ACIP Updates Can Spark Vaccine Conversations With Patients
RSV Vaccination Changes Aim to Simplify Administration
Aug. 22, 2024, Cindy Borgmeyer — As National Immunization Awareness Month, August offers an unmatched opportunity to highlight the importance of staying up to date on recommended vaccines. Given that the CDC’s Advisory Committee on Immunization Practices recently updated some of those recommendations, it’s a particularly good time to have those conversations with your patients.
Vaccines for Respiratory Illness
The ACIP discussed a wide range of vaccine-related topics during its June 26–28 meeting, adopting recommendations that the CDC, AAFP and American Academy of Pediatrics subsequently approved. As fall’s cooler temperatures herald the approach of respiratory disease season, family physicians should be aware of new recommendations for administration of vaccines to protect against the top three culprits: respiratory syncytial virus, COVID-19 and seasonal influenza.
RSV: In 2023, the CDC and AAFP recommended that adults 60 and older “may receive a single dose of RSV vaccine using shared clinical decision-making.” This year, ACIP members voted unanimously to recommend that
adults 75 and older receive a single dose of RSV vaccine and
adults 60 to 74 who are at increased risk of severe RSV disease (i.e., people who have certain chronic medical conditions, such as lung or heart disease, or who live in nursing homes) receive a single dose of RSV vaccine.
According to AAFP liaison to the ACIP Laura Morris, M.D., M.S.P.H., FAAFP, this change should prompt family physicians “to give a more definitive strong recommendation for the group that benefits most, which is the 75-plus group.”
“The younger adult population,” Morris said, “should only be vaccinated if they have high-risk conditions.” Such conditions include lung disease (e.g., COPD), heart disease, immunocompromised status, diabetes, obesity with a BMI ≥40, neurological conditions, neuromuscular conditions, chronic kidney disease, liver disorders and blood disorders. Living in a nursing facility is also a risk factor, she noted.
“Historically, recommendations based on risk are followed more often than those with a shared decision-making component,” said Morris. “We will encounter ‘worried well’ patients who want the vaccine. Family physicians can advise younger, healthier patients that although the FDA has expanded its approval of one RSV vaccine product down to age 50, there was not convincing evidence that benefits outweighed the risks in this group. More information is necessary to give a broad recommendation.”
Story Highlights
Two adult RSV vaccines, Pfizer’s Abrysvo and GSK’s Arexvy, received FDA approval last year. (Only Arexvy is approved for use in patients ages 50 to 59 at increased risk for lower respiratory tract disease caused by RSV.) A newly approved mRNA RSV vaccine for adults, Moderna’s mRESVIA, appears to be modestly effective against any RSV diagnosis, said Morris, although study data is lacking to determine how well this third vaccine option may prevent death or hospitalization.
The effectiveness of nirsevimab (marketed by Sanofi as Beyfortus), the RSV monoclonal antibody for infants, was also discussed at the meeting. “This works really well!” she said. “It is still not clear whether the best practice will be to vaccinate pregnant people or give the infant the antibody after delivery, but it is great to have options.” Nirsevimab shortages that were seen last year are not expected for 2024.
COVID-19: After deliberating between universal and non-universal (risk-based or shared decision-making) vaccination policy options, the ACIP’s COVID-19 Work Group concluded that non-universal vaccination would pose significant implementation challenges and instead recommended a universal approach to vaccination. The ACIP agreed, voting unanimously to recommend the 2024-2025 COVID-19 vaccine as authorized or approved by the FDA for those 6 months of age and older.
Now in the process of being updated, “the new formulation will be based on the KP.2 strain (one of the “FLiRT” variants),” Morris clarified.
Listen and Learn
Anne Schneider, M.D., a 2021 AAFP Vaccine Science Fellow, shared additional updates from the ACIP’s June meeting on an episode of the Inside Family Medicine podcast this month, and 2023 Vaccine Science Fellows Neha Chande, M.D., M.H.S., and Llewellyn Mensah, M.D., M.P.H.&T.M., joined the podcast this week to talk about the fellowship’s impact on their careers.
Although the precise timing of vaccine availability is uncertain, Morris said she anticipates that distribution will begin in September. Indeed, CNN reported this week that the FDA appears poised to sign off on updated vaccines that more closely target circulating strains of the SARS-CoV-2 virus, with all three COVID vaccine manufacturers (Pfizer/BioNTech, Moderna and Novavax) expected to begin shipping doses within days of that authorization. That’s good news, given that test positivity rates have been surging for weeks and wastewater surveillance pegs viral activity levels as very high.
“Many (patients) did not choose to update their vaccine last fall, and although the virus has indeed become less deadly over time compared to its original form, it still confers more risk to many people than influenza,” Morris cautioned. “Of adults who were hospitalized last year, >90% did not take the most recent/up to date vaccine.”
As for concerns that cost may pose a barrier to vaccination, it is anticipated that insurance plans will cover the 2024-2025 vaccines immediately under the Coronavirus Aid, Relief, and Economic Security, or CARES, Act. In addition, Medicare and Medicaid recipients will continue to have access to no-cost COVID-19 vaccines per the Inflation Reduction Act. Similarly, the Vaccines for Children program also will continue providing COVID-19 vaccines at no cost to eligible children.
“As a preventive health service, COVID-19 vaccines recommended by the ACIP should be fully covered without cost-sharing or copay,” explained Michael Monroe, senior manager of clinical and health policy in the AAFP Division of Education, Science and Health of the Public. “Medicare Part B and Medicare Advantage plans also cover COVID-19 vaccines without cost-sharing.”
Influenza: In yet another unanimous vote, ACIP members recommended that all individuals ages 6 months and older (with rare exceptions) receive the seasonal influenza vaccine when it becomes available. For most patients, September and October are the best months for vaccination, with a few notable exceptions:
Pregnant people who are in their third trimester can receive the flu vaccine in July or August to protect their infants after birth, when they are too young to be vaccinated.
Children who require two doses of the vaccine should get their first dose as soon as it becomes available. The second dose should be given at least four weeks after the first.
Vaccination in July or August can be considered for children who have health care visits during those months if there might not be another opportunity to vaccinate them.
Vaccination in July or August should be avoided in people who are in their first or second trimester of pregnancy, as well as in those 65 and older, to mitigate the effects of any potential waning of the vaccine’s efficacy as the season kicks into high gear.
For pregnant people, said Morris, “The timing recommended intends to maximize the antibodies formed and transferred over to baby before birth. An infant born in late summer or early fall will miss all the potential benefits of maternal vaccination if the pregnant person waits until a more traditional time for flu shots after delivery. However, if a person will remain pregnant into late fall/winter (or spring), then we can wait to administer the flu shot until the usual time frame because we are protecting the pregnant person themselves as well as timing some antibodies for baby.”
Morris also noted that unlike the past several years, this year’s vaccine will be trivalent rather than quadrivalent. “One of the flu B strains was not frequently diagnosed, so it was simply removed from the formulation,” she said. That leaves this season’s vaccines — both egg- and cell- or recombinant-based — protecting against an H1N1, H3N2 and a B/Victoria lineage virus. Specifically, this season’s vaccine composition has been updated with a new influenza A(H3N2) virus.
Laura Morris, M.D., M.S.P.H., FAAFP
The AAFP has resources to help facilitate conversations about both the COVID and flu vaccines, which may be coadministered. For help talking with patients about COVID vaccines, check out this guide from the Academy; when it’s time to discuss influenza vaccination, this AAFP resource is designed to help you make a strong recommendation.
Other Meeting Highlights
Another key vote taken during the June meeting, said Morris, involved the pneumococcal conjugate vaccine, with the ACIP recommending PCV21 as an option for adults 19 and older who currently have a recommendation to receive a dose of PCV.
“Prevnar 21 is not just Prevnar 20 plus one,” she emphasized. “It covers 11 different strains than PCV20, including up to 84% of those that cause invasive disease or serious illness. That is an impressive pick up over PCV20, which covers only about 58%. The main gap in coverage for PCV21 compared to PCV20 is serotype 4, which is important in some specific patient populations, including those experiencing homelessness and Alaska Natives.”
Additional pneumococcal vaccines are in the pipeline, Morris said, including a 25- and a 31-valent. Sifting through recommendations for pneumococcal vaccines can be particularly challenging, she noted, so it may be helpful to bookmark the CDC pneumococcal vaccines page, which should be updated with the new ACIP/CDC recommendations soon. Immunize.org also offers reliable information about pneumococcal vaccines, Morris added.
Finally, ACIP members gave a unanimous thumbs up to a recommendation that Vaxelis, a joint Merck and Sanofi product used to prevent diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, and invasive disease due to Haemophilus influenzae type b, should be added as a preferential vaccine option in infants of American Indian or Alaska Native descent. Previously, only haemophilus b conjugate (PRP-OMP) vaccine PedvaxHIB was preferentially recommended for this patient population based on its ability to induce a protective antibody response after the first dose, which is beneficial because Hib meningitis peaks at an earlier age among these infants.
Visit the AAFP’s Immunizations and Vaccines webpage to access a wealth of resources and information, including patient-friendly materials to share.