Flu season is here, and the media is filled with news about the new Covid vaccines, so this is a good time to have a sort of primer explaining the profound importance of vaccination for communities as well as individuals. [email protected], the online MSN programfrom the School of Nursing and Health Studies at Georgetown University, has kindly allowed DailyNurse to share their guide to the essentials of herd immunity and tips for addressing vaccine-hesitant patients and loved ones.
What is Herd Immunity?
Also referred to as “community immunity,” herd immunity is a public health term used to describe a case in which the potential for person-to-person spread is significantly reduced due to the broader community’s resistance against a particular pathogen.
A Glossary of Important Vaccination-Related Terms
Active immunity: Immunity as a result of the body’s antibody creation after exposure to disease-causing pathogens, either through natural infection or vaccination.
Herd immunity threshold: Also called the “critical vaccination level,” this is the approximate percentage of a population that needs to be vaccinated in order to reach herd immunity status.
Immunity: Resistance to a particular pathogen, or disease-causing bacteria, through antibodies.
Inactivated vaccine: A vaccine using a killed form of the disease-causing germ. This vaccine usually requires multiple doses over time to form immunity. Examples include the DPT and Hepatitis A vaccines and the flu shot.
Live attenuated vaccine: A vaccine using a weakened form of a germ to produce an asymptomatic infection and generate an immune response similar to a natural infection, without sickness. Examples include the MMR and chickenpox vaccines.
Natural infection: Contraction of a disease through person-to-person transmission or interaction with disease-causing bacteria.
Passive immunity: Immunity after receiving disease-fighting antibodies from an external source.
R0 (Pronounced “r-naught” or “r-zero”): The reproductive number of a disease that describes the average number of additional cases a single infected person creates.
Subunit vaccine: A vaccine using a component of the germ (such as a specific protein) to produce an immune response. This vaccine does not contain a live germ. Examples include the shingles and HPV vaccines.
Vaccine: A controlled simulation of natural infection meant to trigger antibody creation that helps fight against the disease later, without sickness.
Why is Herd Immunity So Important?
When enough community members are immune to a virus so that it inhibits spread, even those who are not vaccinated will be protected. The “herd” collectively provides insulated safety to all members, which is important for those who are too high-risk for certain vaccinations.
For these individuals, it is important that their community has built an immune response to the yellow fever so they are not at risk of infection and transmission. Individuals who are too high-risk to get a vaccination are often more likely to contract the illness and experience serious symptoms.
Some other reasons why people cannot get certain vaccinations include:
Recent blood transfusion
Underlying medical conditions like lung or heart disease
“It’s like a little nuclear circle,” she said. “So that our babies that can’t get vaccinated yet, or our pregnant mothers, or our elderly with immune systems [that] are not as robust, or people who have certain kinds of conditions that they don’t have the correct immunity, will have protection from the active pathogen that could possibly harm or kill them.”
HITs and R0s: the Science Behind Herd Immunity
In a community where no one is immune to a virus, a disease can spread rapidly and lead to an outbreak. As individuals acquire immunity, either through infection or a vaccine, the disease spreads more slowly because fewer people can pass it on.
In a community where enough members are vaccinated, the disease will stop spreading because the virus will not be able to find susceptible hosts.
The herd immunity threshold (HIT) varies depending on a variety of epidemiological factors. The primary consideration is the infectiousness of a disease. Infectiousness is measured by the Basic Reproduction Number or reproductive ratio—often referred to as R0 (“r-zero”). R0 refers to the number of cases expected to occur on average in a susceptible population as a result of infection by a single individual at the start of an epidemic before widespread immunity starts to develop. So if one person develops the infection and passes it on to two others, the R0 is 2. Herd immunity helps R0 drop below 1.
Here are some examples of R0s for a few well-known infectious diseases:
The Role Clinicians Play in Herd Immunity and Vaccination
Zschaebitz and Thompson-Brazill have years of experience in various health care settings— from travel clinics and trauma units to international research. Some of the ways that clinicians increase herd immunity and vaccination include:
participating in global research to genotype communities and help produce viable vaccines.
administering vaccines so patients can stay up-to-date on immunization schedules and travel requirements.
educating patients on the importance of vaccination and specific information related to different vaccines.
How to Talk to Patients, Family, and Friends About Vaccination
Thompson-Brazill shared her experience speaking with patients who are vaccine-hesitant and said she has learned that one of the roles clinicians play in herd immunity is educating patients about why vaccines are safe and normative for society.
Zschaebitz also shares the importance of herd immunity with patients — often through the retelling of her own experiences genotyping Maasai tribal women for an HPV vaccine.
“We were interested in preventing deaths of cervical cancer because in certain countries women just die,” she said. “Declining a vaccination is sort of a first-world problem because people in other nations would walk for miles to get what we have and what we take advantage of.”
Thompson-Brazill and Zschaebitz’s tips for speaking to vaccine-hesitant friends and family:
Tip #1: Avoid pointed questions that could make someone defensive.
Instead of: “Why wouldn’t you get the shot?” Try: “What about the shot worries you?”
Tip #2: Use storytelling as a way to share your experience.
Instead of: “I can’t believe you are not going to vaccinate your children” Try: “I chose to vaccinate my kids because…”
Tip #3: Refer people to credible, reliable sources.
Instead of: “Why would you believe that? That’s just a hoax!” Try: “The CDC has a lot of useful information about vaccines and potential risks. Have you read what they have to say?”
Tip #4: If you do not know how to respond, recommend an expert who does.
Instead of: “I can’t talk to you about this; we will never agree.” Try: “Have you shared your concerns with your clinician? They will be able to answer your questions.”
A Herd Immunity FAQ
Is it possible to achieve herd immunity without a vaccine?
No, not all diseases can be overcome with herd immunity. For example, herd immunity cannot be achieved for Clostridium tetani, the bacteria that causes tetanus. Although infection is avoidable via individual vaccination, the “herd” cannot provide protection. For example, the immunity of others will not prevent an individual from contracting tetanus after stepping on a rusty nail.
Why do I need to get vaccinated for diseases we already have herd immunity for?
Some immune responses weaken over time, which is why booster shots are so important. Additionally, vaccine refusal can lead to waning community immunity. For example, in 2019, measles outbreaks in New York and Oregon threatened the United States’ 20-year measles elimination status, according to a press release from HHS on measles outbreaks in 2019.
Is immunity from a natural infection stronger than immunity from a vaccination?
Reliable Information Sources on Vaccines and Vaccination
Both Zschaebitz and Thompson-Brazill recommend using nationally recognized, expert-led sources to learn more about vaccines, like the CDC, FDA, and NIH. Some of the additional resources available include:
CDC Immunization Schedules External link : The CDC-recommended vaccination series and timing schedule for children, adolescents, and adults.
The CDC Yellow Book External link : A set of travel health guidelines, including country-specific vaccine recommendations and requirements.
Take plain liquid soap, and apply in a dime-sized drop on your hands; rub with water over palms, fingers, and up to one’s elbows for at least 20 seconds, then rinse thoroughly with clean water. It lacks the dramatically biting, corrosive, “ah, we’re killing germs!” odor of 79% rubbing alcohol or chlorine bleach, but spending less than a minute manipulating an unassuming bottle of hand soap at the sink deploys one of the most effective weapons in our arsenal against viral and bacterial infections. Is soap really that powerful?
Nurses know that the efficacy of hand-washing has long been established by science and that ordinary hand soap—unaccompanied by any additional “germ-fighting” anti-bacterial ingredients—easily destroys more viruses and bacteria than even the costliest hand-sanitizers. But how does it work? Here are some facts that might help your patients understand why they need to spend quality time at the sink.
How Does Soap Work?
Soap is a surfectant. When combined with water, surfectants help the water to spread out and cover surfaces—whether hands, counter-tops, dishes, or clothes—so they can be thoroughly cleansed. In effect, surfectants are a tool for removing germs (i.e., bacteria, viruses, fungi, and protozoa that can cause disease).
As we go about our business, germs on the surfaces and people we touch adhere to the oils on our hands. Water on its own cannot penetrate oils, but rubbing your hands with both soap and water breaks down the oils, which carry germs away as you rinse your hands. The key is in the action of surfectants against oil and dirt. Soap molecules have hydrophilic heads that cling to water molecules and hydrophobic tails that avoid water molecules. When mixed with water, soap molecules form into tiny hydrophobic balls called micelles. As the micelles move across the surface being cleaned, they attract and absorb oils and fats (along with the germs and dirt clinging to those oils and fats). When you rub your hands with soap and water and rinse them under the tap, the clean water carries soap, oils, and germs down the drain.
Soap v COVID-19
breaks down coronaviruses. During the process of hand-washing, according to National Geographic, soap “pries open the coronavirus’s exterior envelope and cause[s] it to degrade. These soap molecules then trap tiny fragments of the virus, which are washed away in water.”
Hand-Washing is an Ancient Practice, but Hand Hygiene is a Modern Development
Humans have been using soaps made from fats, oils, and salts for millennia, but even the efforts of Florence Nightingale failed to convince many people that hand-washing reduces the spread of infection. In fact, it was a 1980s series of food-borne and other infectious outbreaks that prompted the CDC to establish hand hygiene guidelines!
Quote: “Soaps were not to be found in early Ancient Roman baths; even Cleopatra was confined to essential oils and fine white sand (as an abrasive) for cleansing.” –Open University, The History of Soap-Making
Liquid v Bar?
Everyone has at some point faced a gray, gunky bar of soap sitting in a scummed dish and wondered. Quis custodiet ipsos custodes? Or in this case, “who cleans the cleaners?” Despite the dire optics, scientists believe that any soap—yes, even that nasty lump sitting beside your brother’s bathroom sink—is more sanitary to use than no soap at all. In two studies—one in 1965, and another in 1988—researchers actually applied biological contaminants to bars of soap and found that bacteria did not adhere to users’ hands after the washing process. The 1988 study stated, “After washing, none of the 16 panelists had detectable levels of either test bacterium on their hands.” No evidence has emerged to contradict these studies, and the CDC recommends either bar or liquid soaps as a defense against infection.
Regular v Antibacterial?
There is no need to waste money on “anti-bacterial” soaps. The Minnesota Department of Health bluntly states, “Antibacterial soaps are no more effective than plain soap and water for killing disease-causing germs outside of health care settings. There is no evidence that antibacterial soaps are more effective than plain soap for preventing infection under most circumstances in the home or in public places.”
Hand Sanitizer or Soap and Water?
Alcohol-based hand sanitizers are a very convenient substitute for soap and water, but they do not serve as a full-time alternative. Scientists at the CDC decidedly prefer old-fashioned scrubbing: “Soap and water are more effective than hand sanitizers at removing certain kinds of germs… Although alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly, people may not use a large enough volume of the sanitizers or may wipe it off before it has dried.” They also warn, “When hands are heavily soiled or greasy, hand sanitizers may not work well.”
Healthcare providers are an exception, though. The CDC notes that “hand sanitizers work well in clinical settings like hospitals, where hands come into contact with germs but generally are not heavily soiled or greasy.” They recommend that HCPs use sanitizers with 60-95% alcohol “unless hands are visibly soiled,” and add that “an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water.”
Are “Scrubbing Bubbles” Really a Thing?
A soap bubble is made up of two layers of soap molecules with a thin layer of water between them. But does it have a practical use during the cleaning process? From a hygiene standpoint, lather is a useful visual cue as you scrub your hands and it can help create more friction as you rub a surface, but it does not play an active role in cleansing. Even though it is known that hard water creates less lather than soft water, cleaning with either is equally effective. However, most people find lather appealing, so if lather encourages hand-washing it does have value, as long you remember to rinse thoroughly!
Roughly 13 million Americans are affected by incontinence, with elderly patients as the leading demographic. Also known as the loss of bladder control, urinary incontinence can be stressful and embarrassing for patients. November is National Caregiver Awareness month, but it is important at all times to properly advise patients to ensure they’re physically and mentally well. There are several steps and preventative measures that can be taken to lessen stress and uncertainty.
Understand the Basics
Oftentimes, seniors feel overwhelmed with anxiety and embarrassment surrounding incontinence, and try to hide the signs.Approximately 54% of seniors suggest if they suffered from incontinence, they would be ashamed and hesitant to discuss with their loved ones. When caring for an incontinent patient, be sure to monitor for any and all symptoms, while being as helpful and empathetic as possible. To ensure you’re equipped to spot the signs, first, you need to be able to identify the three most common types of incontinence.
Urge incontinence: As the most prevalent type, urge incontinence is the involuntary loss of urine due to an intense urge of urination.
Stress incontinence: Bladder muscles often weaken as individuals get older and sudden physical movements (such as laughing, sneezing, getting up or carrying a heavy item) could contribute to involuntary loss of control.
Functional incontinence:A patient has the urge to urinate but can’t easily make it to the bathroom quickly due to mental or physical disabilities – examples include arthritis, Alzheimer’s, and neurological disorders.
The “Do’s” for Incontinence Care
As habits and routines have drastically shifted compared to pre-pandemic, be mindful that seniors have experienced great change and their typical schedules have been heavily disrupted. With that in mind, try to provide consistency and structure, and implement healthy habits across the board.
A consistent schedule can help alleviate discomfort and anxiety for both the patient and the caregiver. This can include scheduled bathroom breaks, organizing medication weekly, and setting up reminder systems for ordering necessary incontinence products. To help alleviate anxiety around incontinence episodes, be sure to keep backstock of necessary products when applicable. Ensure the size and absorbency of all products are appropriate so that patients know they always have access to the products they need.
Encourage Healthy Eating
Ahealthy diet goes a long way in helping to manage incontinence. Increasing intake of fiber enriched foods and healthy carbs (ie: whole grains and brown rice), adding more vegetables and certain fruits that are also high in fiber, such as berries, bananas, apples, and pears can help overall bowel function and urinary health. This also means avoiding dairy, caffeine, and spicy foods to prevent a potential increase in accidents.
Closely Monitor Fluid Intake
This step is crucial, but unfortunately often overlooked. Individuals with incontinence tend to drink less water, in hopes of reducing the risk of leaks or accidents. Meanwhile, low water intake can actually irritate the bladder and increase the risk of other infections, such as urinary tract infections (UTIs) which in turn causes more frequent, painful urination that can lead to more accidents. Encourage the intake of fluids throughout the day and add more hydrating foods in patients to help keep their bladders healthy.
It’s also important to try to limit fluid intake in the evenings. Many accidents happen at night when a patient either doesn’t wake up to use the restroom or can’t make it there in time. Stopping fluid intake around 6pm can help minimize the chances of nighttime incontinence. Waking up to a wet bed can be very embarrassing for patients. On top of monitoring fluid intake in the evenings, patients may also benefit from wearing an overnight bladder control product as well as using a protective bed covering such as a chux pad or mattress cover.
The “Don’ts” for Incontinence Care
Try not to be reactive
It’s not easy watching a patient or loved one struggle with incontinence, but it’s imperative to exercise as much patience as possible. Try not to get frustrated and be flexible by altering your care strategy appropriately to best fit the patient’s needs. Having honest conversations and offering extended support when needed the most will go a long way in addressing incontinence with dignity and destigmatizing the condition for those living with it.
Avoid terms that could appear insensitive
Words, such as “diaper,” could come off demeaning and evoke shame in the patient. Think about words carefully and ensure you’re being as sensitive as possible. If a patient feels ashamed or embarrassed, they could further hide their symptoms and avoid being honest with you, which could lead to more serious health complications.
The pandemic has been difficult for a myriad of reasons, especially for seniors struggling with incontinence. When caring for an incontinent patient, be aware of all the signs, get them on a routine, implement tips to ensure a healthy bladder and lastly, avoid coming off as reactive and try to be as patient as possible. Empathy goes a long way and will leave the patient feeling more settled during this uncertain, stressful time.
Mica Phillips is Director of Urology at Aeroflow Urology, a durable medical equipment supplier that provides individuals across the country with incontinence supplies through insurance. An advocate for those living with incontinence, Mica is committed to helping men, women, and children navigate their insurance benefits to receive high-quality products that they can depend on.
Telehealth was an option before the COVID-19 pandemic, but it has now become a necessity. In fact, the health care profession has changed significantly since the crisis began, and recent surveys show that two out of three individuals have used telehealth at least once.
Though the transition was a little rough at first, patients and health care providers are starting to get used to telehealth visits. However, we are still in a period of adjustment and learning how to make patients feel confident about virtual appointments. To make this happen, here are six things you can do to help patients feel comfortable during a telehealth visit.
1. Check-In Ahead Of Time
Check-ins are more important in today’s telehealth world. They ensure the clinician has the right information on the patient. Plus, they help keep a record for administrators to track.
However, patients can no longer fill out paperwork at the time of the appointment. Some don’t have the necessary software to download material, fill it out, and send it back. Besides, doing this can increase a patient’s tensions.
To correct this, make sure check-ins are done ahead of time and through an online portal. Plus, keep the registration short. Ask for the most pertinent information so they can finish quickly and be prepared for the appointment. If they’re unsure of what to do, have people available to answer the patient’s questions.
2. Make Sure You Have a High-Quality Online Connection
The most problematic issue patients encounter is the online connection between them and their physicians. Sometimes, issues with lag time and poor video/sound are on the doctor’s end. Other times, it’s related to difficulties with the patient’s internet access.
While communication over an online portal can correct this somewhat, a better solution is telehealth software. Similar to programs like Zoom, these applications allow for a direct connection between the parties.
3. Use a Medical ERP
Telehealth patients don’t want to jump across multiple sites to handle check-in, billing, and appointments. It’s frustrating enough when they had to do it prior to COVID. Now, that added stress makes the situation more painful.
To avoid this, you need to implement a medical Enterprise Resource Platform. Organizations like Kareo offer these types of packages. Customizable, they track both user and doctor history from the initial registration to the last appointment.
4. Make the Most of Your Mask-less Conversation Time
It can be hard to connect with a masked nurse in the office, so make the most of the mask-less conversation permitted by telehealth. Patients want to have a face-to-face connection when they speak to their health care provider. They don’t want to be blocked by a piece of cloth.
As we communicate differently when wearing a mask, it can be difficult to alternate between telehealth and in-office appointments. It tends to be easier to schedule telehealth appointments for one part of the day and in-person meetups later. This also makes it possible for many HCPs to work from home during the mask-less part of their work-day.
5. Keep Your Eyes and Attention on the Patient
It can be easy to get distracted on a telehealth call. Looking at another portion of your computer or swiping through your smartphone away from the camera can convey a sense of disinterest the patient should not have to see or hear.
Be mindful throughout your telehealth visits. Clear your virtual and physical desktop of any distractions. Put your phone on vibrate and move it to a place where it isn’t easily accessible. Make eye contact with your patient. Talk low and speak slowly to help ease them into the proper comfort level.
6. Use Your Skills to Communicate, Inform, and Reassure
Patients are scared. They fear getting COVID and the complications of the virus. They worry about their jobs, kids, and others who have gotten sick. They don’t want their HCP to be cold and distant.
More than ever, you need to use your communication skills to comfort your patients, relate to their feelings, and try to assure them things will be okay. Don’t offer reassurance as an afterthought, and use plenty of eye contact and genuine feeling.
The world of telehealth is still changing. More will be done in the future as technology improves. Until then, you need to utilize both your professional and human skills to keep your patients comfortable. It’s the best way for them to get past their fears.
Diabetes Awareness Day is on November 14: are you up to speed on one of our longer-running pandemics? The second part of our two-part interview with diabetes specialists Debra Dudley, RN, CDN, BS and Lori Weiss, BSN, RN, CPN, CDCES focuses on the challenges of caring for diabetics, advances in treatment, and reliable sources of diabetes information for nurses. Click to see Part One of this interview.
DN: What are the greatest challenges nurses face when working with diabetic patients?
—Debra Dudley, RN, CDN, BS and Lori Weiss, BSN, RN, CPN, CDCES
Debra Dudley: “One of the greatest challenges I have consistently faced over the course of my 50-year career is the lack of time. Time is more essential than ever because the nursing shortage has left many of us overworked. I would love to have daily visits with each patient – even if it’s just a few minutes – to help guide them on their journey because there isn’t always going to be a teachable moment with them during infrequent interactions. This leads to long-term consequences because so many of our diabetic patients return with the same issues. We aren’t able to dedicate the necessary time to provide them with the appropriate education on adequate self-care.”
Lori Weiss: “Time remains the most significant challenge for nurses because they are busy, they are experiencing an increased patient workload, and those patients often have complications that are compounded by their diabetes. Patient safety is imperative, and nurses must balance safety with efficiency in order to treat as many people in need as possible. In order to overcome these obstacles, processes must be implemented that improve workflows and simplify the ability for nurses to do the right thing.”
DN: What technological advances have had the greatest impact on diabetes treatment?
D. Dudley: “There have been significant developments in technology over the course of my career, especially when you consider that early in my career we would place tablets into tubes of urine to measure blood sugar. From an outpatient perspective, the evolution of the continuous glucose monitor has been the most important. It allows a person to check their blood sugar every five minutes, identify if the blood glucose is trending up or down, and make an adjustment based on that trend. There are also mobile applications that help with carb counting, meal planning and exercise tracking – and many of those are free to download.
As far as the inpatient setting, the eGMS insulin dosing software system has been amazing. Once a nurse inputs a blood glucose reading, its algorithms automatically calculate insulin adjustments in real-time. It takes into account a patient’s current blood glucose, their food intake, and how they have reacted to previous doses. This reduces the amount of time a nurse has to spend adjusting doses because they no longer have to reach out to a patient’s provider to make a dose change. Before using this technology, our staff was making a minimum of 3,000 calls per month to providers just for dose adjustments. The amount of time wasted processing dose adjustments was both staggering and frustrating. The use of the Glucommander eGMS has reduced our amount of monthly calls by 95% – from over 3,000 to 150 – and alleviated a significant amount of nurse burden.”
“It’s not uncommon now for patients to inform their nurse or provider of a new app that is helping them manage their diabetes.”
—Lori Weiss, BSN, RN, CPN, CDCES
L. Weiss: “While many of the foundational concepts and approaches to diabetes education and support have remained the same, the tools and resources at our disposal continue to change. Outpatient technology has experienced the highest volume of technological advancements. The most notable [developments] have been the personal and professional Continuous Glucose Monitors, the variety of insulin pumps designed to meet pediatric and adult patient needs, and the explosion of digital and mobile solutions. This has provided patients with more access to information and a deeper understanding of how their decisions impact their disease. It’s not uncommon now for patients to inform their nurse or provider of a new app that is helping them manage their diabetes.
Although the outpatient setting has been most affected by these advancements, the inpatient setting has been able to leverage technology as well. As a Certified Diabetes Care and Education Specialist (CDCES), it is difficult to stay current with all the changes in diabetes care and nearly impossible for a busy bedside nurse to keep track. The eGMS insulin dosing software system has provided busy bedside nurses with an easy and effective way to care for patients. It increases patient safety by eliminating human dosing calculations, streamlines workflow because the algorithms automatically calculate insulin adjustments in real-time, and reduces adverse outcomes associated with hypoglycemia and hyperglycemia.”
DN: What are the most useful sources of information for nurses providing care for diabetic patients?
L. Weiss: “There are many reputable sources both online and in print to assist nurses caring for diabetic patients, but I find the best sources of information to be from the American Diabetes Association and the American Association of Diabetes Care and Education Specialists. The ADA issues its annual “Standards of Medical Care in Diabetes” to help guide nurses and physicians on how to best treat patients with diabetes and glycemic management issues. This is available for free online and includes best practice information on topics that range from nutrition therapy to pharmacologic approaches and recommendations for use of technology. The ADCES provides online courses, practice tools and documents, and webinars from industry experts to share a wealth of knowledge in an ever-changing field.”
Debra Dudley, RN, CDN, BS: Debra’s nursing career has spanned 50 years and she has spent the past 25 specializing in diabetes education and glycemic management. She is currently the Clinical Diabetes Educator for AdventHealth Waterman in Tavares, Florida, and has extensive experience in Pediatrics, NICU, and Maternal Child Health. Debra is an industry leader in providing support for those with a diagnosis of diabetes or pre-diabetes and improving their self-management through informative discussions, classes, and support groups.
Lori Weiss, BSN, RN, CPN, CDCES: After spending more than 20 years on the frontlines as a nurse at health systems in Wisconsin and Dallas, Lori Weiss is now applying her field expertise at the insulin management software company, Glytec, where she serves as the Clinical Project Lead. Lori understands the complex processes, risks, and challenges providers face titrating insulin.