Vaccines Outlook: Hesitancy, Uptake, and Infrastructure with Dr. Angela Shen

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Tune into another episode of Start Your Day with Avalere. In this segment, vaccines experts Richard Hughes IV and Dr. Angela Shen discuss the issue of vaccine hesitancy and the gaps in infrastructure and policy that affect adult vaccine uptake.
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“We are striving to gain a better understanding of the underlying drivers to vaccination decision-making to develop strategies on conversations between providers and parents and individuals around vaccination. That's going to make a difference in addressing the problem.” Dr. Angela Shen


Richard Hughes IV , Managing Director

Richard Hughes IV leads Avalere’s vaccines team, which supports clients with vaccine policy, market access and evidence strategies.

Guest Speaker
Angela Shen, ScD, MPH , Managing Principal, Llama Public Health Consulting LLC
Angela Shen is a retired captain from the US Public Health Service and a health services researcher with expertise in vaccine and immunization policy and practice.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.


Richard: Hello and welcome to another episode of Avalere Health Essential Voice in our Start Your Day with Avalere podcast series focused on our 2020 Mid-Year Vaccines Outlook. I’m Richard Hughes and I lead our vaccines team here at Avalere. I’m joined today by Dr. Angela Shin, a Senior Adviser to our team.

As vaccines increasingly come to market, including a future COVID-19 vaccine, continuing the dialogue on challenges within the vaccines marketplace is essential to improving access and uptake. In today’s episode we will discuss the adult vaccine platform and some of the policy gaps that affect vaccine uptake.

Angela has been one of the most influential thought leaders surrounding the adult immunization platform as it’s developed over the last decade. We’re excited to talk with her today.

Angela, can you start us off with some of the challenges of vaccine hesitancy?

Angela: Thanks, Richard. Vaccine hesitancy is tough. It’s what some people call a “wicked problem” — a complex problem with innumerable causes that is difficult to describe and doesn’t really have a right answer. Vaccine hesitancy has been around since smallpox inoculation began in the late 1790s. We grapple with this issue today in a different way, as public distrust in vaccination is publicized and facilitated through social media. The good news is that public confidence in vaccines is high. Most parents vaccinate, as was evident in pediatric vaccination uptake prior to COVID.

A lot of research has been done to address hesitancy. It has focused on building confidence, understanding the effects of the disease itself, determining who is trusted to make a recommendation, the need for a strong recommendation, and what the characteristics of hesitant parents and individuals look like. We are striving to gain a better understanding of the underlying drivers to vaccination decision-making to develop strategies on conversations between providers and parents and individuals around vaccination. That’s going to make a difference in addressing the problem.

Richard: I wanted to spend a little time today talking about the development of the adult vaccine platform, which is a relatively recent concept given the success of childhood vaccines. Thanks to strong vaccine policy and a strong childhood vaccine platform, we have seen the reduction in burden of illness associated with roughly 14 vaccine-preventable conditions in the 20th century. Tell us how this has played out with respect to adult vaccines.

Angela: The pediatric platform has been really successful. We have several policy levers that support that platform including numerous well-child visits and quality and performance measures, as well as school and daycare entry requirements. Adult platform is a bit of a misnomer in that we don’t have the same regularly scheduled visits as we do for young children and adolescents. Those visits really serve to support and ensure that vaccination happens. For adults, it’s trickier. Many don’t even know that they’re indicated for vaccination. Luckily, we’ve been working on increasing uptake of adult vaccines. About a decade ago, we expanded access to include pharmacists and pharmacies as vaccinators. You can’t walk down your street without seeing a pharmacy with a sign that says, “Get your flu shot here. Get your family vaccinated.” We do have a long way to go for adults, though. We need more healthcare providers assessing and recommending vaccines, and adults need to become more aware of and seek vaccination.

Richard: We also know that the fragmented framework for health insurance coverage in the US can drive some differences around the adult platform. The Affordable Care Act applies to commercial health insurance plans and Medicaid expansion where payers are required to provide first dollar coverage of vaccines. But, in traditional Medicaid, vaccine coverage requirements can vary, which can impact vaccine access for lower income adults. In Medicare, beneficiaries are subject to potentially out-of-pocket costs for Part D vaccines. Those challenges around coverage impact access.

A more technical topic that impacts whether adults get the right vaccines at the right time is immunization information systems (IIS). Can you give us some perspective on IIS and what some of the challenges are around the adult platform within it?

Angela: That’s a good question. One of the key problems is decades of underinvestment in IIS, often known as immunization registries. IIS are systems that serve as repositories of all your immunization records. They started in the late 80s as a pediatric function to identify kids who are due or overdue for their immunizations, and to notify parents. Providers could use the IIS to monitor patient immunization status, while public health could use it as a population-wide tool to target interventions and plan programs.

Today we have over 60 registries as opposed to one national system. About 95% of kids and 80% of adolescents are populated in these networks, but only about 56% of the adult population is captured. This is a problem. Your doctor’s office might use an electronic health record (EHR) to record your shot, but the EHR isn’t connected to the state or city IIS, so the dose you receive might not be recorded in the registry. This means you or your child may not have a complete vaccination record, especially if you get your shots at different locations.

The point of the IIS is to have this centralized repository of all these pieces. This is a really important point because it will be a challenge to track COVID vaccinations. Most of the vaccine candidates are two-dose series, and none of the current vaccine candidates are interchangeable with each other. That means that if you get one dose of Vaccine A, your second dose needs to be for the same type of vaccine, which means that having accurate vaccination information during this pandemic response is critical. Near real-time data for decision making is going to be central to managing any public health emergency.

If I could wave my magic wand and introduce a national immunization registry 20-30 years ago, I would love to see what that might look like and what immunizations and adult immunization uptake would look like today.

Richard: This is going to be very impactful as our country tackles a COVID vaccination effort. We want to ensure that every eligible person gets the vaccine. It sounds like IIS will play a very important role. We could have a whole separate conversation about COVID vaccines, and we do that on a regular basis, but I want to talk with you about COVID’s impact on routine vaccination. I know that could look a little different for childhood and adult vaccines, but what is your perspective on how COVID has impacted access to vaccines that we already have?

Angela: There have been studies in claims data and registries that show vaccination coverage has gone down. This leaves many children, adolescents, and adults under- and unvaccinated. Vaccines are an essential part of the well-child visit, and public health officials and providers have been encouraging parents to come in, recognizing that many are reluctant. Providers, hospitals, and clinics have made significant changes in how they see patients in terms of patient flow and the recommended times in which they see sick children versus well children. The important thing is for folks who are indicated for a vaccination, particularly children and children under two, to make their appointments. If you get behind in the primary vaccination series, it’s difficult to catch up.

From an individual level, it’s important for children, adolescents, and adults to get vaccinated. On the population level, it’s important not to be collecting a pool of susceptible individuals and making certain communities more vulnerable to outbreaks. The pandemic has created a decline in health services and access to health services writ large. Many hospitals, providers, and health systems are seeking to get caught up on missed vaccinations, particularly as we prepare to go back to school or to work. Whatever that looks like, it’s still important.

Flu vaccine will be important in several ways. It will reduce the number of respiratory illnesses, therefore reducing the number of folks getting tested for COVID. It will also reduce the number of folks who need to go into the doctor’s office to get evaluated for flu. It’s more important than ever that all who aren’t contraindicated who are six months or older get the flu shot this fall.

Richard: It sounds like COVID really heightens the importance of flu vaccination, so thank you for sharing that perspective. And thank you, Angela, for joining me in today’s discussion. Your insights are invaluable to me and to our listeners. Thank you all for tuning in today to Avalere Health Essential Voice. If you’d like to learn more, please stay tuned for more episodes, and please download a copy of our 2020 Mid-Year Vaccines Outlook on our website at

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