Preparing for fall, winter vaccine season

This upcoming fall and winter respiratory season there are more vaccines available to protect against serious respiratory illnesses in adults than ever before. With these new choices there are many questions about when to take which vaccine and which ones can be co-administered.
 
Maureen Tierney, MD, and Anne O’Keefe, MD, from the School of Medicine Department of Clinical Research and Public Health provide some guidance to help you make these decisions. They are limiting their comments on vaccination for those over 18.

(Creighton faculty and staff can get a free flu shot at walk-in locations on the Phoenix and Omaha campuses. Learn more.)

COVID-19 Vaccines

The U.S. Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) have just (Sept. 12, 2023) approved and recommended, respectively, a new annual booster vaccination for everyone over the age of 6 months for COVID-19 which covers variant strains that match current circulating strains more closely. Vaccines from two manufacturers (Pfizer/BioNTech and Moderna) will be available soon and one more (Novavax) will likely be approved soon. A CDC advisory panel noted that the benefits of vaccination outweigh the risks for all age groups, but some age groups (e.g., people over age 50, children under 5, pregnant women, and others with underlying conditions such as diabetes or obesity) are at much higher risk from COVID-19. It is especially important for pregnant women to get vaccinated in order to protect themselves and their newborn babies.

We are currently experiencing a fall surge of COVID-19 illnesses. With the return to school this fall, many people are being exposed and infected, so it is important to get your 2023-2024 COVID-19 dose as soon as you can. Please also consider masking in settings with higher risk of transmission such as crowded indoor spaces with poor ventilation.

Influenza Vaccines

Epidemics of influenza (“flu”) illness occur annually, and people of all ages are susceptible to this serious infection. Symptoms can range from fever, cough and several days of severe fatigue/body aches, to pneumonia or worse. Modeling of population-based data estimates that influenza causes approximately 4,900-27,800 deaths yearly, depending on the severity of the season. (Reed et al)

Every year influenza vaccines are updated to attempt to best match the circulating strains. This year all formulations of the inactivated flu vaccines cover four (quadrivalent) influenza strains, two influenza A and two influenza B strains. There are no longer trivalent (covering only three strains) vaccines.

There are a number of different types of flu vaccine available. CDC recommends that all Americans over 6 months of age be vaccinated against influenza. Influenza vaccination has been shown to reduce the chance of getting the flu, but even if you have a breakthrough infection it reduces the severity and then chance of hospitalization or death. Being vaccinated for influenza can also help you protect vulnerable people with whom you may come into contact.

Different vaccines are licensed for use in different age groups, and some vaccines are not recommended for some groups of people.

Available flu vaccines include:

• Standard-dose flu shots that are manufactured using virus grown in eggs. Several brands are available, including Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent and Fluzone Quadrivalent.
• A cell-based flu shot (Flucelvax Quadrivalent) containing virus grown in cell culture, which is approved for people 6 months and older. This vaccine is completely egg-free.
• A recombinant flu shot (Flublok Quadrivalent) which is a completely egg-free flu shot that is made using recombinant technology and is approved for use in those 18 years and older. This shot contains three times the antigen than other standard-dose inactivated flu vaccines, to help create a stronger immune response.
• An egg-based high dose flu shot (Fluzone High-Dose Quadrivalent), which is approved for use in people 65 years and older. This vaccine contains four times the antigen than other standard-dose inactivated flu vaccines, to help create a stronger immune response.
• An egg-based adjuvanted flu shot (Fluad Quadrivalent), which is approved for people 65 years and older. This vaccine is made with an adjuvant (an ingredient that helps create a stronger immune response).
• An egg-based live attenuated flu nasal spray vaccine (FluMist Quadrivalent) made with attenuated (weakened) live flu viruses, which is approved for use in people 2 years through 49 years. This vaccine is not recommended for use in pregnant people, immunocompromised people or people with certain medical conditions.

For those over 65, the following vaccines are recommended: Fluzone High-Dose Quadrivalent vaccine, Flublok Quadrivalent recombinant flu vaccine and Fluad Quadrivalent adjuvanted flu vaccine.

Pneumococcal Vaccines

Can be given at any time, starting now.

A bacteria called Streptococcus pneumoniae can cause serious disease such as pneumonia and meningitis in all age groups but especially in the very young, very old and individuals with certain underlying conditions such as immunocompromised, splenectomy (people without a functioning spleen), cerebrospinal fluid (CSF) shunts and asthma/chronic obstructive pulmonary disease (COPD)/emphysema. Influenza infection can increase the risk of contracting this dangerous bacterial disease. There are two kinds of pneumococcal vaccines available in the United States:

• Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20)
• Pneumococcal polysaccharide vaccine (PPSV23)

Adult recommendations:

According to the CDC, “For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults 65 years or older and adults 19 through 64 years old with certain medical conditions or risk factors. If PCV15 is used, this should be followed by a dose of PPSV23. Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of 65 years old.” Pneumococcal vaccine can be given individually or in combination with any other vaccine.

RSV Vaccines

Although pneumococcal vaccines have been around for a while, respiratory syncytial virus (RSV) vaccines are relatively new. RSV is a virus that also causes more severe disease in the very young and the very old. Although there are not yet vaccines approved for the very young, there are 2 new RSV vaccines licensed for use in adults aged 60 years and older in the United States.

CDC recommends that adults 60 years of age and older may receive a single dose of RSV vaccine using shared clinical decision-making (SCDM) with your healthcare provider. This means that healthcare providers and their patients should have a conversation to determine if RSV vaccination will be beneficial. This differs from routine age-based and risk-based vaccine recommendations from the CDC when they recommend vaccination of all persons in a specified age group or risk group. Under SCDM, the decision whether to vaccinate a patient is individually based and informed by discussions between the patient and their healthcare provider. Older adults may also want to consider whether they will come into contact with young children who are at high risk from RSV disease.

The decision may be informed by a patient’s health status, their risk of severe RSV disease, the healthcare provider’s clinical judgment, the patient’s preferences, the safety profile of the RSV vaccine products low and other factors.

Persons aged 60 years and older who are at highest risk for severe RSV disease and who might be most likely to benefit from vaccination include those with chronic medical conditions such as: cardiopulmonary disease, kidney disorders, liver disorders, neurologic or neuromuscular conditions, hematologic disorders, diabetes mellitus, and, moderate or severe immune compromise (either attributable to a medical condition or receipt of immunosuppressive medications or treatment), as well as persons who are frail; persons of advanced age (over 60 with increasing risk with advancing age); and persons who reside in nursing homes or other long-term care facilities. The vaccines were studied in 2 large studies of about 20,000 people each. There were rare serious side effects in about 3 individuals out of approximately 20,000.

Currently, the RSV vaccine series consists of a single dose. RSV vaccines may appear to provide some protection for at least two RSV seasons. Additional surveillance and evaluation activities are planned to assess how long the vaccines protect against RSV and whether additional doses will be needed.

For those over 65 or others who are eligible and wish to receive some or all of the above vaccines, a frequent question is, can and should these vaccines be given simultaneously.  Although theoretically they probably could all be given together but that would increase the chance of side effects like sore arm, fever, headache, muscle aches and fatigue, so most providers would recommend spacing them out, often to 2 at a time. Of note RSV has only been studied being given in conjunction with influenza.

Resources

COVID-19 vaccine
https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html

Reed C, Chaves SS, Daily Kirley P, Emerson R, Aragon D, Hancock EB, et al. Estimating influenza disease burden from population-based surveillance data in the United States. PLoS One. 2015;10(3):e0118369.

CDC ACIP Presentation Slides: September 12, 2023 Meeting:
https://www.cdc.gov/vaccines/acip/meetings/slides-2023-09-12.html?utm_source=substack&utm_medium=email
 
RSV vaccine
https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html#vax-rec
 
Influenza vaccines
https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm
 
Pneumococcal vaccines
https://www.cdc.gov/vaccines/vpd/pneumo/index.html