Immunization Updates 2024

Special guest Jean-Venable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP, Professor and Director of the Community-Based Residency Program at the Virginia Commonwealth University School of Pharmacy, join(s) us to talk about immunizations.

Listen in as we discuss the latest COVID-19, influenza, and RSV vaccine recommendations and answer some common questions about giving vaccines.

You’ll also hear practical advice from TRC Editorial Advisory Board member, Stephen Carek, MD, CAQSM, DipABLM, the Program Director for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program and Clinical Associate Professor at the University of South Carolina School of Medicine, Greenville.

For the purposes of disclosure, Dr. Goode reports relevant financial relationships [vaccines] with Pfizer, 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, Pharmacy Technician’s Letter,or Prescriber Insights 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 Insights: 

• Chart: Flu Vaccines for 2024-25 (United States)
• Chart: COVID-19 Vaccines 2024-25 (United States)
• FAQ: Preventing RSV
• Resource Hub: Immunization Resource Hub

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Transcript

This transcript is automatically generated. 

00:00:07 Stephen Carek

There's so much that floats around between social media and news media. Their own anecdotal experiences, and my general counseling with patients is some context in.

00:00:17 Stephen Carek

That if you get.

00:00:18 Stephen Carek

Flu the benefits of it greatly outweigh.

00:00:20 Stephen Carek

Any risk that may be associated? I mean, if you're at risk, it's going to significantly reduce your rates of complications from flu hospitalizations.

00:00:31 Kelly Goode

Staff education and re education. We do it all the time and as stuff changes administration, new new technologies, some of the new vaccines don't have needles to reconstitute anymore. Some are shaken, some are not. Some only have 30 minutes that you can give the vaccine.

00:00:51 NARRATOR

Welcome to medication talk, the official podcast of Tier C Healthcare Home, a pharmacist letter, Prescriber Insights RX advanced, and the most trusted clinical resources.

00:01:01 NARRATOR

On today's episode, listening as our panelists review the latest COVID-19 influenza and RSV vaccine recommendations and answer some common questions about giving vaccines.

00:01:12 NARRATOR

Our guest today is Doctor Kelly Goodie from the Virginia Commonwealth University School of Pharmacy and former President of the American Pharmacists Association.

00:01:20 NARRATOR

You'll also hear practical advice from TRC Editorial Advisory Board member Doctor Stephen Carrick from the USC School of Medicine Greenville.

00:01:28 NARRATOR

This podcast is an excerpt from 1 of TRCC's monthly Life CE webinars. Each month, experts and frontline providers discuss and debate challenges and practice evidence based practice recommendations and other topics relevant to our subscribers.

00:01:41

Years.

00:01:42 NARRATOR

The full webinar originally aired on October 15, 2024.

00:01:48 NARRATOR

And now the CE information.

00:01:51 NARRATOR

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians and nurses.

00:01:57 NARRATOR

Please log in to your pharmacist letter pharmacy technicians letter or prescriber insights account and look for the title of this podcast in the list of available CE courses.

00:02:07 NARRATOR

For the purposes of disclosure, Dr. Goodie reports a relevant financial relationship by receiving honoraria from visor and valneva.

00:02:15 NARRATOR

The other speakers you'll hear have nothing to disclose all relevant financial relationships have been mitigated.

00:02:22 NARRATOR

Now let's join tier C editor, Doctor Sarah Clockers and start our discussion.

00:02:29 Sara Klockars

Kelly to kick us off, can you briefly review the main changes to the flu vaccine this season?

00:02:37 Kelly Goode

And Sarah, this year the World Health Organization and the Food and Drug Administration recommended a change. You may recognize that used to have a quadrivalent influenza vaccine to a trivalent influenza vaccine. And that's because there's been surveillance in looking for the influenza B Yamagata language and not found that since March of 2020.

00:02:57 Kelly Goode

And so not having.

00:02:59 Kelly Goode

Don't want to have more antigens than we need, so they removed that be. Oh my God, this year they'll be the 2A's and H1N1 and H3 N 2. And then the influenza B is going to be the Victoria Lien edge. So they were able to make that change for all of our influenza vaccines this year. So the trivalent.

00:03:20 Kelly Goode

And not quadrivalent.

00:03:22 Sara Klockars

Excellent. Thank you. Steven, I was wondering if you can share what conversations you have with patients about which flu vaccine to get and and how do you answer the question which flu vaccine is best when patients are?

00:03:37 Sara Klockars

In the office.

00:03:39 Stephen Carek

In my own practice, the best flu vaccine is the one that patients going to take. But yes, there are guidelines and and at least in my clinical setting, we typically have two available to us for our clinic. We have the five dose Fluzone for and we recommend the for adults over 65 flu block in our clinic too. And somebody if you're in a big healthcare system, they only give you a small handful.

00:04:01 Stephen Carek

1-2 maybe sometimes 3.

00:04:03 Stephen Carek

The vaccines available for you, but to be honest with you in my own clinical practice, I don't know if the data outlines any signific difference. I mean the best 1 is going to be the one they're going to take are the high dose, have they have some added benefits, especially for elderly patients and preventing intensive symptoms reducing hospitalizations. But ultimately any flu vaccines can have significant effects over being non vaccinated, especially for our at.

00:04:24 Stephen Carek

Risk nearly populations.

00:04:27 Sara Klockars

We have had a couple of audience questions where they've had several patients over 65 ask for the regular dose flu vaccine instead of the high dose. How would that conversation go with the patient in your practice?

00:04:42 Stephen Carek

Yeah, I'll talk with them about it and say that, you know, guidelines are going to recommend using a higher dose.

00:04:47 Stephen Carek

Understanding what their concerns are, is it sort of that they make it the.

00:04:50 Stephen Carek

Quote UN quote flu from.

00:04:51 Stephen Carek

The flu shot or have some sort of adverse reaction to it.

00:04:54 Stephen Carek

Let's try to understand what their fears are, but ultimately, if that's the one they're going to take, if they say I don't want to take the higher dose and I'm going to take a regular dose flu shot, I'll give it to them. And again, it's gonna provide benefit. It may not be the optimal benefit of the highest amount of benefit, but at least it's going to significantly reduce symptom variation potentially and and definitely things like complications and hospitalizations.

00:05:14 Stephen Carek

Tamiflu.

00:05:16 Sara Klockars

Which leads us very nicely to efficacy. We have a lot of questions coming in about how do they determine efficacy, how effective are the flu vaccines? I've even seen some headlines about how they're not as effective this year based on data from the Southern hemisphere. So how do you explain the benefits to your patients?

00:05:36 Sara Klockars

Despite some of these headlines or some of the vaccine hesitancy out there.

00:05:41 Stephen Carek

Oh yeah, there's so much that floats around between social media news media, their own anecdotal experiences, and my general counseling with patients. I'd probably give you a 50% chance it's going to probably be effective. And just then there's a lot of strain circulating, and this is only covering kind of the three main ones we want. But what I can definitely provide for you is some context in that.

00:06:01 Stephen Carek

If you get flu, the benefits of it greatly outweigh.

00:06:05 Stephen Carek

Any risk that may be associated? I mean, if you're at risk, it's going to significantly reduce your rates of complications from flu hospitalizations and then try to clarify some misperceptions and misconceptions that things like if I get the flu vaccine, I'm not going to get the flu. Well, that's not necessarily the case, that the goal is that you could still get the flu, but you're definitely, symptoms are gonna be less. Your symptoms should be shorter, potentially be less contagious. And then for a higher risk, patients we talked about the complications and hospitalizations.

00:06:29 Stephen Carek

And those can dramatically go down just being vaccinated.

00:06:30

But.

00:06:33 Sara Klockars

Another question we've gotten, Kelly is should a patient with multiple sclerosis or rheumatoid arthritis receive a high dose or adjuvanted flu vaccine? And if they do, will it be covered by their insurance? So just to kind of expand that question a little further, is should patients on immunosuppressants get high dose or adjuvanted?

00:06:52 Sara Klockars

Flu vaccine.

00:06:54 Kelly Goode

Yeah. So and so some of the confusion might be that in June of 2024, the Advisory Committee on Immunization Practices recommended that someone with a solid organ transplant that's 18 years or over and receiving an immunosuppressive medication regimen.

00:07:11 Kelly Goode

Could receive a high dose or adjuvant and influenza vaccine, but it's not a preferential recommendation similar to the one that Doctor.

00:07:19 Kelly Goode

Carrick was talking.

00:07:20 Kelly Goode

About where it is preferential for somebody who's 65 and over to get an adjuvanted the flu block or get a high dose influenza vaccine. This is they could get it and based on it.

00:07:32 Kelly Goode

Being a recommendation, the insurance should pay for it, but we do find that sometimes it takes about a year for insurances to implement a CIP recommendations, so they may not be willing to pay this year, but that's the recommendation that they could have it. So when we look at someone with multiple sclerosis.

00:07:49 Kelly Goode

Or rheumatoid arthritis.

00:07:50 Kelly Goode

This they would just receive an age appropriate vaccine, not a high dose or adjuvant unless they're 65 years or over.

00:07:59 Sara Klockars

I just have a few more quick questions about the flu vaccine before we move on. How long does the flu vaccine last? Kelly, we have an audience question about.

00:08:10 Sara Klockars

Out this should a patient get a flu booster because they got one at the beginning of August.

00:08:16 Kelly Goode

Yeah, this question it comes up every single year is is, should we have a second flu vaccine and there are a few patients that could get a flu vaccine in August 1 of the the things when we really had just a standard flu vaccine, you know we didn't get flu vaccines as early as we get them now. So the technology is much better. So we can have flu vaccines much earlier, but really patients shouldn't be vaccinated.

00:08:37 Kelly Goode

Until September, so they shouldn't have a vaccine in August unless they're pregnant in their third trimester, or if there's somebody who may never come back during influenza season or somebody a child who may need a second dose.

00:08:51 Kelly Goode

But we do know that the.

00:08:53 Kelly Goode

Influenza vaccines going to provide protection for at least the influenza season. It does, however, can wane over time, and we know that that's going to vary by the strain by the recipient age. But generally we're going to see a persistent of about five to six months, which should carry us through the flu season. And there's not really an indication for.

00:09:15 Kelly Goode

Any patient to get a booster dose of their influenza vaccine, and even even if they were vaccinated in August.

00:09:24 Sara Klockars

Which leads nicely to the next question is when should we stop giving flu vaccines?

00:09:29 Kelly Goode

Yeah, we should stop giving flu vaccines when we run out of flu vaccines or they're expired. We should continue through even the spring. So flu vaccine season in the northern hemisphere is really mostly December through March. However, you know, we see the high rates January, February. If you go to CDC and look at flu weekly, you can kind.

00:09:48 Kelly Goode

Of track influenza.

00:09:49 Kelly Goode

In your communities, we always do that because we want to see when it shows up on the news. That's when patients are gonna come in and say, oh, I need the flu vaccine now because it's circulating. But you can take that flu vaccine in through the.

00:10:00 Kelly Goode

We vaccinate in our practice through March and if we have somebody that's really high risk, we might even do an April depending upon what we're seeing, but really making sure you know your vaccine is unexpired and vaccinating as long as you have flu vaccine.

00:10:13 Kelly Goode

In your practice.

00:10:15 Sara Klockars

Great. Thank you. We're going to switch gears to COVID-19 vaccines now.

00:10:21 Sara Klockars

Kelly, can you review the available COVID-19 vaccine options this season, and specifically, we've had a lot of questions about differences between the M RNA vaccines and the protein based Nova VAX COVID vaccine.

00:10:39 Kelly Goode

Yeah. So we have, we have 3 vaccines that we've had for the last couple seasons. So we have two M RNA vaccines, them on Moderna or the Pfizer bio intech and then the.

00:10:48 Kelly Goode

The backs so just remembering that the M RNA vaccines are that lipid nanoparticle formulated in the nuclei nucleoside modified M RNA. So that's and that what it does is it encodes sort of that spike glycoprotein of SARS COVID 2 which is the COVID-19 disease. That's the virus that causes.

00:11:08 Kelly Goode

Robbed. And so the formulation for this year for the 2420?

00:11:12 Kelly Goode

5 is going to target specifically of the M RNA vaccines, the AMETRON variant of the KP 2 sub lineage of the spike protein, which is a part of the JN one lineage. Just kind of what we're seeing if you look at the variant tracking for COVID, that's kind of what we're seeing and that's what the VIRBAC committee.

00:11:33 Kelly Goode

Were recommended for COVID vaccines for the fall and toward the end of.

00:11:37 Kelly Goode

May or June of this year, and then the Nova VAX is more sort of the protein based vaccine that we're really kind of used similar to our other vaccines and it's going to target the JN 1 variant. And so the COVID-19 vaccine, no vaccines, adjuvanted and that sort of to help the immunogenicity of that and it it has a spike.

00:11:57 Kelly Goode

Protein and a matrix M adjuvant to sort of bring that and make it more imagistic against COVID-19.

00:12:06 Kelly Goode

You're looking at approval for Moderna, and Pfizer for the Spike vaccine com menardi and then the Novavax and then the EU way for your children up to 12. The other ones are 12 years and over. Nova backs 12 years and over, but you have an EUA still for children for the two vaccines that are, they're under 12.

00:12:26 Sara Klockars

Similar to the flu vaccine, it's recommended that all patients aged 6 months and up get a 2024-2025 COVID-19 vaccine. And so with that being, we have this new COVID baccino this year. How many doses do people need?

00:12:44 Kelly Goode

Yeah. So it is. It is a little complicated. So everybody should at least have one of the 2425 vaccines if they've never been.

00:12:52 Kelly Goode

Vaccinated a CIP is actually gonna discuss the dosing for immunocompromised patients next week at the October meeting and sort of really put it into recommendations for clinical guidance as well as potentially a another dose for people who are 65 years and over like they did last year. So my recommendation is really they're these are great.

00:13:13 Kelly Goode

Arts from pharmacist letter and the CDC also has a great chart sort of help you and and we always go always go back and look it up just to make sure as we're looking at people, especially children coming in, whether or not they how many doses they might need depending upon the product we're using.

00:13:29 Sara Klockars

So Steven, I would like you to chime in here since you helped us with the efficacy of flu vaccines, how effective are COVID maccini's and how do you convey the benefits of these vaccines to your patients?

00:13:45 Stephen Carek

Yes, this presents some similar challenges that we have with the flu vaccines. I think the headline for the code of vaccines is just this significant reduction in hospitalizations and mortality associated with COVID. I mean, that's really where this was a game changer, especially when we're going to these peaks through the pandemic on these past few years.

00:14:01 Stephen Carek

As we're as we're sort of like getting more and more data on the efficacy of vaccines, I think we're seeing trends that it's, you know, it does a lot of the same things the flu vaccine may may decrease infection, transmit ability, decreasing intensity of symptoms. But what we're trying to do is just still with COVID really reduce those risk for really severe complications that COVID is really notorious for particularly in our elderly patients.

00:14:23 Stephen Carek

High risk patients and then trying to encourage all people to get vaccinated.

00:14:28 Stephen Carek

And we'll see over the years, go along if we're going to continue the the pattern of annual vaccinations, but continue to emphasize not just the benefit for them, but for the people that they're around their loved ones, particularly those that are high risk for complications.

00:14:41 Stephen Carek

Related to COVID.

00:14:44 Sara Klockars

Thank you. One of the areas of hesitancy with the COVID-19 vaccines, our side effects and so we have had a lot of questions come in about COVID-19 vaccine side effects, so.

00:14:59 Sara Klockars

There's actually a specific question about heart attacks and myocarditis concerns, and can you comment on this? How should we handle some of these COVID maccini hesitancy? So, Kelly, I was wondering if you could comment a little bit on side effects with these vaccines.

00:15:17 Kelly Goode

Yeah, so if you.

00:15:18 Kelly Goode

Look at the safety surveillance. CDC's but we've got 3 plus good years of of safety data on COVID-19 vaccines. And really it's not panned out to have, you know, some of the concerns of, you know, some of the early mists of COVID maccini. I mean, there are some side effects. And when we look at, you know, giving any vaccine.

00:15:39 Kelly Goode

MRA is can be a especially sort of reactive genetic genetic. When you look at potentially pain, swelling, redness at the site, sometimes fever, fatigue, headache, chills, body aches.

00:15:54 Kelly Goode

You know, I have PTSD all my COVID vaccines, but I still go back because I think it's less than COVID to have some side effects, but we do know that, you know, most people may have some of the side effects, but there are a lot of people who don't have those side effects. So it's going to depend upon kind of the vaccine product and sort of the age group of the patient. But mostly, we do know that.

00:16:14 Kelly Goode

Almost 55 to 91% of patients do develop some sort of symptom after a COVID vaccine, but most of them are mild and moderate and occur within the first 3 days and and are resolved mostly a lot of times our patients receive resolved within 24 hours.

00:16:29 Kelly Goode

Children have, you know, not as many side effects really moderately. And they're going to resolve in the the same amount of time. When we look at an M RNA vaccine for the Nova Vacs, it's going to be similar to what we see with other inactivated vaccines. We have tenderness at the injection site, local reaction, fatigue, headache, muscle pain or some of the symptoms that are reported.

00:16:50 Kelly Goode

And it also resolves within one to three days. And if you think about some of the adverse effects and talking with patients, it's.

00:16:57 Kelly Goode

One to three days is much less than potentially what you might have with getting the COVID-19 virus itself or infection, and potentially even having it go into long COVID and having a a much more severe case. So I think that it's definitely worth having those conversations with patients and making sure that you tell them that there's a potential right. So we don't want to.

00:17:20 Kelly Goode

To make them think that it's not going to happen, we always are open and honest with our patients that they could feel kind of bad, but this is much better than COVID.

00:17:29 Kelly Goode

And when we look at myocarditis, that's really in in our young men. And and that's not panning out as as much as we had before. So you do just have to think about in those young adolescent men making sure you kind of have those conversations around the COVID that they could expect to potentially we have seen that with COVID-19 vaccine.

00:17:50 Sara Klockars

Thank you for that. And we actually have an audience question. We have a lot of patients returning to the pharmacy with side effects of COVID vaccines and what should we be recommending for symptom relief.

00:18:02 Kelly Goode

So what we?

00:18:03 Kelly Goode

Do is really recommend what they would normally take for pain or fever. You know you got to make sure you understand history so you don't want to be recommending an inset or, you know, a Tylenol. If they shouldn't be taking it. So that's how we approach it. And they could sort of take that around the clock, especially within that first 24 hours to sort of get through that body aches or.

00:18:22 Kelly Goode

Or how they're feeling?

00:18:24 Sara Klockars

Excellent. Well, thank you.

00:18:26 Sara Klockars

And then one last COVID question.

00:18:28 Sara Klockars

For patients who have a recent COVID infection, should they still get the vaccine? Steven, what are you telling your patients to do?

00:18:37 Stephen Carek

I believe that the CDC recommends 3 months. That's kind of just my general guidance and we're asking them if the patient is due for a COVID vaccine, just asking if they've had it within the past three months. I don't know of any contraindication to getting it beforehand. I guess it's a matter of efficacy, which we don't really know. And then I guess as we talked to getting the vaccine.

00:18:54 Stephen Carek

And.

00:18:54 Stephen Carek

Then having some sort of side effect.

00:18:57 Stephen Carek

Related to it, there could probably be some patients that may benefit. I mean, if they're frequently around patients who may be high risk or maybe there's a, you know, a surge going through their.

00:19:06 Stephen Carek

Community. Maybe a time and a place to do short on that three month interview, but my own practice we're pretty consistent about 3 months or so.

00:19:14 Sara Klockars

Great, thank you. I'm going to go ahead and move us along to RSV vaccines. So this season we have 3 RSV vaccine options. Kelly, can you review those options for older adults this season?

00:19:33 Kelly Goode

Yeah. So last year you may remember we had two options. So we had our Bristol, which is the bivalent vaccine and then the Rex fee, which is the adjuvanted and then this year we have in res via which is an M RNA vaccine. And so they're dosed the same, the same recommendations. So they're considered equivalent.

00:19:53 Kelly Goode

So it doesn't matter which vaccine that you use for patients, they do have a little bit of a different. This is a a time when we think about FDA approval versus what a CIP is, we're recommending. So it is a little bit different in how they've been approved and and the recommendations that a CIP.

00:20:11 Kelly Goode

Has has decided for for the three vaccines and remember a CIP is going to recommend based on cost effectiveness and the ability to get it to the population of target and acceptability as well as efficacy and safety. But they're all administered IM .5 ML's so any product is fine and that patient.

00:20:31 Kelly Goode

Population and the recommendation for 60 and over for the people that are high risk for those 75 years and over for the one vaccine.

00:20:41 Sara Klockars

Thank you. And then, Steven, if a patient already had an RSV vaccine, should they be getting another one?

00:20:52

That's a good.

00:20:52 Stephen Carek

Question eventually, maybe yes. I think that that we're still trying to figure that out. I think guess is maybe every two years count know if you have any other more insight on sort of recommendations move forward. My kind of understanding is possibly every two years, but we'll probably know more in about a year or two.

00:21:10 Kelly Goode

And I think that some of the emerging data.

00:21:13 Kelly Goode

I might put that in about 3 years, but you're right, it's it's not going.

00:21:17 Kelly Goode

To be 1.

00:21:17 Kelly Goode

Year because the data didn't show a better antibody response with an another dose at one year or so, maybe two years, but it might even go as as far as three years or even further just depending upon they're they're beginning to to measure all of that to see what what.

00:21:34 Kelly Goode

What intervals is going to work the best?

00:21:38 Sara Klockars

Thank you. And we also had another question about what is the RSV vaccine really preventing. So Steven, how effective are RSV vaccines and how do you explain this to patients?

00:21:55 Stephen Carek

So RSV a common virus that we see a lot, but I think it's also kind of a a significant cause for hospitalizations, particularly for pneumonia in our older patients. I mean, viruses can be a significant cause for pneumonia Broncho.

00:22:08 Stephen Carek

Need us and older adults and those that are at risk for lower respiratory tract infections. So having this available is is really it's gonna be helpful on that. I mean we we're trying to vaccinate against some of our main causes for pneumonia. But having a vaccine for this and the data show is probably 75 ish, 80% effective in reducing hospitalizations associated with RSD.

00:22:29 Stephen Carek

And emergency department visits, so definitely has some clinically meaningful data to support its efficacy in helping manage one of the common reasons for common viral reasons for lower respiratory tract infections in our older adults.

00:22:43 Sara Klockars

Thank you. And then Kelly, question for someone who has not been vaccinated against RSV yet. What is the right time to vaccinate?

00:22:53 Kelly Goode

If you really want to vaccinate before RSV season, right? So right now they just get one dose. If they haven't been vaccinated, they're gonna have the most benefit. If it's late summer, early fall. Just before that RSV season. So in most of the continental US that's going to be about August to October. However, recommendations is sort of under the shared control decision making.

00:23:12 Kelly Goode

And if if someone deems that we have are going to have our SV, as you can track RSV just like you can track flu. If it looks like we're having a surge and someone's unvaccinated at a later time, then the clinician can decide or provider can decide that yes, we think we should go ahead and vaccinate them based on surveillance and what's happening in the community.

00:23:34 Sara Klockars

Thank you. And we do have several questions coming in about risks with RSV vaccines, particularly Afib risk. So could you comment on that, Kelly?

00:23:47 Kelly Goode

Yeah. So they're in clinical trials. There were some patients that had a FIB. And so they are doing post marketing surveillance on a FIB. The data that was reviewed this year from a CIP, looking forward to the next year after the 2324 season, A-fib didn't emerge as a statistical signal.

00:24:09 Kelly Goode

However, there were two other statistical signals that that did emerge that they're going to monitor, and that's the risk of GBS with the Erec TV and Abismo.

00:24:21 Kelly Goode

However, it doesn't seem like that that was more than just a a signal, and so they're continuing to monitor that as well. And that was in patients really 65 years and over. And then the ITP was also a statistical signal that kind of emerged and they're going back and looking through vaccine.

00:24:40 Kelly Goode

Safety data link to kind of look at the charts on those patients this fall to kind of see was that really a correlation or causal to vaccines, you know that remember that CDC is monitoring through vaccine safety data.

00:24:54 Kelly Goode

Link they're monitoring it through Bayers reports which is a patient, can submit to Baylor so it's not totally they have to go in and and really dig into those systems.

00:25:04 Kelly Goode

Have your patients use the app to submit their information when they take these vaccines because they're really trying to track and monitor, and that would be helpful if you have your patients begin to do just like we did early.

00:25:16 Kelly Goode

On with COVID.

00:25:19 Sara Klockars

Excellent. And then?

00:25:22 Sara Klockars

Just let's briefly touch on when we should give RSV vaccines during pregnancy.

00:25:29 Sara Klockars

Kelly, would you mind tackling that one as well?

00:25:32 Kelly Goode

This one I'm very passionate about. I think that we've really got to be careful because there were a lot of errors last year with this vaccine and and pregnant women getting the wrong vaccine and even infants getting the adult vaccine. So we want to make sure that we have the right vaccine. So it's the Brisco vaccine.

00:25:49 Kelly Goode

And it's recommended for patients 32 weeks through 36 weeks gestation. It's really September through January. So now through January for the that pregnancy.

00:26:00 Kelly Goode

Only we should not give it. It's not like Tdap where we would give a RSV vaccine every pregnancy. We would just give it during one pregnancy. So if I'm pregnant this year then, and I'd have two more children coming through at this point, I would not get an RSV vaccine to protect that infant. That infant should get herself a mab for protection.

00:26:20 Kelly Goode

Once they're born, so it's only one time for that pregnant woman during one pregnancy. But making sure that we have the right product because we don't want to have those errors for patients.

00:26:34 Sara Klockars

Thank you. We've had several questions come in about the CDC recommendations for RSV vaccines and older adults and just wanted to review this recommended for all patients age 75 and older. And then for those 60 to 74 with risk factors. So hopefully that will answer some of those questions coming in.

00:26:53 Kelly Goode

And Sarah, I just want to add to that is that.

00:26:56 Kelly Goode

You don't have to.

00:26:56

Step.

00:26:56 Kelly Goode

Proof that patients meet one of the criteria from 60 to 74. If they say they have heart or lung disease, then it's OK to vaccinate them. If you're in a pharmacy or administrator, you don't have to have a note from the physician saying that yes, they have COPD. The patient's testation is fine.

00:26:58 Sara Klockars

Good point.

00:27:15 Sara Klockars

Great point. Helpful for our pharmacist listening.

00:27:19 Sara Klockars

Thank you.

00:27:21 Sara Klockars

And since it's a busy time everywhere and patients often need more than one vaccine at a time, I see all of the questions coming through about getting multiple vaccines. And so Steven, we've had a few folks ask.

00:27:39 Sara Klockars

What is the Max number of vaccines that can be given out? One visit? Some folks are saying they can give four or five, but they're asking if if that's really something they should be doing. So can you comment on what happens at your practice?

00:27:55 Stephen Carek

Yeah, I think that I've not seen ever specific islands on like, what's the what's the maximum number of vaccines that you can give? And I mean, it's pretty common, especially in kids, since for well, child tricks for kids to give four or five vaccines in one visit. So I I don't see any reason why we couldn't necessarily translate that over into our adult populations now.

00:28:15 Stephen Carek

Now adults is very different than a kid. You know, based on their immune history or medications at the wrong comorbidities. We may want to be thoughtful about how many we give to make sure we sort of have that sweet spot of immunogenicity and make sure they get their response we desire. And I think the most that I've done in clinical practice for adults is probably 3.

00:28:35 Stephen Carek

Within one visit, whether it's a combination of flu COVID, RSV, pneumonia, tetanus, any of the things that that, that's all would be available for. But some of it also may depend on your your clinic protocols, your pharmacy protocols, nurse comforts, patient.

00:28:49 Stephen Carek

Effort. So there's definitely a shared decision making component that goes into it as well, but I at least I'm not a bit. I'm aware of any sort of maximum number that we can't exceed.

00:29:01 Sara Klockars

Kelly, do you have any other comments?

00:29:04 Kelly Goode

I agree, but we've given a lot more than three, so you can give you know you're looking at deltoid muscle so that each vaccine should be separated by 1 inch. So it it depends upon the size of the deltoid muscle. But we can give at least we can give 3 and each deltoid muscle. And if you have two sub cues you can give two more sub cues depend upon the vaccines you're given. So especially if we're trying to catch an adult.

00:29:24 Kelly Goode

That's coming into this country that's not vaccinated. We do a lot of vaccine.

00:29:28 Kelly Goode

With that visit, it's also agree with Doctor Carson. It's based on patient tolerance and and what they can. They're willing to accept and take as many as that we can get in on while they're there and then bring them back to to get the rest of them.

00:29:42 Sara Klockars

Excellent. And the shared decision making is huge. Thanks for bringing that up, Steven.

00:29:46 Sara Klockars

Questions specifically about getting multiple adjuvanted vaccines at the same time. Kelly, how do you respond to that question when patients are hesitant?

00:29:59 Kelly Goode

Yeah, you. There's really not any recommendation that you shouldn't do that. So all vaccines can really be given together at the same time using separate site separate syringes. There is some potential sort of a little bit of evidence and mostly theory that the two adjuvant might be more reactogenicity.

00:30:20 Kelly Goode

And so you might have more reactions if you, especially if you give 2 adjuvant at the same time. And if you do the same arm, I would suggest.

00:30:28 Kelly Goode

One in each arm. That's what we typically will do, but there's not a recommendation to not do it, but you might consider if you think there might be reactions to maybe use a non adjuvanted flu and then an adjuvanted vaccine. If if you're giving a flu with that visit, but there's no contraindication to doing the two together, nor is there any evidence that it decreases.

00:30:49 Kelly Goode

Efficacy of the vaccines.

00:30:53 Sara Klockars

Thank you. We did have a comment about that as well. So thank you.

00:30:57 Sara Klockars

There is a question too about. So if a patient decides to defer vaccination and only get say, 2.

00:31:05 Sara Klockars

When should they come back to get the rest? Is there a minimum or a maximum time in between vaccines?

00:31:13 Kelly Goode

So for inactivated vaccines, there's not a they could come back tomorrow, they could come back later in the afternoon.

00:31:20 Kelly Goode

So there's no minimum interval between two inactivated vaccines. If they're live vaccines and they're not given on the same day the same clinic visit, we would need to wait 4 weeks, and that's a minimum of 28 days between the two vaccines. And that's a theoretical, again, because we think that perhaps that second vaccine, the first vaccine that's given, is remember the.

00:31:41 Kelly Goode

The live have to kind of replicate to begin to work to, to have some immunogenic.

00:31:45 Kelly Goode

That the and so that it might interfere with that second live vaccine being given. So you can't. There's no Grace period in that 28 days. So you have to have the 28 days between those two live vaccines. If you have a live vaccine today, I can get it and activated tomorrow. And vice versa, if I have an inactivated day, I can get a live tomorrow. There's no.

00:32:05 Kelly Goode

Minimal interval between it and activated and alive. It's just the two live vaccines.

00:32:11 Sara Klockars

Excellent. Thank you.

00:32:13 Sara Klockars

And I wanted to wrap up with a little bit about safety. We have actually had an audience question, which makes me think that yours are occurring, but what are the risks of a pediatric patient is accidentally given 0.5 ML's of moderna's COVID-19 vaccine instead of the 0.25?

00:32:33 Sara Klockars

The male dose and I think that just points to dose differences with COVID-19 vaccines and Kelly, can you just share some practical tips that we can use in the clinic and the pharmacy?

00:32:48 Sara Klockars

To help us pay close attention and triple check those doses.

00:32:52 Sara Klockars

You know, especially with this example, since moderna's COVID-19 dose does vary by age, so just some practical tips to share with the listeners.

00:33:01 Kelly Goode

Yeah, this is this is one I'm very passionate about making sure we don't have vaccine here. So it's really so it's it starts from where how you store vaccines, right? So not storing look alike vaccines in in the same area, the storage unit to making sure that you have pediatric and adult formulations that are separated and.

00:33:19 Kelly Goode

Making sure staff are educated, you have to continually educate your staff, right? Because the staff are going to change and you have to make sure that they understand what's being there. So you wanna do that? You wanna prepare one vaccine that for a patient at a time and labeled with the syringe that's there. We in our clinic do double verification. So once the vaccine is pulled and the orders.

00:33:40 Kelly Goode

Compared someone is actually bear. So we now sign that it's BeenVerified, and then who? Who's administered the vaccine? The other thing that's really helpful is that if you're documenting on a piece of paper or even documenting in EHR and a pharmacy system.

00:33:54 Kelly Goode

For what vaccine that you're giving is doing that first and the lot number and the expiration and then you're less likely to give an expired vaccine or give the wrong vaccine, cause now you're doing that and then confirming the patient vaccine, ask the patient and you're here to today to get this is your influenza vaccine, make sure the patient should kind of know what they're getting. And it's another check.

00:34:15 Kelly Goode

And making sure you can show the patient that the syringe that always triple checking those doses and making sure that you have cause errors are are really.

00:34:24 Kelly Goode

A lot more vaccine errors than we think there are, but making sure that you're you're following these steps can really help and making sure you move that expired stock and then just staff education and re education. We do it all the time to make sure everybody and if stuff changes administration, new new technologies, some of the new vaccines.

00:34:46 Kelly Goode

Don't have needles to reconstitute anymore. Some are shaking, some are not. Some only have 30 minutes that you can once you reconstitute, you got to give the vaccine.

00:34:55 Kelly Goode

I mean, so if you don't want to waste it, you got to make sure that patients going to get it, especially if it's a child getting something like a varicella, we have that happen sometimes and then decide they don't want it. We've already mixed it.

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