Sept. 5, 2023 – Move over, flu shot. This autumn, the seasonal vaccine list is longer, more complicated, and could cost more. Besides the flu shot, COVID-19 boosters are expected to be out in mid-September, and a new vaccine for RSV (respiratory syncytial virus) is here.
With that news comes many questions, including who might safely skip the COVID booster this time, why some eligible for the RSV vaccine must pay out of pocket, and whether one vaccine should be viewed as more important than others. Then there’s the back-and-forth about how important it is to get the COVID booster in the same arm as last time. (And did everyone write down which arm that was?) And can you get all three shots in one fell swoop and call it a day?
There’s also the question public health experts can’t answer yet: Will the public be on board with all, some, or none of these vaccines?
The Gamut: From Eager to Fatigued
When it comes to vaccines, the population is generally divided into three groups, said Aaron Glatt, MD, chief of infectious diseases and hospital epidemiologist at Mount Sinai South Nassau in Oceanside, NY, and a spokesperson for the Infectious Diseases Society of America.
One group trusts the science and the process and will take the recommended vaccines, he said. “Some, a sizeable minority, are vaccine hesitant. They need to be shown the data and shown why it’s important for them.” Another group will decline all vaccines, he said, “no matter what.”
“We have people who can’t wait to get their vaccines,” agreed Luis Ostrosky, MD, chief of infectious diseases and epidemiology at UTHealth Houston and Memorial Hermann Health System who is also a spokesperson for the Infectious Diseases Society of America. They call the clinic, often, wondering when they can get them. “Then we have people who are completely [vaccine] fatigued.”
Ask a circle of friends and acquaintances to weigh in, and you may get what an informal Facebook poll produced – reactions all over the board:
- “I am mandated by work to receive flu vaccine and COVID booster. I would get them even if not mandated.”
- “We will get them all.”
- “I will definitely get all the vaccines annually because without them, we would return back in time when people were having their whole life affected by illnesses like polio, tuberculosis, chicken pox, etc."
- “I have not and will not get any of those vaccines.”
- "Full tilt boogie. All the vaccines."
Here is what’s known about the vaccines and what’s to be determined.
COVID Boosters
In June, the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) recommended COVID-19 vaccines for use in the U.S. beginning this fall be updated to a monovalent vaccine targeting the Omicron variant XBB.1.5.
Pfizer, Moderna, and Novavax are expected to offer the updated vaccines, and the FDA is expected to authorize them soon.
For the 2-week period ending Sept. 2, the Omicron variant known as EG.5, or Eris, accounted for 21.5% of U.S. COVID cases, the CDC reported, the most of any variant. According to the Infectious Diseases Society of America, the updated vaccines are expected to protect against this variant.
As of Aug. 23, the CDC is monitoring another new variant, BA.2.86, with 37 reports of it globally (including four in the U.S.). Scientists are looking into how well the updated boosters work against it.
When: Updated COVID vaccines are expected by mid-September, CDC Director Mandy Cohen, MD, MPH, said in a video statement in late August. The first step is the FDA’s regulatory action, then the CDC weighs in. The CDC’s Advisory Committee on Immunization Practices (ACIP) is scheduled to meet Sept. 12 and vote on recommendations for the COVID boosters. Next, the CDC considers the ACIP recommendations and makes its recommendation. The boosters could be available soon after that.
Who needs it? The advisory committee and the CDC will make those recommendations. Meanwhile, experts said that some people may be more in need of this booster than others. “The very elderly who have not been vaccinated within the last 4 to 6 months, people with severe immunocompromise who haven’t been vaccinated within the last 4 to 6 months, and those in high-risk groups who haven’t been vaccinated in the past year are reasonable suggestions,” Glatt said. At this point, he said, “it is very reasonable for some people to decide they are not in need of an additional shot at this time.”
Costs: As the U.S. government sunsets its COVID-19 vaccine program, COVID vaccines are heading to the commercial market. Insured people will likely be covered. Health insurance companies follow the recommendations from the CDC’s Advisory Committee on Immunization Practices when it comes to vaccines, said James Swann, a spokesperson for America’s Health Insurance Plans (AHIP), an industry group. But, he said, it’s not yet known for whom the updated COVID vaccine will be recommended.
The CDC will provide access through the Vaccines for Children program and the temporary Bridge Access Program, due to launch this fall, for uninsured and underinsured American adults.
RSV
The FDA approved two new vaccines to protect against RSV in older adults. This potentially lethal respiratory infection leads to the hospitalization of 60,000 to 160,000 adults ages 65 and up each year and 6,000 to 10,000 deaths in that age group. GlaxoSmithKline’s RSV vaccine is Arexvy, and Pfizer’s is Abrysvo. On Aug. 21, the FDA also approved Abrysvo as the first RSV vaccine for pregnant people during weeks 32 through 36 of pregnancy to protect the baby. Along with older adults, infants are very vulnerable to RSV.
Who needs it? The CDC said adults over age 60 may get the vaccine after discussing it with their health care provider. The CDC has not yet made recommendations on the maternal RSV vaccine. According to a CDC spokesperson, the agency and its advisers are working to set a date to discuss those recommendations. Expect that meeting to occur before the end of October.
Costs: Those who have Medicare Part D, the prescription drug coverage, are covered for the RSV vaccine. But those without Part D are not, and out-of-pocket costs can be more than $300. As for private health plans, “health insurance providers are preparing to implement coverage, though it may take some time to get the appropriate processes in place, and coverage may vary depending on the type of insurance an individual may have,” Swann of the insurance industry group said.
Influenza
Flu vaccines are already available for the 2023-2024 season.
Who needs it? The CDC’s advisers recommend everyone 6 months and older receive a flu shot, ideally in September or October.
For the first time, the CDC has said that those with egg allergies can get any flu vaccine. Most flu vaccines are made with small amounts of egg protein, but the risk of a severe allergic reaction is low, according to the CDC, explaining the change.
Costs: “Coverage of flu vaccines will be routine as in past years,” Swann said. Medicare Part B covers the flu shot each year. Flu shots are part of the preventive care required under the Affordable Care Act and are free with most insurance plans.
Logistics
Better to get these vaccines one at a time, all at once, or COVID and flu, then RSV? And which arms? Last year, some people got both the flu and the COVID booster at once, without issues, Glatt said. “You can get all three at the same time. We just don’t have a lot of experience with it.”
If someone has had significant side effects from vaccines in the past, he said, “it probably makes sense to spread them out.”
Ostrosky plans to suggest patients wait a couple of weeks after getting the COVID and flu shots before getting the RSV vaccine, just to make sure any reactions have gone away. But that order might be different for a pregnant person wanting to get the RSV vaccine, depending on how far along the pregnancy is.
According to the CDC, giving both the flu shot and the COVID shot at the same time is acceptable, either in separate arms or the same one, although one study found that reactions increased by about 8% to 11% when both were given at the same time.
Getting COVID booster shots in the same arm as the COVID vaccination may offer more protection, one study found.
There’s debate about the “ideal” time to get a flu shot, with some wanting to wait until, say, late September so the protection could carry them through the entire flu season. Glatt recommends getting a shot if there is already flu circulating where you live.
To lessen side effects, some people take a “preventive’’ dose of pain relievers. It’s an approach Glatt does not recommend. Instead, he suggested taking these to address side effects once they occur. “Most people don’t need to take anything,” he said.
Expectations and Side Effects
Communications with friends and on social media before getting a vaccine could impact the chance of having side effects, research suggests. Andrew L. Geers, PhD, a professor of psychology at the University of Toledo in Ohio, and his colleagues asked 551 people how much they listened to comments about vaccine side effects from social media posts, news reports, and first-hand accounts from acquaintances before getting the shot. They then asked about side effects after getting the vaccine.
“What we found was, individuals who saw more social media posts about the vaccine side effects reported more side effects,” he said. “Individuals who heard more negative comments from family and friends, same.”
Listening to news reports, he found, did not have an effect on whether people were more likely to have side effects, although he is not sure exactly why. He speculated that the social media communication and talking with acquaintances are more likely to include people we have existing social bonds with, “something that can make communication more persuasive.”
Geers said he is not discounting the fact that some people do have reactions to vaccines, and they should not be ignored. His advice: Don’t expect the worst outcome. “Rather than thinking about all the negative side effects, focus on the positive – what you are doing for yourself, your family, your health.”