This transcript was automatically generated from the video recording and may contain inaccuracies, including errors or typographical mistakes.

Better Together: A Collaborative Approach to Boosting RSV Vaccine Uptake in Adults

Dr. Ruth Carrico (University of Louisville School of Medicine): So, it's a delight to be with you today and with my two amazing co-presenters. When we talk about adult RSV, and we really do continue to - to realize that this is an unrecognized burden.

Risk Factors for Severe RSV Disease

I think in the past, you know, we - we've certainly recognized other respiratory viruses, but RSV continues to be one that we've been a little bit slow to really appreciate its impact. And when we think about RSV, we know that this is a respiratory illness, highly contagious, unfortunately, and one where we do not develop long-term immunity. So, it continues to plague us.

And it can present itself in a couple of different ways. It can present itself with relatively mild upper respiratory tract symptoms, or it can present itself as a much more ferocious character, and that is lower respiratory tract disease. And there are a number of risk factors that can make this worse among our population.

We can have individuals that have some or more - one or more - of these chronic medical conditions, including chronic lung disease, chronic cardiovascular disease. Individuals can be immunocompromised. They can have hematologic disorders, neurologic disorders, or we can have individuals with chronic kidney and liver disorders or underlying medical conditions such as obesity. That is a BMI of 40 or more, or they can have these underlying endocrine disorders, such as diabetes.

Individuals can be residents in a long-term care facility, a nursing home, or they can be the older adult with frailty. So, you can see when you think about the patients that you see, those that are in your patient population, it may be one or more, or maybe even all of these. So, it's a reminder that we need to respect RSV as a - as a problem and then make determinations about what are we going to do to have these discussions and help them to think about protection of our patient population?

RSV-NET US RSV Hospitalizations: Older Age Is a Risk Factor

Now, when we look at some of our national surveillance systems that you may be aware of, the CDC's RSV-NET, that is part of a larger respiratory evaluation surveillance system. And when we look at those individuals that have been identified through this surveillance, and we look at RSV hospitalizations, older age is certainly a risk factor.

So, here we have data from seven consecutive RSV seasons. And when we look at then the impact, you can see the tallest bar are those individuals that are 75 years of age and older. Now, certainly, if you look at the other colored bars, we have disease that is present in those individuals who have been hospitalized. But older age is certainly a tremendous risk factor.

Cumulative RSV Hospitalizations in US Adults by Race/Ethnicity

Now, let's look at some more information from RSV-NET. When we think beyond, because in RSV-NET both the hospitalization is captured, but also some individual characteristics such as race and ethnicity are captured. And when we look at the patients that are experiencing hospitalization, we can see that it does not impact all of our population uniformly.

Look at that purple line at the top. That indicates the Black non-Hispanic individuals who have been identified, laboratory confirmed, RSV, and hospitalized. So, we can see that our Black non-Hispanic patients are impacted to a greater degree than our patients in other racial groups. So again, recognizing the importance of this and thinking about this and how we're going to deal with patients and discussing vaccine as a possible preventive help.

RSV Hospitalizations vs COVID-19 and Influenza

Now, I want to look then at another network. The IVY network is also a CDC network, pulls in data from academic medical centers from a number of states across the US. And again, these individuals have laboratory confirmed RSV and then are looking at - at what is happening with them in terms of outcomes. So, when we look at a period of time in February of 22 through May of 23, across 25 hospitals and 20 states, we had almost 5800 individuals, 60 years of age and older who were hospitalized with an acute respiratory infection. And when you look at what that respiratory infection was, about 300 in this group, 304 had RSV, about 4700 COVID-19, 746 had influenza. And although RSV was less frequent among this group, their outcomes were more severe when we think of their - their hospitalization.

And at the bottom, when you look at those boxes compared with COVID or influenza, are those that were hospitalized with RSV were more likely to require oxygen therapy and ICU admission when compared with influenza. Those with RSV had higher odds of requiring invasive mechanical ventilation or experience death. So, RSV is - is a disease that has - is associated with significant morbidity and mortality, particularly in our older adult population.

RSV Morbidity Extends Beyond Respiratory Illness

So, this information has been used to make some determinations about vaccination, and we'll hear more about that coming up. But I want to think about, you know, what happens to our patients when we are preparing to talk with them about vaccination. What are some information that they may be interested in and that may really soften them if they tend to be more hesitant?

But let's talk about what happens beyond just the respiratory illness. Now, I mentioned hospitalization certainly was an issue. And - and hospitalization may be something that really drives the interest, you know, how can I prevent that for your patients? But I think equally as important, and maybe even more important, is, well, what happens? How do people feel when they have had RSV disease and they have recovered? So, they may have had serious illness, they are hospitalized, but they are able to survive the disease, and they go home. I think it's interesting to review how those patients felt.

So, look at that information at the bottom of this slide. 28% had reduced physical function. About 11% reported that they lost at least one of those basic or instrumental activities of daily living. Almost more than 27 reported severe breathlessness, and more than 20% reported that they now have poor quality of life. So, when we think about then the impact of this on not only the disease - the period of time where they have the recognized disease - but what happens to them afterwards, it becomes important.

Impact of Severe RSV on Quality of Life: Bruce's Experience

And I think Bruce helps to bring this home. And I want you to take a couple of minutes and listen to how Bruce then expresses how he felt once he experienced RSV disease. So, let's hear what his experiences are.

Speaker: Before you got RSV, what was your usual day like, and how did COPD affect your breathing activity level or independence?

Bruce: My normal day was - I take my fluticasone furoate/umeclidinium/vilanterol in the morning, and I wasn't having to use albuterol at all. And the only time I would use supplemental oxygen was when I was exerted, upon exertion. And normally I would sit down to catch my breath - get my breath back.

Speaker: When your symptoms started, did it feel like your usual COPD symptoms or did something feel different?

Bruce: No, it felt different. My breathing had gotten so bad, even with supplemental oxygen, that I had a hard time catching my breath and had a hard time just doing basic activity, like going to the bathroom without being real short winded.

Speaker: What do you remember about being hospitalized around Christmas, and how did being in the hospital affect your comfort, independence, and ability to feel like yourself?

Bruce: I was still restricted in my movement. In the hospital, I could just go to the bathroom and basically lay in my bed. And that was it. My sleep was just on and off every couple of hours. I would sleep only for about two hours and then wake back up. I was on supplemental oxygen the whole time, except for the last, I think, four days of my hospital stay, when I could finally wean off of it.

Speaker: After you left the hospital, what was your quality of life like while you were recovering?

Bruce: It was diminished, but not as bad as before I went to the hospital. I still couldn't go on long trips or make grocery store excursions. I had my daughter go and get groceries for me. It was a while before I could go out into the public and feel confident enough to walk around a grocery store, places like that.

Speaker: How long did it take you to get back to your usual COPD baseline?

Bruce: It's hard to say. I don't feel like I've ever gotten back to what I was prior to the RSV. I still feel like I'm struggling to recover some. It also is hard to differentiate between the progression of COPD and just the consequence of having RSV. It's hard to distinguish between the two.

Dr. Carrico: Oh, so you can see this was a tremendous impact on Bruce and - and when we think about, you know, how he felt afterwards, he kind of ticks off the list, doesn't he, of those outcomes that are of concern.

The State of Adult RSV Prevention: Data and Guidelines

So, I want to move us forward, and I want to - to introduce Dr. Mullen to talk about what is happening there in the state of adult RSV prevention, and to talk about the both the data and the guidelines. So, Dr. Mullen.

RSV Vaccine Uptake Inequities: Race, Ethnicity and Social Determinants of Health

Dr. Jewel Mullen (University of Texas at Austin Dell Medical School): Thank you, Dr. Carrico. It's really sobering listening to Bruce. I don't know who among us hasn't taken care of someone like him, who, even if it's not related to RSV a patient who has said if I had known then what I know now, I would have… or, you know, a family members or others who might wonder, what can we do to prevent this in the future? And that's a part of the theme for me, at least in this section.

But even before I get into all the details around RSV vaccine, I also want to hearken back to some of the earlier data that Dr. Carrico showed as well, reminding us that one, the burden of RSV, as we have seen already through the hospitalization data, does not impact different populations, race, and ethnicity in the same way, there's higher burden. And here this slide drives home some points for us to think about as we work with our individual patients. And - and it's important because it demonstrates for us that - that question, what can I do about it? RSV vaccine for prevention. Vaccine uptake is also not uniform across racial ethnic groups and across people with different social conditions and social determinants of health.

So, these might be themes that are familiar to you related to other communicable and non-communicable diseases, where preventive measures vary. So, for example, here we see that RSV vaccine uptake tends to be lower among the younger age groups of those who for whom the vaccine is recommended. With lower uptake among people in the 60 to 64, in their 60s in general, than in the over 70 to above 80 year age group.

Similarly, we see variation across race and ethnicity with the lowest identified racial or ethnic groups uptake being among Black non-Hispanic adults relevant if we also remember that purple line that showed the much higher hospitalization rate among that group. We also see that vaccine uptake is higher among people with higher income and higher education levels.

And these data were especially striking for me, when released, because oftentimes I - like many of us, rely on really good CDC data that gives us surveillance and questionnaire-based data on who has gotten vaccinated. And over the past few years, I've been relieved to see the suggestion from, say, the National Immunization Survey, which is self-report, where perhaps we had gotten to over 40% of adults over 70 who had already received RSV vaccine since it was released.

But these data are actually from EFPIA and from data collected at a point of care at pharmacies and through physicians’ offices. And so, rather than being self-report, which is always considered less reliable, these data actually represent vaccines that were administered - administered. Are they perfect? No. But they help remind us that we still have a long way to go. And that as - as we see among racial and ethnic groups, among those with lower income and those with less education, we have more work to do to increase vaccination rates.

FDA-Approved RSV Vaccines for Adults

And we have an array of products throuh which to do this. So, here are the three vaccines that the Federal Drug Administration has approved for administration in adults. We have RSVpreF, RSVpreF3 which is an adjuvanted - adjuvanted vaccine, and the mRNA RSV vaccine. Each of them, per FDA, is approved for individuals 60 years and older, and for individuals who are between the ages of 18 and 59 and have at least some risk - increased risk of lower respiratory tract disease caused by RSV.

The RSVpreF vaccine is also approved for administration to pregnant people between their 32nd and 36th week of pregnancy, gestational age. And this is an example of providing immunity to pregnant people that can be conferred to their infants, whose undeveloped immune systems are not yet capable of combating an infection. So, this is administration to pregnant people to protect infants.

Contradictions are histories of severe allergic reactions to any of the vaccine components. So, three options, pre-F, RSVpreF3, and the mRNA1345.

CDC Guidance for RSV Vaccination

So, following RSV approval, we're familiar with having the CDC's Advisory Committee on Immunization Practices also offer guidance that further specifies, or recommends, which groups should get the vaccine. And the current recommendations from CDC/the ACIP are that RSV vaccine is recommended for all adults 75 years or older, and for those who are 50 to 74 years of age, if they have an increased risk of severe RSV, that lower respiratory tract disease.

We touched on this a little earlier in one of the - the questions. When first coming to market, we found that the recommendation from ACIP was that administration decisions required shared clinical decision making.

Last year, just about a year ago, ACIP removed that recommendation.

So, who are those people at increased risk for severe RSV? Well, Dr. Carrico touched on them some already. But now couple of that information with who you're going to recommend the vaccine for, and remember those with chronic cardiovascular, lung, and respiratory disease. So, the Bruces, chronic liver disease, hematologic conditions, obese those with body mass index greater or equal to 40 kg, those with moderate and severe immunocompromise, those with diabetes, with complications and organ damage, those who are on an insulin or an SGLT inhibitor, people with end-stage kidney disease, people residing in nursing homes, and other chronic conditions that you and other health care practitioners might determine places someone at increased risk.

CDC Guidance for RSV Vaccination

Sometimes people say, well, what about those people who aren't age 50 yet? And what can I do about them? And there are, you know, many patients who also say, "Well, I have a risk. Can I get the vaccine, too?" And so, although people ages 18 to 49 were not among those for whom the ACIP/CDC recommended RSV vaccine administration, the FDA did approve vaccines for people in those - that younger age group, if they're at risk of lower respiratory tract disease.

One of the issues that will come up, since this is not an ACIP recommendation to administer the vaccine to them, though, might be payment and reimbursement, and that will vary from state to state. But I wanted to remind us that just because the ACIP did not include that age group in the recommendation, it does not mean that it would not be valuable for them to also, or beneficial, for them to receive the vaccine.

Posttest 1

So, let's go back to the earlier question. If following CDC guidance, would you recommend RSV vaccination for a patient who's 51 years of age with chronic liver disease? Time to vote again. You have the chance to keep or change your original answer. And I'll let our administrator determine when we have enough answers to move us along.

Zachary Schwartz: Thanks so much, Dr. Mullen. Yeah, well, I see the votes are coming in, so we'll keep it open because I see they're still coming in. So, that's great. Slowing down a little bit, still voting. So, I want to make sure everyone's votes count. So, please keep voting. And of course, as soon as I said that they really slowed down. So, I think we have enough. Let's close the poll and have a look.

Dr. Mullen: Okay. I was sitting here wondering whether or not I had been making any clarity in what I was saying. And so, rather than congratulating myself, what I'll do is say good work to those of you who recognize that this individual, age 51, should receive or can receive the vaccine. Any of the three is okay.

IDSA 2025 Guidance: RSV Vaccination for Immunocompromised

So, just thinking about that question, the 51-year-old, well, some people with chronic liver disease do have some kind of immunocompromise, but that - but beyond that, I want to highlight something that might come up for many of you in your work because of the numbers of people that we care for who have a condition that's also immunocompromising.

And so, this recent guidance from the Infectious Disease Society of America is - is something that - this little chart I would consider like an old-fashioned pocket guide that's handy to keep because questions will come up about a variety of different people with immunocompromising conditions and what to do about RSV vaccination from them. And I don't intend to read the detail on every slide. But what I want to point out is that, for those with solid organ transplant, hematologic malignancies, chemotherapy, CAR T-cell therapy, chemo, primary immunodeficiency - immunosuppression, there are clear recommendations for when to give the RSV vaccine ranging from, in the case of organ transplant, a couple of weeks before or more than six months after or, for example, in the case of someone who's on autoimmune immunosuppression, two weeks or more prior to treatment initiation. But then again, at less - no less than three to six months post final infusion.

So again, I don't want to read through all of the details now, but this is a very useful slide. And I wanted to point out a couple of things that the IDSA included in their paper. One of which is that, as you're thinking through with patients when they should be vaccinated, another thing to consider is that their household members who can put them at risk should be vaccinated as well.

The IDSA paper also cited the - the safety and appropriateness, if patients accept it, of co-administering COVID and influenza vaccines. And it acknowledged that there will be ongoing research to further identify sort of the sweet spots for vaccination for any of these individual groups.

RSV Vaccine Efficacy by Season in Clinical Trials of People ≥60 Yr

So, moving us on. I think the - the importance of those recommendations and the recommendations in general are supported by what we know from both clinical trials and real-world experience about the efficacy and the effectiveness of RSV vaccines.

So, here we have from clinical trials a description of the efficacy over three seasons of RSVpreF3 pre-F3 and mRNA vaccines. And the take-home - a couple of take-home messages here. Efficacy is defined in each those studies a little bit differently. But, you know, we talked about from Dr. Carrico section, looking at severe lower respiratory disease or hospitalization, we also look at efficacy in terms of the development of or prevention of a number of lower respiratory tract symptoms.

So, take-home message for each of them is that, over the three seasons, vaccine efficacy is sustained. Another take-home message is that, over those three seasons, it might - it wanes some, but what we don't have at this point is any recommendation for a booster. So, there has not been any evidence showing thus far that we need to boost RSV vaccination or administer a second one, with the exception that I note that from immunocompromised - some of the immunocompromised conditions, a second vaccine might be recommended. So, effective over three seasons, and as the years go by, we have more experience.

Cumulative RSV Vaccine Efficacy: US Real-world Data

Now, that was efficacy. This is also a helpful study because while title tier vaccine efficacy, this is real-world data on that gives us some idea of the effectiveness of RSV vaccine from a study of people who presented to ERs and a review of their electronic health records to determine what their outcomes were: hospitalization, development of a critical - critical illness, or just an encounter in an ED.

And what we see here, as well, is that among individuals who were vaccinated, there was a high degree of effectiveness in preventing hospitalization, critical illness, and ED encounters. And this compared pre-F to Pre-F3, and the effectiveness was very similar between the two vaccines. So, highly efficacious and highly effective.

RSV Vaccine Safety Data With RSVpreF and RSVPreF3

So, the “but what about”-question becomes, what about how safe are these vaccines? And over the past few years, we have contended with a couple of questions in great detail, one of which is whether or not either of these vaccines causes atrial fibrillation or Guillain-Barré syndrome. And there, at this point, is no evidence of a causal association or a causal effect of - for AFib or Guillain-Barré with either RSVpreF or pre-F3.

What has been identified in post-market surveillance, however, is that among people who received the vaccines, there was a slight increase in atrial fibrillation, but I can also state that some of the comparisons were to say, well, does this happen anymore with RSV vaccine than with influenza vaccine? And the answer there is no. So, perhaps a slight increase, but no significant association with RSV vaccine. And there's a suggestion that there's a decrease in recurrent atrial fibrillation with RSV vaccinations, and that might have something to do with what happens with people preventing other illness and the complications attendant to RSV infection.

There has been a signal picked up with a slight increase of cases of RSV-associated or RSVpre-F3-associated Guillain-Barré syndrome. Enough so that the FDA had placed that information, sort of as a warning or information with the vaccines, but the determination of FDA has been that the benefits of the vaccines outweigh their risks. But the warning has been added. No causal association.

RSV Vaccine Coadministration Safety Data

Data that we have now indicate that co-administration with other vaccines is acceptable. RSV vaccine can be given with COVID-19 vaccine, pneumococcal Tdap, shingles, and influenza - influenza vaccines. If vaccines aren't administered on the same day, you don't have to wait any particular interval to administer again.

So, with your individual patients, you may be determining co-administration based on their - their desires. And you base co-administration on the risk of acquiring vaccine-preventable disease, etc., and your patient preference. This comes up sometimes, especially during the beginning of respiratory viruses, and when ideally is when you would administer the RSV vaccine, and that's when you would ideally be administering flu as well.

Panel Discussion

So, Dr. JAM, are you joining us?

Dr. Jacinda Abdul-Mutakabbir (University of California): I am. Thank you so much, Dr. Mullen and Dr. Carrico, for your beautiful presentations. I think it was so great to hear the information that you both brought forward. And you know what? Backstage, we talked about some questions we wanted to get into. But as you both were presenting, I say, you know what? I think we got one that the audience could really stand to hear.

So, one thing that I really gathered from you all's insights and your information, and something that also kind of got me thinking, was just how do we present this information and how do we deal with that misinformation that may be out there pertaining to RSV? So, doctor, Dr. Ruth, I hope you're okay with me starting with that question. And I would love to get your insights. How do you navigate that with your patients, providing that - that evidence based information to them?

Dr. Carrico: Sure. I think, you know - I think the important thing is I always start with wherever the patient is. And, you know, one thing that I've learned since COVID is, you know, my - I used to have kind of the canned presentation. Here's where we, you know - I started the same place. So, it's almost like I used to have a one-size-fits-all. Now I realize that one size fits one, right? And so the important thing is, you know - where is my patient in there?

So, I oftentimes, you know, start with not every vaccine is right for every patient, but let's talk about you. What is it about you that places you at increased risk? And then I want to hear what their thoughts are. This gives them a chance to tell me, you know, what they heard from, you know, a neighbor or read on Facebook or whatever, and then begin to - to say, well, how about if I provide you with some information that I have? And so, you know, I validate the fact that they heard this, and this is a concern. I don't necessarily validate that - that it is true. Because, you know, we'll hear the whole gamut of, you know, of all kinds of, of information, some that's just marginally wrong and then some that's, you know, incredibly wrong. And it - it's, you know, it may be a fact of just misinterpreting what they heard or putting it into their - the story of their life incorrectly.

So, it gives me a chance to provide that information, try to make it relevant to them because, you know, they're not interested necessarily in the population-based information. So, Dr. Mullen, when you talked about like, you know, what have we gotten from the clinical trials that used to be important? Now that real-world evidence becomes more important and it gives me a chance then to try to figure out where the patient’s coming from, what their values are, what they have heard, what their life is like. But it reminds me that it - it ultimately, it brings it all back down. And remembering that that patient now is an N-of-1.

And so, what is it about them? And then make it relevant to them, and then listen to their concerns and be guided by what they are telling me or what their fears are. But at the end of the day, they want to know, will this vaccine help me? And will this vaccine hurt me? And so, Dr. Mullen, you gave me some great talking points to use as part of that discussion.

Dr. Abdul-Mutakabbir: 100%. So, I think that is wonderful.

Dr. Mullen: That's why I talked around and kept repeating signal, but no causation. This came up as a concern, AFib, Guillain-Barré, because in addition to everything that Dr. Ruth said, I want to point out that we have to be confident in the data ourselves to be able to instill confidence about the real-world experience and real-world evidence as well.

Dr. Abdul-Mutakabbir: 100%. Thank you so much, Doctors Carrico and Dr. Mullen. 100%, I agree with every sentiment there. I could not have said it any better.

I do want to bring up an area. So, if you are vaccinating those folks that fall outside of that age range, there may be conflicting information as to whether you can give that vaccine, whether you will be reimbursed if you were to give that vaccine, so on and so forth.

I do want to provide the preface that this is a growing area that we have here, and honestly, it's one that we are all learning together in this moment. So, I want to say that some - for some states, it does vary. So - and I - and I know from even clinician to clinician, it varies from the conversations that I'm having with different colleagues.

So, the vaccines are now - all three of them - approved for those individuals 18 plus. So that accounts for our individuals that may not fit that age recommendation, but they do maybe fit the disease recommendation. So, maybe our immunocompromised folks. So, what I have been hearing is, you know, we have some states that are going with that FDA approval. And then we have some states that are - so some insurance providers - providers that may not provide reimbursement because it does fall outside of that - that age range.

What I can say is what you can do is you can, you know, navigate whether that would - whether the vaccine would be covered before administering that vaccine there, just to ensure that, you know, reimbursement will be something that occurs.

I think I can wrap this up with saying that this is a growing area of evidence and information, and it'll really be kind of a real-world experience that we have. I do hope that with this upcoming viral season, that we have a little bit more clarity on whether we'll be reimbursed. But once again, it is really kind of down to the states to make that decision on how they will navigate with their reimbursement with RSV. At the very least, that's what I'm hearing from colleague to colleague.

So, I will pass it back to you, Dr. Jewel, to wrap up this section of the presentation.

Describing Benefits of RSV Vaccines: 4 Talking Points

Dr. Mullen: Great. Thanks. So, just really wrapping up. In discussing the benefits of the vaccines, there are these four talking points. Consider the complications. Remembering that there are older adults and others with certain conditions that place them at higher risk. And I - I always say no - no scaring people into wanting to get vaccinated, no doom and gloom, just here something to benefit you.

Something else, thinking back to Bruce and that wow, if I knew then what I know now, maybe I would have done more because I got RSV, these are my words, not his, but there was actually no specific treatment for that. And I was quite sick. And I'm still impacted.

Vaccines are available. We just talked about their safety. We've touched on reimbursement. And in general, we know that vaccine - these vaccines are safe. The two issues that we talked about are AFib, Guillain-Barré, no causal relationship. And the general consensus is that getting the vaccine is safer than worrying about those - those two signals that don't have any associated causation.

And then the last thing I would say is if people understand what RSV is, they'll understand the benefit of vaccine more. So, also remember that some people may not have heard of it.

Collaboration With Patients to Increase RSV Vaccine Uptake

Poll 3

So, what we'll get started with is poll three. So, please enter in your barriers that you encounter in collaborating with patients to increase RSV vaccine uptake. So, I will give you all a second to go ahead and put those put - those here.

RSV Vaccine Discussion Roadmap

So, when we think about just this vaccine discussion roadmap, I always say to myself, we have to have a point in which we start. And this is an evidence-based roadmap that we have. So, first and foremost, engage. And I think that doctors Mullen and Carrico really brought that forward with us when they talked about how it is that they engage to combat that misinformation.

So, when we want to establish a partnership and build rapport with that patient, right? We're humans. We like connection, we want to connect. And then we can guide. We can have an open discussion about that RSV vaccine. Me personally, I like to do a yes and approach. So, similar to what Dr. Ruth mentioned, you let them tell you what they've heard about the vaccine, what they - what they're coming into this conversation with. And then you can go ahead.

And that leads us right there to that step three as well, you can provide - you can ask for permission, and you can provide the information that you now have. Dr. Mullen gave you all a lot of great data, evidence-based points to now bring into that conversation.

And then we can summarize, and we can plan because at the end of the day, we want this to be a sustained change, a sustained decision that these individuals make about their health.

So, we can bring we can engage them in that conversation. We can guide them and navigate them to that evidence-based part of that conversation. And then we can summarize, and we can plan. What do we do with this? Are they now ready to get that vaccine? And we continue to remind ourselves, even though it may not be a yes in that moment, that doesn't mean that you can't ever get a yes about that vaccine. So, every encounter is an opportunity for us to get that person one step closer to vaccination.

CDC SHARE Framework: An Approach to Vaccine Conversations

And the CDC also has the share framework. This is one that I use consistently. So, it was really just another way for us to engage in conversation. So, they also have a share. So, we can talk about why the - the reasons why that vaccine is right, Dr. Mullen said, right, you have to let people know that these are the risks for the vaccine, so that they can identify if they fall within that risk.

I do a - a vaccine education program. And I cannot tell you the number of people that did not even know the comorbid conditions that place them at risk. And they say, if I had known, I would have done so. We can highlight just a positive experience with vaccines, personal or clinic. I sometimes bring about my family's experiences. I have a dad that has congestive heart failure. When he and - he had not been vaccinated against the flu, he ended up in the hospital in a very critical situation. But every year since, he has gotten vaccinated, and he has now been in a better predicament. And I share that story as to urge other individuals to get vaccinated.

We can address the patient questions and concerns as we talked about previously. We can remind them not only do the vaccines protect them, but protect their patients. Dr. Mullen brought up, right the IDSA guidance. If people are immunocompromised, it's not important that they - that the immunocompromised person gets vaccinated, not only them, but also those people around them, right? So, that they can have maximum protection.

And then we can explain the potential cost, the hazards of getting the disease. I'm an antimicrobial resistance researcher. So, that's my conversation. I say, you know what? If you don't get vaccinated, that can put you at risk of being in a hospital and then developing an even worse infection for some of these diseases, like RSV, we don't have effective treatments, or you can be exposed to even worse organisms, which can really make your predicament even worse. So, we can bring those into the conversation.

Panel Discussion

So, I'm going to - I'm here again with another panel discussion.

So, I want to pose this first to Dr. Mullen. How do you modify your RSV recommendations based on the patient's priorities? And then after that, Dr. Carrico, if we could get your perspective.

Dr. Mullen: That's great. I basically asked them what - what their inclination is. So, you know, we're not in a shared decision-making framework, but we've had a conversation. And as you've just laid out, I've tried to present all the information that will hopefully lead them to want to receive a vaccine or continue to consider it if they're not ready yet.

So, I try not to suggest what some people are concerned about, which is too many shots at one time. I try I stress risk in terms of seasonality. We know when we have respiratory disease season. I talk to people about what's important to them and how we can maximize the possibility for them to live the life they want to lead. And then, if they've heard something about either GBS or AFib, we put that in some kind of context as well.

And then sometimes it'll just come down to where do we land today? But also with the conversation, if there's a team that we know that we're supporting a person, the next time they come in, leave the door open in case they want to call another week later. And if I have somebody who says, oh, I'm not coming back for a year, because that's all my insurance is going to pay for, if we're not in respiratory disease season, although the interval might not be, the timing might not be great, let's give you your RSV vaccine now, because I might not see you again in September.

Dr. Abdul-Mutakabbir: Fabulous. Dr. Carrico, one - if you wouldn't mind wrapping us up.

Dr. Carrico: Sure - sure. And I think, you know - I try because we have limited amount of time oftentimes with our patients. Sometimes I'll try to wrap things together. So, for example, I may be talking with a patient about diabetes management. And that this is kind of part of that. All right, you know, because diabetes is, you know, is - is a risk factor for severe disease, whether it's RSV or flu or COVID, you know, and try to wrap all of these things together, make it part of disease management instead of something that is necessarily separate.

So, the - the individual sees that, you know, there is a reason behind this. There is a, you know - a bigger purpose. And I know we all want the same thing. We want the best outcome. Doctor Jewell, just as you said. You know, the - how do the - how do the patient live their best life. This is part of it.

And that we can't necessarily forecast. I can't look into the future and say which of these diseases of breathing may impact you, you know, the soonest. It's because we don't know. And because we don't know, let's do what we do know as providing best opportunity for best outcomes, and then present that and then be prepared to accept the patient's decision. And then, you know, for a yes or no. And then that becomes part of our, you know, plan for next visit or next day.

Dr. Abdul-Mutakabbir: 100%. Thank you both so much. I could not supplement it with any other meaningful information that is different. So, thank you both, and I hope that that was helpful to our - to our audience.

Collaboration in the Healthcare Team to Close RSV Vaccination Gaps

So finally, I bring us to the last section of our presentation, collaborating in that health care team to close RSV vaccination gaps.

Poll 4

So, what barriers do you face to RSV vaccination in your health care team?

Importance of a Team-Based Approach to RSV Vaccination

So, when we think about just that importance to a team - team-based approach to RSV vaccination, one thing that I say, and I hope that you all see from the diverse expertise on this, within this conversation, everyone is a participant. Make this a team effort. We can develop a standardized process for vaccination, ensuring coordination between specialty primary care providers. And then we can collaborate with pharmacists. So, oftentimes and a lot of our adult vaccines are provided at the - at the pharmacy. So, it was great for our - our practitioners and primary care providers, as we see here, to coordinate with pharmacists to make that - that end goal happen.

Navigating Vaccine Payments

So, navigating vaccine payments, we think that this is meaningful for you all because this can also help in navigating and moving the conversation with the patients forward. One thing I can tell you is that a lot of folks are very unsure about the coverage for the vaccine. So, Part D co - covers the vaccine administration costs. As you all see here for our adult vaccine dispensing fee, vaccine administration fee, vaccine ingredient costs, however, long-term and post-acute settings require different billing considerations and staff education. Although for our 65 plus, Plan D still usually covers this.

Navigating Medicare Vaccine Payments

When we're thinking about just navigating Medicare and then vaccine payments, our post-acute care is covered a lot of times by Part A, that vaccine there will be covered by Part D. Long term care, meaning if people are to have sustained events following being infected with these viruses, that care is provided by Part D. And then that vaccine is provided once again by that Part D.

So, for those without Medicare Part D, we can explore what that coverage looks like. It may vary by state to state, but when we consider those folks that, you know, may still fall within that disease-related parameter, so those with immunocompromised illnesses and so on and so forth, a lot of those things are covered under Medicare Part B, but those are conversations that we navigate with those patients that fall within those within those areas.

Panel Discussions

So, I'm going to bring us here to our last panel conversation. How do you work within your own health care team to promote RSV vaccination?

Dr. Carrico: Well, I think I want to reinforce exactly what you said, Dr. JAM, that this is a team sport. Our goal is to get the vaccine out of the refrigerator and into our patients. And so - and we only do this as a team. And I try to take advantage of the varying relationships that people will have in - in the practice. For example, you know, we - we'll - we may have a medical assistant that really is like a, you know - knows every patient really involved with them. That may be the person that I rely on to have then a, you know - an - a discussion of - of substance with - with patients.

I also want to find out what they're hearing. And I want to know what they are feeling because we all need to be in lockstep, we all need to be, you know, singing from the same hymnal, maybe not using the same words, but we all need to be having the same message.

And I want to find out what are the barriers, what are the challenges that they are having? Because maybe there's some, you know, some individualized role playing that we may want to do, you know, in the office. And then take advantage of technology using the patient portal, text messaging, whatever else. It's not an easy thing to do, but it's an important thing to do that it is a team process.

Dr. Abdul-Mutakabbir: 100%. Dr. Mullen, if you had - if anything, different or additional to add.

Dr. Mullen: Briefly, especially seeing what some of the barriers were that people listed, remember and remind people that RSV is a life course condition. We're talking about adults, and some people really still are just thinking about RSV in infants and babies. There's family interest. There's life course interest. And, as we continue to worry about childhood immunizations, let's not forget that many adults can also fall through the cracks, and RSV is one where we haven't even filled the cracks yet. So, let's try to do a good job with that as we keep immunization rates up in general.

Dr. Abdul-Mutakabbir: 100%. Thank you both so much. Once again, you have covered the bases. I could not agree more. Integrate your interns. Integrate the students. Integrate the medical assistants. This is a team sport. Everyone can have a role. There's never - there is never not a good opportunity to bring up preventative care.

Key Take-home Points

So, as we conclude this presentation, I do want to give some key take-home points. RSV called the substantial morbidity and mortality in older adults. We can - we - we have our several disease risks there. Vaccine inequities persist. Several FDA-approved RSV vaccines exist with strong efficacy, and coadministration is acceptable. RSV vaccines are generally safe. And then the vaccine uptake may improve with collaboration within the health care team.

Posttest 2

So, for our posttest if, can you all let us know if you are confident in discussing RSV risk and vaccination benefits with eligible adults? Remember this from the first time, from the first go round, this is now your opportunity to show everyone what you have learned. So, if you can go ahead and respond to that question there, please.

Dr. Abdul-Mutakabbir: Thank you so much. We can definitely see a change from our pre-test to our posttest, with most of our responses being agree and strongly agree. So, we are so happy that you all are now confident in discussing those RSV risk and vaccine benefits.

Posttest 3

So, we will go ahead and move forward to our posttest three question. I have ideas to offer my team to improve RSV vaccine uptake among all eligible patients. So, once again, we - we are starting to

1. Strongly agree;
2. Disagree;
3. Neither agree nor disagree;
4. Agree and then strongly agree.

I'll let you all vote.

Fabulous. Once again, we are now heading more so into that agree and strongly agree area in comparison to our other groups. I want to say fabulous job, everyone. I'm so happy you all have ideas to offer your team for increasing RSV vaccine uptake. We will go ahead and answer that question. It was are we - are we recommending annual RSV vaccination?

Q&A

I will say that I am not recommending annual RSV vaccination, and it's really because our data does not support that currently. So, right now we are at the. You receive the RSV vaccine one time. And that is where we are stopping until we have additional data that suggests otherwise. If folks are immunocompromised, the recommendations may be different. And that is for them to talk with - with the individual that provides their care for that immunocompromising disease state.

So, Dr. Mullen and Dr. Carrico, if either of you are navigating that differently, I'm sure that the audience will really benefit from the insight.

Dr. Mullen: We'll all continue to follow the data.

Dr. Carrico: That's right. I tell my patients now, stay tuned. You know - I'm glad that they asked that that they are interested. I think our data showed that we have some waning over time. But again, not to that point that - that is creating a change in recommendation because again, we look at risk benefit. And so, you know, nothing is without risk. And we want to make sure then the benefit is clearly present to outweigh a risk of anything more frequent. And so, that requires evidence. So, stay tuned. And we will - we will revisit that, I'm sure again in the future.

Dr. Abdul-Mutakabbir: Absolutely. I think we have another question, and I would consider that same approach. So, have you considered revaccinating our high-risk patients? Once again, when I consider, you know, the data, the data does not suggest revaccinating currently at this moment. So, we do not see that significant waning to the point that a revaccination would put the patient in a better disposition if they had not had it. That is not where we are with the RSV data right now.

So, I do provide that information to patients and, you know, allow for that decision to be made. But once again, for our folks that are immunocompromising, I leave that conversation and how it is that they navigate their care with the person that is providing it. But my recommendation is guideline-based.

So, if either of you have different responses to that question, then we can supplement that. And I think after that question, we can conclude our time here.

Dr. Carrico: Absolutely. I think it goes back to the individualized conversation with their health care provider. That is a one-on-one discussion. They find out what - what is likely to be the best benefit to the patient?

And then, as I tell my patients, your insurance company is not responsible for your health, you are. And sometimes then we - we look beyond health coverage, but that has to be a decision that the patient is able to make with - with eyes wide open, because we know vaccines, although they are helpful, they are also expensive. And so, we want to make sure that we are doing things, you know, not only for health-wise, but also financially for patients. And so, this is a collaborative decision that needs to be made between the provider and the patient.

Dr. Mullen: And remember that some - some individuals may have vaccine fatigue. And there - and among older adults, there are some conditions such as strep pneumonia, where people are saying, how many more of those kinds of vaccines do I need? So, people might be happy right now to hear that we're not saying, here's another annual shot for you.

Dr. Abdul-Mutakabbir: Good point. Fabulous point. So, just these things to take on with you all as you - as you go into your practice. It has been the utmost pleasure to present alongside two of the best clinicians that I have come into been able to encounter throughout my time.

So, with that, I leave you all with the. You can go online to receive more information regarding what was presented here in this program. Thank you all for attending.