still better than getting to not being vaccinated or not protected.
Dr. Kwo: Yeah, so I agree completely. And I agree with you. You had a very important point, which is that as our EHRs evolve, more of them will interface with pharmacies and other healthcare clinics for immunization.
In California, for instance, we can track the immunizations, and that's very helpful for us to be able to identify the appropriate candidates for vaccination. In addition, something that we work with our primary care physicians regarding is making sure that an evaluation of anyone who has any type of liver disease that needs to be investigated includes protective serologies as well, is an added measure to ensure that the appropriate people are identified. So, we do look to see if, you know, we talk about the triple panel as part of our screening.
We make sure we include core and surface antibody, but we also check for total HAV as well. And we just do this because even though, you know, hepatitis A is relatively endemic in the Pacific Northwest and the western part of the U.S., I mean, we still surprisingly, have individuals who require the hepatitis A vaccine. And it's essential that we identify these people.
Dr. Wang: That's a good point, Paul, that you can just we can also do serology tests. So, I often do that for my patients coming in for physical. I say we do serology tests for hepatitis A, B, C, you know, Hep C for the screening.
But, and usually by normalizing it and not thinking about risk factors, right, it becomes like a universal approach. We check everybody for HIV, Hep A, hep B and hep C. And then that's a great way to start, especially if they don't recommend their vaccine status.
Dr. Mullen: Okay, thanks.
Increasing Vaccine Uptake in High-Risk and Underserved Groups
So we touched on a little bit of this earlier in terms of identifying high risk groups and increasing uptake among them, including underserved groups. And, you know, I go back to keeping the system intact for supporting strong provider recommendations.
I don't think those are going to go away. And we talked about shared clinical decision-making. And a number of the models, shared clinical decision-making models incorporate a step that's called evaluate your patient's choice once you've had a conversation.
And the evaluation of a patient's choice is the perfect opportunity to say, I understand, and to also share your insights and thoughts about how what a patient might be leaning at a particular time matches up against what your strong recommendation would be. Because whether or not you're going to say, in a practice setting, you make it as easy as possible to have standing orders so that your vaccinator, your nurse, or whoever also knows that they don't have to come to you to have an order signed in the moment. There's the opportunity to revisit the possibility of vaccination for somebody who maybe in April said, "No, thank you," but comes back in June or July, and then a subsequent conversation is ready to go ahead. And you don't want to have the absence of an order there, keep someone from being able to then go ahead and get their vaccine.
And then once again, every visit can be an opportunity to look at some key preventive services such as vaccinations, so as not to miss them. And I oftentimes remind people if they think they're going to see somebody once or twice a year, don't wait until the next time. Seize the moment and do things.
Innovative delivery methods, fortunately, are becoming somewhat less innovative as community organizations, public health agencies, and then, other sites where people at risk are seen, as we see, correctional settings, homeless shelters, also collaborate with practitioners to be able to assess risk, start vaccination, but also coordinate a care transition so that if somebody leaves that setting, once again, you're able to keep going and continue a series. Taking the opportunity to remind people when co-administration with other vaccines is really safe so people don't have to think they have to sequence one visit after another just to get a shot.
And then to also think about, and maybe this is more relevant for some catch-up schedules for children as well, where you can accelerate schedules to get to completion.
So once again, I'm old enough to be able to state that I believe we're past the time when people are just rejecting the notion of electronic health records, no particular product to be named specifically. But increasingly, we're leveraging all of this to be able to improve the care we give our patients, and so, reminder systems. Integrating access to decision support tools – not for clinicians, as well as for patients – so that another part of what we can do for people who still have questions is give them tools, not just the tools of the words that we use, but things that they can hold on to and review for further discussion with us.
Anything you want to add?
Dr. Wang: I think scheduling their next appointment before they leave is huge, because people will come back, but then they will forget if it's not already scheduled. And then just as a reminder, so people know that hepatitis B comes as a two-dose vaccine now, which is really helpful because the two-dose vaccine is done in one month, so they don't have to spread it out with six months, and that's been shown to really improve completion rate too.
Dr. Mullen: Yeah. So, having information readily available that matches to a person's payer status is also really important, because it may seem that even if you don't stock a vaccine or you're not quite sure, coordinating with pharmacies, coordinating with public health departments, identifying risks in a risk category that maybe will qualify someone for a vaccine can also keep costs in and of itself as being a barrier.
Addressing Vaccine Hesitancy
Okay, vaccine hesitancy. Sometimes I hesitate to use the word "vaccine hesitancy," because we have talked about it so much, and so, you know, but acknowledging that not everyone says yes right away, I can say. There are many different reasons that someone might not readily accept vaccination once it's offered to them, and some of – and we're not going to get into all the reasons for that, but I will say that, especially among some of the groups that we've just talked about, you know, who might be immigrants, who might be underserved, whether or not it's language barriers or lack of information, sometimes the difference between accepting a vaccine and having confidence in a vaccine and not is whether or not they have adequate information delivered in a way that really suits their needs.
And so, that being said, having a conversation that gives people a chance to ask questions, to say what their concerns might be, to listen to them, and then respond in a culturally humble way, and there's no one-size-fits-all to what culturally humble means. No one-size-fits-all. It really is important to having a conversation that validates where someone might have concerns, addresses what some of their issues are, revisits any questions they might have, and then wrap up what's been discussed.
And some of that really is just what I also want to say is the heart of the ways in which many of us came into medicine to practice, and many of us still don't want to lose the ability to do, in our engagement with our patients, and that will go a long way. And with that, coupled then, I will say, with a potential strong recommendation, you've created a context in which a strong recommendation might feel less like an order or a directive and more like an expression of a recommendation for somebody's well-being. I'm going to ask my colleagues who are practicing physicians if there's anything they want to add to that.
Dr. Kwo: Yeah. And in addition, I would just say that I really emphasize, or at least when I'm discussing vaccination, the primary concerns arise from safety, and particularly because of just newer vaccines that have been introduced that, you know, just have, if you will, been associated with a variety of outcomes. And it is sometimes hard for patients, I think, to cut through all the information and misinformation that they hear.
But one of the things that I emphasize is that the vaccinations that we're discussing, hepatitis A and B, have enormous longitudinal track records for safety, including infants, including pregnant women, and so that there really aren't – there really now are just an abundance of data that show that what we're recommending is perfectly safe, and particularly, those with liver disease. These are people who derive just so much more benefit with essentially no downside.
Dr. Mullen: Right. And so, Paul, that point reminds me, you know, as we close up on vaccine hesitancy, that the discussion with a patient, really, the space needs to be a no-judgment zone kind of space because if somebody is a little bit questioning, or a lot questioning, or uncertain, we ought not come to us judging them. And we also ought not assume we know what's driving their lack of confidence about the vaccine.
Safety definitely is huge, but some of those other logistical barriers. There are logistical barriers for patients, too, around cost and around time, and around convenience, or around how many at once. So, this is even more why the whole interviewing, the whole conversation, is so key.
So, this is another really important piece around particular risk groups and the opportunities and barriers for them to get vaccinated. So, vaccines in non-traditional settings, for example, people who are already engaged in syringe services programs. In Austin, Texas, where I work, we have a huge collaboration between community paramedics, EMS, and physicians from our community health centers who do lots of mobile outreach.
And they, as well, along with healthcare providers in jails and prisons, are using these opportunities. And once again, someone who's willing to start there in the same way that they need all of their other medications need to have a transition plan that enables them to complete a series if it's not a one-time vaccine for something.
I think Su's point earlier about serologies is also a good one. And here, again, meeting people where they are, that other step to assess immunity and help people understand what their risk can be in the context of their life, way of life, and lifestyle is also important.
Anything you want to add?
Dr. Wang: Yeah, I think this point about injection drugs and people who use them in convenience, what I noticed is, in the CDC recommendations is that if somebody's at risk, and they're in a high-risk group, that you may just want to vaccinate without testing, which, as a primary care provider, is odd to me, right? Because I'm so used to, like, let's ascertain your serology first, and then look to see if you need it if you're not immune. But I think the point there is, like you were saying, seize the opportunity, right? Vaccinate them, make sure they're safe, and don't lose the chance to do that, because they may not come back.