Become a Vaccine Champion

A few years ago, I was chatting with a mom in our church parking lot. When she told me her oldest child was getting ready to go to college, I shared in her excitement. As a parent, I know what a wonderful experience it is to give children wings to fly out of the nest. Everyone at church knows I’m a nurse and a passionate advocate for vaccines, so my next question was no surprise.

“Have you gotten your child the meningitis B vaccine yet?”

“Oh sure,” she said. “We got the meningitis vaccine that’s required for school.” She’d wanted to be sure her child was protected.

“I couldn’t agree more, and I want the same thing,” I replied. “That’s why I asked about meningitis B.”

The mom had never heard of the meningitis B vaccine, so she thought it couldn’t be that important. And anyway, meningitis is meningitis, right? With all the other vaccines children already receive, why was this one necessary?

“Those are excellent questions,” I said. “I know you’re really just trying to sort all of this out and do what’s best for you and your family. May I have permission to answer your questions?”

When she nodded, I told her about my background—that I’ve spent most of my career learning about and giving vaccines. I’ve taken several courses from the Centers for Disease Control and Prevention (CDC), the Vaccine Education Center at Children’s Hospital of Philadelphia, and other places, and I read more on vaccine topics every day to stay current. I told her that in my research, I’d learned that the only strain of meningitis seen on college campuses in the last 10 years is meningitis B—but the vaccine isn’t mandatory because the disease is considered very rare.

“If it’s so rare, why does my child need a vaccine?” she asked.

“It won’t be rare if your child contracts it,” I told her. “And the only protection against it is the vaccine.”

I told this mom that a very dear friend of mine had lost her 17-year-old daughter—her only daughter—to meningitis B before there was a vaccine available. And more recently, an adolescent who lived not far from me had also died from meningitis B. I told her that I knew a few people who had survived it, but their lives had been changed forever because of lost limbs or permanent organ damage.

“May I have your permission to discuss the vaccine further and tell you what I’ve learned?” I asked.

When she agreed, I asked her what questions she had about the vaccine. She asked if it was safe. I told her the meningitis B vaccine was tested very vigorously in thousands of people before it was licensed, and it was found to be safe and effective. The most common side effect is a sore arm.¹ I told her that I believe so strongly in the science that I’d convinced my nieces and nephews to get the vaccine for their children. The mom found this very reassuring.

“Have I answered all your questions?” I asked. She said I had, and that I’d given her a lot to think about.

I left her with a final thought: “I hope you decide to ask your healthcare provider about the meningitis B vaccine before your child leaves for school. I know I wouldn’t let my child leave home without that potentially lifesaving vaccine.”

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I have conversations like this all the time. They have been part of my career in public health for more than 30 years. I’m a nurse with expertise in immunizations, and in my work communicating the importance of vaccines to the public, I’ve seen a range of emotional responses to the topic of vaccines. Vaccination is an emotional issue for me, too. It’s the reason I became a nurse.

I grew up in a family suffering the ravages of diseases that are now vaccine preventable. One summer Sunday morning in 1923, my mother, Mildred Bliss Koslap—then just 3 years old—woke up to find that her right arm and leg were numb and she could not get out of bed. She was terrified. Her parents were distraught. After some effort, my grandfather was finally able to locate a kindly physician to make a weekend house call to the guest house in upstate New York where they were staying on vacation. The physician took one look at my mother and announced that it was polio. My mother had no idea what that meant, but she clearly remembered the fear in her parents’ faces.

The guest house was thrown into chaos. Not much was known about polio in those days, but none of the other guests wanted to be near a sick child. Everyone else left, and the owner of the house insisted that my grandparents pay for all the lost business. For three weeks, my mother was quarantined there until the physician deemed her able to travel back home to continue her isolation. She spent months confined to her bed, unable to move her right side, feed herself (she was right-handed), or see her siblings.

The treatment for polio at that time was hot wet packs applied to the limbs to relieve the painful muscle spasms. My mother hated them because they made her even hotter in the summer heat—but she really hated the strengthening exercises she had to do when the packs came off. The packs continued for over a year, and the strengthening exercises lasted for years after that.

My mother recovered, but life was different for her. She learned to write again, this time with her left hand, because polio had changed her dominant hand. By the time she was able to walk by herself again at 6 years old, her right leg had become shorter than her left, giving her a slight limp. She went to school, grew up, and had children, but being a polio survivor colored my mother’s entire life. She would not allow my sisters and me to go swimming in the summer, and she limited the number of other children we were allowed to play with—she was always afraid one of us would get polio, too. When the Salk vaccine was approved in 1955,² my mother could not get us vaccinated fast enough. She wasn’t alone; every parent she knew was just as anxious to get their children protected.

At that time, I was attending Catholic school in the village where I was raised. While we children weren’t excited about getting a shot, we knew what contracting polio would mean for us. I clearly remember sitting in my second-grade classroom the day our teacher told us one of our classmates had been hospitalized with polio. I asked if they’d been put in an iron lung. Pretty heavy stuff for a 7-year-old. So when it was time to get vaccinated, I walked with the nuns and 400 other schoolchildren the mile up the hill to the public elementary school where the shot was being administered. We marched into the auditorium and, one by one, made history. After that, summers were very different. We could swim and play with our friends as much as we liked. Polio became a distant memory for everyone except those of us who lived through it.

Once we had the vaccine, we were done with polio—but it wasn’t done with my mother. Her right side began to weaken in her 40s, and by her mid-70s she could no longer grasp things with her right hand. Her physicians had no idea why this was happening. I was a nurse by then and had started working in my local health department with vaccines. There, I learned that physicians at the CDC and the National Institutes of Health had been studying a new polio complication in which spasms and paralysis returned in many survivors over time. The complication became known as post-polio syndrome.³ I was sure my mother had it. When I finally convinced her physicians to read the published article on post-polio syndrome, they agreed with my diagnosis. By the time my mother died at age 98, polio had robbed her of the ability to walk independently and care for herself.

My mother’s experience with polio was instrumental in my becoming a nurse advocate for vaccination, but my path was also shaped by my grandmother’s experience with cancer. In 1955—the same year that the polio vaccine saved me and countless other children—Mary Skapura Koslap, for whom I was named, died of cervical cancer. My grandmother did not have the same access to medical care that we enjoy today. She had no annual Pap smear because a simplified test wasn’t routinely given until 1957.⁴ When she was finally diagnosed, it was too late; cancer had taken over her body, causing necrosis and pain. My aunt, who lived with and cared for my grandmother, worked tirelessly to keep her clean and comfortable. She changed and disinfected bed linens multiple times a day, but all the bleach in the world could not cover up the smell as my grandmother rotted to death.

My grandmother died from a disease that is largely preventable today thanks to a vaccine. Human papillomavirus (HPV) causes cancer of the cervix, oropharynx, anal canal, vulva, vagina, and penis, but the HPV vaccine could prevent 90 percent of these cancers.⁵ The data are compelling. I can only imagine the additional time my family might have had with my grandmother—and the suffering she might have been spared—if this vaccine had been available in her lifetime. That’s why I tell her story every time I give an adolescent the HPV vaccination. I never want them to have to face what my family experienced.

Vaccines are the number one public health achievement of the 20th century.⁶ Research shows that vaccines have saved countless lives, and they increase our longevity. And they’re not just for babies; vaccines are important at various times along the lifespan. But fear and misinformation can cloud the evidence that vaccines work. This has become more obvious during the COVID-19 pandemic, which has for the first time in many years interrupted our country’s increasing longevity with its disproportionate impact on Black and Latino communities.⁷ We now have vaccines that can reverse this disturbing trend and make real headway in keeping our communities safe, not just from COVID-19 but from other serious illness and disease. What we need are nurses to be vaccine champions and empower others to follow the evidence.

Nurses as Vaccine Champions

I often describe myself as a “dinosaur” when relating my nursing experiences because I’ve been doing this for so long. But my passion and conviction for this work are just as strong today as they were on the day I took the Nightingale Pledge at graduation in 1969. In the final line of the pledge, I promised to “devote myself to the welfare of those committed to my care.”⁸ To me, that means doing all I can to protect my patients—not only encouraging them to get vaccinated, but also setting an example for them by getting vaccinated myself. I see it as a moral responsibility. I start every day with an unspoken promise to my patients: “As I care for you, it is my job to protect you from all harm. That means any harm from your illness or its symptoms, from outside forces including the care environment, and from other people if necessary.”⁹

I have never met a nurse who took the Nightingale Pledge for granted. We consider caring for others in their time of need personally and professionally rewarding and one of our most sacred responsibilities. We are born leaders and take-charge people. We don’t stand on ceremony; we jump into action during emergencies. We save lives on airplanes and stop to help with motor vehicle accidents. And all this is in addition to the work we do daily to keep our patients safe with our excellent assessment skills. We are singularly well suited to the work of vaccine advocacy.

By virtue of our profession, nurses have a head start in championing vaccines for ourselves, our patients, and our communities. Ours is the most trusted of all professions.¹⁰ We are rated highly because we’re seen as honest and ethical. The public trusts that we put our patients’ needs ahead of the interests of others. Our voices are heard and our opinions are respected because of what we do. No matter what field of nursing we practice, we all spend much of our time educating patients. We have a way of speaking that makes complicated material understandable without talking down to patients.* We need to use that influence to clarify misinformation about vaccines, reassure each other and the public that the science behind vaccines is solid, and encourage everyone to get vaccinated. I truly believe that every nurse should be a vaccine champion and that every nurse can be a vaccine champion. It all starts with conversations with fellow nurses who may be hesitant about vaccines.

The reason to start these conversations with our colleagues is simple: our patients depend on us to protect them from harm, and this includes the harm we can inadvertently cause them ourselves. The medical literature has clearly demonstrated that healthcare workers can be vectors of highly transmissible pathogens like influenza and measles.¹¹ Not surprisingly, one of the best ways to protect patients from pathogens we are carrying or come into contact with is vaccination.¹²

I would never expect a nurse colleague to do something that I wouldn’t do or something that is not supported by the best available evidence. And the evidence clearly indicates that vaccines are safe and effective. Obviously, no vaccine is 100 percent effective or guaranteed; there is always a small risk of infection or negative reaction. But there is also risk in daily activities like driving a car or walking across a street. We do those things as safely as possible because we understand that the benefit of getting where we need to go far outweighs the risk.

So I start with me. I ask for permission to have a conversation, and I approach the conversation from the perspective that being vaccinated myself—and getting my family vaccinated—is the right thing to do for everyone I care about, including my patients. It is never about yelling or belittling a colleague who disagrees with me. It’s about building trust: I listen to my vaccine-hesitant nurse colleagues and address their concerns one by one in a way that I believe may persuade them to trust the evidence and realize that being vaccinated is part of our responsibility to protect each other and our patients.

The CASE Model

I have found that it’s much easier to have these conversations when there is a paradigm to follow. The paradigm that I have taught to countless colleagues is the CASE model for addressing vaccine hesitancy and communicating science. This model was developed by Alison Singer, president of the Autism Science Foundation, who believes that high-emotion conversations like those about vaccination must be approached from a place of shared beliefs and a desire to find common ground.^† The model has four steps: Corroborate, About Me, Science, and Explain/Advise. The rationale for patterning the conversation in this way is that people tend to make better decisions about vaccination when they receive relevant, credible, and comprehensive information about a topic; when they feel their concerns are heard; when they aren’t belittled; and when they feel they have control over the decision.¹³

Corroborate: In this first step, you as the vaccine-committed nurse should acknowledge the other person’s concern about vaccines and find something on which both of you can agree. This step is important because it sets the tone for a respectful, successful talk. We all have so much information coming at us from the news, social media, the internet, and other people, and it’s all relayed with such conviction and passion that it’s easy to get caught up in whether or not the information is actually based in science. But no matter what two people think about vaccines, there is always something both can agree on (for instance, you might agree that the amount of information is overwhelming!). And when you speak with kindness and genuine care and concern for the other person—as nurses are prone to do—barriers to successful discussions are often reduced.

About Me: Here, you describe what you have done to build your knowledge base and expertise to establish trust and credibility. In this step, I often mention that I have worked for a health department for 30 years and am very active in two national vaccine advocacy organizations: I am a nurse consultant for Immunize.org, and I’m on the Scientific Advisory Board of Vaccinate Your Family. I talk about the science-based news, journal articles, and studies that I have read and the many courses I have taken on vaccines. Because I believe personal stories are very powerful, I also tell the other person about my family history with vaccine-preventable diseases, and I disclose that I am vaccinated myself, along with my children and grandchildren. 

Science: At this point, you’ve already centered your perspective in science, so in this step you describe what the science says. Talk about the studies conducted over time that have clearly shown vaccines are safe and effective and why you trust the science. I often mention here that I trust the science because I am a nurse scientist. Be careful not to overwhelm the other person by relying too heavily on scientific studies—it can be a turnoff for some. And remember that for every study you cite that supports immunizations, they may cite a “study” that supports the opposite. If they do, discuss that study and be ready to talk about why its findings may not be scientifically supported or the best available evidence.

Explain/Advise: Finally, give advice to the other person based on the science. Explain that vaccines are critical to our health and well-being because they prevent diseases that cause real harm. Tell them that you want the same thing for them that you want for yourself: to be healthy and to protect yourself and others from vaccine-preventable diseases. 

All conversations using this model should begin by asking the other person for permission to start a discussion. I often ask, “May I have your permission to tell you what I’ve learned about this vaccine?” When I have respectfully asked, I have never been refused. After each step in the model, I pause and ask, “Have I answered all of your questions?” I ask these questions using this wording because I believe they give the vaccine-hesitant person a sense of control in the conversation—and we all want to feel like we are in control and not being told what to do or believe. Some vaccine-hesitant people are already defensive, expecting to be told that they are wrong and that their fears and concerns will not be heard or addressed. Establishing respect and giving them control to steer the conversation helps remove these barriers to a successful discussion.

The CASE model can be used for conversations about any vaccine, but considering the COVID-19 pandemic of the last two years, this vaccine conversation is especially important. Here’s how you could use the model to speak to a nurse colleague (or to a family or community member) who is hesitant about receiving a COVID-19 vaccine:

You [Corroborate]: I heard that you have some reservations about the COVID vaccines. I get it. These vaccines were made really quickly compared to other vaccines. Honestly, I was worried about it at first, too. I wasn’t sure all of the usual testing was completed and all the right safeguards were followed.

Nurse Colleague: Yes! I’m really worried about how fast these vaccines were pushed through and the new technology. How do we know the science was done right?

You: We’re worried about the same thing! We both want to make sure the science was done right. What other issues with the vaccine are concerning to you?

Nurse Colleague: Well, what about the testing? How do we know all of the safeguards were followed in testing the vaccine on people? And I’m also concerned the vaccines could cause damage and affect my ability to have a healthy baby.

You: Those are excellent questions. I know you’re really just trying to figure out what’s best for you. May I have your permission to answer your questions and tell you what I’ve learned about the COVID vaccines?

Nurse Colleague: Yes, I’m interested in your perspective.

You [About Me]: I’ve read about all that had to happen for these vaccines to become available in the United States. I went to scientifically supported websites by the CDC and the Vaccine Education Center at Children’s Hospital of Philadelphia and found that the COVID vaccines went through the same rigorous testing as every other vaccine. I searched for the best available evidence that COVID vaccines are safe and effective, and I found it on those sites.

I agree that the idea of “new technology” for the COVID vaccines can sound concerning, but I’ve learned that this technology has been around for more than 20 years.¹⁴ We haven’t used it because it is expensive technology, and we had little need for it until now because we had vaccines that worked well and were cheaper to produce. But the testing process was not changed at all. The clinical trials were completed for this vaccine just as for all other vaccines. In fact, the COVID vaccines are being more closely monitored for safety than any prior vaccine.¹⁵

Nurse Colleague: OK. Maybe there’s more to this than I thought. But I still have those other questions.

You [Science]: May I tell you another interesting thing I learned?

Nurse Colleague: Nods in agreement.

You: While COVID vaccines were certainly made available much more quickly than previous vaccines, this was only possible because massive financial and human resources were dedicated to this effort in response to the pandemic—but the vaccines still had to undergo the same safety testing as other vaccines. They were tested in tens of thousands of people, and the results of these tests were carefully reviewed. In the US, these reviews were completed by independent experts advising the Food and Drug Administration and the CDC. Billions of people have now received a COVID vaccine, and multiple systems are in place to make sure these vaccines keep being safe.¹⁶ All the evidence points to the benefits of vaccination far outweighing the risks.

Nurse Colleague: OK, but what about the risk to fertility and pregnant women? I read on the internet that the COVID vaccines can cause infertility and damage fetuses.

You: I hear your concern about the effect an mRNA vaccine might have on fertility. I wanted to make sure I learned everything I could about that, too. To affect our bodies in that way, the mRNA would have to have access to our DNA. But I learned that doesn’t happen. The mRNA never enters the cell where DNA is located, so it can’t influence genes. And both the mRNA and spike protein—the bit of coronavirus that helps it enter human cells—are only in our bodies temporarily.¹⁷ The CDC is currently studying the safety of the vaccines, and so far it has no evidence that they are problematic—in fact, the CDC advises pregnant people to get vaccinated.¹⁸ The most common side effect of the vaccine seen in pregnant people is a sore arm following injection. Have I answered all the questions you have about the vaccine and pregnancy?

Nurse Colleague: I think so. I didn’t know all the science behind the vaccine.

You [Explain/Advise]: I didn’t either, initially. But several of my friends and a family member suffered from COVID. With what we know about how serious this disease can be, I was excited to hear about vaccines being produced so quickly—but like you, I had concerns. Learning how rigorous the approval process was and how safe the vaccines are really calmed my mind. It’s amazing that we have vaccines to help prevent this disease for those we love and care for. My family members and I have all gotten vaccinated. I hope you will, too.

Using CASE to Clarify Misinformation

As vaccine champions, we are empowered not only to share what we’ve learned about vaccines, but also to dispel myths and misinformation that could prohibit others from choosing to vaccinate. Myths about the COVID-19 vaccines abound; a few that have become widespread claim that they make our bodies magnetic, that they contain microchips to track our movements, and—as seen in the sample conversation above—that the vaccines alter our DNA and can harm pregnancies.¹⁹

The CASE model can be very effective when we hear another nurse mention something about vaccines that sounds incorrect. In this situation, we need to first be comfortable enough to ask where the nurse heard or read that information, and then go check out the source for ourselves. The rest of the conversation can begin from there. I believe that if nurses who are sharing misinformation can be engaged in an open, respectful conversation to discuss their fears about the vaccine, hearing about the best available evidence and receiving answers for their questions could make a difference in their thinking and stop misinformation in its tracks.

I experienced this recently, while I was volunteering to administer COVID vaccinations for my hometown’s county health department. I was working with an obstetrics nursing colleague who had experience in the labor and delivery, newborn nursery, and postpartum units, in addition to being a childbirth educator. This colleague told me she’d seen a huge increase in infants with low birth weight since pregnant people had begun receiving the COVID vaccine, and she didn’t think the number of pregnant people who had died from COVID could compare with the number of low birth weight infants.

“I’m very surprised to hear that,” I told her, “since so many people have lost their lives and/or their babies to COVID. But I hear your concern, and it would concern me, too. May I share with you what I’ve learned about pregnancy and the COVID vaccine?”

When she agreed, I mentioned that I daily monitor data that come directly from hospitals. I’d also read the CDC’s findings on this topic: those who contract COVID during pregnancy and have symptoms have a twofold higher risk of ICU admission and 70 percent increased risk of death compared with symptomatic people who are not pregnant.²⁰ What’s more, a very large study found no association between vaccination during pregnancy and preterm birth or low birth weight.²¹ In fact, the growing body of data shows just the opposite: the CDC’s COVID vaccine pregnancy registry, which tracks pregnancy outcomes of those who received vaccinations, has found no increased risk of miscarriage among those vaccinated before 20 weeks gestation and no safety concerns for those vaccinated later in pregnancy or for their babies after birth.²² Comparing these data against the known severe risks of COVID during pregnancy demonstrates that the benefits of pregnant people receiving a vaccine outweigh any known or potential risks.

“I believe the vaccine is safe and effective in pregnancy,” I told her. “I’m already vaccinated, but if I were pregnant, I’d take it. And if my daughters-in-law were pregnant and had not yet been vaccinated, I’d recommend they get vaccinated as well. Have I answered all the questions you have?”

The nurse said that she’d never heard the evidence presented in that way, and our discussion had changed her thinking. I truly believe this was possible because we had a nurse-to-nurse conversation and she trusted me as a colleague. I also believe our conversation was a step in empowering this nurse to be a vaccine champion herself and make the case for vaccination with her colleagues and patients. This is what it’s all about!

Of course, not every conversation results in a changed mind or a decision for vaccination. If I can get the other person to even engage in a discussion, and if I can leave them with something to think about, that’s progress. But progress is impossible if I approach them as if they are crazy or intentionally trying to harm others with incorrect information. So instead of “Where on earth did you hear that? You’re wrong!,” I tell them, “I’ve heard that, too. Can we talk about it?” Remember that we want a conversation, not a confrontation—and our vaccine-hesitant colleagues have the same good intentions for their families and patients as we do. Our goal is to listen to each other and find common ground from which to work together.

Empowering Each Other

When nurses empower each other to be vaccine champions, we can make an unbelievable impact to prevent disease in our communities. Several years ago, I worked for the Suffolk County Department of Health Services in New York, in a health system that included eight primary care centers and a skilled nursing facility. Part of my focus was improving the influenza vaccination rate, which at that time was 20 percent across all facilities. Knowing that success could only happen if we approached the problem together, I reached out to all of the facilities’ nursing supervisors to talk about why the rates were so low. The supervisors believed healthcare workers needed greater buy-in as team members in the effort to protect themselves and their patients from influenza. So we got to work, building the trust and having the conversations necessary to make a difference.

Each supervisor provided opportunities for healthcare workers to receive influenza vaccinations at their facilities during work hours. They also discussed the vaccine with each nurse and staff member, emphasizing the responsibility each had as healthcare workers to protect patients from influenza and answering questions about the effectiveness and potential side effects of the vaccine. One by one, the nurses and other staff began to get vaccinated. They would trade off and cover each other’s patients or duties for the time it took to get vaccinated. Once a vaccinated employee returned to duty, another took their place in line for vaccination. It became a contest to see which facility could get the most healthcare workers vaccinated in the shortest period.

In one year, the vaccination rate across all facilities rose to 60 percent—but the project didn’t end there. The nurses continued to work together over the ensuing years to bring staff immunization rates up over 90 percent. This was a clear case of nurse empowerment,²³ and the Suffolk County project became a model for the CDC and the national paradigm for staff immunization programs.²⁴ This is what can happen when nurses own vaccination. And the more we do it, the easier it becomes.

We nurses can do this work. We can start by getting vaccinated ourselves, and then we can use our incredible influence to empower each other to follow the evidence and serve as examples for our communities. We can muster the nerve it takes to start these crucial conversations. My experiences watching my mother and grandmother suffer from now-preventable illness and death are what give me the nerve every day to start these conversations—and I have no doubt you have similar stories to lean on. We owe it to ourselves. We owe it to each other.

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Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP, is an adjunct clinical assistant professor at the Stony Brook University School of Nursing and the owner of Pediatric Nurse Practitioner House Calls. She chaired the National Association of Pediatric Nurse Practitioners’ Immunization Special Interest Group and has served on the National Vaccine Advisory Committee.

*For tips on speaking with patients, see “Improving Communication and Care: How Clinicians Can Increase Health Literacy and Equity” in the Spring 2021 issue of AFT Health Care. (return to article)
^†Although the CASE model has not been empirically tested, it shares many features with promising approaches to patient-provider communication; for a review of these approaches, see “Communicating with Vaccine-Hesitant Parents: A Narrative Review.” (return to article)

Endnotes

1. Centers for Disease Control and Prevention, “Meningococcal Vaccination for Adolescents: Information for Healthcare Professionals,” page last reviewed October 12, 2021, cdc.gov/vaccines/vpd/mening/hcp/adolescent-vaccine.html.
2. Science History Institute, “Jonas Salk and Albert Bruce Sabin,” last updated January 8, 2017, sciencehistory.org/historical-profile/jonas-salk-and-albert-bruce-sabin.
3. Centers for Disease Control and Prevention, “Post-Polio Syndrome,” page last reviewed September 23, 2021, cdc.gov/polio/what-is-polio/pps.html.
4. S. Tan and Y. Tatsumura, “George Papanicolaou (1883–1962): Discoverer of the Pap Smear,” Singapore Medical Journal 56, no. 10 (2015): 586–87; and M. Linder, “Pap Smear Management: An Update on Recent Recommendations,” Ob/Gyn Clinical Alert, January 1, 2021.
5. Centers for Disease Control and Prevention, “Human Papillomavirus: For Healthcare Professionals,” page last reviewed November 1, 2021, cdc.gov/hpv/hcp/index.html; and Centers for Disease Control and Prevention, “Cancers Caused by HPV Are Preventable,” page last reviewed November 1, 2021, cdc.gov/hpv/hcp/protecting-patients.html.
6. Centers for Disease Control and Prevention, “Ten Great Public Health Achievements—United States, 1900–1999,” Morbidity and Mortality Weekly Report 48, no. 12 (1999).
7. T. Andrasfay and N. Goldman, “Reductions in 2020 US Life Expectancy Due to COVID-19 and the Disproportionate Impact on the Black and Latino Populations,” Proceedings of the National Academy of Sciences of the United States of America 118, no. 5 (February 2021).
8. The Truth About Nursing, “Florence Nightingale Pledge,” truthaboutnursing.org/press/pioneers/nightingale_pledge.html#gsc.tab=0.
9. The Truth About Nursing, “I Am Your Registered Nurse,” truthaboutnursing.org/action/posters/i_am_your_rn_8.pdf.
10. L. Saad, “U.S. Ethics Ratings Rise for Medical Workers and Teachers,” Gallup, December 2, 2020.
11. P. Orr, “Influenza Vaccination for Health Care Workers: A Duty of Care,” The Canadian Journal of Infectious Diseases 11, no. 5 (2000): 225–26; and R. Huttunen and J. Syrjänen, “Healthcare Workers as Vectors of Infectious Diseases,” European Journal of Clinical Microbiology & Infectious Diseases 33, no. 9 (2014): 1477–88.
12. Centers for Disease Control and Prevention, “Vaccine Information for Adults: Recommended Vaccines for Healthcare Workers,” page last reviewed May 2, 2016, cdc.gov/vaccines/adults/rec-vac/hcw.html.
13. A. Singer, “Making the CASE for Vaccines: Communicating Vaccine Safety Data to Parents,” Centers for Disease Control and Prevention National Immunization Conference, April 21, 2010, slideplayer.com/slide/10827723.
14. M. Nahm, “COVID-19 mRNA Vaccines: How Could Anything Developed This Quickly Be Safe?,” UAB News, May 25, 2021.
15. Centers for Disease Control and Prevention, “Developing COVID-19 Vaccines,” updated September 8, 2021, cdc.gov/coronavirus/2019-ncov/vaccines/distributing/steps-ensure-safety.html.
16. US Food & Drug Administration, “COVID-19 Vaccine Safety Surveillance,” December 7, 2021, fda.gov/vaccines-blood-biologics/safety-availability-biologics/covid-19-vaccine-safety-surveillance.
17. Centers for Disease Control and Prevention, “COVID-19: Understanding mRNA COVID-19 Vaccines,” updated January 4, 2022, cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html.
18. Centers for Disease Control and Prevention, “COVID-19: V-Safe COVID-19 Vaccine Pregnancy Registry,” updated January 20, 2022, cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafepregnancyregistry.html.
19. Centers for Disease Control and Prevention, “COVID-19: Myths and Facts About COVID-19 Vaccines,” updated December 15, 2021, cdc.gov/coronavirus/2019-ncov/vaccines/facts.html.
20. Centers for Disease Control and Prevention, “COVID-19 Vaccination for Pregnant People to Prevent Serious Illness, Deaths, and Adverse Pregnancy Outcomes from COVID-19,” Health Alert Network, September 29, 2021.
21. H. Lipkind et al., “Receipt of COVID-19 Vaccine During Pregnancy and Preterm or Small-for-Gestational-Age at Birth—Eight Integrated Health Care Organizations, United States, December 15, 2020–July 22, 2021,” Morbidity and Mortality Weekly Report 71, no. 1 (January 2022): 26–30.
22. Centers for Disease Control and Prevention, “New CDC Data: COVID-19 Vaccination Safe for Pregnant People,” August 11, 2021.
23. M. Koslap-Petraco and L. Mermelstein, “Flu Shots for Health Care Providers—a Strategy That Works” (paper presented at the Centers for Disease Control and Prevention National Immunization Conference, Nashville, May 2004), slideplayer.com/slide/14487484.
24. M. Koslap-Petraco and B. Harper, “Influenza Vaccine: Leave No Vaccine Behind in Suffolk County, NY” (paper presented at the Centers for Disease Control and Prevention Annual Immunization Conference, Atlanta, March 2006).

[Illustrations by Francesca Gastone]