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Figure: COVID-19 vaccine, social EMFigureWe treat a large number of people presenting with issues relating to homelessness, noncommunicable chronic diseases, psychological crisis, and substance misuse at St. Vincent's Hospital Melbourne, a large inner-city tertiary public teaching hospital in Melbourne, Australia. Our most frequent ED patients are disproportionately affected by these predominantly social issues with increasing prevalence. Nearly a quarter of all emergency visits in Australia last year were from people living in the most socioeconomically deprived areas, according to the Australian Institute of Health and Welfare. (https://bit.ly/3rOn5KK.) Australia has been fortunate to largely circumvent the magnitude of COVID-19 mortality experienced by our colleagues overseas, but strict and protracted lockdowns in Victoria and New South Wales have contributed to an increase in mental illness, family violence, housing instability, and drug and alcohol dependence, with implications for emergency department visits and ongoing safe health care provision, including immunization against COVID-19. It soon became apparent in our ED that vaccination among our heavy users was lagging behind the general population—20 percent lower. (Emerg Med Australas. 2021 Oct 8; doi: 10.1111/1742-6723.13883; https://bit.ly/3dA7iqx.) We implemented an opportunistic vaccination program to address this in the ED that prioritized patients who are Indigenous Australians, homeless, and living with substance misuse and addiction issues, family violence, and other social vulnerabilities. Countering Misinformation Most of our unvaccinated patients are not averse to immunization, proffering an arm for a jab then and there in the ED when offered an opportunistic vaccine, but a number of challenges to safely obtaining a COVID-19 vaccine persist. Vaccination centers often require advance bookings and commitment to a time slot at least a week away, which is difficult to commit to when faced with ongoing competing priorities such as housing instability, language barriers, reliance on cash-in-hand work, and threats of family violence. Vaccination booking also largely relies on online systems that are inaccessible to someone without reliable internet or a smartphone with data. We initially implemented opportunistic vaccination in the ED to help those who couldn't get vaccinated, rather than those who wouldn't, and we also found that a simple conversation with an engaged clinician and a hot cup of coffee was sufficient counsel to change the minds of many vaccine-hesitant people. Promoting good health literacy over the course of the pandemic has proven difficult, and many patients describe not really knowing who or where to get accurate or personalized information on the vaccine, finding it difficult to differentiate between legitimate medical sources online and metastatic misinformation masquerading as fact on social media. We can also address personal concerns and contextualize risk in the ED in a way that the patient can directly comprehend. Much has been said, for example, about the risk of venous thromboembolism post-vaccine, but explaining that you're twice as likely to get struck by lightning as you are to get a blood clot gives some accessible perspective. Conversations about opportunistic vaccination in the ED have proven a valuable reminder of individual health autonomy for people living with family members who are vocally averse to vaccination. Opportunistic vaccination is facilitated with the support of the nearby vaccination center that maintains dose storage and cold chain resources to prevent waste. A number of drawn-up vaccination doses are provided to the ED each morning where they are stored in the department's drug room at room temperature for up to six hours. Once an eligible patient is identified in the ED, the vaccinating clinician can walk into a cubicle with the dose ready to counsel, consent, and vaccinate the patient in one interaction. Social EM Unused vaccines can be swapped out for newer doses from the vaccination center prior to expiration to facilitate vaccines throughout the day. Vaccination governance, immunizer training, and administration requirements vary by location, though the majority of systems rely on local documentation and electronic databases for recording immunizations, which can be accessed from the ED. The unequivocal value of opportunistic vaccination in the ED re-emphasizes the necessity of social emergency medicine as a subspecialty addressing the needs of society's most vulnerable and marginalized people, who are universally more likely to be sicker and to seek health care in an emergency setting. Even before COVID-19, the remit of emergency departments had already extended beyond the realm of immediate physical health care provision in response to increasing numbers of patients presenting with complex and chronic complaints and an ever-widening range of biopsychosocial conditions. The global outcomes observed with COVID-19 and socioeconomic disadvantage over the past two years do not illustrate new patterns of morbidity and mortality, and many of the public health issues associated with the pandemic are not unprecedented; structural racism within health systems, inaccessible health information, and the impact of inadequate living conditions on disease acquisition and health-seeking behaviors are longstanding problems, and the pandemic has only cast a magnifying glass over gaping chasms of existing health inequities. The detrimental impact of the pandemic will last for decades to come, but the legacy and lessons learned from COVID-19 must be catalysts for conversation and action on the social and cultural determinants of global health in clinical practice. Dr. Simons thanks Jennie Hutton, BMBS, MPH, and Sally Harding, BPharm, for their role in establishing the opportunistic vaccination program at St. Vincent's Hospital Melbourne. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Dr. Simonsis an emergency department registrar working in Melbourne, Australia. She is British-trained with postgraduate study in global public health at University College London and an academic interest in the determinants of health, incorporating social justice perspectives and advocacy into emergency clinical practice for socially vulnerable people. Follow her on Twitter@SarahNSimons.

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