Is it Vaccine Hesitancy? (Thompson 9/22/2021)

Many thanks to Dr. Cherriese Thompson for a thought-provoking Grand Rounds this week titled "Is it Vaccine Hesitancy?" in which she explored the historical and present day impediments that make it challenging for BIPOC to accept and receive the COVID-19 vaccine and discussed ways to mitigate barriers to vaccine admin and acceptance. 

Dr. Thompson defined vaccine hesitancy as: "a delay in acceptance of refusal of vaccines despite availability of vaccine services". This definition, Dr. Thompson, told us, assumes a level of complacency, convenience and confidence. We may want to question these assumptions. 

A recording of her presentation is available HERE.

Here are my notes:

We all know that COVID-19 disproportionately affected BIPOC in the US with increased rates of hospitalizations and death over population levels (see image below)

Racial breakdown of vaccine trials: while these vaccine trials have been praised for inclusion and diversity, there is still much work to be done to be sure they are reflective of the population

Rates of vaccination by race/ethnicity (updated 9/21/2021):

Concerns about COVID-19 vaccination in communities of color include medical and structural racism, as well as historical and present day trauma

For Black/African American people

• Centuries-long history of experience of discrimination in health care, being ignored or dismissed: "if you haven't cared about me in the past, why should I believe you care about me now?
• slave ships in Middle passage: sick slaves thrown overboard or forced treatment
• medical experimentation on black women's bodies
• withholding medical treatment for slaves
• 1973: yellow fever outbreak, one physician believed black people were immune and didn't give treatment
• 1932-1972 Tuskegee study, knowingly withheld treatment to 400 black men for syphilis to watch the progression (100+ died) 
• Concerns about vaccine incentives: lack of trust in governmental organizations 
• "Medical racism: The New Apartheid" antivax organization, film specifically targets black communities, weaponized history of experience of black people, "should you really get this vaccine?", false claims regarding potential vaccine harm
• Social media: misinformation on Twitter and FB, e.g. Nicki Minaj (famous rapper) on Twitter:
  
  
  

For Hispanic/Latinx people

• concerns about female fertility
• concerns that the vaccine contains stem cells, ethical to take vaccine if prolife?
• worries that the vaccine itself may give you COVID
• Spanish language information (on Whatsapp and Telegram channels) discuss ineffectiveness of masks, vaccine ineffective
• Vaccine being used to track down immigrants and deport them

For Native American/Indigenous

• historical trauma leading to skepticism
• 1970: Family Planning Act: sterilization of more than 25% Native American women without consent
• 1989 Havasupai Tribe asked for assistance from John Martin, anthropologist to understand diabetes in their community; blood samples provided were used without their consent to study schizophrenia, alcoholism, inbreeding and origins and migrations of their people
• concern people might be injected with COVID from the vaccines
• huge concern about speed of manufacture
• historical distrust: "Am I willing to gamble that they care this time?"
• lack of involvement of their own populations in clinical trials

And, unfortunately, this is not just about historical trauma, but ongoing/current lived experiences for BIPOC

• 2.2020: Jean-Paul Mira, French intensivist suggested studying COVID in Africa where there are no masks, no ventilators, no resuscitation--> propose trialing meds in Africa to ensure safety
• 9/2021: Arkansas prisons: physicians giving ivermectin without consent (experiment) to treat COVID-19, "we never knew they were running experiments on us"
• 9/2020: ICE detention centers in Atlanta: immigrant women having hysterectomies without their consent/knowledge
• 2020 Dr. Susan Moore, family medicine physician and geriatrician in Indiana, died of COVID-19 2 weeks after videoing her story and expressing concern that her treatment at her local hospital was compromised due to her being black: having been called a drug seeker. "I put forward and I maintain that if I was white, I wouldn't have gone through that  . . .This is how black people get killed: when you send them home, and they don't know how to fight for themselves."

• 

  https://www.youtube.com/watch?v=7v1Oyp_bBGk

Reframe. This is NOT hesitancy. There are real impediments, many impediments. 

• Among the impediments: skepticism, lack of accurate information, actual vaccination access, including online only signups, issues with appointment scheduling transportation
• Having the time to be vaccinated: working multiple jobs
• Valid concerns about being unable to get vaccinated due to vaccine side effects and not be able to take time off work, or because you are caring for others
• Pharmacy Deserts (residents living >1/2 mile from a pharmacy), many exist in communities of color. A lot of these communities lack reliable transportation to get/to from pharmacies to get vaccines. CVS, Rite Aid, Walgreens, local pharmacies may not have capacity to carry and administer these vaccines 

Okay, what can we do?

1) Get more BIPOC included in clinical trials

• recruitment of diverse populations, particularly Native American communities-- working with sovereign government and respecting data sovereignty
• FDA: Enhancing the Diversity of Clinical Trials, ideas include reducing visit frequency, provide flexibility, using electronic communication if possible
• PhRMA's Equity Initiative
• building trust and acknowledging mistrust
• reducing barriers to clinical trials access
• utilizing real world data
• boost info of diversity and inclusion in clinical trial participation

2) Increase access to trusted information

• There is so much misinformation/disinformation out there, more accessible
• meet people where they are: go into the community, being present to answer questions
• being a resource to isolated populations
• Empower individuals to question info they see on social media, question the source, question the validity
• Provide trusted information: Voto Latino partnered with another organization to provider accurate info to Latinx (they also partnered with Uber/Lyft to transport Latinx to vaccination)
• CDC: information on vaccine equity, increasing uptake in racial/ethnic communities, communication toolkits, printed resources and posters in multiple languages

3) Improve access to vaccination sites

•     mobile vaccination units
•     reach places where access to healthcare is already a problem (rural and urban)
•     targeting opening vaccination sites within vulnerable communities (i.e. Roseland Library)
•     pop up vaccination sites
•     home vaccination (to the most vulnerable)
•     clinics and pharmacies providing access

4) Foster trust and utilize empathy

• creating a space for patients in the room
• take the power away, ask the patient "Can I talk to you about the COVID vaccine? What are your concerns? What have you heard about it? How has it affected you?"
• Create open dialogue to explore skepticism
• foster continued discussion
• provide accurate information
• show empathy: patients often will trust their doctor over time, if they felt heard/held

5) Shift the blame

• there will be skepticism; don't blame the individual patient for their skepticism
• relieve the blame to foster an environment of trust and open dialogue

6) Increase BIPOC pipelines in healthcare

• more funding and access for BIPOC in healthcare
• "Because I am black, and I have been vaccinated. . .and I hear your concerns. . .Here is what I experienced." That means so much to a lot of my black patients

7) Dismantle structures of racism inherent in medicine

Many thanks to Dr. Susan Milam Miller, who gave an excellent Grand Rounds this week titled "Caring for our Children, our Family, and Ourselves during COVID-19". Dr. Milam Miller covered a range of topics about our mental health in this pandemic-- from March 2020 as Alexander and the Terrible, Horrible, No Good Very Bad Day, to community and complex trauma, ambiguous loss, and unresolved grief, to trauma-informed care, and even a bit about the magic of a window into children's lives via video visits.

HERE is the recording of Dr. Milam Miller's presentation. 

Here are my notes:

Dr. Milam Miller reminded us that no child exists as as single entity-- children exist within their natural environment, including their families and their community. Listening between the lines to children and their attached adults is important. Knowing what their natural environment looks like is also key.

Clearly, here in Sonoma County, many children (and adults) have lived the trauma of several fire seasons and evacuations, compounded for the last year and a half by the COVID-19 Pandemic. These traumas have caused a tremendous amount of stress for many of us-- children are no exception. As such, we can expect to see signs of traumatic stress in our children.

Traumatic Stress manifests in a range of responses in adults and children:

• Emotional: emotional dysregulation (sadness, fear), numbness, detachment
• Physical: somatization (headaches, stomach aches insomnia), changes in brain function, hyperarousal
• Cognitive: how we think about ourselves and others, triggers, re-experiencing, nightmares/daymares, dissociation, dampening of connection via thoughts and emotions
• Behavioral: the way the mind directs the body: self harm, substances, avoidance (behaviors that are NOT adaptive over time, even if they help at first)
• Interpersonal: pulling away from loved ones, difficulty trusting and forming trusting relationships

Identifying these "adaptive" behaviors that may not serve us over time is key to helping our patients and ourselves survive the trauma. 

Community Trauma  is a strong and powerful shaper of relationships and health

How does a community emerge from trauma? How do we recover and repair? How do healthcare providers care for their community in times of trauma but also for themselves? How do we model for our children and families what healthy coping with community trauma entails?

Complex Trauma describes both children's exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure. ... They usually occur early in life and can disrupt many aspects of the child's development and the formation of a sense of self. In COVID times, the list of multiple traumatic events may be long

• what about medical trauma of repeated COVID testing?
• what about shutting down schools?
• what about losing church and extracurricular activities?

Ambiguous loss is a loss that occurs without closure or clear understanding. This kind of loss leaves a person searching for answers, and thus complicates and delays the process of grieving, and often results in unresolved grief. I personally found myself intrigued for the rest of the day by this notion of ambiguous loss-- classically a dear one who disappears on a hiking trip, never to be found again. What about these years of pandemic create ambiguous loss?

• what does it mean to have never finished fourth grade because schools shut down in March 2020?
• what does it mean not to have a graduation ceremony from high school?
• what does it mean to go through puberty during pandemic times without community support?

Trauma Treatment classically has 3 stages:

• Stage 1: Stabilization and establishment of safety (this may include psychotropic medications, DBT to help managing distress, relationship building)
• Stage 2: Addressing and processing of trauma memories or related beliefs and/or grieving the losses inherent in trauma (this is somewhat controversial but has been standard of trauma treatment)
• Stage 3: Restoring or creating connection between survivors and their communities by increased engagement in meaningful and positive activities and relationships

Unsurprisingly, in trauma healing, relationship building is key.

Trauma informed care

“Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. 

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice and choice
• Culturally, historic and gender appropriate

Relationship and relational care is everything. Dr. Milam Miller says at some point, we expend WAY too much energy on individual treatments and interventions, really we need to consider community interventions, group treatments, and shared treatments. I love 

Closing questions to ponder from Dr. Milam Miller

1) Who is your buddy? (i.e. the person you call, lean on, ask for help)

2) What does healthy coping look like in these times?

3) Can you recognize the ambiguous loss of this COVID pandemic for the families you care for? Once recognized, how do we process our grief?

Birth Equity (Jimenez, Lund, Bacon 9/8/2021)

Many thanks to Drs. Jimenez, Lund and Bacon for an important presentation on Addressing maternal health disparities and birth equity this week. A full recording of their excellent presentation is available HERE.

https://youtu.be/Y2uJEZyT1ZE

My notes:

What is birth equity? Birth equity is the assurance of the conditions of optimal births for all people with a willingness to address racial and social inequities in a sustained effort  

https://www.cmqcc.org

Dr. Jimenez led off with a review the concept of race. 

• The notion of race is a social construct designed to divide people into groups ranked as superior and inferior. Societies use race to establish and justify systems of power, privilege, disenfranchisement and oppression
• Scientific consensus: race has no biological basis (we are all one race)
• In a racialized society like the US, we are all assigned a racial identity, whether we are aware of it or not
• Geographic ancestry (which does have genetic importance) is not the same thing as race (which does not)
• 1700s, Carl Linnaeus, father of modern taxonomy, classified our own species into races based on reports from explorers and conquerors 
• Americanus, Africanus, Europaeus, Asiaticus, Monstrosus
• Western concept of race is based on a classification system that emerged from, and in support of, European colonialism

He followed with a review of racism and bias

• Racism is an organized system premised on the categorization and ranking of social groups into races, and devalues, disempowers, and differentially allocates desireable societal opportunities to racial groups regarded as inferior (Bonilla-Silva 1996)
• Racism often leads to the development of negative attitudes (prejudice) and beliefs (stereotypes) toward non-dominant stigmatized racial groups and differential treatment (discrimination) of these groups by both individuals and social institutions 
• Bias is a decision we make so quickly that it simply occurs to us as data; we don't even rela

Dr. Jimenez finished his section with real life examples of racism in maternity care (past and present) and an encouragement that we must begin to come to terms with our own past

• The 2018 story of tennis star Serena William's emergency c-section, complicated by PEs and failure of her physicians to listen to her and diagnose her quickly
• Slave-holding surgeon (Francois Marie Prevost) pioneered c-section surgeries on American enslaved women's bodies through repeated experimentation
• In the 1840s, J Marion Sims, father of modern gynecology, was a plantation physician and then gynecological surgeon in Alabama--> experimental surgeries on enslaved women for vesico-vaginal fistulas. Did not use anesthesia, despite it being readily available. Got rich and famous from his work.
• Consider reviewing the image below to understand how racism impacts obstetric care

Dr. Lund took part 2 of the presentation to review disparities in maternity care in the US

• Black women experience far worse outcomes than any other racial or ethnic group. Black women:
• are 3-4x more likely to die than their white counterparts
• comprise 13.5% of live births, but 35.5% of pregnancy-related deaths
• have higher preterm delivery (13.4% vs. 9%)
• have higher c-section rate (RR 1.23)
• have higher PPH rates (3% vs. 1.6%)
• have higher peripartum infection (4.9% vs. 4.1%)
• Pre-E, diabetes, and and unintended pregnancy are also higher for black women
• American Indian/Alaskan Natives (AI/AN) are also at risk for adverse outcomes
• Black and AI/AN infants are more likely to die in their first year of life
• black infants diet at greater than 2x rate of white infants (11.4 vs. 5.2 per 1000 live births)

California has been working hard since 2006 to reduce our maternal mortality rates, and it's working!

(this graph below shows a decline by 55% 2006 to 2013)

However, despite tons of successful work to reduce maternal mortality, the disparity ratio (black women vs. white women) remains unchanged (see image below):

Dr. Lund also shared some of our local stats at SSRRH

• ~50% of our deliveries are to Hispanic patients (~ 20% US-born and 30% foreign born)

• Another 37.5% of our deliveries are to non-Hispanic White identified Patients
• 4.5% of births to Asian or Pacific Islander patients
• <2% of our deliveries to non-Hispanic Black identified Patients
• About 2% “other” which primarily represent American Indian/Alaskan Native patients
• A full 6% were race/ethnicity “unknown”

Dr. Lund shared important outcomes for our maternity patients, including NTSV c-section rates, maternal morbidity, preterm birth rates, unexpected newborn complications, and exclusive breastfeeding at discharge:

• Hispanic born US rates of pLTCS are the lowers of all, much lower than state average
• Non-Hispanic black patient cesarean rates are about 4% higher than almost all others but lower than state average. 
• Our “other” category (largely AI/AN) exceptionally high NTSV c-section rate. Total # of patients in the “other” category higher than for non-hispanic black but still only about 145 patients over 5 years. 

And for preterm birth:

• Non-Hispanic Black preterm birth rate is similar to others at our facility and lower than state average, however note that #’s are quite small so should continue to trend over time 11 patients out of 124 patients total in 5 years. 
• Rate of PTB among white patients higher than the rest of CA
• “Other” preterm birth rate is quite high, mostly represented by AI/AN individuals, numbers still low 28 patients out of 144 over 5 years. 

What can be done?

Dr. Bacon capped off this week's Grand Rounds presentation with a series of recommendations of how you might engage in local advocacy and beyond to work on birth equity:

• Individual work: if you are unsure where to begin and/or unsure about what you think about this information, individual work is the place for you
• consider reading and/or listening to podcasts, listening to the experiences of others (particularly BIPOC), assessing your own personal unconscious bias, and work on retraining your brain on these biases
• Listen to Dr. Camara Jones
• Visit Project Implicit
• I personally recommend Seeing White on Scene On Radio as a good place to start (we have been listening to this as a faculty for our anti-racism work)
• 
• Institutional work
• there are lots of robust toolkits and trainings to help guide institutions
• these might help you help guide YOUR institution
• try: CMQQ, ACOG/SMFM, https://blackmamasmatter.org/, CDC's Hear Her campaign
• Locally, attend CEDAWG grand rounds, September 22 Foundations for Health Equity Workshop, UCSF Differences Matter, Trauma informed care trainings
• Check out the SSRRH Labor Culture Committee (LCC) at SSRRH (inquire with Julie Barajas or 

• Community Work
• Workforce development, pipelines
• Community health workers
• Doulas
• Black midwifery
• Centering pregnancy
• Statewide and National work
• Pay attention to what is happening in politics and policy:
• SB65: a bill that creates a committee to investigate maternal deaths, examines adding a doula benefit to medi-cal funding, and helps low income communities have access to midwifery care
• California AB4: removing documentation status for Medi-cal benefits
• Governor Newsom's 2022 budget, which includes California extension of OB Medi-cal to 1 year postpartum
• Also take a look at commonwealthfund.org Maternal mortality and maternity care project

And more resources:

Jenee Desmond-Harris: Implicit bias means we're all probably at least a little bit racist. https://www.vox.com/2014/12/26/7443979/racism-implicit-racial-bias

Eric Deggans: 'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist. https://www.npr.org/2020/08/24/905515398/not-racist-is-not-enough-putting-in-the-work-to-be-anti-racist

Camara Phyllis Jones, MD, MPH, PhD: 

• Allegories on Race and Racism (TEDx): https://www.youtube.com/watch?v=GNhcY6fTyBM

• The Cliff of Good Health: https://www.urban.org/policy-centers/cross-center-initiatives/social-determinants-health/projects/dr-camara-jones-explains-cliff-good-health

https://www.projectimplicit.net/

CDC Hear Her campaign: https://www.cdc.gov/hearher/resources/download-share/warning-signs-poster.html

ACOG Health Equity Curriculum: https://www.acog.org/education-and-events/creog/curriculum-resources/additional-curricular-resources/health-equity

ACOG CO 649 (2015): Racial and Ethnic Disparities in Obstetrics and Gynecology https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2015/12/racial-and-ethnic-disparities-in-obstetrics-and-gynecology.pdf

Black Mamas Matter Alliance Toolkit: https://blackmamasmatter.org/resources/toolkits/

Concussion Management in Primary Care (Affleck, Ohkubo, Matthew 9/1/2021)

Many thanks to Dr. Monica Ohkubo,  Dr. Ty Affleck, Athletic Trainer Chelsea Matthew, and DNP Surani Kwon for a great interdisciplinary Grand Rounds presentation from the North Coast Concussion Management team on Concussion Management in Primary Care. 

A recording of their presentation is available HERE. 

Driven by increased attention on head injuries over the last decade, the standard of care for sport-related concussions has changed significantly from a general If you feel okay, it's okay, go back in and play mentality to a much more evidence-based stepwise management approach to concussion. 

• In US, there are 1.3-3.8 million concussions annually, close to 300,000  ER visits (2010-2016)
• In football alone, 7.7% NFL players experience concussion (this amounts to only about 130/year), but if 4-6% of high schoolers also experience concussion, this amounts to 1.2 million/year
• People with history of concussion are more likely to have another
• Hx migraine, depression, insomnia cognitive problems, visual abnormalities-->  concussion can unearth or exacerbate these conditions (learning disability can be activated, depression can represent or be exacerbated)
• Many used to believe that most athletes recovered from concussion in 7-10 days with a few stragglers. . .new evidence has found that after 2 weeks less than 1/2 of athletes with concussion have fully recovered

Initial Concussion Care: "You don't know how bad it is until it's over" -Dr. Ohkubo

• You cannot assign a time frame for recovery as soon as the concussion is recognized  (but by state law, it's always at least 7 days)

• NO return to play in same game/practice
• Monitor for deterioration over the first few hours after injury (s/sx bleed)
• Early follow-up with someone trained
• Physical rest
• Mental rest: no phones, no school/shortened school
• Per state law, any high school athlete with a concussion must follow up with physician trained in concussion management for medical clearance

Best practices for Concussion Management

Standardized Concussion Assessment Tool (SCAT5)

The SCAT-5 is a validated tool to use for concussion evaluation. Includes several components: GCS, c-spine evaluation, symptom evaluation, cognitive tests, balance tests, memory, coordination, and 6 step return to play guidelines. The link above will take you to the full 8 page document.

Of note, the symptom evaluation on the SCAT includes  22 symptoms: physical, emotional, mental, sleep. Different areas can be differentially affected

Athletes also can cover up symptoms because they are used to pushing themselves, so pay attention to the individual answers

Eye and Balance Test

Balance testing (BESS): 20 second each feet together hands on the hip eyes closed, non-dominant leg, tandem stance with non dominant foot in the back

Neurocognitive Testing

Gold standard is baseline testing (pre injury) to be able to assess extent of injury if/when it occurs

SRJC and SRCS are doing this for all athletes: Computerized neurocognitive baseline and f/u testing

Athletic Trainers

 Athletic trainers are (board certified, link between healthcare provider and the athlete and parent) important resource to be able to be available to do concussion training/prevention as well as assist with assessment and return to play protocols

• prevention and recognition of injury, referral, treatment rehabilitation
• academic modification
• objective assessment at sideline, retesting
• referrals for physician, mental health support
• facilitation of return to play protocol
• day to day contact with athletes

Treatment and Management of Concussion

1. Cognitive and physical REST is huge. Academic accommodations have to be provided by doctors specific form that physicians need to fill out (e.g. half days at school, extra time on tests, reduced homework load, note taking, not on computer all the time)
2. Diet: appetite changes after concussion (more/less hungry). Eat small things through the day
3. Hydration: nausea, drinking small amount during the day
4. Sleep: sleep patterns can change (more/less than normal, frequent waking). Don't wake a sleeping athlete. Sleep is important in recovery. Naps: not after 3pm
5. Exertion: people recovering both physical and mental, though small sub-symptom exercise can help recovery. 
6. Stress: interpersonal arguments, emotions can change post concussion, crying out of nowhere (not criers), lights/sound noise: bright lights, fluorescent lights, sunglasses (accommodation), loud sounds (e.g. PE class)
7. Do NOT push the symptoms

Return to Play Process (CA state law)

• Anyone diagnosed with concussion, must go through the process that starts with a medical evaluation, and then start 7 day process
• For contact sports, athletes must get a two step medical clearance
• Each step MUST be separated by at least 24 hours
• If symptoms return at any step, stop the activity, let rest for the rest of the day and return to the same step

***********************************************************

Step#1      Rest until asymptomatic

MEDICAL CLEARANCE

Step#2:     Light aerobic activity (walk around track or football field)

Step#3:     Sport specific exercise (running, swimming)

Step#4:     Non contact training drills (shooting, serving, setting)

MEDICAL CLEARANCE

Step#5:     Contact practice

Step#6:     Contact game

************************************************************

It's important to note that concussion symptoms tend to cluster: "Concussion picks on everyone's weakness". 

Someone may have minimal to no symptoms in one category but profound deficits in another. Directing your attention to where their symptoms are is a key take home. 

• vestibular
• cognitive/fatigue
• ocular
• post-traumatic migraine
• anxiety/mood
• cervical 

Specialists can be helpful depending on the problem: concussion specialist, vestibular rehab, neuro opthamologist, neuropsychologist

Use of neurocognitive tests

Gold standard is to have a baseline and post-test injury test. That way you can compare the two. IF you don't have a baseline, there are standardized scores based on age/educational level that you can use to make your assessment.  

Specifically, the computerized neurocognitive test ImPACT used at SRJC and SRCS (see image below for an example report)

Other tools:

• Vestibular and oculomotor testing (VOMS test)
• A "Home SCAT test": ideally, athletic trainers are supporting the return to play process; however, if there is no athletic trainer to link to care, consider using parent to help athletes get through the process. Have the athlete go through above steps and have parent administer a variation on the SCAT (below)
• Light aerobic exercise (in Dr. Affleck's words, "oxygen") can help speed recovery
• Disrupted sleep? Consider melatonin

Additional References/resources:

CDC: www.cdc.gov/concussion/

UPMC: www.upmcphysicianresources.com

northcoast concussion.org 

CIF physician letter to school: https://cifstate.org/sports-medicine/concussions/CIF_Physician_Letter_to_School_after_Concussion_Visit.pdf