Moving Medicine
Patient trust and vaccines, with Sandra Fryhofer, MD
Oct 20, 2023
Featured topic and speakers
Hear from physician experts on strategies to address vaccine hesitancy with patients and updates on current COVID variants, flu and RSV vaccines. This episode was created in collaboration with the PermanenteDocs Chat podcast and is hosted by family physician Alex McDonald, MD, featuring guest Sandra Fryhofer, MD, AMA liaison to the CDC’s Advisory Committee on Immunization Practices and immediate past chair of the AMA Board of Trustees.
Speaker
- Sandra Fryhofer, MD, immediate past board chair, AMA; and AMA liaison, Advisory Committee on Immunization Practices (ACIP)
Host
- Alex McDonald, MD, family medicine physician and host of PermanenteDocs Chat, Kaiser Permanente
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Unger: Welcome to Moving Medicine—a podcast by the American Medical Association. Today’s episode was produced in collaboration with the PermanenteDocs Chat podcast. It features immediate past chair of the AMA Board of Trustees, Dr. Sandra Fryhofer. She'll talk about the safety of vaccines, updates on current COVID-19 variants, and strategies for establishing trust and vaccine acceptance with your patients. Leading the conversation is the host of PermanenteDocs Chat, family medicine physician, Dr. Alex McDonald.
Dr. McDonald: Hello everybody and welcome to this week's PermanenteDocs Chat. Thanks all for joining, wherever you may be watching or listening. I'm your host, Alex McDonald. As most of you know by now, I practice family and sports medicine here at Kaiser Permanente in Fontana, California, as part of the Southern California Permanente Medical Group. So, I am very excited for today's chat. This is another collaboration with the American Medical Association. Today we're going to be talking about COVID, RSV, flu vaccines, and what I like to refer to now as winter respiratory illness season with our amazing guest, Dr. Sandra Fryhofer. Dr. Fryhofer, thank you so much for joining us.
Dr. Fryhofer: Well, Alex, thank you so much for having me. I'm really looking forward to our chat.
Dr. McDonald: Absolutely. So, Dr. Fryhofer wears many, many hats. I cannot list her CV here, unfortunately. But most specifically, she's the American Medical Association, I believe you're the president-elect, if I'm not mistaken. And she also—
Dr. Fryhofer: No, no. No, I'm not the president-elect. I'm the immediate past chair.
Dr. McDonald: Okay. Sorry. See? There you go, I've already screwed up. So, the immediate past chair. But more importantly, she's also on the Advisory Committee of Immunization Practices, which obviously goes through the data and the science regarding a lot of vaccines and recommendations to the FDA, and CDC, and various other regulatory bodies. And then many other roles—past president of American College of Physicians and extensive media training. So, maybe you can give me some media tips while we're here and doing this webinar.
Dr. Fryhofer: I think you're really funny. But I am a liaison to ACIP, which is the CDC's Advisory Committee on Immunization Practices. And I've been a liaison for more than 20 years. First for ACP, the American College of Physicians, and then for both the ACP and the AMA, the American Medical Association. And then, when I was elected to the AMA Board of Trustees, I had to limit to being only the AMA liaison to ACIP. And over that time, I've served on many, many ACIP vaccine workgroups. And currently some of the ones I serve on include the COVID vaccine workgroup, the flu vaccine workgroup and the adult schedule workgroup.
Dr. McDonald: Wonderful. Excellent. So, clearly a huge amount of knowledge and experience. And I'm really hoping to get some pearls of wisdom here for all of our listeners. So, we're going to be going through a whole bunch of information. If you're out there listening or watching live, you have questions, please drop them in the Q&A. We'll get to as many as we can, this is only about 20 minutes or so. We like to keep this kind of condensed and high yield, so get your questions in early. But let's just jump right in. Dr. Fryhofer, tell us a little bit more about who you are and what you do for your day job, so to speak.
Dr. Fryhofer: Well, I'm in private practice, general internal medicine in Atlanta, Georgia. I see patients in the office every day. I also take call. So, as far as my work with vaccines is concerned, and being a liaison to ACIP, being a practicing physician is really helpful because I hear firsthand the questions patients are asking. And I also experience firsthand how difficult sometimes it is to get patients vaccinated and how difficult it is sometimes to find the vaccines to do it.
Dr. McDonald: Mm-hmm. Yep, absolutely. Well, let's jump in here. Again, I don't like using the term “cold and flu season.” I like using the term winter respiratory illness season because I think that's more reflective of what's actually happening. And right now, we have a large disconnect between the health risks of flu, RSV and COVID, and patients' understanding of those risks and illnesses. So, can you share a little bit about some of the latest data regarding general public sentiment surrounding some of these illnesses? And also then, the sentiments surrounding the vaccines for some of these preventable illnesses?
Dr. Fryhofer: Sure. Well, for the first time ever, we now have vaccines to protect against all three of these viruses that you've been mentioning, COVID, flu and now RSV. NFID, which is the National Foundation for Infectious Diseases, just released the results of its annual adult immunization survey. And Alex, the results are very disturbing. This survey found that many adults underestimate the seriousness of these viruses. They don't have confidence in the safety of vaccines, they don't have confidence in the effectiveness of vaccines.
And as a result, many say they don't plan to get vaccinated. In fact, for flu, more than one in four adults at higher risk of flu complications said they're not going to get a flu shot. Only 40% of adults said they plan to get a COVID vaccine, only 40% of adults said they plan to get a dose of the RSV vaccine. And this is very concerning. We've got to raise awareness and address any misconceptions. These vaccines are safe and effective, and they've gone through extensive safety testing before they're licensed or authorized. Understand, these vaccines can keep you out of the hospital, they can save your life. And this is a message we've got to make sure that our patients understand.
Dr. McDonald: Yeah, I think I saw some of that data myself recently, and it's really pretty scary. Especially as, again, a primary care physician, my job is to prevent. If we can prevent illness rather than just treat it once it's here, that's the panacea, ultimately. And so, this data was really concerning to me. So, we'll kind of jump back to that, more about confidence and how to talk to patients about that. But let's delve into the nitty-gritty of some of these new vaccines and updated vaccines. And so, let's start with COVID. Obviously, we have an updated COVID vaccine for this winter. Can you tell us a little bit about this, how it's different from prior? And then, who may be eligible for this as well?
Dr. Fryhofer: Sure. Well, a dose of the new updated COVID mRNA vaccine is now recommended for everyone age six months and older. This is a universal recommendation, just like the one we have for seasonal flu vaccines. The old bivalent BA.4/BA.5 Omicron booster is out. It's no longer authorized. The official name for this new XBB.1.5 monovalent version is the 2023/2024 COVID vaccine. Or you can just call it the updated COVID vaccine. For those age five and older, a single dose is all you need to be up to date, regardless of previous vaccination status, and even if you've never had any previous COVID vaccinations.
Now, that's because everyone age five and older is thought to have had at least some immunity to COVID from vaccines, from previous infection or both. For younger children, those age six months through four years old, they also need at least one dose of this new updated vaccine. But they also have to prime their immune system with either two doses of Moderna, or three doses of Pfizer. Patients with immunocompromising conditions need more vaccine doses overall. They need a three-dose initial series of either mRNA vaccine product. They also need a dose of the updated vaccine. And they can get additional doses of the updated vaccine if it's recommended by their physician. So, that's for mRNA.
Now, there's breaking news from the FDA. Just yesterday, Novavax updated a vaccine, has now been authorized for emergency use for those age 12 and older. If you've been previously vaccinated and choose to get a Novavax, all you need is a single dose. Those who have not been previously vaccinated will need two doses of the Novavax updated vaccine. So, the good news here is we now have a choice of two different updated COVID vaccine platforms to choose from—the mRNA or the protein-based, adjuvanted version by Novavax.
Dr. McDonald: Yeah, that was a very concise summary of a lot of information. Can you tell us a little bit about the differences between the mRNA versus the Novavax? And what might sway you to pick one versus another or recommend one versus another for certain patients?
Dr. Fryhofer: Well, I think that we have more data about the mRNA, just there have been more doses distributed. But the mRNA platform is new, and some people just aren't comfortable with it. So, the exciting thing about having this different platform is now there's a choice. If you're someone that, for whatever reason, just doesn't want to get an mRNA vaccine, you can get this protein-based vaccine, which is a more classical platform and maybe what people are more used to. I personally have gotten all mRNA vaccine doses, and I've even gotten a dose of my updated vaccine. I got it the Saturday after it came out.
Dr. McDonald: Oh, I'm jealous. I have to get my updated vaccine still. It's been hard to find availability right now. The rollout is not quite as smooth as maybe we were hoping it would be or when it was previously. Can you tell us maybe a little bit more about that rollout and how, without the federal government purchasing these vaccines, how now we're back to this sort of patchwork availability and cost for these vaccines? Can you share a little bit about that from your perspective?
Dr. Fryhofer: Sure. The federal government is no longer fully funding these vaccines. And so, they're in the commercial market, they're available at pharmacies, you have to sign up online. And what's happening here in Atlanta, there's been a greater demand than there has been availability. So, I've had patients sign up online, they get there and they've run out of vaccine. So, it's been a little bit frustrating. But in some ways, that's good that people seem to be more interested in getting this vaccine. Another thing to know is this updated vaccine can be given at least two months after your last COVID vaccine dose. And if you recently had COVID, you no longer have to wait that three months after infection to get an updated vaccine dose. And I was really glad to hear that. In fact, I asked that specific question at the ACIP meeting because recently I'd seen an uptick in cases of COVID. They weren't super severe cases, but I just realized that my patients really needed a boost. So, you can actually get a dose of the updated vaccine when you've recovered from the infection.
Dr. McDonald: Right. And that was my next question, you read my mind regarding prior vaccinations and prior COVID illness. So, at this point, two months or even after that acute illness period has passed, people are eligible. Is that correct?
Dr. Fryhofer: Right. Two months after your last vaccine dose, or when you've recovered from a recent COVID infection.
Dr. McDonald: Perfect. Unfortunately, a lot of people are done with COVID in this nation. But COVID is not done with us, so to speak. And so, what comments or what suggestions do you have for patients who want to move on and don't really think they're at risk? And then, what advice may you have for physicians as we counsel our patients regarding the importance of getting the updated COVID vaccine?
Dr. Fryhofer: Well, fortunately, COVID is not as bad as it's been in the past. But still each week we're seeing thousands of hospitalizations and hundreds of deaths due to COVID. And in the recent weeks, we were starting to see rates of hospitalizations beginning to increase. I've certainly been seeing a lot more cases in my practice. We know adults aged 65 and older, as well as those with multiple underlying medical conditions, are at greatest risk of severe outcomes if they get COVID. We also know that children aged five to 17 are less likely to suffer severe illness. But still hundreds of children in this age group died from COVID in 2021 and 2022.
And Alex, half of the children who died had no underlying conditions. There is no group that clearly has no risk from COVID. Even children and adults with no underlying conditions still can experience severe illness due to COVID. And then, we think about these new variants that are emerging. Our immunity is beginning to wane. This updated vaccine will increase our immune response against circulating variants and will help protect us. Our challenge now is to find vaccine and to get it into arms.
Dr. McDonald: Right, exactly. And I always tell people, the best vaccine is the one that you can get. Especially if supply is short. And hopefully that problem will diminish over the weeks as things roll out. And those who want to get vaccinated are able to get their vaccine. With just one dose, hopefully that'll be less of a barrier than two doses, such as prior vaccine rollout. Lots more we could cover there, but in the sake of time, I want to switch gears a little bit to RSV and the new tools we have here now to treat RSV. So, tell us a little bit about RSV. I think most of the laypeople had never heard of this before last year, maybe. But those of us who work in medicine obviously have heard about RSV quite extensively. So, tell us about RSV, and who are at highest risk of severe illness and complications from respiratory syncytial virus as well.
Dr. Fryhofer: RSV is highly contagious. And for most of us it just causes a nasty cold, but for the very young and the very old, RSV can lead to hospitalization, life-threatening pneumonia and even death. RSV is the most common cause of hospitalizations for infants in the United States. And most infants are affected in their first year of life. And just about every child will have had it by the time they hit two years old. RSV kills between 100 to 300 children under the age of five each year in the United States. And the vast majority of those children, about 79% of those less than two years old who get RSV, had no underlying medical conditions. This means all young infants are at risk of RSV. The CDC also—
Dr. McDonald: Yeah, I remember—
Dr. Fryhofer: Yeah, go ahead.
Dr. McDonald: Sorry. No, no, go ahead.
Dr. Fryhofer: I was going to talk about the effect on older adults. The CDC says that RSV is to blame for as many as 60-160,000 hospitalizations in those age 65 and older, and anywhere from 6-10,000 of these older adults die from it. And as a reminder, the RSV season usually lasts around four to five months, typically from October through March. You mentioned winter respiratory viruses, a lot of these really start in the fall.
Dr. McDonald: Right, exactly. Which is why it's important we start vaccinations in September, in the fall, which dovetails very nicely. Now, we have two brand new tools to protect both the very young as well as the very old regarding RSV this season. Which personally, again, primary care doctor, all about prevention, I'm really excited about these preventative tools. So, can you tell us about these new tools we have?
Dr. Fryhofer: That's right. We have vaccines and we have monoclonal antibodies. And so, for the very first time ever, we have these new tools to help older patients and also to protect babies against RSV. There are two RSV vaccines now available. One is by GSK, it's called Arexvy, and it contains an adjuvant, which is the same adjuvant that's in GSK’s recombinant shingles vaccine, Shingrix. The other vaccine, Abrysvo, by Pfizer, does not contain an adjuvant. But it is bivalent, meaning it protects against two different RSV strains, RSVA and RSVB.
Both of these are recommended for those age 60 and older under shared clinical decision-making, which means you and your patient have to discuss and decide. Just about all adults hospitalized with RSV have underlying medical conditions, and nearly half of them have three or more underlying medical conditions. The top three medical conditions in adults hospitalized with RSV include heart disease, chronic lung disease and diabetes. And nearly a third of those hospitalized have congestive heart failure. We also have a seasonal maternal RSV vaccine dose, which is now recommended for pregnant people at age 32 to 36 weeks of pregnancy to protect babies born during RSV season. Only Abrysvo, the one that does not contain the adjuvant, is approved right now for pregnant people. That could change if the other one is FDA approved for this age group. But for right now, just Abrysvo for the pregnant persons.
And the timing of the maternal RSV vaccine matters. Remember that the RSV season typically ranges from October through March, so we give the maternal RSV vaccine from September through January for pregnant people at 32 to 36 weeks of pregnancy. And the concept is you give the vaccine during pregnancy, so Mom's protective antibodies are then passed on to baby, protecting the baby during those first few months of life in which these babies are so vulnerable. And it takes about 14 days after getting the vaccine to build up protective antibodies. There's also a monoclonal antibody, nirsevimab, that's now recommended for babies. And the recommendation is you can give a dose for babies under eight months old experiencing their first RSV season. You can give a second protective dose for older babies up to 18 months that are experiencing their second RSV season if they're still at risk for severe disease.
Dr. McDonald: Right, so a lot of really good tools for, again, our older patients—or sorry—our more experienced patients, if you will, who have some underlying medical conditions, our expectant mothers, and then our brand-new babies. And they're slightly different tools. And so, I'm looking forward to seeing how effective this is to really reduce the illness for these vulnerable patients. That was a great summary. And last but not least, let's not forget about flu. Influenza is here, it's here every year. We have just decades worth of data regarding flu and flu vaccines and how effective they are. So, is there anything new this season regarding the flu vaccine?
Dr. Fryhofer: Well, one thing that's not new is everyone six months and older needs flu vaccination every year. All the flu vaccines now are quadrivalent. But the newest flu news is for those with egg allergy. And it's not which vaccine they can get. Of course, those with egg allergy can get any age- and health condition-appropriate vaccine, either egg-free or egg-based. But what's new is where they can go to get their vaccine. Egg-allergic individuals no longer require additional safety measures beyond what others would get.
And also, a reminder for those 65 and older, the higher dose in adjuvant versions are preferred. They're more effective than the standard dose vaccine in protecting these older patients. And there are three of them, and they're one of a kind in their category. These include the high-dose vaccine Fluzone High-Dose, which is four times stronger than standard vaccines. The recombinant influenza vaccine Flublok, which is three times stronger than the standard vaccines. And also, Fluad, which is the only adjuvanted flu vaccine that's available. It's the same strength as the standard vaccine, but it has an adjuvant added to boost its immune response.
Dr. McDonald: Great. And then lastly, again, speaking about this time period where we are increased risk of transmitting these diseases during the population, let's talk about co-administration. Because prior, we wanted to separate out different vaccines. Right now, if I understand correctly, we can do all the appropriate vaccines in one visit at one time. Is that correct?
Dr. Fryhofer: Yes. All three of these vaccines can be co-administered together and with other vaccines with one exception. COVID vaccines should not be co-administered with mpox vaccines. Now, I will tell you, Alex, last month, we were in September, I was encouraging people to try to get their COVID vaccine. Because I thought we still had a little bit of a wiggle room in getting those flu vaccines in. We sort of say if you get your flu vaccine before Halloween, you're good to go. But I've had several patients just get them all at the same time and haven't gotten any complaints. I'm sure their arm was a little sore, but if there's any problem getting access to the vaccine or getting to the pharmacy, it's better to get it done than wish you had.
Dr. McDonald: Yep, I always tell my patients, "Look, you're here now. Let's just get it done, taken care of. Yeah, you may feel a little more fatigued for the next day or two. Your arm may be sore. But the risk of being tired and a sore arm pale in comparison to getting ill and hospitalized, and even potentially death." This has been such a good conversation. There are a couple quick questions from the audience here I want to touch on. Do you have any recommendations for our physicians who want to chat with their patients who maybe are immunocompromised regarding all of these vaccines? And particularly those who may be a little bit resistant, but are at high risk of complications from any of these winter respiratory illnesses, do you have any recommendations there?
Dr. Fryhofer: Certainly, immunocompromised patients need these vaccines. They need all three of them. The RSV would be indicated only if they're age 60 and older because that's the FDA approval at this point. But they need all three of these. So, just answering their questions. One of the ways that I approach talking to patients of vaccines is called the AIMS method. The A stands for announce. Announce that you're going to give a vaccine. So say, "Okay, let's go, you need to go get your COVID, your flu and your RSV vaccine." I, if you get any pushback, I is for inquire. If they don't want to do it, sort of ask why, "Why not?" M is for mirror. Repeat the question and make sure you understand what they're asking in a very non-confrontational way. And then, S is for secure trust. Answer those questions but keep the conversation open.
And I've found that that's really helping. And I'm seeing, right now, a big difference in the response to these three vaccines than maybe I did last year. I don't know if people are just seeing their friends come down with COVID. I think our experience this time last year with that little triple-demic we had of RSV, COVID and flu is people are starting to sort of think about that. But then, when you hear this NFID survey that not everyone is thinking like my patients, it is concerning. But immunocompromised patients need to get these vaccines for sure.
Dr. McDonald: Yeah, I love that AIMS methodology. And one thing that I think is really important, especially as a family physician and practicing primary care, I often will care for the entire family. And I'll call them tag-along flu shots, or tag-along vaccines. If the baby is there and Mom's there, I'm like, "Hey, you know what? You should get your flu vaccine as well. Make sure the whole family is protected." I think the other piece is I've had a lot of patients be very resistant over time for any number of vaccines. And just building that trust and repeating the same message over and over again, eventually some of my patients have come around and been like, "All right. You know what, Doc? You've taken care of me for 10 years. I trust you, I trust your judgment." And just making sure you leave the conversation open and doing it in sort of a non-judgmental way I think is so valuable. Because if you shame and blame, they just sort of shut down and then that degrades trust. And nobody wins, quite frankly.
Dr. Fryhofer: Right. And there's a lot of misinformation out there. And certainly, we as physicians, we are a trusted source of information. There are also ... I encourage patients to check websites with trusted sources of information. Our AMA website is one of them, and we have regular AMA Updates on various topics. I do regular updates on our ACIP meetings. But physicians are a trusted source, so the AIMS method, I've found in my practice, is really, really helpful.
Dr. McDonald: Wonderful. Well, this has been wonderful. Tons of information. So, hopefully everyone out there listening can go back and listen to this again or share with friends or family so we can all make sure we have the right information. Thank you so much for joining us. I really appreciate your expertise and taking your time for us today.
Dr. Fryhofer: Thank you so much, Dr. McDonald. And it's been a pleasure to be on your show today.
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Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
