key: cord-0831245-ovzbmlvd authors: Serper, Marina; Liu, Chung‐Heng; Blumberg, Emily A.; Burdzy, Alexander E.; Veasey, Stephanie; Halpern, Samantha; Lander, Elaine; Sigafus, Matthew R.; Bloom, Roy D.; Dunn, Ty B.; Abt, Peter L.; Reddy, K. Rajender; Mehta, Shivan J. title: A pragmatic outreach pilot to understand and overcome barriers to COVID‐19 vaccination in abdominal organ transplant date: 2021-09-22 journal: Transpl Infect Dis DOI: 10.1111/tid.13722 sha: 791982e79dfc21caf3e9c4e7479edf0d70b5cd3d doc_id: 831245 cord_uid: ovzbmlvd BACKGROUND: Solid organ transplant recipients (SOTRs) are at increased risk for adverse outcomes with coronavirus disease 19 (COVID‐19). Early data show a lower severe acute respiratory syndrome virus 2 (SARS‐CoV‐2) spike antibody immune response among SOTRs leading to patient concerns about vaccine efficacy. Public health messaging has largely left out immunocompromized individuals leading to a higher risk of vaccine misinformation. The American Society of Transplantation recommends COVID‐19 vaccination for all SOTRs; however, patient concerns and beliefs about vaccination are largely unknown. METHODS: We conducted a transplant‐center‐based, pragmatic pilot trial to encourage COVID‐19 vaccination among 103 unvaccinated SOTRs. We assessed vaccine concerns, barriers to vaccination, answered questions about efficacy, side effects, and clinical recommendations. RESULTS: A total of 24% (n = 25) of SOTRs reported that they will schedule COVID‐19 vaccination after the study call, 46% reported that they will consider vaccination in the future, and 30% said they will not consider vaccination. Older age and White race were associated with lower willingness to schedule the vaccine, whereas Black race and longer time from transplant were associated with higher willingness. Common vaccine concerns included lack of long‐term data, inconsistent messaging from providers, scheduling inconvenience, and insufficient resources. Follow‐up approximately 1 month after the initial outreach found 52% (n = 13) of liver transplant recipients, and 10% (n = 3) of kidney transplant recipients subsequently received COVID‐19 vaccines for a vaccination rate of 29% among respondents. CONCLUSION: Transplant center‐based vaccine outreach efforts can decrease misinformation and increase vaccination uptake; however, vaccine‐related mistrust remains high. protein among SOTRs compared to the non-transplant population. 3, 4 Despite this diminished immunogenicity, a recent early report by Malinis et al. showed markedly decreased infection rates among SOTRs who received SARS-CoV-2 vaccination. 5 The American Society of Transplantation (AST) recommends COVID-19 vaccination for all SOTRs whenever feasible, continuation of current immunosuppression regimens, and ongoing adherence to social distancing and protective measures regardless of vaccination status. 6 However, public health messaging has not specifically targeted immunocompromized patients and has been inconsistent among this group, potentially leading to confusion and vaccine hesitancy. Our transplant program, a large tertiary care center in the mid-Atlantic, has reached out to SOTRs with several email blasts and messages urging vaccination. Additionally, vaccination is being uniformly encouraged by transplant clinicians. However, the effect of these initiatives is unknown. Our previous work showed that immunosuppressed patients had a high level of trust in their physicians with regard to COVID-19 vaccination. 7 Therefore, we conducted a transplant-center-based, pragmatic outreach pilot to encourage SARS-CoV-2 vaccination among unvaccinated SOTRs using principles of motivational interviewing. Secondarily, we assessed vaccine beliefs, concerns, and barriers to vaccination among a cohort of liver and KTRs. This was a pragmatic study designed to be integrated into clinical care with brief and targeted assessments. Potentially unvaccinated patients were called at random by transplant center staff (nurse coordinators or research coordinators) and were asked a screening question, and patients who responded "YES" were excluded from the analysis. If they answered "NO," the study team used principles of motivational interviewing to assess vaccine concerns, reasons for not yet getting the vaccine, provide further clinical information on antibody response, known side effects, clinical effectiveness, and up-to-date AST recommendations. 6 Motivational interviewing in this study followed the three core tasks in the three-component model: Exploring, Guiding, and Choosing. 9 The research staff first attempted to understand the participants' thought processes and causes for hesitation, then objective vaccine data were provided when the root causes for hes- Pennsylvania and deemed to be under the umbrella of quality improvement; therefore, no consent was required. We evaluated the following COVID-19 vaccination outcomes during the phone call: (1) vaccine scheduled during call, (2) patient to schedule vaccine on their own, (3) will consider vaccination in the future, and (4) not considering vaccination at this time. We created a composite variable for willingness to be vaccinated by combining the outcomes "vaccine was scheduled during call" and "patient to schedule vaccine on their own." We also collected semi-structured patient feedback regarding vaccination concerns or barriers. Using our previous methodology, 7 we obtained information on age, sex, self-reported race/ethnicity, median zip-code estimated household income, organ transplanted (liver or kidney; simultaneous liver/kidney was categorized as liver transplant), time from most recent transplant, and insurance. Descriptive statistics including proportions as well as median, Figure 1 shows the study flow diagram of the entire population of LTRs not yet vaccinated or scheduled); this was slightly larger than 100 as multiple team members were making calls simultaneously. Vaccine outcomes stratified by organ type are shown in Table 1 and in Figure 2A . Table S1 . The proportion of SOTRs who were Black and Hispanic included in the study did not differ from non-respondents (Table S2 ). In exploratory analyses, we assessed whether COVID-19 vaccination status was associated with previous influenza vaccination in 2019 and 2020 and found no significant associations (Table S3 ). Concern about lack of efficacy and safety data of the COVID-19 vaccine in patients with transplants was cited with the most frequency in all SOTRs (n = 7 in LTRs; n = 13 in KTRs). Related to this concern were uncertainties about the duration of the immunity in transplant recipients, specifically, and the interactions between the vaccinations and immunosuppressive regimens. LTRs attributed their hesitation to lack of long-term vaccination data (n = 6, 6%), distrust in the vaccine development process and governmental agencies (n = 4, 4%), recommendations from their healthcare professionals to not be vaccinated (n = 3, 3%), potential side effects (n = 2, 2%), and inconsistent information about the vaccines (n = 2, 2%). KTRs have cited further instructions from their healthcare providers (n = 6, 6%), uncertainties about vaccination from a medical standpoint (n = 4, 4%), and distrust toward the COVID-19 vaccines (n = 3, 3%) as reasons for not being vaccinated. Among those who expressed willingness to be vaccinated, 30% of the respondents expressed they were "too busy" or had insufficient resources to schedule for vaccination prior to the calls. Our findings demonstrate patient's desire for additional short-term and long-term efficacy and safety data of COVID-19 vaccines in SOTRs. Patients are keenly interested in better understanding the duration of immunity, the need for regular evaluation of antibody titers, and any changes required in immunosuppression. However, as the evidence Nationally, the proportion of Black and Hispanic people who have received COVID-19 vaccination is lower compared to their proportion of the total population in most states; although these gaps have been narrowing as of July 2021. 8 We specifically designed the program to reach out to at least 50% of Black and Hispanic due to these gaps. In our cohort, however, we found Black race was associated with a higher willingness to schedule the vaccine once information was provided. This finding of higher willingness among Black SOTRs may suggest that the lack of vaccination in these groups may be more likely due to systemic barriers such as knowledge and access rather than entrenched vaccine beliefs. Therefore, transplant-based vaccination outreach efforts may particularly have high yield for certain populations, in geographic areas where vaccination rates may be low, and access and knowledge barriers persist. We must note certain study limitations. This was an outreach pilot and limited in scope. However, the outreach effort was efficient and could be easily implemented within transplant center workflows. Our study was conducted in a large transplant center in the mid-Atlantic with a relatively high uptake of COVID-19 vaccination; findings may not be generalizable to other areas. On the other hand, transplant centers located in geographic regions with low vaccine uptake may experience higher conversions to vaccination with outreach, particularly if public health messaging in those areas remains confusing or inconsistent. Given the cross-sectional nature of the study, we have not yet been able to verify whether willingness to schedule vaccination led to vaccination. We explored correlations between COVID-19 vaccine hesitancy and the annual influenza vaccine and noted there was no significant association (Table S3 ) and showed there was no significant association suggesting the fact that misinformation or unclear messaging may be playing a role in COVID-19 vaccination hesitancy among those who are otherwise willing to be vaccinated for influenza. Research staff involved in outreach lacked formal training in motivational interviewing. However, staff were provided background reading on principles of motivational interviewing, given the time-sensitive nature of the initiative to educate SOTRs regarding the COVID vaccines. There are current challenges with accurately capturing data on vaccinations conducted outside the health system resulting in phone calls made to already vaccinated individuals. In conclusion, our transplant center-based vaccine outreach effort was pragmatic, can decrease misinformation and increase vaccination uptake; however, vaccine-related mistrust remains high. Identifying unvaccinated SOTRs and providing clear and consistent guidance and also navigation toward vaccination may increase vaccination among SOTRs. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study Is COVID-19 infection more severe in kidney transplant recipients? Antibody response to 2-dose SARS-CoV-2 mRNA vaccine series in solid organ transplant recipients Reduced humoral response to mRNA SARS-CoV-2 BNT162b2 vaccine in kidney transplant recipients without prior exposure to the virus Effectiveness of SARS-CoV-2 vaccination in fully-vaccinated solid organ transplant recipients Future economics of liver transplantation: a 20-Year cost modeling forecast and the prospect of bioengineering autologous liver grafts COVID-19 vaccine perceptions among patients with chronic disease in a large gastroenterology and hepatology practice Latest data on COVID-19 vaccinations by race/ethnicity. Kaiser Family Foundation Motivational interviewing: moving from why to how with autonomy support Flu Vaccination Coverage, United States, 2019-20 Influenza Season Barriers of influenza vaccination intention and behavior: a systematic review of influenza vaccine hesitancy The association between influenza vaccination and socioeconomic status in high income countries varies by the measure used: a systematic review Influenza vaccine hesitancy in a low-income community in central New York state We would like to thank Christopher Snider and Mary Williams for assistance with data acquisition and Renee Westmoreland for assis- The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.