HealthOctober 09, 2023

Flu, RSV, and COVID-19 vaccine updates: What pharmacists need to know for the fall 2023 season

By: Kaitlyn Rivard, PharmD, BCPS, BCIDP

With the right resources and a commitment to keeping patients educated, we can make sure we’re cutting through confusion and offering the best available immunization care.

Navigating the challenges of multi-vaccine visits during this flu season

As we move into the respiratory virus season, the many changes in vaccine recommendations can be fatiguing for providers and patients.

For the 2023-2024 influenza vaccine season, products will look the same, although the recipe has changed in anticipation of what the prevailing strains of flu will likely be. This season, the H1N1 strain was updated.

Pharmacists may also see increased volumes of patients wanting multiple vaccines per visit and should prepare accordingly. While the Advisory Committee on Immunization Practices (ACIP) permits vaccine co-administration, pharmacists should be prepared to take more time per visit than what they would be used to for a simple flu shot.

RSV vaccine: A new option for patients over 60

A new vaccine we expect to see interest in this season is the RSV (respiratory syncytial virus) vaccine, which is recommended for patients 60 years and older using shared clinical decision-making. As a newly approved immunization, some patients may not know to request the RSV vaccine during their visit. It’s important that healthcare providers educate eligible patients about the opportunity to receive the RSV vaccine: “There is a new vaccine available to protect you against RSV, which is a cold-like virus that can result in hospitalization for patients 60 years and older. In addition to your flu and COVID-19 vaccine, can I offer you an RSV vaccine today?”

Vaccine transparency: Ensuring patient awareness of care and costs

Key to the discussion of all immunizations is making sure patients understand how each vaccine will be covered by their health insurance. This is an area where pharmacists and payers can help patients navigate their options.

Most health insurance plans are required to include vaccines recommended by the ACIP as a covered benefit. It can be tricky, however, for patients to identify whether a particular immunization is covered as a medical benefit or a pharmacy benefit under their insurance plan.

For example, the RSV vaccine will be covered under Medicare Part D, so patients 65 and older with Medicare will have to get their vaccine at the pharmacy (not in a medical office) for it to be paid for in most cases. Patients with private health insurance plans should be advised to check with their insurance company to confirm how the RSV vaccine will be covered prior to seeking vaccination.

What is changing for COVID-19 vaccines?

Based on previous COVID-19 vaccine rates, it’s estimated that uptake of the next iteration of the COVID-19 vaccine will be 20% or less of the US population, meaning for every five flu shots we may give, only one patient might accept a COVID-19 shot.

It's a time of change for COVID-19 vaccine for two reasons:

1. Annual vaccines likely

Unfortunately, the current COVID-19 bivalent vaccine is becoming less effective against the emerging variants like the XBB.1.5 and the EG.5. Fortunately, the FDA and the ACIP have been working with manufacturers on a new monovalent formulation to become available this fall. This means we're starting to see the COVID-19 vaccine become similar to flu, where we can expect an annual change in the recipe based on the predominant circulating variants.

2. Shots no longer free

The United States public health emergency program for providing COVID-19 vaccines free through our health departments has ended. The COVID-19 vaccine 2023-2024 formulation that is anticipated to debut in September will come at a cost of around $100 per dose. Pharmacies and provider offices should be prepared to purchase stock of the 2023-2024 formulation once available and educate patients that vaccination may be associated with cost-sharing or co-payment depending on their insurance plan.

The new COVID-19 formulation is not expected to add extra steps to the pharmacy workflow, as it will be the same as flu or any other vaccine administration and billing procedure. While detailed information on the new vaccine will not be provided until the FDA and ACIP have weighed in, it is anticipated that co-administration of the new COVID-19 vaccine with flu and RSV vaccines will be permissible. Adverse effects from co-administration are likely to be minor (fatigue, arm soreness), and the benefits outweigh the risk of a patient not returning for a future vaccination appointment.

When the new COVID-19 vaccine is authorized, it is important for providers to stay current with the ACIP’s recommendations for use of COVID-19 vaccines. Because COVID vaccine recommendations change so fast, it is a best practice to stay current with the following resources:

Latest vaccine options for pediatric patients

With so much focus on flu and COVID vaccine season, we can’t forget that there have been other updates to the schedules that providers need to keep in mind and communicate to their patients.

One exciting update for pediatrics is the availability of expanded pneumococcal conjugate vaccines, PCV15 (Vaxneuvance) and PCV20 (Prevnar 20), which are both now approved for use in the infant immunization series. These latest vaccine options provide protection against additional pneumococcal serotypes that were not included in the PCV13 (Prevnar 13) product.

Since the pneumococcal vaccine is part of the routine infant series for every baby, administered over four doses at 2,4, and 6 months and then again at 15-18 months, children due to start or complete the series can receive PCV15 or PCV20 at their next scheduled vaccination. If a child has already received their primary series, unless they're at higher risk of disease, they will not need to be revaccinated.

How can pharmacists provide patients with the latest information on vaccines?

With the pandemic, we saw a lot of vaccine hesitancy, misinformation, and confusion with constantly changing vaccine recommendations, especially as the formulations changed. When the bivalent COVID-19 vaccine rolled-out in fall 2022, we found that many patients were unaware of their eligibility to receive the updated formulation. Often, patients offered a “COVID-19 vaccine” would respond, “I've already gotten mine.” They didn’t realize when there were updated recommendations or a new formulation. That’s why it’s so important that healthcare providers are specific when discussing vaccinations with patients: “You are eligible for the new, ‘updated’ COVID-19 vaccine that provides better protection against the strains we are seeing in our community. Would you like to receive this updated COVID-19 vaccine today?”

Specificity includes

  • Explaining that there is a good vaccine available and what exactly it offers protection from.
  • Explaining why the patient is a candidate for this vaccine and/or what the recommendations are for receiving it.
  • Clearly asking if you can offer you that patient this vaccine today.

No matter how newsworthy a disease or its associated vaccine, we cannot assume patients are aware of ongoing changes in that vaccine’s availability or recommendations. This year, there is a lot of buzz amongst healthcare providers and the health literate surrounding the RSV vaccine. However, there are also many people who don’t even know what RSV is!

We should use every patient visit as an opportunity to review vaccine history and eligibility. Patients coming in for their annual flu vaccination should be screened for eligibility for additional vaccines. That’s the perfect moment to bring up that they may also be due for COVID, RSV, or other routine vaccines such as pneumococcal or tetanus. Even if they don’t get it that day, you are at least reminding them that there are vaccines in the adult schedule that they’re also eligible for.

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Kaitlyn Rivard, PharmD, BCPS, BCIDP
Infectious Diseases Clinical Pharmacist, Cleveland Clinic
Kaitlyn Rivard, PharmD, BCPS, BCIDP is an Infectious Diseases Clinical Pharmacist at Cleveland Clinic, with subspecialty in Pediatric ID, Vaccines, and Public Health. Dr. Rivard is the pharmacist co-chair of the Cleveland Clinic Vaccine Governance Committee and has clinical and operational oversight of vaccine operations.
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