Respiratory Viral Season: Fall 2023 Edition - Dr. Dora Anne Mills

 

Dora Anne Mills, MD, MPH

The View from Maine Sept 17, 2023

Respiratory Viral Season: Fall 2023 Edition

 

Below is an overview, recommendations, and common questions related to this year’s respiratory viral season. At the very end are links to references with more information, in order by topic as they appear below.

 

Last week, the US FDA and US CDC issued approvals and recommendations for the updated fall 2023 COVID-19 vaccine. Everyone 6 months of age and older is recommended to receive the updated COVID-19 vaccine as well as an annual influenza vaccine. Both vaccines are updated and formulated to protect against the strains that are circulating and/or predicted to circulate this fall and winter.

 

One of the main lessons we’ve learned from the pandemic has been the importance of taking some simple steps during respiratory viral season, which is the fall and winter, when we more commonly see influenza, RSV, and other respiratory viruses.

 

Although we don’t fully know if COVID-19 has a regular season or not, we know:

•   COVID-19 incidence has recently been increasing, including upticks in the numbers of people diagnosed and hospitalized as well as higher wastewater levels;

•   COVID-19 virus continues to mutate;

•   Our immunity continues to wane, whether it is due to past vaccination and/or infection. This is much like influenza – infections in the community wax and wane, the virus mutates, our immunity wanes. And therefore, for both COVID-19 and influenza, we need an updated vaccine periodically.

 

Here are the basic recommendations for this respiratory viral season:

 

•   COVID-19 VACCINE. Get an updated COVID-19 vaccine sooner than later, given that there is an uptick in infections and our immunity has waned. But also be patient; the supply is being distributed as I write this, so it may take a few days or a couple of weeks before you can find an appointment.

 

•   INFLUENZA VACCINE. Get an updated influenza vaccine. Two major options in terms of timing.

o   One option is to get vaccinated as soon as possible with influenza and COVID-19 at the same time, especially since this is a more convenient option for many people. I’d also get both at the same time and soon if you have plans for upcoming major travel or gatherings.

o   Another option is if it’s easy for you to get vaccinated (e.g., you live near pharmacies that vaccinate), then wait until you hear of influenza emerging in the state where you live, and then get vaccinated. This is fine, so long as it’s at least 2 weeks after any prior vaccine of any type. But do remember that it takes another two weeks for vaccines to provide significant immunity, so keep that in mind if

you’re got travel or similar plans. One reason for considering this option is that immunity from influenza vaccine wanes after about 6 months, so getting vaccinated later in the fall (October or even early November) may be more protective if we have a late influenza season.

 

•   RSV VACCINE. If you’re 60 or older or pregnant in your third trimester, talk with your provider about the RSV vaccine, and consider getting it. Monoclonal antibodies against RSV should be considered for newborns and infants.

 

•   HAND WASHING. All of us should increase our attention to washing hands frequently during respiratory viral season.

 

•   IF YOU ARE AT HIGH-RISK. If you’re at high-risk for severe disease or otherwise don’t want to get a respiratory illness this winter (COVID=19, influenza, RSV, etc.), then consider:

o   Monitoring respiratory illnesses in your area, much like the weather. Hopefully someday there will be dashboards that are easier to read, just like the weather. But in the meantime, US CDC is merging the tracking of influenza, COVID-19, and RSV on this site, where you can also see data for some states: https://www.cdc.gov/surveillance/resp-net/dashboard.html

o   Wearing a high-quality mask (e.g., an N95) when in indoor crowded areas when respiratory illnesses are high;

o   Paying attention to ventilation when respiratory illnesses are high;

o   Keeping testing kits for COVID-19 handy.

 

 

Some Common Questions:

 

Why should I get a COVID-19 updated vaccine?

•   The virus that causes COVID-19 is always changing, and as with influenza, immunity from COVID-19 declines over time, whether immunity is from prior infection and/or vaccination. Receiving an updated COVID-19 vaccine can boost immunity and protect against the variants currently responsible for most infections and hospitalizations in the United States.

•   It is effective. Last season, those who received the fall 2022 COVID-19 vaccine

saw greater protection against illness and hospitalization than those who did not receive the vaccine. 

•   The vaccine is safe. To date, hundreds of millions of people have safely received a COVID-19 vaccine under the most intense safety monitoring in U.S. history.

•   It protects against Long COVID. Vaccination also reduces your chance of suffering the effects of Long COVID.

•   It helps prevent you from transmitting COVD-19 to others.

•   In short, the updated COVID-19 vaccine will protect you, your colleagues, and your loved ones.

How can I get an updated COVID-19 vaccine?

You may need some patience. The vaccine is in the process of being distributed by the federal government, with the priority being to chain pharmacies. As with health care across the country, many of them are short staffed. Community health centers are also receiving early shipments of federally-purchased vaccine.

•   Check with your local pharmacy and other community settings (such as community health centers), many which can be found here: https://www.vaccines.gov/search/. Pharmacies may be the quickest way to get vaccinated, since vaccine is being distributed by the federal government to many pharmacies this week. A number of community health centers are also receiving vaccine and funds to put on clinics.

•   Maine-specific sites can be found here: https://www.maine.gov/covid19/vaccines/vaccination-sites

•   Check with your primary care provider. Many primary care practices will be scheduling clinics for their patients, however, the distribution to many of them is scheduled for later than the chain pharmacies and community health centers. So, maintain some patience.

 

What if I don’t have insurance to cover the COVID-19 vaccine?

•   The US CDC Bridge Program is distributing vaccine and funds to chain pharmacies and a number of community health centers so they can provide COVID-19 vaccines for those without insurance coverage. You can locate these at: https://www.vaccines.gov/search/.

 

What if I don’t want to get a COVID-19 mRNA vaccine?

•   Novavax should be approved/authorized soon by the FDA. It is a more traditional vaccine. As a recombinant protein vaccine, it is similar to some influenza and hepatitis vaccines.

 

What types of COVID-19 vaccines are there this year?

•   There are two mRNA vaccines:

o   Moderna COVID-19 Vaccine (2023–2024 Formula) is authorized for children ages 6 months–11 years; SPIKEVAX is the licensed Moderna product for people ages 12 years and older. These vaccines are hereafter referred to as updated (2023–2024 Formula) Moderna COVID-19 Vaccine.

o   Pfizer-BioNTech COVID-19 Vaccine (2023–2024 Formula) is authorized for children ages 6 months–11 years; COMIRNATY is the licensed Pfizer-BioNTech product for people ages 12 years and older. These vaccines are hereafter referred to as updated (2023–2024 Formula) Pfizer-BioNTech COVID-19 Vaccine.

•   There is also a more traditional recombinant protein vaccine:

o   Protein subunit vaccine Novavax COVID-19 Vaccine, Adjuvanted (hereafter referred to as Novavax COVID-19 Vaccine) is likely to be authorized soon by US FDA for people ages 12 years and older for primary vaccination and, in certain situations, as a booster dose in people ages 18 years and older.

 

Can I get more than one vaccine at a time?

Yes. For people eligible for all three vaccines this season, I would suggest getting the influenza and COVID-19 vaccines in one visit, and the RSV vaccine later. But if getting that third vaccine is challenging, then it’s fine to get all three shots in one visit.

 

What if I recently had a COVID-19 infection?

Your immunity is fairly high for three months after an infection, so you can wait for three months after an infection to get your next COVID-19 vaccine. However, if you’re concerned (high-risk or others around you are high-risk), then you can get your next dose as early as when you’re fully recovered from the infection.

 

What if I recently received a COVID-19 updated vaccine (the bivalent one issued in the fall of 2022)?

Wait two months after receiving your last COVID-19 vaccine in order to receive an updated one.

 

What if I recently received another type of vaccine?

If you’ve recently received a non-COVID-19 vaccine, wait 2 weeks to get the updated COVID- 19 vaccine.

 

What’s the difference between the new updated COVID-19 vaccine and the one from last fall?

•   Last fall’s was a bivalent vaccine, i.e., it reflected the original circulating strains as well as the Omicron BA.4 and BA.5 subvariants.

•   This fall’s vaccine is a monovalent, i.e., it reflects the currently circulating Omicron XBB1.5 variants.

 

Where can I get additional information on COVID-19? US CDC: Coronavirus Disease 2019 (COVID-19) | CDC

 

If I’m 65 or older, which types of influenza vaccine should I get?

There are three influenza vaccines recommended for those 65+:

•   High-dose quadrivalent (Fluzone): https://www.cdc.gov/flu/prevent/qa_fluzone.htm (only for 65+); or

•   Recombinant quadrivalent (Flublok) (for 18+) https://www.cdc.gov/flu/prevent/qa_flublok-vaccine.htm; or

•   Adjuvanted quadrivalent (Fluad) (only for 65+) https://www.cdc.gov/flu/prevent/adjuvant.htm.

 

I have other questions related to influenza vaccine?

https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm

 

I have other questions re: the RSV vaccine for older adults 60+:

https://www.cdc.gov/vaccines/vpd/rsv/public/older-adults.html#

 

What about children?

Children <5 are at high-risk for severe COVID-19 as well as influenza illness, the latter even in a fairly normal flu season. They are also at highest risk for severe RSV.

 

•   Influenza Vaccine for Children:

o  

The southern hemisphere is often a bellwether for what we see for an influenza season. In Australia this last few months (their winter), influenza hit early, was fairly severe, and was especially severe among children

o   Children and youth need an influenza vaccine annually. Those younger than 9 who get the influenza vaccine for the first time (or who have only had 1 dose before July 2022) should be vaccinated it in 2 separate doses at least a month apart. FMI: https://www.cdc.gov/flu/highrisk/children.htm

 

•   COVID-19 Vaccine for Children:

o   Half of children and youth (<19 years old) who died of COVID-19 (since Omicron) had no predisposing conditions.

o   Everyone 6 months and older is recommended for the COVID-19 vaccine. The number of doses a child will get depends on their age and health status, and whether they get the vaccine made by Pfizer-BioNTech or the vaccine made by Moderna. These vaccines differ in dosage and number of shots, but both are safe and effective, and are equally recommended. Kids 12 and up can also get the Novavax vaccine. Talk to your child’s doctor if you have questions about the different vaccines and how many doses your child needs.

o  

The pediatric COVID-19 vaccination schedule for children can be found here: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim- considerations-us.html. Basically, children 6 months – 4 years get an initial 2 doses of Moderna or 3 doses of Pfizer vaccine; and those who have had a previous mRNA vaccine, can get 1 or 2 doses, depending on the number of prior doses.

 

•   RSV Protection for Young Children:

o   Monoclonal antibody (nirsevimab) for newborns and infants – one dose for all infants <8 months old during the fall or spring, and for some high-risk children 8

– 19 months old, a second dose; vaccine should be available this fall: https://www.cdc.gov/media/releases/2023/p-0803-new-tool-prevent-infant- hospitalization-.html

o  

Vaccination of pregnant women in the 3rd trimester to protect newborns/infants: https://www.mayoclinichealthsystem.org/hometown-health/speaking-of- health/rsv-vaccine-for-moms-to-be-and-infants#

 

What are the choices for treatment?

•   For COVID-19? https://www.fda.gov/consumers/consumer-updates/know-your- treatment-options-covid-19

•   For influenza? https://www.fda.gov/drugs/information-drug-class/influenza-flu-antiviral- drugs-and-related-information#ApprovedDrugs

Treatments for RSV are mostly supportive, that is, there are no specific medications to commonly treat RSV.

 

 

What am I (Dora) personally doing?

•   I will be getting the COVID-19 vaccine soon, I hope in the next 2 – 3 weeks. Ideally, I’d like to wait for the Novavax vaccine because of some inflammation issues I’ve experienced. However, I don’t want to wait long, since I realize COVID-19 incidence has increased, and an infection is more likely to precipitate inflammation than the vaccine.

•   If I get the COVID-19 vaccine after early October, I will be vaccinated against influenza at the same time.

•   For influenza, I normally take the recombinant influenza vaccine, e.g,, the quadrivalent recombinant vaccine, Flublok, though it sometimes takes a while to find those settings that offer it https://www.cdc.gov/flu/prevent/qa_flublok-vaccine.htm.

•   I’m planning on getting the RSV vaccine at least two weeks after I get the COVID-19 and/or influenza vaccines, likely won’t be able to get this until later October or November.

•   I’m not wearing masks yet in grocery stores, but I also generally shop at uncrowded times. If I were in a crowded indoor theater, I’d wear a mask, given the uptick in COVID- 19 and given that RSV and influenza seasons are likely upon us.

 

 

References:

•   Last Week’s US FDA COVID-19 Vaccine Approvals/Authorizations: https://www.fda.gov/news-events/press-announcements/fda-takes-action-updated-mrna- covid-19-vaccines-better-protect-against-currently-circulating

•   Last Week’s US CDC COVID-19 Vaccine Recommendations: https://www.cdc.gov/media/releases/2023/p0912-COVID-19-Vaccine.html

•   Respiratory Season Tracking: https://www.cdc.gov/surveillance/resp-net/dashboard.html

•   How Do I Find a COVID-19 Vaccine:

o   Anywhere in the U.S.: https://www.vaccines.gov/search/

o   In Maine: https://www.maine.gov/covid19/vaccines/vaccination-sites

•   COVID-19 Vaccine Effectiveness: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-02/slides-02- 24/COVID-07-Britton-508.pdf

•   Safety of COVID-19 Vaccines: https://www.cdc.gov/coronavirus/2019- ncov/vaccines/safety/safety-of-vaccines.html

•   Long COVID: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

•   Overview of COVID-19 Vaccines: https://www.cdc.gov/coronavirus/2019- ncov/vaccines/different-vaccines/overview-COVID-19-vaccines.html

•   Info on Moderna:

o   Authorized for 6 months – 11 years old: https://www.fda.gov/vaccines-blood- biologics/coronavirus-covid-19-cber-regulated-biologics/moderna-covid-19- vaccine

o   Spikevax = Moderna approved for 12+ years old: https://www.fda.gov/vaccines- blood-biologics/spikevax

•   Info on Pfizer:

o   Authorized for 6 months – 11 years old: https://www.fda.gov/vaccines-blood- biologics/coronavirus-covid-19-cber-regulated-biologics/pfizer-biontech-covid- 19-vaccine

o   Comirnaty = Pfizer vaccine approved for 12+: https://www.fda.gov/vaccines- blood-biologics/comirnaty

•   Info on Novavax: https://us.novavaxcovidvaccine.com/non-hcp?

•   Influenza Vaccine:

o   Influenza Vaccine for those 65+:

▪   High-dose quadrivalent (Fluzone): https://www.cdc.gov/flu/prevent/qa_fluzone.htm (only for 65+)

▪   Recombinant quadrivalent (Flublok) (for 18+): https://www.cdc.gov/flu/prevent/qa_flublok-vaccine.htm; or

▪   Adjuvanted quadrivalent (Fluad) (only for 65+): https://www.cdc.gov/flu/prevent/adjuvant.htm.

o   Summary Info: https://www.cdc.gov/flu/professionals/acip/summary/summary- recommendations.htm

o   Recombinant Influenza Vaccines:

▪   https://www.cdc.gov/flu/prevent/qa_fluzone.htm

▪   https://www.cdc.gov/flu/prevent/qa_flublok-vaccine.htm

•   RSV Vaccine: https://www.cdc.gov/vaccines/vpd/rsv/public/older-adults.html#

•   Children:

o   Influenza Vaccine in Children: https://www.cdc.gov/flu/highrisk/children.htm

o   Severe Influenza in Australian Children This Last Few Months: https://theconversation.com/heard-of-kindy-flu-theres-no-such-thing-but-kids-are- at-risk-this-flu-season-for-one-simple-reason-207825

o   COVID-19 Vaccine Schedule: https://www.cdc.gov/vaccines/covid-19/clinical- considerations/interim-considerations-us.html

•     Treatments:

o   For COVID-19: https://www.fda.gov/consumers/consumer-updates/know-your- treatment-options-covid-19

o   For Influenza: https://www.fda.gov/drugs/information-drug-class/influenza-flu- antiviral-drugs-and-related-information#ApprovedDrugs