Surgery During a Pandemic? COVID Vaccination Status Matters — or Not

Judy Stone, MD

June 13, 2022

An online survey captured mixed information about people's willingness to undergo surgery during a viral pandemic in relation to the vaccine status of the patient and staff. The findings showcase opportunities for public education and "skillful messaging," researchers report.

In survey scenarios that asked people to imagine their vaccination status, people were more willing to undergo surgery if it was lifesaving, rather than elective, especially if vaccinated. The prospect of no hospital stay tipped the scales further toward surgery. The vaccination status of hospital staff played only a minor role in decision-making, according to the study published in Vaccine.

But as a post-hoc analysis revealed, it was participants who were not vaccinated against COVID-19 in real life who were more willing to undergo surgery, compared to those who had one or two shots.

In either case, too many people were unwilling to undergo lifesaving surgery, even though the risk of hospital-acquired COVID-19 is low. "Making this choice for an actual health problem would result in an unacceptably high rate of potential morbidity attributable to pandemic-related fears, the authors write.

In an unusual approach, the researchers used Amazon's Mechanical Turk to electronically recruit 2006 adults. The participants answered a 26-item survey about a hypothetical surgery in an unnamed pandemic with different combinations of vaccine status for patient and staff.

Co-author and anesthesiologist Keith Ruskin, MD, University of Chicago, told Medscape Medical News that they "wanted to make this timeless" and independent of COVID "so that when the next thing came about, the paper would still be relevant."

The researchers were surprised by the findings at the extreme ends of attitudes toward surgery. Some were still willing to have elective surgery with (hypothetically) unvaccinated patients and staff.

"And people at the other end, even though they are vaccinated, the hospital staff is vaccinated, and the surgery is lifesaving, they absolutely won't have surgery," Ruskin said.

He viewed these two groups as opportunities for education. "You can present information in the most positive light to get them to do the right thing with what's best for themselves," he said.

As an example, Ruskin pointed to an ad in Illinois. "It's not only people saying I'm getting vaccinated for myself and my family, but there are people who said I got vaccinated and I still got COVID, but it could have been much worse. Please, if you're on the fence, just get vaccinated," he said.

Co-author Anna Clebone Ruskin, MD, an anesthesiologist at the University of Chicago, said, "Humans are programmed to see things in extremes. With surgery, people tend to think of surgery as a monolith — surgery is all good, or surgery is all bad, where there is a huge in between. So we saw those extremes.... Seeing that dichotomy with people on either end was pretty surprising."

She continued, "Getting surgery is not always good. Getting surgery is not always bad. It's a risk-vs-benefit analysis and educating the public to consider the risks and benefits of medical decisions, in general, would be enormously beneficial."

A post-hoc analysis found that "participants who were not actually vaccinated against COVID-19 were generally more willing to undergo surgery compared to those who had one vaccination or two vaccinations," the authors write.

In a second post-hoc finding, participants who reported high wariness of vaccines were generally more likely to be willing to undergo surgery. Notably, 15% of participants "were unwilling to undergo lifesaving surgery during a pandemic even when they and the healthcare staff were vaccinated," the authors write.

Keith Ruskin hypothesized about this result, saying, "What we think is that potentially actually getting vaccinated against COVID-19 may indicate that you have a lower risk tolerance. So you may be less likely to do anything you perceive to be risky if you're vaccinated against COVID-19."

The authors state that "the risk of hospital-acquired COVID-19 even prior to vaccination is vanishingly small." The risk of nosocomial COVID varies among different studies. An EPIC-based study between April 2020 and October 2021 found the risk to be 1.8%; EPIC describes the fears of a patient catching COVID at a hospital as "likely unfounded."

In the UK, the risk was as high as 24% earlier in the pandemic and then declined to ~5% a year ago. Omicron also brought more infections. Rates varied significantly among hospitals — and, notably, the risk of death from a nosocomial COVID infection was 21% in April-September 2020.

Emily Landon, MD, is an epidemiologist and executive medical director for infection prevention and control at the University of Chicago Medicine. She told Medscape Medical News that the study's data was collected during Delta, during a "time when we thought that this was a pandemic of the unvaccinated. But there was serious politicization of the vaccine."

Dr Emily Landon

Landon said one of the study's strengths was the large number of participants. A limitation was, "You're going to have less participants who are generally poor and indigent, and fewer old participants, probably because they're less likely to respond to an online survey."

She added, "But the most interesting results are that people who were wary of vaccines or who hadn't been vaccinated, were much more willing to undergo surgical procedures in the time of a pandemic, regardless of status, which reflects the fact that not being vaccinated correlates with not worrying much about COVID. Vaccinated individuals had a lot more wariness about undergoing surgical procedures during a pandemic."

It appeared "individuals who were vaccinated in real life [were] worried about staff vaccination," Landon noted. She concluded, "I think it supports the need for mandatory vaccinations in healthcare workers."

The study has implications for hospital vaccination policies and practices. In Cumberland, Maryland, when COVID was high and vaccines first became available, the Maryland Hospital Association said that all healthcare staff should be vaccinated. The local hospital, UPMC-WMHS, refused.

Two months later, the local news reporter, Teresa McMinn, wrote, "While Maryland's largest hospital systems have 'led by example by mandating vaccines for all of their hospital staff,' other facilities — including UPMC Western Maryland and Garrett Regional Medical Center — have taken no such action even though it's been eight months since vaccines were made available to health care workers."

The hospital would not tell patients whether staff were vaccinated, either. An ongoing concern for members of the community is the lack of communication with UPMC, which erodes trust in the health system — the only hospital available in this rural community.

This vaccine study supports that the vaccination status of the staff may influence some patients' decision on whether to have surgery.

The Ruskins and Landon have disclosed no relevant financial relationships.

Vaccine. 2022;40:3536-3539. Abstract

Judy Stone, MD, is an infectious disease specialist and author of Resilience: One Family's Story of Hope and Triumph Over Evil and of Conducting Clinical Research, the essential guide to the topic. You can find her at drjudystone.com or on Twitter @drjudystone.

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