Enhancing knowledge about mRNA vaccines

Welcome to Inside Family Medicine, where you hear from leaders and peers in your specialty while learning about new tools and resources. I'm your host, Michael Monroe, a member of Team AAFP. Today we're talking with two AAFP Vaccine Science fellows about why mRNA vaccines matter, and how to empower family physicians and their care teams to confidently address patient questions, reduce misinformation and seize vaccination opportunities early.

Dr. Ann Schneider is a full-time practicing family medicine physician at Endeavor Health and Heads their vaccine committee. She's also the medical director at the Student Wellness Center at North Central College in Naperville, Illinois. She graduated from Midwestern University Chicago College of Osteopathic Medicine and completed her family medicine residency at McNeil Family Practice Center in Illinois.

Dr. Mina Kahn is a family physician who has practiced in rural Alabama for the past 23 years, 19 of which have been in private practice. She graduated from Aga Khan University Medical College in Pakistan and completed her family medicine residency at Medical Center East in Birmingham, Alabama. Dr. Kahan is also the medical director of the Red Crescent Clinic of Alabama, a free clinic for medically underserved patients.

Thank you so much for both of you for joining me today. Thank you. First, let's talk about why you chose family medicine as a specialty. You, Dr. Kahan, let's start with you. Yes. I developed a passion for health promotion and disease prevention early in my career. I think some of it stems from the fact that about one third of my medical school curriculum was.

Gauge towards these aspects and community medicine in general. And I feel that that is what encompasses family medicine as a specialty. Uh, I also love the variety that family medicine brings to my day-to-day activities. I love seeing very young children and in the next room, MACA geriatric patient and that variety is what really drives my day.

Absolutely. I think that variety, that full scope of family medicine is what draws a lot of people to the specialty. Dr. Schneider, what about you? Yes, I completely agree. I was undecided in medical school and as I went through rotations, I realized that I did love a bit about every specialty and, and that is the beauty of family medicine.

I get to do a bit of every specialty from skin procedures to managing diabetes to pediatrics. You know, one of the most rewarding aspects for me is being able to provide care to an entire family. Knowing that I get to be a part of keeping each family member healthy and having my older patients update me on their grandchildren, who I see as well, I'm extremely grateful.

I love that. Yeah. And certainly one of the biggest parts of that practice too, I'm sure is vaccines, immunizations, the importance of preventive medicine. So I'll start with you, Dr. Schneider, just diving right in. What are the fundamentals that folks need to know about mRNA vaccines and what should every family physician know going into this?

So mRNA vaccines contain messenger, RNA. That essentially is like a set of instructions. Those instructions tell your body to make a harmless piece of a virus, for example. Like the spike protein from the COVID-19 virus. After vaccination a few of your cells read mRNA instructions, make the harmless viral protein, and briefly display it on their surface.

It's important to note that this protein itself cannot cause disease. Your immune system then sees the unfamiliar protein and recognizes it doesn't belong, and because of this creates antibodies and trains your immune systems memory cells. This way, if you're exposed to the actual virus, your immune system is already prepared to recognize the virus and respond quickly to prevent or lessen illness.

The mRNA in vaccines is broken down and removed by our bodies within hours today. It's a really a beautifully designed vaccine, and there are some differences between the mRNA vaccines and non mRNA or more traditional vaccines. With the non mRNA vaccines, we're giving the immune system the antigen itself.

That might be as a killed virus, like in the Hepatitis A vaccine, a weakened virus like with the varicella vaccine or a purified protein like with hepatitis B vaccine, just to name a few. The immune system recognizes that foreign material and builds memory from it. Mechanistically, you could say traditional vaccines show your immune system the virus or bacteria, for example, and mRNA Vaccines show your immune system how to recognize the virus.

Safety wise, both non mRNA and mRNA vaccines undergo large randomized trials and ongoing post-authorization surveillance. Both can cause short-term side effects that are typically mild, like a sore arm or fatigue. Ultimately the take home message with non mRNA vaccines versus mRNA Vaccines is not a story of old versus new.

Or safe versus unsafe. It's the story of different engineering solutions to the same immunologic problem. And as far as evidence of efficacy, randomized controlled trials done prior to the mRNA COVID-19 vaccine rollout and published in the New England Journal of Medicine showed high efficacy against symptomatic disease.

An ongoing post-authorization surveillance continues to show a benefit for preventing severe disease. There is ongoing safety surveillance as well. There is a small increased risk for myocarditis with the mRNA COVID-19 vaccines. This is primarily seen in young males after the second dose. But the risk is low and cases are usually mild, and most importantly, the risk of myocarditis from COVID-19 infection is higher than that from the vaccine itself.

As of now, there's no real world data cases of myocarditis with the new mRNA, RSV vaccine, multiple science-based medical societies, including the American Academy of Family Physicians and the American Academy of Pediatrics. Endorse mRNA vaccines for their safety and efficacy.

I love that. Thank you, Dr.

Schneider. I, I love how you described it as a story talking about the history of vaccines is not one of old versus new. It is a progression over time of safety and efficacy leading to improved outcomes for patients at every level. Thank you. I think one of the things that's most important is talking about some of the myths or common misinformation or misconceptions about mRNA vaccines compared to some of the other versions of vaccine Dr.

Khan. How can clinicians effectively address some of those common myths or misinformation that patients might be coming into practice having heard? I think Dr. Schneider's also already laid a pretty good framework for, for me to respond to this question. And I'm gonna go over a couple of questions that I know I would encounter in my practice.

And a lot of physicians will, even though there's strong evidence of a safety and efficacy, we're well aware that there's still a, a large proportion of the population that they remain skeptical of the safety. Some of the specific questions we encounter are like. mRNA vaccines were rushed into production without the years of testing that previous vaccines have undergone.

And so is that true? Does that make it any less safe? But the fact is that these vaccines, even though they were introduced by Pfizer BioNTech and Moderna for protection against COVID-19 in a record 11 months during a global pandemic. But the framework for these vaccine was already late decades earlier.

Animal studies on mRNA or Messenger, RNA were conducted as early as the 1960s, and clinical studies in humans were conducted in the early two thousands. The specific technology employing lipid nanoparticles to improve the immunogenicity of mRNA particles for the COVID to 19 vaccines was actually proven, effective and safe in 2017.

So they were. Already on track to produce vaccines that employ this specific mechanism or technology. Another concern that we encounter a lot is that do mRNA vaccines modifying human DNA. The fact remains that the mRNA never even enters the cell nucleus. Dr. Schneider already touched upon how the vaccine actually works by producing a spike protein.

Uh, but the fact is that the messenger, RNA. Remains in the cytosome of the cell, and that's where it triggers the production of that harmless protein called the spike protein. And then again reemphasizing that it breaks down very rapidly and leaves the system after that. I think a third one that's been top concern has been vaccination during pregnancy.

And can there be harm to the fetus associated with that? There's been a lot of study going on about this, and there's been data obtained from the Vaccine Safety Data Link, which is a large database that assesses all post vaccination, assesses any kind of risks that have been identified, and in over 42,000 pregnancies, there was not seen to be no increased risk of major birth defects after first trimester vaccination, and no increased risk of neonatal adverse effects either.

In fact, COVID-19 as a disease is actually associated with a higher maternal complications such as preterm births and thromboembolic disease. So by vaccinating we we're reducing these risks rather than increasing them.

Having those conversations, I'm sure is always a challenge in practice and finding ways to be empathetic and understanding of that.

The information that they're hearing from other sources and providing ways to correct that disinformation or finding ways to encourage them to reconsider vaccination at their appointment, I'm sure is always a challenge. Are there any specific tools or kinds of language that you use that you could give us that provide an opportunity to build trust or reinforce those scientific facts when you're talking to patients?

Yes, absolutely. When we talk to our patients about mRNA vaccines, we need to make sure that we start with a caring and non-judgmental tone. Relay medical facts in a straightforward and simple manner. Try and avoid medical jargon that could be difficult for them to understand, and that alone may be alienating to them.

We can state the facts about the vaccine and then allow the patients to express their specific concerns. Try and avoid interrupting them as they ask their questions since this suggests that they were not validating their concerns. Once they've expressed what they're worried about, we can respond with facts such as discussing real world data that we, we have available to us.

We can refer them to reputable websites, such as one that I fall back on a lot is the AFP's own familydoctor.org that's designed to provide the public with evidence-based guidelines and education about multiple topics including vaccines. Discussing personal experiences can also be very helpful, such as ensuring my patients that I and my family feel safe receiving these vaccines and we rely on the protection that they provide to prevent vaccine com preventable diseases.

If we as physicians are able to effectively communicate about benefits, risks, and side effects of the vaccines, patients will be more confident in the decision to adhere to recommendations provided by their primary care physicians. I love that part about sharing a little bit of your own personal experience and how you approach these considerations or approach these important topics for yourself and for your family.

Dr. Schneider, what other communication techniques can clinicians use to talk about mRNA vaccines, especially with vaccine hesitant patients or patients who aren't sure. One thing we do know about vaccine hesitancy, most hesitant patients are ambivalent, not necessarily anti-vaccine or anti-science. And so to approach hesitant patients, motivational interviewing is an effective technique you can use in motivational interviewing.

You first ask if it would be okay to discuss a vaccine. This in and of itself can immediately reduce resistance. This way too. Patients can opt to say no if they don't feel comfortable with the discussion at that time. And in this case, it's a good time to mention that you're free to discuss it at a future visit during motivational interviewing, ask open-ended questions like, what have you heard about mRNA vaccines?

Reflect back what is heard to confirm you're hearing your patient, and then add additional information in a way that's not just fact dumping. Ultimately, you're trying to help your patients make a well-informed decision based off of accurate information, and it's important to frame vaccination as part of preventive care, not separate or extraordinary.

While it's helpful to bring up vaccination at every office visit when appropriate annual checkups or annual wellness visits are an excellent time to discuss vaccines, just like breast cancer and colon cancer screening for risk reduction, it's good to talk about vaccines in that same way as reducing risk.

This way, patients are less likely to single out vaccines as exceptional or risky. This is vital specifically for, for mRNA vaccines because they're new enough in the public's eyes to not necessarily be part of that regular vaccine schedule. They've known in the past. Discuss vaccines in the same way as talking about their blood pressure or talking about cholesterol medication for parents and caregivers.

Using a presumptive approach to routine care, including vaccination can be particularly effective. So make a statement like At today's visit, we will check growth and development, answer your questions, and provide routine care, including vaccinations recommended for this age. I use presumptive approach in pediatric visits all the time.

In particular, since I've been using this for my nine through 12 year well child visits, it's been noticeably effective in increasing HPV vaccination rates and easy for me to then working COVID-19 vaccines as well. And I recently saw an adult patient of mine who I've been seeing for years. For her annual wellness visit and we were reviewing preventive health recommendations as we were reviewing those, I noticed that she had not received the most recent version of the COVID-19 vaccine.

She'd had previous versions and so it surprised me. She had not received the most recent one. And I have a kind of particular flow for wellness exams that my long-term patients are very aware of. That captures all the important preventive health maintenance areas, including vaccines. And so when I got to our usual vaccine discussion.

I told her I noticed she was not up to date on her COVID-19 vaccine and asked her if she was open to discussing this. So she agreed and noted she'd been reading some things on social media about mRNA vaccines, and because of this, she had had some new concerns about their safety. So after acknowledging her concerns and answering her questions, she asked for my recommendation and I told her.

I continue to recommend this vaccine for you because it lowers your risk for severe illness, and really by allowing her to lead the discussion and stating my recommendation in a calm, non pushy way, this really helped her come to the decision to get the updated version. I love that. Thank you so much for sharing the real world example.

I think those kind of illustrative examples of those conversations that you have with patients and making that strong recommendation to help move them towards vaccination is really helpful for, for your colleagues that are dealing with this in practice every day too. Dr. Kahn, Dr. Schneider mentioned the importance of encouraging vaccination in every patient visit, whether or not it's part of the conversation before the day, or if it's just encouraging routine vaccination, or checking in about opportunities for vaccination and having a consistent process or a system in place to make sure that those conversations are happening regularly.

How can primary care teams create those systems to reduce? Missed opportunities to immunize either with mRNA vaccines or non mRNA vaccines. Yes, certainly I can address that. But I do wanna add just one tiny note onto what Dr. Schneider's talked about, which was very useful, is that we always try and keep the door open if a patient declines a vaccine, and the conversation by saying, you know.

Think about it a little bit and you can come in and make a decision to get that vaccine later on. You'd be surprised how many people in my practice will chew on it for a little while and come back and get received that vaccine and sometimes even bring their family members with them to get it. So that's just one additional fact here.

I agree completely. Yeah, I agree completely, Dr. Kahn. I think it also helps people feel like you're not gonna give up on them. Mentioning that you're gonna talk about it at another visit or it is amazing how many patients we both then have had that will come back after the third visit and make that decision to get the vaccine.

So it's helpful to keep talking about it at E each visit for sure. I love that. I love that message about not giving up on patients every opportunity right now talking about team-based approach, and I feel like that's best way to approach vaccination in our practice. We need to ensure that all members of the medical team have access to the state and immunization registry, and that's the first thing we do if we ever have a new employee, is make sure that they have that active access.

We should assess patient's immunization status prior to or during every visit. That's something that a medical assistant or a nurse can do so that the burden's not always on a physician who's also addressing other health concerns at that same visit. So every visit should be an opportunity to catch up on vaccines, so if we are aware of what they're missing, we can generate that dialogue.

Techniques that work in most practices may include electronic health records. Most EMRs or electronic health records have an alert system that can be set up to notify physicians of age appropriate vaccines that are due at the time of the visit. We should utilize these features whenever possible. One specific technique that works well in my practice is setting up an appointment for a vaccine at the time that the patient is taking up from their current visit.

For example, if the they present to the office in July. We know that the newest COVID vaccine will be available for distribution in September. At the same time that the flu vaccines are given, we can put them on our vaccine schedule. That way they'll get a reminder of an upcoming appointment, and our staff can also see if they end up missing the appointment.

So they can reach out to them via phone or patient messaging, portal or mail. And this, I feel like in our practice, has increased uptake of vaccines. This is not addressing hesitancy, but it's those people whose vaccines just slip through the cracks because life catches up on them, you know? But other techniques that have worked in my practice specifically is, and it's, this is a demand based thing that sometimes we'll set up a half day vaccination clinic, but most of the time we are able to just work vaccines into a regular scheduled appointment.

So this is uncommon for us to have to do that.

So we've shared a lot of great information today. What are two main points that you hope your listeners take away from this conversation? Dr. Kahan. I feel like we need to make sure that the patients feel heard and not dismissed when they express their concerns about mRNA vaccines or really any other vaccines.

We can't fully control a narrative because patients often come with preconceived notions about what is true and false as far as vaccine science goes, but we can definitely guide the narrative towards facts and hopefully empower them to make the decision to vaccinate. Great. What are your thoughts, Dr.

Schneider? mRNA vaccine technology is safe and effective like we've talked about, and we have credible scientific evidence of this, and they're endorsed by major medical societies. So as clinicians, it's crucial for us to feel comfortable in our knowledge of mRNA vaccines in order to have meaningful and impactful conversations with our patients.

You know, physicians consistently rank at or near the top of trusted sources for medical advice for patients, even during these times of high levels of misinformation. And so while we're seeing and hearing loud anti-science and anti-vaccine voices, as clinicians are trusted and well-informed voices just need to be louder.

I love that. So I'm hearing as kind of a call to action for today's discussion. Let's make every patient interaction an opportunity to, to talk about health, to prevent illness, and to encourage vaccination to our listeners. If you'd like to learn more about choosing family medicine or would like valuable AAFP resources on vaccination, please see the links in our show notes.

If you enjoyed today's episode, let us know by dropping a line at aafpnews@aafp.org. Be sure to share the episode with your followers on social media and tag the AAFP. Thank you, Dr. Kahn and Dr. Schneider for joining me today. Thank you. Thank you.