COVID-19 reached a pandemic status in early 2020, creating an unprecedented global public health crisis. As of early 2021, much has been learned about COVID-19 but much more remains to be explained. COVID-19 has been labeled as discriminatory because various disparities in clinical courses and outcomes have been attributed to the disease. Although disparities exist for certain groups, the risk of infection recognizes no sociodemographic boundaries. None remain untouched by its reach beyond healthcare, invading how we live, work, and play. Thanks to accelerated vaccine production and emergency use authorizations, millions of people are being vaccinated daily. However, herd immunity remains many months away, and both primary and secondary health care strategies continue to be required.  

All are at risk for COVID-19 infection, but certain groups are particularly vulnerable. The U.S. Centers for Disease Control and Prevention (CDC) cites certain acute and chronic health conditions as having a greater risk for severe disease experience and death (CDC, 2020a). The risk may be compounded by the condition’s type, advanced stage, number of comorbidities, and how well the condition is managed (CDC, 2020a). Disease management became increasingly problematic during 2020. Lack of healthcare access, overwhelmed hospitals and providers, inability to utilize telehealth, and fear of disease exposure resulted in delayed or denied care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Studies show that certain ethnic and racial groups are more likely to experience severe COVID-19 disease or death (CDC, 2020b; Zakeri et al., 2020; Atlantic Monthly Group, 2021), with Black, Indigenous, and Latinx groups being most affected. The risk for severe COVID-19 disease increases with age, with older adults at the highest risk (CDC, 2020a). Other factors, such as where one lives, works, or gathers, can also increase infection risk. Gold et al. (2020) recognized that absence of data to quantify chronic COVID-related morbidity among survivors, known as long-haul-COVID, also disproportionately affected different people groups. While the world awaits the safety of herd immunity, it remains necessary for nurses to embrace tradition and offset invasive disease risks with efficient and specific anticipatory guidance.  

One path to reducing COVID-19 disease severity and deaths is to return to our nursing foundations by providing the appropriate anticipatory guidance. Nursing anticipatory guidance is a patient education activity that includes age-and situation-appropriate information about healthier living and disease prevention (CDC, 2018). As always, the best strategy is prevention. Instruct patients on avoiding exposure to COVID-19. Continue social distancing, wearing masks, washing hands, and getting vaccinated when their turn queues up. But have a backup plan in place. As adherence to social distancing and mitigation efforts wane, inevitably, disease exposures and subsequent recurrent surges of COVID-19 infections will occur. 

Advise patients the same as we have always done – eat healthily, get exercise, watch your weight, take your medication, and keep your doctor appointments. However, that same nursing anticipatory guidance is now underscored with the knowledge that those same foundational health strategies also save lives. Those same strategies reduce the complexity of comorbid conditions that confound and compound the risks of severe COVID disease, long-haul-COVID, and death. The fear of severe or fatal COVID-19 infection may be an effective motivator for better chronic disease management. If disease exposure is inevitable, the best option is to meet COVID disease at the best health and disease maintenance level possible.   

At present, the timing of confident herd immunity is unknown. Global vaccination efforts cannot be accurately predicted, primarily due to two factors – access and acceptance. Access is sporadic, with countries competing for millions of doses as quickly as they are produced, and each country determining its own strategy for vaccine roll-out. For poorer countries, access may depend upon the kindness of strangers and donations from more affluent and better-resourced nations. Rural inhabitants may have more difficulty accessing a vaccination site than those residing in more populous locations. 

Vaccine acceptance has become increasingly controversial over the last few decades – a disturbing development, given that vaccination is required to develop definitive herd (or community) immunity. The CDC defines herd immunity as a “situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination or prior illness) to make its spread from person to person unlikely” (CDC, 2020c). Many parents have refused traditional childhood vaccinations such as measles and varicella (aka chickenpox), citing concerns of health-related consequences, religious/conscientious objections, or a preference for acquiring natural immunity through disease exposure. 

Opting out of vaccinations has led to sporadic disease outbreaks due to reduced herd immunity. For the COVID-19 vaccine, added opt-out concerns include accelerated vaccine development and various misinformation about their safety. Some healthcare workers who conventionally promote vaccination have paused, choosing to wait and see what long-term effects COVID vaccines may pose. Ultimately, COVID vaccination is a personal choice, and that choice should be respected. Anticipatory guidance efforts should be directed towards eliminating vaccine misinformation and promoting a science-based vaccine acceptance (or rejection) decision. 

Just as disparities occurred in disease outbreaks and severity, community or herd immunity will likely also be sporadic and varied. Whether acquired through disease exposure or vaccination, immunizations depend on community disease prevalence, vaccine availability, and acceptance. The role of the nurse in reducing COVID disease severity, and accelerating herd immunity is to provide timely and appropriate nursing anticipatory guidance. As always, encourage optimal health and treatment compliance. Promote COVID-19 mitigation strategies (masking, hand-washing, and social distancing). Advance science-based vaccine acceptance decisions and eliminate misinformation. Now, as we begin to see the light at the end of the COVID tunnel, it becomes necessary for nurses to embrace tradition and abate COVID risks with efficient and specific anticipatory guidance.  

References: 

Atlantic Monthly Group. (2021). The COVID Tracking Project. Available online at https://covidtracking.com/ 

Centers for Disease Control and Prevention [CDC]. (2018). Environmental health and medicine education: Anticipatory guidance and environmental health. Available online at https://www.atsdr.cdc.gov/emes/training/page19.html

Centers for Disease Control and Prevention [CDC]. (2020a). Coronavirus disease 2019: People with certain medical conditions. Available online at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html 

Centers for Disease Control and Prevention [CDC]. (2020b). Coronavirus disease 2019: Health equity considerations and racial and ethnic minority groups. Accessed online October 27, 2020, at https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html 

Centers for Disease Control and Prevention [CDC]. (2020c). Vaccines & immunizations: Glossary. Accessed online March 8, 2021, at https://www.cdc.gov/vaccines/terms/glossary.html#commimmunity  

Gold, J.A., Rossen, L.M., Ahmad, F.B., Sutton, P., Li, Z., Salvatore, P.P., Coyle, J.P., DeCuir, J., Baack, B.N., Durant, T.M. , Dominguez, K.L., Henley, S.J., Annor, F.B., Fuld, J., Dee, D.L., Bhattarai, A., & Jackson, B.R. (2020). Race, ethnicity, and age trends in persons who died from COVID-19: United States, May–August 2020. MMWR Morbidity & Mortality Weekly Report, 69(42), 1517–1521. DOI: http://dx.doi.org/10.15585/mmwr.mm69

Zakeri, R., Bendayan, R., Ashworth, A., Bean, D.M., Dodhia, H., Durbaba, S., O’Gallagher, K., Palmer, C., Curcin, V., Aitken, E., Bernal, W., Barker, R.D., Norton, S., Gulliford, M., Teo, J.T.H., Galloway, J., Dobson, R.J.B., & Shah, A.M. (2020). A case-control and cohort study to determine the relationship between ethnic background and severe COVID-19. Lancet eClinical Medicine, 00(2020), 100574, 1-11. DOI: https://doi.org/10.1016/j.eclinm.2020.100574

Bio‐ Juanita Graham, DNP-RN, FRSPH; Public Health Nursing Consultant