Watch the AMA's COVID-19 Update, with insights from AMA leaders and experts about the pandemic.
Featured topic and speakers
In today’s COVID-19 Update, L.J Tan, PhD, MS, chief policy and partnerships officer at Immunize.org (formerly Immunization Action Coalition or IAC) and the co-chair of the National Adult and Influenza Immunization Summit, discusses the importance of adult immunizations and "community immunity" in both the future of primary care, as well as preventing future pandemics. AMA Chief Experience Officer Todd Unger hosts.
National Immunization Awareness Month (NIAM) is an annual observance held in August to highlight the importance of vaccination for people of all ages. Visit the CDC website for more information.
Learn more at the AMA COVID-19 resource center.
- L.J Tan, PhD, MS, chief policy and partnerships officer, Immunize.org, and co-chair, National Adult and Influenza Immunization Summit
Unger: Hello, this is the American Medical Association's COVID 19 Update video and podcast. Today, we're talking about the importance of adult immunizations in both the future of primary care and the future of pandemics. I'm joined today by Dr. L.J Tan, chief policy and partnerships officer at the Immunization Action Coalition in Saint Paul, Minnesota. Dr. Tan is also the co-chair of the National Adult Immunization Summit and the National Influenza Vaccine Summit.
He's asked me to call him L.J for the rest of this interview. I'm Todd Unger, AMA's chief experience officer in Chicago. L.J, thanks so much for joining us again.
Dr. Tan: Todd, thank you so much for welcoming me back. It was a pleasure doing this the last time. And I'm just honored to be able to do it again. And just to let your listeners know, the Immunization Action Coalition just rebranded itself to Immunize.org, so essentially rebranded to our website URL. So easy for all of your listeners to come find us on the web.
Unger: That's excellent. I'm all about the branding. So I think that's a great move.
Well, it's been a while since we talked. But the last time we did, you spoke about the call to action that your organization, together with others, had issued to increase immunizations among adults. And since then, seeing a case of polio pop up in the U.S. and an uptick in other vaccine-preventable diseases. Let's start by talking about where we stand right now. Are we seeing declines in routine adult immunizations?
Dr. Tan: Yeah, that's a great question, Todd. And I think one of the challenges is that we're still seeing the impact of the pandemic reducing preventive care visits. And as you mentioned earlier in your introduction, that's still something that we care a lot deeply—care deeply about is—are these preventive visits.
And because of the reduction in preventive care visits, we're seeing lots of opportunity to give adults the vaccines that they're recommended for. So while we see a little bit of an uptick, in terms of the vaccination coverage rates, we are nowhere where we want to be or need to be. And so, that remains a challenge.
And the biggest part of the problem here is that we are struggling still in the United States with real time data. So in other words, being able to say right now, today, how many people have been vaccinated against a specific adult vaccine preventable disease? So we can look back at the data.
The most recent data we have goes back about a couple of years. So that remains a continual challenge, right? And so, having real time data will allow us to do more.
But we do know that there are resources that are coming soon. So for example, the CDC this past flu season, has introduced real time coverage data for influenza vaccinations. And that has turned out to be extremely useful, because when we know within a week where the coverage rate for vaccines for flu are, we're able to say, "OK, we're not where we want to be. Let's launch a campaign." Like, for example, AMA had a great campaign last year on trying to get people vaccinated against influenza, right?
So if we have real time data, we can react. And the great news is that there will be more resources in addition to what CDC has done. Vaccine Track is going to be launching on August 8. And for full transparency, it is a publicly accessible data platform. But it is funded by a vaccine manufacturer.
But it is publicly accessible. It uses medical insurance claims data to help identify vaccination trends. And again, to those of us in public health, having the ability to look at that real time data will allow us to map the answers to the questions that you're saying in a real—immediately and then, of course, react.
We can then say, hey look, pneumococcal vaccination rates aren't where they should be. What can we do to push them up, right? So again, it all starts with the data.
Unger: L.J there's a big concern now that, with the development of COVID vaccines and the pushback that we've seen from very strong antivaccine, anti-science aggression movement that has relied heavily on misinformation, that this might have spilled over into other routine vaccinations, both for adults and kids. Can you talk about what's driving some of the declines that we're seeing?
Dr. Tan: Yeah so, unfortunately Todd, it is absolutely true, what you've just said. Interestingly, at least in the adult population, before COVID hit us, there was not that much what we call vaccine hesitancy or lack of vaccine confidence in the adult population. Now, we've been dealing with this in the pediatric population for quite a while, ever since, obviously, some of the scares where surrounding measles vaccines and autism, right? So that goes back a while.
But in the adults, generally, that has never been that strong antivaccine sentiment. But because of COVID-19, there is now a stronger antivaccine sentiment among the adults. And unfortunately, because of the way some of the issues around masking and vaccination have become politicized, that has definitely spilled over. And what has happened is that those folks who are antivaccine, that antivaccine movement have begun to leverage that to actually impact routine vaccines, as you said.
So one of the things we're seeing at the state level, for example, are a lot of antivaccine legislation bills that initially started as anti-COVID vaccine but now have been broadened by the antivaccine movement to include school entry requirements, for example. And that is, for us, extremely scary as public health advocates because, as we know, we want to keep our schools safe for our children so that they can study and feel safe health wise.
And if we take away these school entry requirements, we're going to change that environment dramatically. And that's something we do not want to see. So absolutely, some of the declines that we've seen in coverage in routine vaccines is because of the fact that we've got some spillover from the antivaccine movement.
Unger: You use the very scientific term, scary. That's exactly what was going through my mind as you were talking about that. Is this the only driver? Or are there are other drivers out there that might be affecting this kind of immunization for routine immunizations?
Dr. Tan: So right now, this is one of our biggest concerns, because it does tie in with some of, as you know, the WHO has declared vaccine confidence or lack of vaccine confidence—some people call it vaccine hesitancy—as one of the biggest challenges for public health coming up, right? So it reminds us that that's still there. And that was before COVID. So with COVID, it has indeed become one of our primary drivers that we're concerned about.
There are other drivers for the decline in routine immunization coverage rates, one of which I mentioned earlier. Obviously, it's access to preventive care visits, right? Because people were sheltering in place, because people were not able to access primary care as easily, kids included as well as adults, we obviously had—we had less access to vaccination.
So that's beginning to shift. But one of the things I said the last time we were together, and it's still true today, is that it's not just about getting back to where we were in terms of coverage levels before COVID. Because we missed millions, and millions and millions of doses of vaccines during COVID, we have to catch them all up. And so, in order to catch them all up, we actually have to do better than where we were before COVID.
And that is the challenge that's facing us, is this idea that we have to increase access points. We have to increase preventive care visits. And then when we do that, we still have to do better than we were doing before. So that's another driver for those lower immunization coverage rates that we've seen.
And then, COVID is still here, as you know, Todd. And so, it is still this big thing that hovers over a lot of us, as we see this surge in BA.5 across the country. We all know there's data that shows that when COVID surged, preventive visits went down. And immunization coverage rates went down.
So that is still a very important driver is this big pandemic that's sitting behind us. And of course, monkeypox is beginning to rear its ugly head as well.
Unger: Well, we're going to talk about that in just a moment. But I think that that point you make there about, we're in catch up mode and these successive waves of COVID that are dampening people's routine visits put us at a—just a continuing disadvantage to get back to where we need to be. And just when we think we're seeing a light at the tunnel, we've got a potential new pandemic on our hands, monkeypox which you just talked about.
You said, quote, this reminds us all that we're still very vulnerable to the next pandemic. How is this situation, and a vaccine deployment and tracking been different from monkeypox and it has been for COVID? And has it revealed a continuing set of flaws, maybe, that we saw in our health—public health infrastructure that came very evident during COVID?
Dr. Tan: Yeah, I think the big thing it revealed to us is that—and I think the last time we were together, I talked about how this idea that we have to sustain this infrastructure that we have created for COVID-19. The other thing that this monkeypox outbreak has reminded us is that we still need to be able to coordinate within the government and within public health who is managing that outbreak.
So what was really interesting with monkeypox was that, because the vaccine against monkeypox was actually the vaccine against smallpox—so the vaccine against monkeypox, it was the vaccine against smallpox, right? And so, the vaccine supply that you hear people talking about was managed in what we call the strategic national stockpile. So it was part of a stockpile of medications and vaccines that we had kept for strategic reasons, such as bioterrorism, right?
The whole fear, if you remember Todd, when smallpox was—could be changed into a bioterrorist weapon. So the vaccine was kept in this strategic national stockpile. And so, when monkeypox hit us and we wanted to use that vaccine to treat—to take care of monkeypox, it was coming from a source that we had not used before, in terms of distribution, deployment, and tracking of vaccines. And of course, when you have that challenge, sometimes, the pieces don't necessarily align in terms of, as you know, there are silos. And sometimes, the silos take a little bit longer to communicate.
So what has happened is that, while we have this impressive COVID-19 vaccine deployment and tracking system that we built, the monkeypox vaccine that's going out is not being used inside that infrastructure. And absolutely, public health knows this. And we're beginning to reconnect the dots. But because of that, it has been very challenging to all the immunization managers in the states, as they're wrestling with one system for COVID-19 and then the second system for monkeypox.
But we're learning. And we're going to make sure that this—these flaws that have been revealed won't happen again in the future. So I think, this is something that we keep thinking and moving forward on, as we prepare for future pandemics.
Unger: It does sound familiar, because back to COVID, product and distribution, separate things and—in terms of the lessons that we're learning from the COVID era. Are there other ones, between this and monkeypox, that we're learning right now to strengthen the infrastructure you've talked about, to be better prepared for, really, whatever mother nature is going to throw at us?
Dr. Tan: Yeah, so I think this takes us back to the whole idea of routine adult immunizations. And I think, maybe, we'll be talking a little bit about this as we go forward as well. It's—I think, one of the big things that we've learned is that, firstly, public health was always underfunded. So that's a big one, right?
And then the second thing that we're learning, even with monkeypox, is that when there are diverse populations that we're trying to reach—and as you know, monkeypox right now is focused within the MSM population, or what we call the men who have sex with men population. When we have these diverse populations that we have reached, we need to do—we need to pay particular attention to equity. We need to make sure we're doing everything we can to firstly reach these populations and to get them the vaccines that they need, right?
So that's one—that's the second lesson we learned, right, is that we were underfunded—we have underfunded public health. We have had always had challenges with equity. We need to do better with that.
And then, the other thing I think we've learned—and this is the adult immunization component—is that we didn't have an adult immunization infrastructure. We had an adult—we had a pediatric immunization infrastructure that was very well established due to—partly due to a program called the Vaccines for Children program. But unfortunately, we didn't have a similar program in the adults.
And so, there was very few infrastructure support for when we needed to get a lot of vaccines out to adults very, very quickly. So we had to build that as a result of COVID. So I think one of the things I've learned now is that, if we had done our routine adult immunizations well, we would have had an infrastructure in place that would have been ready to respond to the next pandemic.
And so, going forward, we need to take what we have built with COVID and expand it to all routine adult immunizations so that we can sustain that infrastructure. So that when the next pandemic hits—and who knows what it will be—we're ready to—we're ready with an infrastructure that we can immediately use to immunize all the adults that need to be immunized or, even bigger, to get medications, antibiotics. You can use the same infrastructure to get that medication out to people who need it as well.
Unger: Do you think—in addition to, say, the infrastructure that you're talking about that there also seems to be a real issue around leadership, and who owns what and who is leading. Do you think the recent changes that have been announced by the administration, in terms of getting that leadership in place, is going to make a difference here? And how do we carry that forward into future challenges?
Dr. Tan: Yeah, I think that's a really good question, Todd. And I do think the changes are looking to address some of that. Some of these leadership changes trying to consolidate some of the programs are important.
However, I think it's—I think we have to acknowledge, we're dealing with a lot of moving parts, especially when you're talking about pandemic response, right? Because you're talking about testing, surveillance, epidemiology, vaccinology, research and development, and finding a way to intersect all of them under one common leader may not be possible. I think, in this case, we're talking about leadership communication as well, trying to make sure that leaders responsible for individual parts of this moving picture are able to communicate easily and without judgment. And I think that's important.
Unger: It is interesting. Back to your product distribution communication, we think about what it takes to get initiatives underway, how important it is to see all three of those things integrated. And I have to imagine that part of what you're saying is, it's—we really need to prepare for the future, have that infrastructure in place, have these systems in place.
I have to imagine it's pretty challenging to focus on the future when, as you said before, we're still in the pandemic right now. Now we have another one on top of that, new variants, new things being thrown at us. How do we manage through that current environment and prepare for the future at the same time?
Dr. Tan: Yeah, so I think this is the resource issue. I think one of our problems when we underfunded public health is that a lot of our public health workers are doing multiple jobs. And so, as a result, there's a lot of data out there now talking about what the impact of the COVID pandemic has been on public health workforces.
And they're stressed. There's a lot of depression. There's a lot of public health workers who just retiring, because it's been a really difficult three years.
And so, when you have an underdeveloped public health workforce, I think we're not able to proactively plan. We're reacting. That's what it is, right?
Something comes, we get—we build the COVID infrastructure, right? And as we take a breath and say, all right, now we can take this and respond, get ready to respond for the future, before we're ready to do that, we get hit by something else. And that same public health workforce is now asked to divert and manage this next outbreak. And then, when they're managing this, COVID variants pop up. And then that same public health workforce is asked to come back and take care of this.
So we need a more robust public health workforce as well, so that we can manage what we have to do proactively and also be able to react to the next outbreak, because the outbreaks are not going to be foreseeable. What is foreseeable is how well our workforce is prepared and how well our infrastructure is prepared. What's not foreseeable is that next outbreak.
I bring us back to 2009, H1N1. And we're talking about influenza pandemic preparedness. And we're talking about how—where we were predicting the next flu pandemic was going to emerge from. And H1N1 2009 came from Mexico. It totally took us by surprise, right?
So it is not foreseeable. That part is not foreseeable. So we will always have a reactive component. The job we have to figure out is be proactive and, yet, have enough resources to address the reactive at the same time.
Unger: Well, obviously, physicians play a critical role in getting us out of the situation that we're in and preparing for that future that you're talking about. And in terms of that future, you said that you think that immunizations, as an adult immunizations will be the next frontier for primary care. Tell us what you mean by that and how physicians can help be a part of the solution to that.
Dr. Tan: Yes, absolutely, so I think, let's start from that top level we talked about. If we had an adult immunization, a routine adult immunization program in the United States, right, where we're regularly giving the routine adult vaccines that are recommended—now, remember, there are six vaccines in the U.S. that are routinely recommended for adults.
There's flu. There's pneumococcal. There is hepatitis B. There is zoster, all right? There is Tdap, which is tetanus, diphtheria, pertussis and then, of course, COVID. So there's a lot of routinely recommended vaccines for adults now.
So if we get those into the arms, that's that infrastructure that we talked about earlier, right? That will be a big part of that. So how do we do that, right? It's got to be part of primary care. It's got to be that primary care discussion that every physician has with their patients.
And remember, physicians are the most trusted source of information for patients. So when a physician says, hey, I'm taking and owning primary care with you as my patient and part of that is a discussion about the routine adult vaccines that are required that you take, you are establishing that next infrastructure that we're going to rely on to handle the next outbreak or the next pandemic.
And so, I think this is how solutions—how physicians can be part of that solution by advocating, by assessing, recommending adult vaccines that are routinely recommended for their patients and giving them. They will create, not just in their offices but also at the local, at the regional, and then ultimately at the federal level, an infrastructure that will be resilient for the next pandemic.
Unger: L.J, I think I know the answer to this. But if we don't do what you're talking about, if we don't get back on track with these kinds of routine adult immunizations at the rates that we need, what kind of future are we looking at?
Dr. Tan: So that's scary to use that very scientific, word as you mentioned earlier, right? Because I think, if we don't get back to where we were, if we don't get our vaccine coverage rates back to where they were in both pediatrics as well as in adult care, we're going to see outbreaks.
We'll see measles coming back. We'll see mumps coming back. We'll see chicken pox coming back. And we'll see other vaccine-preventable diseases that we have essentially forgotten about returning, because we will reach a critical point where the, what we like to call the herd immunity—but I like the word the community immunity—has declined to a point where you are no longer able to protect each other because of the vaccination coverage rate has gone down so much, right?
And so, we'll see those diseases start to return. And I think people have forgotten that those diseases don't come without morbidity. They come with mortality. And they also come with cost impacts as well.
And then, heaven forbid, we see these diseases surge, like flu at the same time that COVID is surging. And then our health care system will have this surge impact. And then, as we all know, we've just been hearing this for the last three years. We're going to have to deal with that as well.
So there are dramatic consequences in terms of mortality, morbidity, cost if we get these outbreaks returning. So I think that's a significant reality check. I really hope we don't get there, Todd.
Unger: Same, L.J, thanks so much for joining us today, such important information. And—
Dr. Tan: Thank you.
Unger: —such a huge reason to get those immunizations. We'll be back with another COVID-19 Update video and podcast soon. For all our videos and podcasts, check out ama-assn.org/podcasts. Thanks for joining us today. And please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.