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We know a large percentage of the U.S. population falls into a vaccine-hesitant group. In fact, only 60% of Americans plan to be vaccinated against COVID-19, according to an article in The Atlantic.1 Given that rheumatology patients are among the vulnerable, we asked a handful of ACR/ARP members whether they have been vaccinated themselves and how they are broaching the topic with their patients.
Below are some tips to help get the conversation about vaccination started with your patients.
Acknowledge Concerns
Suleman Bhana, MD, FACR, chair of the ACR’s Communications and Marketing Committee and a rheumatologist in practice at Crystal Run Healthcare, West Nyack, N.Y., says, “I have been vaccinated, along with my adult family members.”
Dr. Bhana says he is recommending all his patients get vaccinated. “I ask them the following questions during a visit: 1) Did you get your COVID-19 vaccine yet? 2) Do you have an appointment or plan to get it? 3) Do you have any concerns about that vaccine that I can help answer?
Dr. Bhana
“I tell them that a national organization has convened a group of physician scientists to give guidelines and recommendations, and I paraphrase the ACR position statement, indicating that all patients with rheumatic and musculoskeletal diseases should receive COVID-19 vaccination, including those on immunomodulatory therapy.2
“I then go over any questions they may have about medication management.
“I find it best to acknowledge their concerns within reason. In the rare event I have a patient who states, ‘There are microchips in the vaccine,’ that ends the conversation for me.”
Talk to Every Patient
Dr. Monga
“The great news is that a majority of my patients are already vaccinated at Houston Methodist,” says Kanika Monga, MD. Dr. Monga completed her internship and residency training at the University of Texas Health Sciences Center, Houston, where she also performed a fellowship in rheumatology. She is a rheumatologist at Houston Methodist Academic Medicine Associates.
“I broach the topic with every patient I see in my clinic,” says Dr. Monga. “I respect that each patient is different and may be on different levels of understanding of what is safe and available for them. I reassure them that we have excellent guidance from the ACR, especially when it comes to specific DMARDs/biologics.
“We go through some of the charts together. I remind them that, at the end of the day, their personal choice matters most, but I am available to help dispel myths and acknowledge concerns they may have. I also add that my own family has gotten vaccinated as well.
“As a pregnant patient myself,” continues Dr. Monga, “I understand the importance of getting vaccinated to protect me, the community and my baby. My obstetrician strongly recommends vaccination because she believes pregnant patients are more likely to get a COVID-related illness if they are exposed to the virus.”
The Science Supports Vaccination
Dr. Arabelovic
“Based on the data up until now, the vaccine is of great benefit to protect against COVID-19,” says Senada Arabelovic, DO, Brigham and Women’s Hospital, Boston. “The vaccine has shown to be effective and safe.”
Mr. Richardson
Bob Richardson, PT, FAPTA, agrees. “I believe science supports the positive effects of vaccination,” he says. Mr. Richardson is a practicing physical therapist at Maria Parham Medical Center, a Duke Lifepoint hospital, located in Henderson, N.C. He says a high percentage of his patients are seniors and the hospital is a rural facility. “In this area, I see very few patients and friends who refuse vaccination,” he says.
“I do recommend to my patients that they take the vaccine,” says Mr. Richardson, “and I share with them that I have done so, and I explain that the side effects have proved to be minimal.
“I have always believed in vaccinations, for example, polio. I took the first generation of Dr. [Jonas] Salk’s polio vaccination and, subsequently, influenza vaccines.”
Protect Your Family, Too
“Getting vaccinated yourself may also protect people around you,” says Dr. Arabelovic.
That’s an aspect Sean Fahey, MD, a rheumatologist in practice at Piedmont Healthcare, Mooresville, N.C., emphasizes to his patients: “I point out the benefit of vaccination beyond the individual receiving the vaccine—to other patients, family members and society. We are moving to a new normal.
“I recommend all patients get vaccinated. I typically present the balance between risk and benefit of the choices as a way to frame the discussion. We know the risk of COVID is variable, but there is potential long-term morbidity, as well as a low, but real, chance of death, especially in patients with multiple risk factors. The risk associated with vaccination is lower than the risk of COVID-19.
“I have received my two doses of mRNA vaccine. My choice was driven by several factors: putting my money where my mouth is, setting a good example for my office staff and patients, and protecting my family—including my octogenarian parents who live with me.”
Target Your Conversation
Dr. Ursani
“I am recommending all my patients get the vaccine—except for those who have had a prior, severe anaphylactic response to a vaccination or those patients who have previously developed a neurologic condition, such as Guillain-Barré syndrome or transverse myelitis post vaccination,” says Mohammad A. Ursani, MD, RhMSUS. “Further, I have a long discussion on the risks vs. benefits in patients who are currently pregnant or breastfeeding, and make sure to emphasize the data in this population suggests the vaccine is safe for the fetus or child.”
Dr. Ursani is a private practice rheumatologist in The Woodlands, Texas, and serves as an adjunct faculty member for the University of Texas, Houston, Internal Medicine Residency Program. He also serves as a volunteer for the ACR and is an ambassador for the Young Physicians Organization for the Harris County Medical Society.
In broaching the topic with his vaccine-hesitant patients, Dr. Ursani says, “I attempt to understand why individuals are hesitant to receive the vaccine and address their questions and/or misconceptions directly. I attempt to demystify the misinformation that is often quoted by providing sound sources with statistical data. I review the benefits of getting vaccinated vs. the risk of not getting it.
“From what I have learned,” he continues, “most people who are initially hesitant, once provided with sound, unbiased data with confidence, are more likely to be at ease with receiving the vaccine. If the individual still refuses, I am sure to bring it up at their next clinic visit after providing sources for them to read over and contemplate.”
Dr. Ursani was vaccinated as soon as it became available for healthcare personnel in his area. “I have seen firsthand how severe COVID-19 infection can be, even in individuals who may not have any comorbidities or risk factors. I have reviewed the efficacy and safety data in the vaccine trials and have no doubt that it is beneficial for me and my family.
“As a physician, I believe in science, and I hope to act as a role model and influence my community members and patients to do the same.”
Keri Losavio is the staff editor of The Rheumatologist, a position she has held since 2014.
References
- Engber D. America is now in the hands of the vaccine-hesitant. The Atlantic. 2021 Mar 22.
- The ACR COVID-19 Vaccine Clinical Guidance Task Force. COVID-19 vaccine clinical guidance summary for patients with rheumatic and musculoskeletal diseases. American College of Rheumatology. 2021 Mar 4.
ACR Guidance Statement: Recommendations for Use of the COVID-19 Vaccine in Patients with Rheumatic & Musculoskeletal Disease2
| Guidance Statement | Level of Task Force Consensus |
|---|---|
| RMD and AIIRD patients should receive COVID-19 vaccination, consistent with the age restriction of the EUA and/or FDA approval.* | Moderate |
| RMD patients without an AIIRD who are on immunomodulatory therapy should be vaccinated in a similar fashion as described in this guidance for AIIRD patients receiving those same treatments. | Moderate |
| Based on the data for the mRNA COVID-19 vaccines available in the U.S., there is no preference for one COVID-19 vaccine over another. Therefore, AIIRD patients should receive either vaccine available to them. | Moderate |
| For a multi-dose vaccine, AIIRD patients should receive the second dose of the same vaccine, even if there are non-serious adverse events associated with receipt of the first dose, consistent with timing described in CDC guidelines. | Strong |
| Healthcare providers should not routinely order any lab testing (e.g., antibody tests for IgM and/or IgG to spike or nucleocapsid proteins) to assess immunity to COVID-19 post-vaccination, nor to assess the need for vaccination in a yet-unvaccinated person. | Strong |
| Following COVID-19 vaccination, RMD patients should continue to follow all public health guidelines regarding physical distancing and other preventive measures. | Strong |
| Household members and other frequent, close contacts of AIIRD patients should undergo COVID-19 vaccination when available to them to facilitate a cocooning effect that may help protect the AIIRD patient. No priority for early vaccination is recommended for household members. | Moderate |
| While vaccination would ideally occur in the setting of well-controlled AIIRD, except for those patients with life-threatening illness (e.g.,in the ICU for any reason), COVID vaccination should occur as soon as possible for those for whom it is being recommended, irrespective of disease activity and severity. | Strong-Moderate |
*age ≥16 as of January 2021
RMD=rheumatic and musculoskeletal disease; AIIRD=autoimmune and inflammatory rheumatic disease; EUA=emergency use authorization; FDA=Food and Drug Administration; mRNA=messenger RNA; CDC=Centers for Disease Control and Prevention; ICU=intensive care unit
