Heal first, then vaccinate: How 9 systems are connecting COVID-19 survivors with the vaccine

Anecdotal reports from physicians on the front lines of the latest COVID-19 surge suggest disbelief, shame and fear are common emotions among many unvaccinated patients who contract the virus and need to be hospitalized. 

Here, nine physician leaders share how they approach conversations with hospitalized COVID-19 patients who ask for the vaccine, along with how they connect recovered patients and their family members to vaccination opportunities. 

Leaders shared their insights with Becker's via email and phone from July 28-30. Responses were lightly edited for clarity and length. They are presented alphabetically.

Neera Ahuja, MD. Clinical Professor of Medicine at Stanford (Calif.) Health Care: We are very supportive of promoting vaccinations for all individuals who are interested and encouraging vaccination and individuals who are uncertain if they wish to receive it.  

For hospitalized COVID-19 patients who are interested in the vaccine, our recommendation is to wait 60 to 90 days until the infection has cleared the body, and the patient's antibody response has been mounted and stabilized before receiving the vaccine. This can be set up as an outpatient.

Additionally, for patients presenting to the hospital who have not been vaccinated and do not have COVID-19 as their admitting diagnosis, we are offering the Johnson & Johnson vaccine upon discharge, which is a "one and done" [single dose] vaccine.

George Anesi, MD. Attending Physician in Pulmonary and Critical Care Medicine at the Hospital of the University of Pennsylvania (Philadelphia): Most COVID-19 hospitalizations today, and especially those with severe disease in the [intensive care unit], are [among the] unvaccinated [population] and therefore are largely preventable tragedies. Unvaccinated patients with severe COVID-19 who request a vaccine break our hearts because their disease could likely have been prevented and because the vaccines do not treat acute COVID-19 pneumonia.

But on the other hand, we embrace any and all opportunities to get anyone vaccinated who has not previously been, including those who recover from COVID-19, as the vaccines offer superior protection compared to natural infection. We can vaccinate hospitalized patients before discharge, regardless of their reason for hospital admission, or set up vaccination in an outpatient follow-up appointment. The only patients who require any sort of a substantial waiting period after recovering from COVID-19 are those treated with monoclonal antibodies or convalescent plasma, which is a small minority.

G.R. Scott Budinger, MD. Chief of Pulmonary and Critical Care at Northwestern Memorial Hospital (Chicago): Vaccine-induced immunity to SARS-CoV-2, the virus responsible for COVID-19, is more effective and longer lasting than immunity induced by natural infection. Therefore, we encourage all survivors of COVID-19 in the system to undergo vaccination with any of the approved vaccines after recovery. 

Patients who receive convalescent plasma or monoclonal antibodies against SARS-CoV-2 as part of their treatment should wait 90 days after those therapies were administered to receive a vaccine. We discuss the importance of vaccination with all of our patients suspected of post-acute COVID-19 syndrome seen in the Northwestern Medicine Comprehensive COVID-19 Center. 

Panagis Galiatsatos, MD. Director of the Johns Hopkins Tobacco Treatment and a Pulmonary and Critical Care Medicine Physician at Johns Hopkins Bayview Medical Center (Baltimore): First, we must recognize we're in a tough situation in regards to the pandemic. We can't be so arrogant as to say "the science is enough" to have all Americans vaccinated. This always happens — if science was enough, everyone would've stopped smoking. We have to engage with people without judgement and stigma. If you want to get people to listen, you have to know what motivates them — their culture, their values. Community engagement is now the best thing we can invest in moving forward. We can't sit back anymore in our ivory towers and wonder why people aren't following science. Instead we have to focus on engagement and education. 

When patients ask for the vaccine, I tell them, "Yes, once you get through this we will sign you up when you're eligible." This is an educational moment for anyone and everyone. When you have the entire family there, I say, "Let's talk about the vaccine. What's your status? You're not my patient but I want to talk about it with you." 

We connect COVID-19 patients with those resources. We have a tech system that follows up, but every patient I care for gets my personal email and a phone call. We're in a pandemic — patients need to see me as a human being, from one person to another. The people who are refracting from this vaccine, there just isn't a trust there. They don't see me as a person who they trust. 

Roopa Kohli-Seth, MD. Director of the Critical Care Institute at The Mount Sinai Hospital (New York City): Our inpatients can be offered COVID-19 vaccination 14 days or so after they are asymptomatic or recovered from a severe illness. Certain patients are immunocompromised, so obviously we cannot vaccinate them after 14 days. So our clinicians educate the patients and families when it is appropriate to receive the vaccination based on their unique clinical status. Some patients shed [the virus] for a much longer time, so we do offer them vaccination at discharge after consulting with infectious diseases and infection prevention colleagues. It is a joint decision to offer them the vaccine.

We can also offer it to them as inpatients, and we have multiple venues where patients can think about vaccination, can come back, ask any questions and talk through their thought process. We have a critical care recovery clinic, so we educate the patient about the recovery clinic and ask them to come back to us with any health issues. We provide tele-ICU consult services where we have more conversations. And we set them up with clinics where they can come as an outpatient and get their vaccination. Mount Sinai Health System also has a center for post-COVID care where patients are tracked and offered vaccinations. And there is a pulmonary clinic where they do the same. Now, Mount Sinai is offering vaccinations at home, too. 

Some of our patient population is still skeptical. The top three things they ask us about are whether the vaccine will affect their fertility (no), if they need to get vaccinated if they just had COVID-19 (yes) and about vaccine side effects they are worried about. We tell them we have a trove of data on millions of patients now showing us that vaccinations are safe. So it involves a lot of reassurance, and patients do come back and get vaccinated. 

Inga Lennes, MD. Senior Vice President for Performance Improvement and Service Excellence at Massachusetts General Hospital Physicians Organization (Boston): Per the CDC guidelines, vaccines are not indicated while patients are ill with symptoms of COVID-19. We recommend waiting until an infected patient has recovered. After recovery, patients who have been positive for COVID-19 should be vaccinated. If a patient was treated with monoclonal antibody therapy or convalescent plasma, vaccination should wait for 90 days. 

Beyond the criteria for vaccination, we always try to handle these conversations with compassion. We know that unvaccinated patients are fearful and can have feelings of guilt when they have severe illness caused by COVID-19. We always offer compassion first and expert medical care. Often, these situations offer the medical team the opportunity to discuss and educate the patient's family and close contacts who may also be unvaccinated and are open to learning more about how the vaccine prevents serious illness and consider vaccination.

Patients who recover from COVID-19 and are eligible as an inpatient can receive vaccination prior to discharge if ordered by the inpatient team. We also schedule unvaccinated patients into our vaccine clinics at the time of discharge to allow for the appropriate delay related to therapy.

Faisal N. Masud, MD. Medical Director of Critical Care at Houston Methodist Hospital, Vice Chair for Quality and Patient Safety, and Medical Director of the Cardiovascular Intensive Care Unit at Houston Methodist DeBakey Heart & Vascular Center: Our initial focus is getting the patient better. Typically, when patients are quite sick, we say, "Let's get you better first, and then we'll discuss the vaccines." The last thing we want to do is have them feel like these things have to be done right now. More often than not, patients and their family are already expressing regret, concern and sometimes shame that they did not or could not get vaccinated. Oftentimes they are expressing shock and bewilderment. It's amazing how many people are still in disbelief that, one, they got COVID-19 and, two, that they got sick from it.

So the first thing we try to do is just listen. We want to be able to understand where they are coming from and their challenges. And then when the patient and/or the family is ready — meaning the patient is medically steady — then we start having conversations about why the vaccine is still important even if you recovered from COVID-19.  And we share recommendations for families if they are not vaccinated. We remind them that we have chosen to not only vaccinate ourselves, but also our own family members. We also tell them you don't have to experience the sickness from COVID-19 to realize that it is real. Why does everyone have to go through COVID-19 to say it's real? Don't do that — learn from others.

Very early on last year, we established our COVID-19 recovery clinic because we knew a lot of these patients would need support. On top of that, we have a software solution called CareSense that lets us connect with patients getting admitted to the hospital via technology. We prime them and get them lined up for not only follow-up care, but getting vaccinated. If any of their family members are open to it, we also get them set up with vaccination appointments. What we have seen is that's the moment they're very open to real and truthful medical knowledge. They realize the importance of vaccination and that this is a real disease that causes harm. And if we line up that appointment for them, they show up. The goal is to give them information and encourage them to share with their circle of friends, because I do believe — and we've seen it — that people telling each other is more powerful than other sources.

Nida Qadir, MD. Associate Professor of Medicine at the David Geffen School of Medicine at UCLA and Associate Director of the Medical Intensive Care Unit at Ronald Reagan UCLA Medical Center (Los Angeles): For patients who are critically ill, these questions can be heartbreaking because you know their suffering could have been avoided had they been vaccinated previously. I usually tell patients in this situation that while the vaccine won't help them at this moment, we can plan for them to get the vaccine after they recover to reduce the chances of them ever getting this sick again. I also tell them that they still have a chance to help their loved ones by encouraging any who remain unvaccinated and aren't currently infected to get the vaccine.

We have the ability to give the vaccine while a patient is hospitalized. However, most patients who are hospitalized with severe COVID-19 unfortunately cannot get the vaccine until after they go home. This is because current guidance suggests that before giving the vaccine, we wait until there have been at least 20 days since their first positive test, symptoms have improved and fevers have resolved. Additionally, for patients who received certain therapies such as monoclonal antibodies, the CDC advises that we wait 90 days. A minority of patients will meet those criteria before they leave the hospital, but most will not. For those patients, we make sure that follow-up and home monitoring are set up before they go home, and when the timing is appropriate, they are able to obtain the vaccine from our outpatient pharmacy.   

Todd Rice, MD. Associate Professor of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center (Nashville, Tenn.): We now offer COVID-19 vaccines to inpatients who are being discharged. If they were hospitalized with COVID-19, we counsel them that the CDC recommends waiting 90 days from their infection to get vaccinated. This is a recommendation, and the patients are free to do what they want. Many of them ask to be vaccinated prior to discharge, even if they are not past the 90 days. If we vaccinate a patient, we almost always use one of the mRNA vaccines — and we write down the date that the patient is to get their second jab, informing them that they can come back to a Vanderbilt vaccination site to get the second shot, or they can go wherever their mRNA vaccine is available (often CVS, Walgreens, a primary care clinic, etc.).

 

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