Flu Vaccine Updates

Special guests Lauren B. Angelo, PharmD, MBA from the Rosalind Franklin University of Medicine and Science and Jean-Venable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP from the Virginia Commonwealth University School of Pharmacy join us to talkabout influenza vaccines.

Listen in as they review flu vaccine recommendations for the 2023-2024 influenza season.  

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
• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Anthony A. Donato, Jr., MD, MHPE, Associate Program Director, Tower Health System Internal Medicine Residency Program and Professor of Medicine at the Drexel University College of Medicine
• Douglas S. Paauw, MD, MACP, Professor of Medicine at the University of Washington School of Medicine

For the purposes of disclosure, Dr. Angelo reports relevant financial relationships [vaccines] with Moderna (honorarium); Pfizer (speakers bureau). Dr. Goode reports relevant financial relationships [vaccines] with Merck, Pfizer, Sanofi, Valneva (honorarium).

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

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

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

• Chart: Flu Vaccines for 2023-2024

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Transcript

Narrator 0:05

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homo pharmacist letter, prescribers letter, RX Advanced, and the most trusted clinical resources. On today's episode, we'll listen in as our expert panel reviews flu vaccine recommendations for the 2023-2024 influenza season. Our guests today are Dr. Lauren B. Angelo from the Rosalind Franklin University of Medicine and Science and Dr. Kelly R. Good from the Virginia Commonwealth University School of Pharmacy. 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. Dr. Andrea Darby Stewart from the University of Arizona College of Medicine Phoenix. Dr. Anthony Donato from the Tower Health System. And Dr. Douglas Powell from the University of Washington School of Medicine. 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 August 21st, 2023.

CE Narrator 1:13

And now, the CE information.

Narrator 1:18

This podcast offers continuing education credit for pharmacists, physicians, and nurses. Please log into your pharmacist letter or prescriber's letter account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Angelo reports relevant financial relationships by receiving an honorarium from Moderna and participating on a Speaker's Bureau for Pfizer. Dr. Good reports relevant financial relationships by receiving an honorarium from Merck, Pfizer, Sonofi, and Valneva. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editor, Dr. Sarah Clockers, and start our discussion.

Sara Klockars 2:00

Our first article reads: You'll play a key role in optimizing flu vaccines for 2023-2024. So, Kelly, we're hoping you can get us started and give us a brief overview of the big changes to the flu vaccines for this season. And then comment on the flu composition this season and how it may differ from last season.

Jean-Venable “Kelly” R. Goode 2:25

Yes, thank you, Sarah. So the all flu vaccines this year will still be quadrivalent. We do have one slight change in the influenza vaccine composition for the H1N1, you know, the quadrivalent, your two A's and two Bs. So H1N1, H3N2. In H1N1, it's still going to be the Victoria sort of virus for the egg-based vaccines in the Wisconsin. But you remember when we name our A, it's the A, it's where the strain was first discovered, the strain number, and then the year it was discovered. So that it has been updated a little bit, but it was still, it's still the A strain that was found in Victoria and the A strain that was found in Wisconsin. But all vaccines will continue to be quadrivalent for this season of 2023-24.

Sara Klockars 3:16

Thank you for that. So just one minor change. Hopefully they'll be effective. And we'll get to that in a few minutes. But first, can you comment on the updated CDC recommendations for vaccinating people with an egg allergy? So this was the other main change. We had some questions about screening for egg allergies. Do we still need to do that? And then the other question that we had a lot of was the observation period. So there was a little bit of confusion around that. So can you comment on the changes coming around egg allergy?

Jean-Venable “Kelly” R. Goode 3:56

Yes. So as you've noticed over the last few years, some of the recommendations around egg allergy and influenza vaccines have sort of changed or loosened up. And this year they did a real um analysis of the reports to bears as well as the egg content of the influenza vaccine and the percent of population that has egg allergies and what those reports were for anaphylaxis to the vaccine adverse event reporting system. And so the ACIP has made a recommendation now that all person aged six months with egg allergy should receive influenza vaccine unless another contraindication exists. And so we're still going to screen according to best practices for all allergies, and we're going to be prepared for an allergic reaction just like we would be prepared for any vaccine. But any influenza vaccine for a patient with egg allergy is appropriate as long as you're looking at the recipient's age, health status, can be used. So you can either use a vaccine that might have some egg content or egg protein, or you might be able to still use the egg-free vaccines, the cell cultured and the recombinant vaccine for someone with egg allergy if they'd prefer to get that. And we're no longer limited to a setting where people, a more medical setting than perhaps a pharmacy, but everybody should be following those best practices to take care of an adverse reaction for any vaccine. And so that's what pharmacists would be expected to do, or any healthcare provider in um administering influenza vaccine this year.

Sara Klockars 5:30

Thank you for reviewing all of that. Another question that comes up is and you mentioned that the CDC did a thorough review. How often, Kelly, do we see a patient with a history of egg allergy have a reaction to the flu vaccine? And how does that compare to the general population having a bad reaction?

Jean-Venable “Kelly” R. Goode 5:53

Yeah, so if you look at it, the Bears reports is what they've looked at. So from 2017 to 2022, there were 178 anaphylaxis reports after an um inactivated influenza vaccine. And of those, 18 people had egg allergy. So you can have you know a reaction to a flu vaccine that's not because you have egg allergy, but you might have another reason to have anaphylaxis to the vaccine. So it's very when we look at egg allergy affecting the population, it's about 1.3% of all children and about 0.2% of all adults. A lot of children outgrow that. It's usually associated with the topi and asthma in a in a younger child. So we don't really see a much increase in those reactions compared to the general population.

Sara Klockars 6:46

Excellent. Thank you. And another question we're getting is we got it actually a few times from our reviewers, is why do we still have egg-free vaccine options? And so these options are still available and folks are wondering when to use them. And so are these an option for patients who've had anaphylaxis to a prior egg-containing flu vaccine? Or if someone's had anaphylaxis to a prior flu vaccine, should we avoid all flu vaccines in that scenario?

Jean-Venable “Kelly” R. Goode 7:18

So if a person has had a prior anaphylactic reaction to an influenza vaccine, we would not readminister that influenza vaccine. So we want to be make because we don't know why, what was the cause of anaphylaxis? The blue cell vaccine flu block were really created. There's a couple reasons, right? So it's it's based on egg allergy and sort of our recommendations from ACIP were a little bit stricter around eggs. You know, when I first started doing flu vaccines, we didn't do egg, if somebody had egg allergy, we didn't give them a flu vaccine at all. And so we've seen the recommendations as we know and in science gets better. But the other thing about these two vaccines is they're made a little bit differently. They we don't, we're not relying on the chicken eggs or the hen eggs to to grow the strains and be able to produce the vaccine. So these vaccines can be spooled up much faster, and the flu sylvax and flu block can be made much quicker than waiting on that six months for the vaccine. And so that's why we see that we have vaccines earlier in our practices than we would have before. And so when we think about that, these are still appropriate. Flu Silvax is now down to six months, so it could be an option for children up through adults, and then the flu block is 18 and over, and actually, flu block now has a preferential recommendation for for people 65 years and over. So it also has a role in that population, even though it is considered to be egg-free.

Sara Klockars 8:42

Yes, excellent. Thank you for that information. Andrea, how are you discussing the egg allergy with your patients?

Andrea Darby Stewart 8:52

Yeah, I mean, the American Academy of Allergy and Immunology has said that we don't need to worry about this since about 2019. So I've been trying to have these conversations. Unfortunately, everybody's everybody's consent forms, you know, have big, big bold writing. It do not administer if there's an egg allergy. So I talk with my patients about this, I reassure them. Most people will believe me, some have to go to their allergy office and get confirmation, and then they'll come back or they'll get the um taken care of at that office for those allergists that are still supplying them for those who have significant egg allergies, just for out of a sense of reassurance. But basically, I'm just trying to help re-educate people. Um, unfortunately, this is going to become one of those myths in medicine, I think, that we have to deal with probably for the next decade.

Sara Klockars 9:42

I agree. Reed, did you have something to add to the conversation? I see you chatting.

Reid B. Blackwelder 9:49

Yeah, well, I think uh Andrew's point is so on target. Medical myths are fascinating, but this is something that is so ingrained. If I'm trying to say to a patient, there's really not a risk, and yet my consent form right has it written down, that's gonna be a problem. So I would mention in the article that it would be very appropriate to consider changing your consent forms and just removing it. Otherwise, you're gonna really create a bit of cognitive dissonance.

Sara Klockars 10:15

That's a good point, Doug.

Douglas S. Paauw 10:18

Yeah, I mean, it's one of my favorite topics is medical myths. And and the the landmark article came out in 2014, so almost 10 years later, the CDC is coming out and saying what we've known. Yeah, certainly the allergists have known for a long time, and and I think the world's divided into people who react to things and people who don't. And the egg allergy piece got sort of woven into this, and just without data, with the the biggest article is like 4,800 individuals with egg allergy getting influenza vaccine with no episodes of anaphylaxis related to it. And I agree totally with Reed, it really we lose credibility when we ask about egg allergy and then we ignore it. So I I I'm all for getting rid of asking about it and then treating it like was mentioned. Yes, anybody could potentially have a reaction to a vaccine, they're very uncommon, and be prepared for that. But this egg allergy group is really not at at significantly higher risk.

Sara Klockars 11:15

And the other piece with that too is the package labeling. Not all package labels are updated, so that's another you know, concern as well. And it's hard to you know talk someone into that if it's in all these other places. So excellent discussion on the main changes this season. So let's just dive in and talk about a few of the general vaccine recommendations, Lauren. I'm wondering if you could comment on what flu season's expected to look like this season. When is it expected to peak with all the other respiratory viruses going around? Uh, would love your perspective on that.

Lauren B. Angelo 11:56

Sure, thanks, Sarah. Well, I think with COVID, it has made watching and tracking respiratory viruses a bit more challenging. I know we had one year when COVID was um you know first upon us where flu uh rates were very low, in fact, solo um, you know, and the CDC looks at some of that tracking, they really didn't have enough numbers to make any um strong conclusions about that year. And then I think it was last year we had our peak as we would typically see it, and then we had an uptick again later in the spring, which was unexpected. So I think as we're going into this year, it is a little bit difficult to predict. Cases start to pop up around this time of year. If we're in a typical year, we're gonna see cases, you know, really start to take hold in the winter months. So when we're into November, December, and that peak is typically in January and February. But again, it's so hard to know. So it's just important to be vaccinating earlier on. The other interesting uh, I guess, numbers to watch are from Australia. So they're opposite of us, and so they're just wrapping up their flu season. And I was just checking, you know, what was going on with them. And they've had a rough year. They're this their winter months were a bit of a challenge this year with flu, hitting some of their closing in and some of their record highs. Children were impacted uh more than in previous years. So I think these are just things to watch um as we move into our fall and winter months.

Sara Klockars 13:25

Great. And we do say in our article to vaccinate now. So this will go to press and be our September issue. So ideally in September or October and continue as long as flu is circulating. What are your thoughts on that wording? Or would you edit it and just leave it vaccinate now if someone comes in?

Lauren B. Angelo 13:45

Now give me pause. I don't know. I've seen I've seen the flu signs everywhere as I'm driving around the city of Chicago. But really, if you look at the CDC guidance, those to be vaccinated in August is a smaller number. The majority of our patients, uh the CDC is advising that we wait until September, October, because we really want that flu vaccine to last the duration of our flu season. And so getting it on board too soon might be doing a disservice to our patients. So when we say now at publication date, which would be September, that would be accurate. But I would be careful vaccinating uh most of our patients too soon.

Sara Klockars 14:24

Okay. And then we have a question from the audience kind of on this topic. Is should anyone wait until later in the season? So would you ever recommend somebody wait till after October to get their flu vaccine?

Lauren B. Angelo 14:37

No, I don't think we have any guidance as to needing to do that. You know, I would say if we can get everyone vaccinated before the end of October, that's really our goal. Because we don't know what the season's going to do and when cases are going to peak. Um so I think just sticking within the September, October months is really what we need to be doing.

Sara Klockars 14:57

Okay, great. That's super helpful for our wording. And then quick question too, when should we stop giving them?

Lauren B. Angelo 15:05

When you run out of vaccine. There you go. Following vaccines have expired. Yeah, please don't use expired vaccine. But you know, most of our supplies um and the dating will last us, you know, through the spring months. And so, again, as we saw, I think what was a year ago, that uptick in the spring. So it's important to keep vaccinating anyone who hasn't yet been vaccinated, even if we're into you know, March, April, May.

Sara Klockars 15:30

Okay. Good. That is super helpful. And then can you comment on how effective you flu vaccines are expected to be this season? That's always a question we get. And I'm always like, what's predict?

Lauren B. Angelo 15:45

Well, the reason um as Kelly mentioned, they changed the um H1N1 component because we saw that was the predominant um strain that was circulating last year. And even in Australia, I think they were hit pretty hard with that. And so hopefully, you know, by changing what's in that vaccine will help target that. But when we look at just the in general our flu seasons, the CDC will report out anywhere from 40% to 60%. It's so hard to really target what that's going to be moving forward. Um, we hope on the higher end of that, but sometimes when we see those H3 and two seasons as the predominant seasons, those vaccines tend to be less effective. And the other thing I'll add is we're dealing with respiratory viruses. It is really hard when we talk about vaccination to just overall prevent the virus from entering our bodies. What we're trying to do is prevent us from getting really sick, ending up in the hospital, ending up with significant morbidity or mortality from these. And so as we look at effectiveness, we're talking not just preventing flu, but preventing getting really sick from the flu as well.

Sara Klockars 16:56

Okay. In our article, we say to explain that people given last year's flu vaccine were about 40 to 70 percent less likely to be hospitalized for influenza. Do you think that stat works better or should we stick with the 40 to 60 percent, the usual?

Lauren B. Angelo 17:11

Well, they're yeah, they're not that much different. I'd be curious what others um on the panel think about that. But I think, you know, I when we talk about even COVID and RSV, we have shifted that conversation a little bit to keeping people out of the hospital and keeping people from getting really sick. So it's an important number to share. But when it's not that much different from actually getting the flu, is what the CDC's been reporting out. I think tailored the conversation to what your patients' concerns are, who's in front of you and what their risks are.

Andrea Darby Stewart 17:45

Okay, that's a good point. Just as we talk about kind of numbers for patients, I think we run a little bit of a risk that, you know, everybody thinks that if they get the flu shot, they're not gonna get the flu. If they got the flu and they had a flu shot that somehow things were failed. I just think we need to be, I would I would love to have be able to be a little bit more accurate in how we put this for patients so that we don't set ourselves up for this concept of failure every season. And I don't have a good answer for it. Would love to invite commentary on that, but it's definitely a challenge.

Sara Klockars 18:22

Yeah, Stephen, how do you discuss the benefits of blue vaccines with your patients?

Stephen Carek 18:28

Oh yeah, I mean, it's it's very much individualized. I would definitely try to re-uh remind them of some of the data you guys present. I mean, this is really a vaccine that's intended to prevent you from getting so sick and be hospitalized. It may help reduce the duration of symptoms or the intensity of the symptoms. It's a great way to protect you and your family from getting really sick, protect your loved ones from getting sick. But I still think there's just this persistence of I don't know if it's if it's misinformation that's on social media or the lay media, where it's just the belief that the flu vaccine is going to prevent you from getting the flu. And I just try to sort of say that no, that's not likely. What really want to do is make sure that if you were to encounter it, you're gonna be have less symptoms, shorter symptoms, not be hospitalized, and hopefully there'll just be a minor sort of viral URI type uh course.

Sara Klockars 19:17

Okay. And so the recommendations haven't changed. So any age-appropriate flu vaccine for everyone six months and older, and the recommendations for flu mist haven't changed, keeping that in mind for healthy non-pregnant patients ages two through 49. And I just wanted to reiterate and spend a little time or before we have to move on on the um vaccines for a patient 65 and and over. So, which vaccines are preferred in this age group? And do you recommend one over the other? What do you do if you don't have one available and you have a patient in your pharmacy? Lauren, can you answer that question for Yeah?

Lauren B. Angelo 20:00

Thank you for asking because this was a recent change. It wasn't with this year's um recommendations, but I believe it was last year's, where the ACIP, the advisory committee on immunization practices, came out with uh a preferential recommendation. So we hadn't seen that yet for flu vaccines. We'd all been wondering about it and if it was ever going to happen. And so they finally had enough data to review um the you know who's who's most impacted by this and that age group and what vaccines seem to be most effective again at keeping people from getting really sick, keeping people out of the hospital. And so the recommendation, as we see here, it's either an adjuvented vaccine or one of our higher dose vaccines. So as you see on the slide, the flu ad is going to be your adjuvented, and then both flu block and flu zone high dose are considered our higher dose vaccine. So all three of these are viable options for your um 65 years and older flu block has been uh available for ages 18 and older, but because it has three times the antigen as our standard dose influenza vaccines, it has shown some promise in our older patients. And so these are great choices. Now you did ask, Sarah, if we don't have these, what do you do? Well, you don't send people away. The recommendation is still go ahead and vaccinate with any age-appropriate influenza vaccine. But if you have one of these in stock, this is going to be um the direction that you'll go.

Sara Klockars 21:23

So, yes, that's an important point is don't send them away, vaccinate with any age-appropriate vaccine. So don't wait. So excellent. And one, let's try to get to a couple more questions. We had an audience question. Would you ever recommend two doses of flu vaccine for a patient? Especially if a patient got their vaccine earlier in the summer. Uh, Lauren, would you want to take that question?

Lauren B. Angelo 21:50

I can. I want to so when you say two doses, I stop for a minute because there are children less than nine years of age when they're getting vaccinated for basically the first dose. Or they haven't had yet two doses, and they do get two doses four weeks apart. So that's a separate group, but it looks like what we're asking about here again, if we had gone ahead and vaccinated somebody in August, but maybe we shouldn't have because the CDC says to wait, should we do a booster? And no, we're not doing boosters. The hope is that this will carry them through our flu season. So we're not going to see a second flu shot being given to anybody. I think the exception might be if they're in the traveling to the southern hemisphere in the their winter months over the summer. Perhaps we'd consider something like that. But that's a good point.

Sara Klockars 22:39

I do want to answer this question, which also came up last season. We have so much interest in combination vaccines and a lot of questions about we want a combo flu COVID vaccine. Will it be here this fall? Lauren, do you want to comment on the studies around the combo vaccines?

Lauren B. Angelo 22:57

Yeah, this has been a hot topic. And I think we're all, I think, hopefully optimistic we'd have one this year. But I think we're still chasing COVID, right? And we're still seeing changes made to that vaccine. And you know, we'll probably have the monovalent XBB as we go into the fall for that. And so I think because we haven't really been able to pinpoint the makeup of these COVID vaccines from year to year, it's challenging to then throw an influenza vaccine into the mix and have a combination product in the event that the COVID-19 vaccine needs to change. And so I think we're still in that holding pattern, just kind of watching how COVID plays out. But I do think we will see one eventually because I think patients are kind of putting the two together when they think about the fall season and getting their flu shot, then they're going to go ahead and get their COVID-19 vaccine around the same time. Um you mentioned RSB. So I think it's hopeful. And studies are still ongoing looking at that.

Sara Klockars 23:56

Thank you. And yes, we're all just waiting, like you said, hopefully optimistic. Andy, we have a hospital question for you. If a patient isn't sure they had the flu shot, should it be given during hospitalization anyway, or just to be sure they're covered, or should you dig a little deeper?

Anthony A. Donato 24:14

Yeah, there's um there's no real benefit to getting a second shot, but if I if I really don't have great follow-up and I'm not sure, I'd rather them get it. The people that are are leaving a system or uh really just don't have any great records that cross over, I will sometimes just make sure they have it.

Sara Klockars 24:33

Okay. Not necessarily harmful, but not helpful either, if they haven't had one. Okay.

Narrator 24:41

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 prescribers letter 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 Prescribers Letter websites. If you're not yet a pharmacist letter or prescribers letter 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 dot com. Thanks for listening to Medication Talk.