There's more than a flu shot to consider as winter approaches

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. It's flu shot season, but there are additional vaccines adults may consider at the same time. For details, I'm talking with Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease and an associate professor of medicine at Upstate. Welcome back to "The Informed Patient," Dr. Asiago-Reddy.

[00:00:31] Elizabeth Asiago-Reddy, MD: Thank you for having me. It's good to be with you again, Amber.

[00:00:35] Host Amber Smith: Let's start with what's important to know about this year's flu shot. Do you have a projection for how severe this season will be?

[00:00:43] Elizabeth Asiago-Reddy, MD: Well, last year we had an early spike in flu cases, and so that appeared to be concerning initially, and it was a rough go at the beginning. But actually as the season progressed, the numbers evened out, and so they weren't very different from pre pandemic numbers -- though they certainly were up from a couple of years during the pandemic when we saw low numbers.

So I don't think we're expecting anything too out of the ordinary. And this may be more of a typical pre pandemic flu season this year. There are some numbers in Australia that appear to show younger children still having a lot of experience with the flu. So we may see something like that, as the southern hemisphere often is our predictor for the northern hemisphere.

[00:01:31] Host Amber Smith: How does this year's vaccine compare with previous years?

[00:01:36] Elizabeth Asiago-Reddy, MD: This year it's a similar makeup in terms of the numbers of components that are in the flu vaccines. There is one adjusted component from last year. And that's just exactly what we're supposed to be doing, is trying to keep up with the trends that we see and the types of viruses that are circulating. So this is a goal to match the circulating virus strength better.

[00:01:58] Host Amber Smith: And we just have to wait and see how well we did until after the season, right?

[00:02:02] Elizabeth Asiago-Reddy, MD: Correct. Or somewhere halfway through at least. Yes.

[00:02:06] Host Amber Smith: Will there be a nasal option for people who don't like needles?

[00:02:10] Elizabeth Asiago-Reddy, MD: Yes. It's called the L A I V, (Live Attenuated Influenza Vaccine), and there are some groups of people who cannot receive that vaccine. So the individuals who are potentially eligible are aged 2 to 49 years without severe immune compromising conditions. So the patient themselves should not be severely immune compromised, and their immediate contacts also should not be severely immune compromised. So that means their close caregivers and family members. And also children who have a history of asthma between the ages of 2 to 4 should not receive this vaccine. Otherwise, it is a good option for individuals who don't like needles.

There's also a needleless option for adults. It's given through an autoinjector that goes into the muscle by a different mechanism aside from the needle. Word on the street is that it still can cause some pain, so it's not necessarily less painful, but for individuals who really can't stand the sight of a needle, that might be an option if they can locate a healthcare provider who's offering that.

[00:03:15] Host Amber Smith: What about people over age 65? Are they still recommended for a higher dose vaccine?

[00:03:23] Elizabeth Asiago-Reddy, MD: Yes. So there are a couple of different options for individuals who are over age 65. One of them includes a higher dose of one of the components of the vaccine that's been shown to improve the immune response.

There's also an adjuvanted vaccine that would be add a different option. Or, the recombinant vaccine. So all of those are options for people over the age of 65 and, well, 65 and older, and those are available both through primary healthcare providers as well as a number of pharmacies.

[00:03:56] Host Amber Smith: Now, when should Central New Yorkers get vaccinated, and how long does the protection last?

[00:04:04] Elizabeth Asiago-Reddy, MD: Ideally the best time is late September, early October to be vaccinated. And that's because flu season usually starts to kick in by the end of October. It's most severe during January, oftentimes, although, like I said, last year we did have an early spike in cases, so it's possible we could see something like that again.

The goal is to get the vaccine in about four weeks before the flu season hits. But also you don't want to give it too early because the flu season lasts for several months, and the immunity does wane over time, relatively quickly. So after about 12 to 14 weeks, unfortunately, you're going to experience some waning of immunity. And so we're trying to cover the best of both worlds by giving it right around the end of September, early October, so that you catch the first few cases that may be coming through, but also have immunity, hopefully, lasting long enough through the early spring when we still may see some activity.

[00:05:08] Host Amber Smith: Do you know, does everyone in the community have access to flu shots? Are they free, or is there a charge?

[00:05:16] Elizabeth Asiago-Reddy, MD: This is a good question, and it relates to vaccines across the board, including COVID. So, New York State does an excellent job because in general there are fewer people who are uninsured or underinsured in New York State compared to a lot of other states. So, Medicaid, Medicare, all the exchange program insurances, commercial insurances that you would get through your jobs, those are all going to cover flu vaccine as well as COVID vaccine.

For people who are in some kind of an insurance gap, the best place to look is with the health department. So the local health department, including our health department, will offer coverage for adults through the Vaccines for Children Program. So that program actually also covers adults who are underinsured as well. So again, the health department is the best place to check if you find yourself in that gap.

[00:06:12] Host Amber Smith: Well, I've got some questions about the COVID vaccine also, but before we get into that, is there a vaccine now for respiratory syncytial virus, or R S V, for adults?

[00:06:22] Elizabeth Asiago-Reddy, MD: Yes, there is. So this is something new that has just come out. There were actually two vaccines that were evaluated in June by the F D A, (Food and Drug Administration) one that's made by G S K and one that's made by Pfizer. Those are called Arexvy and Abrysvo, respectively. And they're both highly effective in preventing severe lower respiratory tract infection from respiratory syncytial virus or R S V.

The G S K Arexvy appears to be slightly more effective when we look at the available data. And it had a unanimous vote of approval, versus a couple of dissenters on the Pfizer vaccine. But both were approved, and both, again, are effective and preventing severe disease and specifically lower respiratory tract disease -- so that means pneumonia -- in adults, age 60 and up.

So these are currently being recommended as a single dose for adults age 60 and up. What we don't know right now, to my awareness, is whether there'll be additional recommendations for others who might have risk for respiratory syncitial virus based on immune compromise. At this point, I'm only aware of the older adult option or recommendation at this point.

And that also matches -- I know my talk is not primarily about children -- but there is a monoclonal antibody available for children, which is new as well. So with these combinations of prevention options, we're hoping that we'll have a less severe R S V season than last year. So last year was a very severe R S V season that was somewhat unprecedented.

[00:08:07] Host Amber Smith: Is the R S V vaccine something that people can ask about when they go to get their flu shot and potentially get them both at the same time?

[00:08:16] Elizabeth Asiago-Reddy, MD: I would definitely recommend anyone who's eligible asking their primary care provider about all of these vaccines and how best to give them in combination. For right now there's no contraindication to getting all three vaccines together at the same time -- so that would be flu, R S V and COVID.

It looks like, because the. R S V vaccine is adjuvanted. What that means is that there's a medication put into the vaccine that boosts the immune response. There's a possibility that people might have some more symptoms associated with getting multiple vaccines delivered at once.

That having been said, when reviewing expert advice and realities on the ground, what happens when you split up vaccines is that people oftentimes just don't get them. And so it would be better to get all three, especially for those individuals who are at highest risks. So those include the people in the age groups recommended, and especially those with comorbidities.

[00:09:19] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago-Reddy, Upstate's chief of infectious disease, about fall vaccinations for adults. We'll be entering our fourth fall winter of COVID. Where do things stand with vaccine boosters in terms of what's recommended?

[00:09:41] Elizabeth Asiago-Reddy, MD: This year, actually, starting from the spring, a number of the bodies making recommendations for vaccines made things a lot simpler for COVID. And what that means is that we have done away with the primary series for COVID. What is recommended for all age groups that are eligible for vaccination is that they get a single dose of the most updated vaccine.

So right now, the most updated vaccine up until maybe a month from now is the bivalent, what we call booster, and the goal is to kind of move away from the use of the term booster and look at COVID vaccines as more of an annual vaccine. But because we knew this kind of product as a booster, that's what we're talking about. So we're talking about, right now, a bivalent booster.

So if you had a single dose of a previous booster, you may be done. So if you already have received the currently available booster, you may be done until newer products come out in about a month. Or if you were never vaccinated, then you may, if you really want to be vaccinated now, you would just get a single dose of that bivalent booster. The only exceptions to that in terms of the dosing would be people who are moderately or severely immune compromised, who may need additional doses to get up to what's recommended in terms of their level of immunity.

Now starting in September sometime -- we're being told towards the end of the month -- we anticipate that we will have new COVID annual vaccines, and those are derived from some of the omicron variants that we've seen circulating, specifically one of the variants called xbb.1.5. And so we anticipate a better immune response to currently circulating variants with the updated vaccines that are anticipated to come out in about a month. So it leaves a little bit of a gap between now and one month from now for those who might have an additional level of risk or concern. But that's where we currently stand.

[00:12:00] Host Amber Smith: So are infectious disease experts looking now at COVID more like a seasonal flu where people would come and get vaccinated during flu season for protection against COVID?

[00:12:13] Elizabeth Asiago-Reddy, MD: Yes. That's the goal. The goal is to simplify the vaccine regimens and what we've seen pretty much across the board is that in climates where we experience a cold weather winter season, that particular time of year tends to be the worst for COVID. COVID is a little bit more, I would say, unsettled in its seasonality compared to flu, where we still see some irregular spikes in disease activity that may fall outside of the typical winter season, or maybe a bit different, depending on the climate that someone's living in. So we have seen spikes in warm weather environments when people are probably spending a lot of time indoors because of air conditioning. So there's still some irregularities with COVID.

That having been said, by and large, it makes sense for us to turn this into an annual vaccine. It's much more straightforward for people. It's going to be easier for people to get other vaccines that they need to protect them from things that may be just as severe or even more severe than COVID at this point. And it allows for taking into account, like I said, what's likely to be the most severe period of time for COVID, which is the cold weather months.

[00:13:33] Host Amber Smith: Well, let me ask you about a couple other things that I think are adult vaccines that maybe are not seasonal -- or maybe they are; I'm not sure -- pneumonia, and the shingles vaccine. Are those things that people need every year?

[00:13:48] Elizabeth Asiago-Reddy, MD: They don't need them every year.

Pneumonia vaccine can be very confusing for people because what it is specifically referring to is a vaccine to help prevent the bacteria, streptococcus pneumoniae, which can cause pneumonia, as well as other severe types of infections like meningitis. So it's not a universal pneumonia vaccine, and unfortunately people still can get pneumonia from other causes, even having received this particular vaccine. But streptococcus pneumonia for much of my career and life was the number one cause of bacterial pneumonia, and it wasn't until these vaccines were introduced that it actually became less common. So this has been a highly effective vaccine.

So the pneumonia vaccine targeting strep pneumonia is something that older adults age 65 and older should all receive at least one dose of. And there are many, many other people that should receive a dose of this at a younger age. These include individuals with a lot of different chronic comorbid conditions such as diabetes, chronic obstructive pulmonary disease, immune compromising conditions. This is something that you would want to speak with your primary care health provider about to see at what age and what combination of doses you should receive. It also gets updated fairly regularly, so the recommendations that I give you today could be different a year from now. But suffice it to say that at least one dose for older adults as well as those with particular chronic medical conditions. So that's the strep pneumonia vaccine.

And then the other vaccine that you mentioned is Shingrix, or the current shingles vaccine. We previously had a different shingles vaccine that was available several years ago that's no longer in regular use. And the Shingrix vaccine is a means to boost the immunity against the chickenpox virus. So why do we need this? When people become infected with the, what we call, wild types -- so the original strains of chickenpox virus -- that virus stays inside our bodies for our entire lives and later can reemerge during periods of stress, immune compromise, or for just random reasons that we don't understand.

It can reemerge in the form of shingles. And shingles is a very painful and potentially very debilitating rash that is oftentimes found on the trunk, but could be found on the face, ears, eyes, different places throughout the body. And so what we're seeing happen in the community at this point is that because children for the last several years have been vaccinated against chickenpox, there is a massive decline in circulation of the chickenpox virus throughout the communities. That's also called the varicella virus. And because of that decline, people are not actually getting naturally boosted. So it used to be that, let's say, you know, I went to my cousin's birthday party and one of the kids there had chicken pox, and I would actually get naturally boosted by being exposed in that situation. And that's not really happening anymore because most children have been vaccinated. So we are experiencing a waning of immunity against that virus, which could result in an increased risk of shingles.

So the shingles vaccine is to try and boost our immunity against the chickenpox virus and prevent shingles from happening. And that one is recommended for adults aged 50 and up. It's a two dose series and also recommended for people with immune compromise at younger ages, from age 18 up. So we think that the Shingrix vaccine immunity will probably last about 10 years. It may be longer. We're not exactly sure. So there may be additional recommendations coming out about that in the future.

[00:17:53] Host Amber Smith: Well, this has been very helpful, Dr. Asiago.-Reddy. Thank you so much for your time.

[00:17:58] Elizabeth Asiago-Reddy, MD: Absolutely. I appreciate being on. It was great to talk with you.

[00:18:01] Host Amber Smith: My guest has been Dr. Elizabeth Asiago-Reddy, the chief of Infectious disease at Upstate. The Informed Patient is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.