COVID-19 Vaccination in Patients with Rheumatic Disease

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With a large percentage of the U.S. population unsure whether they will get vaccinated against COVID-19, rheumatology patients remain vulnerable. On May 13, the ACR hosted a virtual town hall highlighting ways rheuma­tology providers might effectively approach their patients who have not yet decided to get a COVID-19 vaccine.

Get the Slow Yes

Dr. Manning

At the outset, Kimberly Dylan Manning, MD, FACP, FAAP, a professor of medicine and the associate vice chair of diversity, equity and inclusion at Emory University School of Medicine, Atlanta, expressed her dislike of the term vaccine hesitancy. She prefers the term deliberation, the act of thinking and deciding carefully about something, which she believes imparts more power to both patients and providers. After all, different people need different information to be comfortable making big decisions.

Repeatedly, Dr. Manning emphasized the importance of building rapport: “What kind of therapeutic alliance have you worked at to make sure [your patient] wants to say yes to you?” she asked. Body language and inviting intonation are key, as are respectfully listening to patients and showing you have heard them.

From attentive listening, clinicians can gain valuable information they can use to influence their patients over time. Eventually, some patients will slowly turn from a no toward a yes. “That’s one of the most encouraging things,” said Dr. Manning. “Depending on who you are, your deliberation process might require a little bit more. Just keep planting that seed.”

Not all patients have the same questions about, or knowledge of, COVID-19 vaccination. Asking patients about their specific concerns allows clinicians to tailor the response to the patient. For example, a patient may bring up a concern about how quickly the vaccine was created. It’s helpful to acknowledge and validate the concern. Then a clinician may provide specific reassuring context—explaining that researchers have been studying other coronaviruses for years and work on mRNA vaccines is not new.

You may mention the new vaccines were subjected to all the typical steps in vaccine development and evaluation, including phase 1, 2 and 3 clinical trials. Don’t assume your patient knows what that means. Provide an explanation: “That means studies were conducted in people, not just animals, beginning with tests in a few healthy volunteers (under a hundred) and moving up to large-scale tests in people with the disease (hundreds to thousands) to ensure the vaccine is safe and works as intended. The vaccines are safe. More than 302 million people in the U.S. have now been vaccinated, with rare serious side effects and very few deaths—about 7 per 1 million vaccinated women between 18 and 49 years old—positively linked to vaccination.”¹

“When we start respecting our patients [and giving them] the science,” said Dr. Manning, “you’ll be surprised at how many people will say, ‘That makes sense.’”

Counter Concerns

Dr. Phillips

For some patients, statistics may be a helpful tool, noted co-moderator Chris Phillips, MD, of Paducah Rheumatology, Kentucky. For example, Dr. Phillips said he might contrast the small risks of thrombosis from the Johnson & Johnson vaccine with the much greater risks of mortality from COVID-19, using specific numbers. “Sometimes I think our patients … misvalue how likely those things are to happen, so trying to recenter that is sometimes helpful,” he said.

ACR President David R. Karp, MD, PhD, chief of the Rheumatic Diseases Division at UT Southwestern Medical Center, Dallas, remarked on a particular concern that many rheumatology patients have: the risk the vaccine may trigger a flare. “I tell patients that if you have a flare [after a vaccine], we can treat you, but in the meantime, you are protected from a disease that is deadly. Thus far, thousands of patients with rheumatic and autoimmune diseases have been vaccinated and have done well,” Dr. Karp said.

Dr. Karp

Sometimes, clinicians feel an urgency to get their patients vaccinated as quickly as possible, Dr. Manning noted. But by trying to understand patients’ specific concerns and gently and repeatedly bringing up the subject, clinicians may gradually make an impact. “Yes, there is urgency when it comes to being vaccinated for COVID-19, but if you don’t keep trying to plant the seed and keep the trust open, we definitely aren’t going to get there,” she said.

Dr. Blanco

Irene Blanco, MD, MS, a professor in the Department of Medicine, Albert Einstein School of Medicine, New York City, and co-chair of the ACR’s Diversity, Equity and Inclusion Subcommittee of the Collaborative Initiatives (COIN) Special Committee, noted that rheumatologists regularly engage in hard conversations with their patients, especially those who have complicated diseases. “How do we keep those conversations going?” she asked.

Dr. Manning said it’s important to approach all patient questions directly and in a non-patronizing way. For example, ask a patient concerned they might be microchipped when getting the vaccine what they think that could mean. Don’t pass judgment, but continue to ask patients respectful, but probing, questions. “Particularly when there is not racial or cultural concordance or there are some areas where there isn’t trust, judgment could close the door, and you want to keep the dialogue going,” she said.

Racial Inequities

Specific concerns and life experiences more common among some groups may influence minority patients’ perceptions of COVID-19 vaccines and their personal willingness to be vaccinated.

“The old pandemic of social injustice is happening at the same time as the new pandemic of COVID-19. So that is impacting vaccine deliberations and what our patients are thinking about,” said Dr. Manning. It’s important to acknowledge the valid, historical reasons an individual from a minority group may think others may not have their best interests in mind. For example, Dr. Manning referenced the infamous Tuskegee study of syphilis patients in Macon, Ala., in which Black men were not adequately informed about their condition, nor offered effective treatment when penicillin became available in 1943.²

Historical inequities may lead some minority patients to have concerns that they may be unfairly and unsafely being used as test subjects, even today, Dr. Blanco noted. It does not help that rheumatology, like many medical specialties, is not very diverse. “I think, like many medical fields, we have a hard time having those difficult conversations around race, especially when providers are not racially concordant with [their] patients,” she said.

One of most important things a provider without racial concordance can do is to sincerely acknowledge the terrible experiences of minority communities in medical and other settings. From there, a real conversation can begin. “I think it goes wrong when people brush over [the topic] because it is so uncomfortable,” Dr. Manning said.

Physicians can also consider and voice their own differences in background. For example, a white male rheumatologist may verbally acknowledge his own privilege and say that, because of his life experiences, he may have different worries and perceptions from his patient. “That can mean a lot to your patient and really make people feel seen,” said Dr. Manning. From there, providers can let their patients know they are available to provide support and answer their questions about the vaccine.

The ACR has an extensive list of vacci­nation resources for providers talking to their patients, including a patient-focused infographic.

References

1. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html.
2. https://www.cdc.gov/tuskegee/timeline.htm.