Vaccine FAQs

Special guest Shana Castillo, PharmD, MBA, RPh, Associate Professor of Pharmacy Practice at Creighton University’s School of Pharmacy and Health Professions joins us to talk about vaccinations.

Listen in as they discuss the latest recommendations for COVID-19 and influenza vaccinations, along with options to prevent respiratory syncytial virus (RSV), and practical approaches for giving multiple vaccines in a single visit.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Reid B. Blackwelder, MD, FAAFP, Associate Dean of Graduate and Continuing Medical Education and Professor of Family Medicine at East Tennessee State University
• Stephen Carek, MD, CAQSM, DipABLM, Clinical Assistant Professor of Family Medicine, Prisma Health/USC-SOMG Family Medicine Residency Program at the USC School of Medicine Greenville
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University

None of the speakers have anything to disclose.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter and Prescriber Insights:

• Chart: COVID-19 Vaccines
• FAQ: Flu Vaccines for 2023-24
• Chart: Preventing RSV
• Algorithm: Addressing Vaccine Myths and Hesitancy

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The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

Narrator 0:04

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homo pharmacist letter, prescriber insights, RX Advanced, and the most trusted clinical resources. On today's episode, we'll listen in as our expert panel discusses the latest recommendations for COVID-19 and influenza vaccinations, and options to prevent respiratory synstitial virus, RSV. Additionally, our panel will discuss practical approaches for giving multiple vaccines in a single visit. Our guest today is Dr. Shana Castillo from Creighton University. You'll also hear practical advice from panelists on TRC's editorial advisory board, Dr. Reed Blackwelder from East Tennessee State University, Dr. Stephen Carrick from the USC School of Medicine Greenville, and Dr. Craig Williams from the Oregon Health and Science University. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include in TRC's letter articles. The full webinar originally aired on October 16, 2023.

CE Narrator 1:08

And now, CE information.

Narrator 1:11

This podcast offers continuing education credit for pharmacists, physicians, and nurses. Please log into your pharmacist letter or prescriber insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now, let's join TRC editor Dr. Sarah Clockers and start our discussion.

Sara Klockars 1:36

So we're all gearing up this fall and winter with lots of vaccines. They're in full swing for the triad of respiratory illnesses this fall and winter. So let's review the recommendations starting with COVID-19. In our October issue, we wrote about the updated mRNA COVID vaccines. And we now have the Novavax that's approved. So, Shayna, could you briefly review the updated recommendations for the monovalent updated COVID-19 vaccines that cover the Omicron XBD 1.5 variant? Sure. Thank you, Sarah.

Shana Castillo 2:20

Happy to be here. So really the recommendation we're going to see for COVID is really kind of similar in a way to the flu vaccine recommendation in that it's going to be for everyone six months and older. And so really the recommendation is for everyone to get that vaccine. Now we've got the Pfizer vaccine and we've got the Moderna vaccine, which we we know can be dosed all the way down to six months. The NovaVax, which was just recently approved, is really only for people 12 years of age and older. But really, if it's a vaccinated adult, they're just going to get one dose of this updated vaccine unless they're an immunocompromised patient.

Sara Klockars 3:15

I think we'd like to spend just a couple of minutes just reviewing those updated vaccine options. Steven, would you mind just kind of giving us an overview of the two different types?

Stephen Carek 3:28

Yeah, I mean, as far as uh my understanding is two main vaccine types now, the mRNA and the protein-based vaccine. We're all familiar with the MRA vaccines, so we've been utilizing over the past few years since vaccines first became available for COVID, most commonly being the Moderna and the Pfizer versions. Um now uh at least with the past year, utilizing the protein vaccine or the Novavax, sorry, the adjuvant vaccine that we have been given out these past, what, 12 months now?

Sara Klockars 3:59

Excellent. Thank you. And as you mentioned, Shana, the the different types um are for different age groups, they also have different recommendations for use. And so would you mind reviewing when we would recommend which one? Because I do think it is a little confusing. Initially with the mRNA, it was just one updated dose for everyone five and older. But now with the Novacs in the picture, it's a little different.

Shana Castillo 4:34

Yeah, so I should have said that when I mentioned the Novavax earlier, but so six months to four years, they're gonna get multiple doses depending on their age, their prior vaccination, and at least one of those is gonna be a dose of the updated vaccine. And so for six months to four years, if you're gonna give a Moderna or a Pfizer, and you're either gonna give two doses of the Moderna or three doses of the Pfizer if they're unvaccinated. If they are vaccinated, it it changes a little bit based on what they've had. So five years and older, if you're using Pfizer or Moderna, you're gonna give one dose of the updated vaccine. 12 years and older, you're gonna give one dose of the updated vaccine if it's a Pfizer or Moderna. If it is the Novavax, it depends on if they've been vaccinated or not. So if they have had a private prior COVID vaccination, you would give one dose. No prior COVID vaccination, you would give two doses. And then immunocompromise gets a little bit trickier. And so that again depends on prior vaccination, but you're gonna give at least one dose of the updated vaccine and then possibly more doses as well. And with the NOVAVAX, you're gonna consider additional doses as well. So the immunocompromise, I think it's a little bit trickier, and that's where I maybe would look things up if I had a chance to, because it's a little bit more complicated. I think really five years of age and older with no immunocompromisation is the easiest one to remember because you can just do one dose of an mRNA or two doses of Novavax if they haven't had any vaccination. It's a little trickier in that younger age group and the immunocompromised population.

Sara Klockars 6:28

I know we've had some questions about differences. So I think the question that everybody wants to know is would you consider using the mRNA vaccine over the Novavax? Or I've actually seen some people say that they want to track down the Novovax based on some information that they've seen on side effects. Can you comment on that?

Shana Castillo 6:52

I don't think we have enough information to say one is necessarily better. I would say, you know, I think mRNA has kind of been the gold standard from the get-go. But I would say if someone only has Novavax available, go with Novavax. I think getting vaccinated would be more important than waiting for a certain vaccine. So that I guess that would be my comment.

Craig Williams 7:20

We still do encounter some hesitancy. The whole mRNA vaccine thing still is kind of out there in different pockets. And so it's nice to have an option for people to just, for whatever reason, have an opposition to the technology or what they've read about the mRNA vaccines.

Reid B. Blackwelder 7:35

This is Reed. I mean, I I agree. I'm still hearing that as well. And while vaccinations shouldn't have a political connotation, there's no question there is with the misinformation. It can be very tough to overcome that. So it is kind of nice to have an option that, from a patient perspective, is more like what they're used to, and they don't have to worry about the new technology for which there's unfortunately a great deal of suspicion.

Sara Klockars 8:00

So let's jump in and move on to influenza so we can get to some questions at the end. And we wrote about this in our September issue. Shayna, can you just briefly review the main changes for this year's flu vaccine?

Shana Castillo 8:16

Yeah, there really only two main changes in the recommendations this year. They updated the composition as is always kind of one of the major changes every year. And then the the second major change was that guidance for people with egg allergies. So it used to be that if someone had a very severe egg allergy, we wanted to only vaccinate them in a medical facility where there was experience managing severe allergic reactions. They've done enough studies now, they've got enough data to determine that really the risk of anaphylactic reaction in someone with egg allergy isn't any different than the risk with anyone else. And so the the new recommendation is that anyone with an egg allergy can get any vaccine and it can be in any setting, and the precautions that should be taken are the same as the precautions that should be taken for anyone getting a flu vaccine. We do still have the egg-free, so the cell-cultured vaccine and then the recombinant vaccine are still available, and those are both egg-free. So if someone really doesn't want to get a vaccine that has some egg in it, then they could get those.

Sara Klockars 9:38

Awesome. Thank you. And as you said earlier, the sound the recommendation in general sounds very similar to the COVID recommendation in that we would recommend any age-appropriate vaccine for everyone six months and older. So that's that's helpful that they're similar. But I do think we want to review, there are some nuances with the different products. So could you just briefly you mentioned the two egg-free options, but can you briefly review what other patients might need a different or you would recommend a different vaccine for?

Shana Castillo 10:18

Yeah, so for patients over 65, the recommendation is for them to get 65 and older, I should say. The recommendation is for them to get that high-dose vaccine or the adjuvanted vaccine or the recombinant vaccine. So the reasoning there is that because those have either a higher amount of antigen or they have that adjuvant adjuvant, it just boosts those patients' immune system a little bit more. And since they're high risk at that age, we want to we want to try to do that. Oh, and then the other thing is that we want to just remember that that live attenuated intranasal vaccine is really only for healthy people, non-pregnant people, and the ages for that one are two through 49. So it's really much narrower group of patients that can get that one.

Sara Klockars 11:15

Yes, and I think we get a lot of questions too about vaccinating in pregnancy. So could you just comment on that? I think there are just questions on. We we say here not to use the live attenuated vaccine.

Shana Castillo 11:33

Yes, but but they definitely should be getting an inactivated vaccine. Pregnant women are at very high risk for influenza complications. And so we want to make sure that we are definitely vaccinating them with an inactivated vaccine. And any trimester, you know, sometimes people are hesitant to get vaccines that first trimester, but this is one that should be given anytime during pregnancy.

Craig Williams 12:00

Think too, Sarah. We've always used the selling point to some passive immunity for your child. So regardless of their personal history, we sell a little bit to uh protect your child that may be born right into a bad flu season in several months.

Sara Klockars 12:12

Let's go ahead and move on to RSV vaccines so we have time to get to some of the QA. We wrote about the RSV vaccines in older adults in September. We've had some changes and updates to this vaccine as well. So let's just start off with a quick overview of the available vaccines, and then we'll go on to who we would recommend them for. Would you mind reviewing that, Shayna?

Shana Castillo 12:41

Yeah, so we have two vaccines here now, the abrisbo and the arex V. And the ErexV is the one that is the adjuvante. The abrisvo is not. They are both approved for adults 60 years of age and older. Arex V was originally approved, and then um the abrisbo was approved, and then they also got the um approval for pregnant patients between 32 and 36 weeks gestation.

Sara Klockars 13:16

Excellent. Thank you. And uh Reed, I wanted to ask you how do you discuss with your patients whether or not to get the RSV vaccine, especially since it's really too soon to say how well either of these prevent hospitalizations in older adults.

Reid B. Blackwelder 13:37

That's a great question. So uh I yeah, I'm frustrated this country is one of two in the world that has direct-to-consumer advertising. But I will say for RSV, the ads are certainly out there heavily promoting the vaccine, and it gives a good opportunity to talk about it. And I usually point out that uh we did suffer through the tridemic, the influenza COVID and RSV. And I basically share that you know, my my experience has been that while this has generally been a pediatric illness, and certainly the the population we're most worried about, we're now seeing very unusual behaviors and and more, I guess probably the ability to pick it up better in adults, and that it is not just a cold, that it actually is a fairly serious infection. So I think by bringing up that things are different now than they used to be, and they may or may not truly be that different, but I think the impression is, and because RSV hasn't been quite as politically charged as COVID, it seems to be something that kind of uh dovetails into the discussion about PNUVAX and some of the other protections. So um I have not found a lot of resistance to that discussion. That doesn't mean people will get the vaccination, but at least they're open to talking about it in the context of protection.

Sara Klockars 14:57

We also have the bivalent adjuvant-free vaccine abrisvo for pregnant folks that Shayna had mentioned. Uh, and we've gotten a lot of questions about the role of this since we also have the monoclonal antibodies that we can give to the infant. So can you, Shana, comment on when pregnant patients should get the RSV vaccine and how effective it is?

Shana Castillo 15:24

Yeah, so really we're we're working on those maternal antibodies that are being passed on to the the child, right? And so we're gonna try to give this between 32 to 36 weeks of pregnancy. So September to January is when we're gonna give this to pregnant women to try to protect those babies. And you know, there there is another agent that I think we're gonna talk about that we would actually give to the babies, but I think this would be our first choice if we can give this to the mom while they're pregnant. This would be our our first step in protecting that baby.

Sara Klockars 16:07

Yes, and I think it's a little tricky this year since these are just now coming out and we're headed into RSV season. So, yes, we are gonna talk briefly about the monoclonal antibodies. We have Pallavisimab and then the new Nursivimab, which are both given via IM injection in the office. And so these provide immunity a little bit quicker than the vaccines, where you're kind of relying on the mom to kind of produce that immunity. And we did write about Nurciva Mab in our October letter. So this month we're kind of working on the FAQs with these two agents. And I wanted to just kind of briefly review a few of these snippets of information from our article to get everyone's thoughts. So with both of these options and no head-to-head data, we just discussed that you know we'd really encourage giving the vaccine. But if you had access to both options, how do we help parents decide what to do?

Stephen Carek 17:13

With the patient uh in front of you and talking with the parent, it's uh at least from our perspective, do what we can do now and always be in favor of vaccination and sometimes even counseling against some of the potential side effects of the monoclonal antibodies, and that there can be some uh hypersensitivity reactions that may not be easily predictable. And um so far, as far as I understand, the vaccine's fairly safe. And as you said, we can start protecting the infant in the wound, that'd be a great place to start.

Shana Castillo 17:42

Yeah, I I 100% agree with that. If we can if we can start there, I think that would be my argument to to do that. But there are some women who are just very, very hesitant about getting vaccinated when they're pregnant. And so that might be something that you come up against. But I I do think that if we can vaccinate the mom, that's our best option.

Sara Klockars 18:08

Great. Thank you for that. And I think another big question that we are currently getting, and we've gotten a lot since the RSV vaccine and NiceBamab are both available, is would we ever vaccinate the mom and give the infant Nicevamab?

Shana Castillo 18:27

There are very rare situations where if um the baby is born, if we vaccinated the mom and they they have the baby less than two weeks after the vaccination, then we would go ahead and give the monoclonal antibody. Or if there's some reason why we think that the immune response isn't going to be effective, or if the mom got the RSV vaccine and it wasn't in season. So those would be the rare occasions when we would do that.

Sara Klockars 19:01

So let's go ahead and jump over to the vaccine FAQ section of the presentation. And we're gonna actually dive in and answer some questions we've been getting over the last month, and then review some of the wording that will be in our November draft, our article, and then we'll answer some of the audience questions if we have time at the end. So I think the number one question, and actually the first question that we got from folks this evening, and I think it's because there's just been some conflicting messages out there from experts along the way with these new vaccines being approved, but is can patients get COVID, flu, and RSV vaccines at the same time? So, Shina, would you take a stab at answering that question?

Shana Castillo 19:50

Yes, absolutely. In fact, I told my my 75-year-old parents to go get all three at one time, um, because there's there's really no reason not to. I know that there's been some controversy out there and there's been some discussion about do you produce as many antibodies if they're they're given at the same time, but there's been really no reason to say that clinically it's any different to get them separately as to get them at the same time. Um, the only thing, and I think you I don't know if this is a question that might be coming up, but the only thing that might come into consideration is that if you're giving the adjuvanted RSV vaccine and you want to give an adjuvante flu vaccine, they say you can consider giving a non-aduvented flu vaccine because there's just not data on giving multiple adjuvanted vaccines at the same visit, but they also offer the caveat of, but if that's what you have, give it. There's no data to say we can't give it either. They just say that that's a consideration that you can take. There's no max number of vaccines that um we can give at one time. I think adults maybe are a little bit more concerned about getting multiple vaccines at one time when we're so used to doing it in children, right? Children get multiple vaccines at one time, and usually we don't blink an eye. We just, I think, have to kind of consider that and and and think to ourselves, you know, there there's really no max of vaccines that that we can get, and there's no data that shows that it really reduces any effectiveness.

Sara Klockars 21:44

Thank you for that. Um, Stephen Ari, do you want to chime in on how you have these discussions with your patients?

Reid B. Blackwelder 21:52

Well, I I really agree with uh what we sort of already said. If you're there and you can get a vaccine, get it, get all All of them rather than try to space them out. And I love the comparison that I use all the time is children get multiple vaccinations, and as pointed out, we don't bat an eye. So I think it is a it's a way into helping people sort of get the vaccines all at once. Once somebody's ready to go, they often will be okay with with almost all of them.

Sara Klockars 22:22

So let's get into a little bit about strategies for giving multiple vaccines. You know, we often, as you mentioned, give give three or four at a time. Um we give many vaccines to children and use a lot of different strategies with them. In our article, we say if giving more than one vaccine use different limbs, especially with those that may cause local reactions. So we have some that we know that you know might be a little bit more likely to do that. So would you agree with that? Do you have anything else to add to that statement?

Shana Castillo 23:00

Yeah, no, I I I totally agree. If you can use different arms, that's great. If if you can't use different arms, though, for whatever reason, it's fine to do them all in in one as long as you're separating them, you know, by about an inch if you can. But if you if you can use different limbs, that's ideal. That way we can identify a reaction more easily.

Sara Klockars 23:27

Try to inject the most painful vaccine last in a limb by itself if possible. And a couple of examples we have here are HPB and MMR. Um, are there other examples that you would add to this list?

Shana Castillo 23:42

Maybe tetanus, you know, tetanus is notoriously um gives people a sore arm. So maybe if I was giving that one, I might try to inject that one last as well. Sounds good.

Sara Klockars 23:55

Another common question that we get is can multiple vaccines be combined in one syringe? No. No, don't do that.

Shana Castillo 24:08

No.

Sara Klockars 24:10

We are gonna put that in our article and gave an example here that it's okay to give FDA approved combo vaccines. There are many, many out there for children to try to reduce that, you know, vaccine burden. But just a good reminder for everyone that we shouldn't be combining vaccines. Another question that we've had a several of tonight as well is if patients are coming back for the second vaccine, how long should they wait? So if they want to space out, say COVID and RSV, how long should they wait between vaccines?

Shana Castillo 24:48

Well, those since those are two inactivated vaccines, it doesn't really matter. I mean, they could come back tomorrow if they wanted to. So there's no real reason. There's no real reason for them to space it out, but if they would want to, it's totally up to them because inactivated vaccines don't don't require any space between them.

Sara Klockars 25:12

Yeah, and I think that's a good point. I think there was some initial information that came out slash misinformation that you know folks should wait two weeks because we keep getting that two-week question. And just so the audience knows that you don't have to wait for these inactivated vaccines. But I think we want to go ahead and say if someone's getting live vaccines at a different time. So it is okay to give inactivated and live together. Um, but what's the recommendation if they decide to separate out live vaccines?

Shana Castillo 25:49

Yeah, so then you have to wait. If you're giving a live and a live, you'll have to wait four weeks. So they would not be able to come back for four weeks to get that second live vaccine. Now, if they if you give a live and yeah, they want to come back for uh an activate, that's fine. Or if you give an inactivated and they want to come back for a live, but two lives has to be spaced out.

Craig Williams 26:14

Awesome. Sarah, can I ask you what what is the science behind that? Uh are we worried that if they are gonna get sick, we don't want to give two at the same time, or is there a science to the lack of immunity? You just need that time frame?

Shana Castillo 26:30

It's because the the two interfere with the replication of each other, and so you don't get the the antibody response that you want.

Sara Klockars 26:39

Another question that we were getting is can we give vaccines through a tattoo? Yes.

Shana Castillo 26:48

You can get vaccines through a tattoo. You want to try to aim for the lightest part as possible. Um, so if you have, you know, a bunch of really dark colors, if there's a lighter color that you can put it through, that's better. But if you really don't have that option, it just put it put it wherever. The only thing to be aware of is that your skin there is probably going to be a little bit thicker and it might require a little bit more force to get that needle through.

Sara Klockars 27:19

In our article, we say to um advise patients to expect arm soreness or pain for a couple of days after any IM vaccine. And then we often get the question about should people use their dominant arm or their non-dominant arm, or should they rest their arm after vaccination, which I think is kind of the tendency is to not move it. So in our article, we say recommend using the arm. Is that what you tell your patients as well?

Shana Castillo 27:49

Yes. So I'm right-handed and I will I will always try to get a vaccination in my right arm because I know I'm gonna use that arm more often. And I I try to tell patients to do the same. They don't always take you up on that, but if the you know, if their dominant arm, it's usually better because they'll move it more.

Sara Klockars 28:10

Good tip. And then in addition to like applying a cool compress for pain afterwards if needed, are there any other suggestions you have pre-vaccination?

Shana Castillo 28:23

Yeah, so so we don't really recommend that patients pre-vaccinate with like acetaminopen or an NSAD ibuprofen or something like that. They do come to you and say, I already took this. Obviously, you're not gonna say, well, I'm not gonna vaccinate you now, go ahead and vaccinate them. But but most patients we would suggest waiting until after the vaccination to see if they really need it. You know, there I think there when COVID first came out, I think there was some questions about if we take ibuprofen, does it diminish the immune response when the COVID is is vaccine is working? And I don't I don't know what the the final statement on that ever was, um, but we try to just wait and kind of take them on a PRN basis after if we can.

Sara Klockars 29:16

What are some tips that we can use to help patients proceed with vaccination?

Shana Castillo 29:23

Yeah, so this is this is a tough one because it's hard to convince people what they feel happened, you know. So we can point out that that sometimes you know people can have reactions to vaccines, meaning those like flu-like symptoms, the aches and the fevers and that kind of thing, but it's not the actual flu. You know, I I usually will tell patients this isn't completely inactivated vaccine. There is no flu virus in this, so there is no possible way for this to give you the flu. But that that's harder to convey sometimes than than you want it to be, you know, but just educate them as best as you can.

Craig Williams 30:10

I'll just second that, Sarah. I think a lot of patients are pretty open to exactly that kind of little bit. There's no actual live virus in there, it can't happen. That's they I think find that reassuring, even if they're not totally buying it when you're saying it. But that's the right line.

Sara Klockars 30:27

Stephen, is there anything else that you say to your hesitant patients?

Stephen Carek 30:31

Yeah, I think I think Reed mentioned this earlier, but it's also just acknowledging the amount of miss and disinformation that's out there about vaccines and just trying to express that you're here, you're here to answer their questions, hopefully provide insight. Doing so in a non-judge-judgmental manner is really important to do. Because I think a lot of patients, again, this is a lot of science and a lot of uh information that they may not be familiar with. So trying to speak to their level and trying to provide context and understanding, and just knowing that you're trying to make the best decision for their health. Sometimes that can be empowering and hopefully allow them more insight and maybe even change their minds.

Sara Klockars 31:07

What are some tips to help prevent errors when doing so?

Shana Castillo 31:12

Storing your vaccine separately, making sure you're double checking everything, making sure you have the right dose, making sure you're you're labeling it when it's drawn up, you're storing everything appropriately, you know, that I think those are just the best practices that we can do as pharmacists. And it starts with just staying organized. And you have some great other tips here to take only the needed doses to the area, confirm your patient, and make sure that you ask them, is this the vaccine that you're getting today? Making sure the product and the dose are correct, and then showing the patient the labeled syringe. The other thing I always kind of make sure I do before I give the vaccine is I know they've answered the questions on the, you know, the intake form or whatever, the screening form, but I generally will kind of run through those with them verbally before I give the vaccine just because I want to try to prevent as many reactions or errors as I can. So kind of going through that again is is kind of my last step.

Narrator 32:32

We hope you enjoyed and gained practical insights from listening into this discussion. Now that you've listened, pharmacists, physicians, and nurses can receive CE credit. Just log into your pharmacist letter or prescriber insights account and look for the title of this podcast in the list of available CE courses. You'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools, from the Pharmacist Letter and Prescriber Insights websites. If you're not yet a pharmacist letter or prescriber insights subscriber, find out more about our product offerings at trchealthcare.com. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. It helps spread the word about our show and is a great way for you to let us know how we're doing. You can also reach out to provide feedback or make suggestions by emailing us at contact us at trchealthcare.com. Thanks for listening to Medication Talk.