Part 2: National Vaccine Advisory Committee Recap with Chair Robert Hopkins

November 2, 2020

Robert Hopkins, chair of the National Vaccine Advisory Committee, discusses the most pressing issues coming out of the recent NVAC meeting and pharmacy's role amid the COVID-19 pandemic.

Drug Topics®: Hi, I'm Gabrielle Ientile with Drug Topics® and today I'm going to be speaking with Dr. Robert Hopkins, the chair of the Health and Human Services’ (HHS) National Vaccine Advisory Committee (NVAC) about their sessions that were held virtually in September.

Dr. Hopkins is a professor of internal medicine and pediatrics and director of the Division of General Internal Medicine at the University of Arkansas for Medical Sciences in Little Rock, Arkansas. He is also associate program director of the UAMS internal medicine-pediatrics combined residency, and chief of adult medicine at Arkansas Children's Hospital, and we're very excited to have him on Drug Topics® and Medical World News from MJH Life Sciences.

To start out, can we start with you introducing yourself, a little bit of your professional background and your work with NVAC?

Hopkins: I'm Robert Hopkins. I'm a professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences. I trained in a combined med-peds, or internal medicine pediatrics residency, and I've been on faculty here at UAMS since I completed my training in 1993.

And currently, I'm the director of the division of General Internal Medicine. I'm an associate program director for our med-peds residency program. My most recent role is that I'm running our drive-thru COVID screening program.

I'll give you my philosophical intro first. Particularly when it comes to the issue of pharmacy and medicine in general, and on the topic of vaccines, I think right now we're in a time where we have to recognize that really everything we do, when it comes to prevention, when it comes to interacting with the public, if we're not focusing on them as team-based activities - meaning me as a clinician at an academic medical center, my colleagues in our on-campus outpatient pharmacy, those at Walgreens or CVS or the mom and pop pharmacy, that's 2 blocks up the street - if we're not all trying to work together to get our patients vaccinated, whether it be a 3 to 18 year old or somebody that we've traditionally done, 18 and above, we've got to communicate back and forth from both directions.

But if the pharmacist, the practices, the public health, folks, the hospitals aren't working toward the same goal, we're never going to get where we need to be with vaccination. And, we've done really pretty well with childhood vaccination up until COVID slapped us in the face. But I think given the extraordinary situation, I know many of my colleagues and pediatrics are pursuing administrating vaccines to kids, because of the concern about that being 1 of the things that really gets kids into the primary care office. But right now, we're not getting a lot of those folks, those families and kids coming in anyway. And we need to do anything we can to try to support the vaccination efforts. And so that's my philosophical underpinning to everything I say.

Drug Topics®: I saw that some presentations also advocated for the importance of avoiding the “twindemic” of COVID-19 and the flu. And that we can avoid the twin damage partly by having a unified national message promoting the flu vaccine. And they gave example of Australia's response, do you believe that we've been able to create and maintain this unified message on vaccination and this pandemic?

Hopkins: I think we've been working toward that. I think the messaging coming out of HHS, coming out of CDC coming out of public health agencies, and coming out of academia and practice, I think all of us are speaking with the same voice that we really need to get as many people vaccinated as possible.

The challenge that we're faced with, though, and you may have heard this from some in the pharmacy community also, is we have received our initial orders of the vaccine, but I understand that there are some challenges in getting additional vaccine for those that need more vaccine available, that most of those supplies have been bought up by the federal government. We're going to have a challenge if we're going to vaccinate more than our usual numbers in getting that additional vaccine out so that we're able to get it into people's arms. The communication strategy is moving in the right direction.

We still have some work to do, particularly to some of our communities where people are not normally accepting of vaccines, and those that have trust issues with the healthcare system in general. But those communications need to continue. We need to continue to work with people to build that trust, 1 on 1 as well as within the community.

Drug Topics®: And then in regard to immunization, more broadly: one of the September presentations homed in on how the pandemic has produced declines in adult immunization rates including herpes zoster (HZ) coverage, which declined by 67%.

So how can pharmacists proactively increase these other immunizations’ uptake among patients amid this pandemic?

Hopkins: Well, I think we have to do several things. First, we have to make sure that our pharmacists, much like our providers in other practice settings, have appropriate personal protective equipment (PPE).

We need to make sure that our patients, our community members that are coming in to the pharmacy, know that they have an opportunity for safe and effective vaccination in the pharmacy; that the pharmacist has the protective equipment when they come out to vaccinate them, that they've got their mask, their face shield or goggles, they've got plenty of gloves, so that they can vaccinate the patient and give them confidence that this is a safe interaction.

The physician needs to be communicating with patients, particularly our Medicare patients who are going to have to get that shingles vaccine primarily through the pharmacy to get it paid for, that it is a safe and effective thing to do to get your shingles vaccine now. You're going to be going into your pharmacy anyway to get your prescription medications or other things, let's get that shingles vaccine done if it's not already been done.

We've got to have the communication piece and we've also got to protect those that are doing the immunization and receiving immunization.

Drug Topics®: And then you mentioned confidence. Confidence has been a big issue and a big question in terms of this COVID-19 vaccine, and several studies have addressed a lot of mistrust. And so how can pharmacists and more broadly, healthcare professionals, address patient questions about the safety and efficacy of vaccines?

Hopkins: Well, I think we need to focus on 3 factors. Number 1, the vaccine development process for these COVID vaccines is requiring all of the same steps that we normally require to approve any vaccine in this country. You have to go through preclinical studies, you have to go through phase 1, phase 2, phase 3 studies. And equally importantly, after the vaccine is approved under emergency use, or a license application, there's the phase 4, which is ongoing evaluation of safety in that vaccine, once it gets into the community. Those process steps remain.

What we've done with Operation Warp Speed (OWS) is instead of having those being in a series, in a line along a graph, many of those steps are now being done in parallel. By doing it in parallel, we don't skip a step, we maintain all of those same steps, but we do them at the same time. That increases cost, because not only are we doing those evaluation steps, but we also got factories being geared up to produce these vaccines. If a vaccine turns out not to be effective, or as unsafe, that's lost. We're not going to use an unsafe product or a product that doesn't work.

We're investing a lot of money to make these processes happen in parallel, but we're not skipping steps. We're going to evaluate the safety of these vaccines very carefully through the federal process as well as experts from outside of the federal government to evaluate safety. I think we need to reinforce those messages, and that while we're going to start with vaccine not available for everybody that wants it, we're going to have to start with a tiered set of recommendations. We will move from highest priority meaning highest risk first to wider use as soon as we have vaccine available. And we all need to work together to make that happen and protect as many people as possible as quickly as possible.

Drug Topics®: So earlier you mentioned sessions focused on minorities. I wanted to ask you a little bit about that: they tackled consistently lower adult vaccination coverage and minorities, a trend that hasn't really been addressed according to the NVAC presentation that I sat in on. Do you see pharmacy as being a place of impact in guards these inequalities in vaccination, especially for the flu and COVID vaccine?

Hopkins: Well, I think that that is it is an it's going to be an ongoing challenge, and it's one, again, that we have to come back to consistent messages across professions.

I think about if I have somebody that comes in to see me as a new patient, particularly somebody that's from a poor community, doesn't have a whole lot of financial resources, and may have misconceptions or concerns about trust in the health care system. When I interact with that person, I want to be as clear and as professional as I can throughout that interaction. I would hope to do that for everybody that I see.

But it's particularly important that those that are from communities that have been under cared for in health care and across our society, recognize that. I'm going to have to work to build that trust with every encounter with that patient, to the point where they understand when I talked to them about, I strongly recommend you get a flu vaccine today, because I want you to have the same protection I give to myself, to my family and my team.

I want them to understand that that's being given as a strong recommendation based on knowledge, science, and that they have faith in me to accept that. I think it's the same kind of process with a pharmacist. I think if you talk to patients in the community, many of them have great faith in their pharmacist, particularly when you think about the fact that people go into a pharmacy far more often than they go into the doctor's office. So we need to make sure that we reinforce those messages of safety, of efficacy, make a strong, proactive recommendation for those vaccines, so that we can protect our patients. Because vaccines do no good when they're on a shelf. It's only the act of immunization that helps protect patients.

Drug Topics®: And then I'm thinking of Dr. LJ Tan’s presentation, which touched upon the increased use in telemedicine, that we should be working towards creating innovative connections for vaccine recommendation. But he also said something to the effect of we can't administer a vaccine online. I was wondering how do you see telemedicine functioning in regard to improving vaccination rates?

Hopkins: Well, it's a benefit and a bust, is what LJ was trying to get across.

I look at you through the camera here, I can have you turn to your left, and I can vaccinate you, in theory in your right shoulder. But I can't actually get that vaccine into you. But what I can do is give you a strong recommendation for why this vaccine is important. I can make sure that in my system, that I have opportunities for you to either come into the office or come through our drive thru and get the flu vaccine. And if you're not wanting to do those things, or if you prefer, you're going to go to your pharmacy tomorrow, well Gab, go to your pharmacy tomorrow and get your pharmacist to give you your flu vaccine.

I want you protected. If it will help facilitate things, I'm happy to send that order your pharmacist so he knows that we're communicating that you need the vaccine. And what I ask on return is that they also put that information in the registry or pop me back a quick message let me know that the vaccine was done, so that we all reinforce that communication, and that we're all working toward that patient's health.

Drug Topics®: And then another presentation also expressed that in order to return to the country's vaccination rates to pre-COVID, in part what needs to happen is ensuring that clinicians are compensated for increased costs of innovation. What do you see as needing to change in order to make that clinicians and pharmacists are also being supported in this pandemic?

Hopkins: Well, there are a couple of challenges there. I think the vaccine administration fees that are paid by Medicare for adult vaccines are pretty reasonable. Unfortunately, the vaccine administration fees that are paid by Medicaid are variable across the country. There are some places where the vaccine benefits, these are pretty reasonable, and others where they're minimal.

And we have to recognize that it costs money to run a refrigerator. It costs money for you to have staff to inject vaccines. It costs money to keep the lights on in the office, to have an electronic medical record in for you to provide information that goes to the state immunization information system.

And we need to make sure that there are supports in place that we're able to do those things, to provide the vaccines and actually vaccinate in our communities. And we have not done that as uniformly as we ought to. This has been a real challenge for pediatric practices for many years. The practices that provide most of our childhood vaccines to the vaccines for children program are vaccinating a large number of patients covered by public programs that don't provide much in the way of vaccine administration coverage. And we've got to pay for that, whether the vaccine is administered in the pharmacy, in the office or in public health.

Drug Topics®: Are there any topics that you feel that we didn't cover that you want to touch upon or any last takeaways that you wanted to talk about?

Hopkins: I think it we are in an unprecedented time. I think it is absolutely critical that all members of the healthcare community, from those that clean the floors, to those that give the vaccines, to those that make the recommendations. Pharmacists, physicians, all other health care providers, we've all got to be working together in order to get our patients protected to recover from this COVID epidemic.

I'm not wearing my mask now, but I will tell you, it's I think it's absolutely critical that all of us wear masks, that all of us wash our hands regularly. I think if we're working in a healthcare setting, whether in the pharmacy or in the physician office, in addition to the mask, we also need to use eye protection.

We've got to protect ourselves and the healthcare community, but we've also got to protect our patients and protect our communities. And so we all need to be speaking with the same voice on these areas and if we're not all collaborating, we're missing an opportunity.