Respiratory Triple Play: Vaccination Is the Key
New vaccines for flu, RSV, and COVID-19
As a trifecta of viruses converge this fall and winter, the United States has an unprecedented infection control counterpunch: vaccines for the 2023-2024 flu season, new shots for respiratory syncytial virus (RSV), and the latest formula for COVID-19 immunization.
“I have been a promoter of vaccines for many years, and this year we have an extraordinary opportunity,” William Schaffner, MD, of Vanderbilt University said at press conference at the National Foundation for Infectious Diseases (NFID). We were warned — with good reason, it turns out — of a similar “tripledemic” for the 2022-2023 respiratory season.
According to Scott Rivkees, MD, a pediatrician at Brown School of Public Health in Providence, RI, “The tripledemic of 2022 infected millions, overwhelmed hospital systems, and killed more than 100,000 people in the United States over the four-month peak span of these viruses.”1
That kind of toll can be blunted this season with new RSV vaccines for young and elderly risk groups and the latest flu formulation based on what has been circulating in the Southern Hemisphere.
The new COVID-19 vaccines target Omicron subvariant XBB.1.5, the predominant strain earlier this year that since has been overtaken by other subvariants.
“People vaccinated with Moderna’s updated COVID-19 vaccine, which includes a component that corresponds to the XBB lineage of the Omicron variant, showed a strong immune response against some of the variants that are common now (XBB.1.5, EG.5.1, and FL.1.5.1),” the Centers for Disease Control and Prevention (CDC) reported.2 “These data signal that the updated 2023-2024 COVID-19 vaccine likely can provide strong protection during this fall and winter virus season.”
The new monovalent messenger ribonucleic acid vaccines by Pfizer and Moderna are recommended for everyone ages 6 months and older. An updated protein-based vaccine by Novavax is approved for those ages 12 years and older.
The most significant new vaccines may be those for RSV, the leading cause of hospitalization of infants. Pregnant women should be vaccinated at 32-36 weeks to confer RSV immunity to their unborn infants. “Most infants will likely only need protection from either the maternal RSV vaccine or the RSV immunization for babies, and not both,” the CDC noted.3
The CDC recommended the RSV vaccine for adults ages 60 years and older, using shared clinical decision-making in conversations with their providers. Both new RSV vaccines use an attenuated part of the virus to generate an immune response.
The influenza, RSV, and COVID-19 vaccines may not prevent initial infection but can lessen the severity of the viruses and may help prevent long COVID. Their safety profile is strong, and the current thinking is the vaccine risk is dwarfed by the potential adverse outcomes in the unvaccinated who are infected by one of these viruses. “Flu, COVID-19, and RSV can cause a range from mild to severe symptoms,” said Patsy Stinchfield, RN, MS, CPNP, president of the NFID. “We don’t know who will get those severe symptoms. Potentially life-threatening complications can occur — hospitalization and death — and this happens even in healthy children and adults. Many people who are hospitalized with these diseases have no underlying conditions.”
Vaccine Apathy, Resistance
Yet, vaccine hesitation — which always has been an issue to some degree — appears to have become entrenched in the public mindset as a result of mass misinformation during the pandemic. A 2023 survey by the NFID found that less than 25% of respondents were concerned about any of the three respiratory viruses.4
“The data show that many U.S. adults are underestimating the seriousness of flu, COVID-19, and RSV, and they do not plan to get vaccinated,” Stinchfield said at the NFID press conference. “In fact, fewer than one in four U.S. adults are worried about themselves or someone in their family getting infected with flu — just 22%, and just 23% for COVID-19 and even less for RSV, at 19%.”
More than 1 in 4 (28%) U.S. adults who are at higher risk for flu-related complications do not plan to get vaccinated, she added.
Among survey respondents, the top reasons for not getting immunized against the seasonal flu — which are similar to the common excuses given for declining any vaccines — include:
• concern about potential side effects (32%);
• do not trust vaccines (31%);
• do not think vaccines work very well (27%);
• concern about getting sick from vaccines (27%).
“This tells us is that there continues to be significant mis- and disinformation about vaccines and a greater need for education and awareness,” Stinchfied said.
For more than 50 years, hundreds of millions of people in the United States have safely received flu vaccines and millions of COVID-19 vaccine doses have been given around the world, she said.
“Serious adverse events are rare,” Stinchfield added.
Most Child Deaths Unvaccinated
In the 2022-2023 flu season, 174 children died and 80% of them were not vaccinated, said Amanda Cohen, MD, of the CDC respiratory diseases branch.
“Those who were at the highest risk for hospitalization last season were similar to what we’ve seen in the past: adults older than 65 years and children under 5 years old,” she said. “The flu vaccine is imperfect — its efficacy varies from year to year and you can still get infected and even die after vaccination.”
Still, it has a profound effect, considering that last season influenza vaccination reduced the risk of flu-related hospitalizations in adults by half and by about 75% children, she said. “On the other hand, we saw last year that actually less people received flu vaccine than they did pre-pandemic,” Cohen said. “We’ve been seeing these concerning declines, especially in some of the groups that are particularly at higher risk for flu. We saw about 6% less children get the flu vaccine about 15% less pregnant women. For healthcare workers — who are in contact with sick people during flu season — 5% [less of] them got vaccinated. We are continuing to see gaps in the recommended vaccinations.”
COVID-19 continues to hit those older than 65 years of age the hardest, but there are severe cases and long COVID in children.
“I’ll just say, for me as a mom of two girls, half of our young children who are in the ICU [intensive care unit] with COVID have no underlying conditions,” Cohen said. “[This] led us to this recommendation for COVID vaccination for everyone who is over the age of 6 months.”
Regarding RSV, the CDC estimates that 80,000 children younger than 5 years of age were hospitalized with the virus last season. In addition, 160,000 older adults were hospitalized with RSV.
“We also saw some tragic loss of life due to the virus,” she said. “As many as 300 children younger than 5 [years of age] and 10,000 older adults died from RSV.”
A pediatric nurse practitioner at Children’s Hospital Minnesota for 44 years, Stinchfield has seen too many of these cases in person.
“The reason all of us are doing this [vaccine] work is because, in our careers, we have seen terrible outcomes from these diseases,” she said. “We have all seen people, including young children, die.”
- Rivkees SA. How to avoid the tripledemic of respiratory diseases this winter. Time. Published Sept. 16, 2023. https://time.com/6314785/how-to-avoid-the-tripledemic-of-respiratory-diseases/
- Centers for Disease Control and Prevention. Updated COVID-19 vaccine recommendations are now available. Published Sept. 12, 2023. https://www.cdc.gov/respiratory-viruses/whats-new/covid-vaccine-recommendations-9-12-2023.html
- Centers for Disease Control and Prevention. Update on RSV and new vaccine recommendation. Published Sept. 22, 2023. https://www.cdc.gov/respiratory-viruses/whats-new/rsv-update-2023-09-22.html#:~:text=In%20August%202023%2C%20CDC%20recommended,using%20shared%20clinical%20decision-making
- National Foundation for Infectious Diseases. 2023 National Survey: Attitudes about influenza, COVID-19, respiratory syncytial virus, and pneumococcal disease. Published Sept. 28, 2023. https://www.nfid.org/resource/2023-national-survey-attitudes-about-influenza-covid-19-respiratory-syncytial-virus-and-pneumococcal-disease/
As a trifecta of viruses converge this fall and winter, the United States has an unprecedented infection control counterpunch: vaccines for the 2023-2024 flu season, new shots for respiratory syncytial virus, and the latest formula to protect against COVID-19.
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