Maricopa County's Disease Detectives: Rebecca Sunenshine, MD & Nick Staab, MD
By Edward Araujo, Managing Editor, Arizona Physician
Photography by Ben Scolaro, scolarodesign.com
From Print Issue - Spring 2022
Americans are hesitant to receive vaccines for numerous reasons. From not having access, not being able to pay for it, to just not wanting a shot, vaccine hesitancy has proven to be a major obstacle to reducing many infectious diseases.
Yet at a local level, public health leaders work tirelessly to bring awareness, education, and solutions to stop the spread of disease and to prevent future pandemics.
YOU CANNOT FIGHT DISEASE UNTIL THE EXPERTS FIND IT
Sometimes referred to as disease detectives, key players in the effort to improve population health are epidemiologists. A big tool in their toolbox is vaccines. Charged with leading the efforts to combat disease and educate the public are Rebecca Sunenshine, MD, FIDSA, medical director for disease control at Maricopa County Department of Public Health (MCDPH) and R. Nicholas Staab, MD, MSPH, medical epidemiologist at MCDPH. They and their teams identify the source of disease, define populations at risk, and recommend strategies to control or stop the spread of diseases. As physicians, they are qualified to combine clinical aspects of disease with the science of population health.
Dr. Rebecca Sunenshine has been at MCDPH since 2009 when she came over from the state health department to support the H1N1 pandemic response and has led the Disease Control Division since 2011. She now also serves as Medical Director for disease control providing medical and epidemiology technical guidance to the Executive Director. These roles are in addition to her role as a CDC Career Epidemiology Field Officer assigned to Maricopa County and Captain in the US Public Health Service. Her specialties are internal medicine and infectious disease. Dr. Sunenshine graduated from Indiana University’s School of Medicine and then completed both her residency and fellowship at Oregon Health & Science University, followed by the CDC Epidemic Intelligence Service fellowship in applied public health from 2004-2006 at CDC in Atlanta.
Dr. R. Nicholas (Nick) Staab has been a medical epidemiologist at MCDPH since 2020. Dr. Staab’s prior experiences include being medical director of the Bureau of Epidemiology and Disease Control at Arizona Department of Health (ADHS) and a pediatric hospitalist at Phoenix Children’s Hospital. He attended the University of Southern California’s Keck School of Medicine and completed his residency in pediatrics at Advocate Christ Medical Center in Oak Lawn, Illinois. Dr. Staab earned his Master of Science in Public Health degree from George Washington University.
PUBLIC HEALTH’S DISEASE PREVENTION
By collecting and analyzing data, medical epidemiologists like Drs. Sunenshine and Staab can make informed recommendations to Marcy Flanagan, executive director of MCDPH. One of the important data sources at their disposal is a state system called Medical Electronic Disease Surveillance Intelligence System (MEDSIS). It allows for real-time reporting of case investigations, which inform about disease trends and allow for rapid identification of potential outbreaks. Another tool is the Arizona State Immunization Information System (ASIIS). Vaccinators are required to input COVID-19 data within 24 hours to the immunization registry (and all pediatric vaccine data), making this tool highly effective for understanding vaccination rates and and communities to target for vaccination drives in Maricopa County.
Educating the public, including parents of children, has been of the utmost importance for both physicians. Dr. Staab states, “Sometimes these are longer than expected conversations, and that’s okay.” Dr. Sunenshine does not believe in pressuring but offering facts, empathy, and exploring people’s specific reasons about vaccine
hesitancy. As new facts emerge about diseases, the county has more opportunities to communicate with hesitant populations.
“The most important predictor of a parent vaccinating their child is that their primary care physician or nurse recommends it.” - Dr. Sunenshine
Educating physicians and healthcare providers is pivotal to achieve a higher vaccination rate. Dr. Sunenshine states, “The most important predictor of a parent vaccinating their child is that their primary care physician or nurse recommends it.” Talking to parents about the vaccinations that are required or recommended by the Advisory Committee on Immunization Practices goes a long way toward getting children vaccinated for a variety of diseases, including COVID-19.
FRAMING THE HESITANCY PROBLEM
MCDPH knows of vaccine-hesitant communities that predated COVID-19. Dr. Staab says some reasons include lack of access and cost of healthcare, preference for infection-derived immunity, a distrust of government, misinformation, and other social determinants of health.
Access and cost of healthcare are issues that continue being a problem in getting the public vaccinated. From lack of individual transportation to facilities that administer vaccinations to lack of insurance which increases out of pocket costs, not having access to vaccines has proven to decrease vaccination rates, per Dr. Staab. “People who don’t work for a large enough employer that provides health insurance are less likely to have access to vaccines,” says Dr. Sunenshine. The lack of vaccine availability through primary care providers makes access more difficult.
Another problem that public health faces in getting people vaccinated is some of the population’s preference for infection-derived immunity, which comes from infection with the disease organism. Unfortunately, reaching herd immunity through previous infection can take much longer, increase costs of healthcare resources, and risk more lives.
Distrust of government has always been an issue for vaccines. It is fed by misinformation, a history of unethical government and non-government studies, misunderstandings about vaccine side-effects and how the body develops immunity from vaccines, and questions about the efficacy and safety of vaccines.
Misinformation and disinformation about vaccines, by news sources and social media platforms, have slowed vaccination rates. That effect has accelerated during the COVID-19 pandemic.
Finally, social determinants of health impact one’s likelihood of accepting vaccines. Some examples are household living conditions, philosophical and cultural beliefs, and religious affiliations.
MCDPH COMBATS VACCINE HESITANCY
Finding solutions to increase vaccination rates has not been easy for Drs. Sunenshine and Staab. They forge ahead by building strong partnerships and collaborations, using effective messaging to destabilize frequent misinformation and disinformation, and collaborating directly with specific communities to create significant inroads and build trust.
Relationships with a variety of partners has been indispensable, says Dr. Sunenshine. Partnerships with Maricopa County’s healthcare systems are what allowed large numbers of residents to get vaccinated quickly when the COVID-19 vaccine first rolled out. ADHS plays a significant role in collecting data. Dr. Staab raves about The Arizona Partnership on Immunizations (TAPI), which has helped the county to identify healthcare providers who are more easily accessible to the public in specific vaccine-hesitant communities. Local leaders help in connecting healthcare providers who are willing to go into communities in need of vaccines.
"I just use a lot of tools we've learned over the last year in terms of what's effective to different people. Trying to meet people where they are, understanding that for some families it is a quite easy decision and for others it is not." - Dr. Staab
Typically, the county health department counters misinformation by placing factual and easy-to-understand information about vaccines through a variety of channels including its website, social media, local television, and radio. More importantly during COVID-19, Dr. Sunenshine states, “We work directly with local leaders in vaccine-hesitant communities as well as primary care physicians and nurses.” Local leaders from nonprofit and faith-based organizations are relied upon as trusted messengers to the communities they represent. Primary care physicians and nurses speak to their patients consistently, making them better messengers to combat misinformation.
“The community plays a pivotal role in public health’s battle against vaccine hesitation,” states Dr. Sunenshine. When the public has a positive experience getting vaccinated, they share that message with friends and neighbors. Dr. Sunenshine finds key allies in non-profit and faith-based groups. “They have done an excellent job of sharing the county’s message on vaccines to their respective communities,” says Dr. Sunenshine.