On The Cover
Sonya Collins
CDC’s ACIP has voted unanimously to recommend that everyone aged 6 months and older receive an updated 2024–2025 COVID-19 vaccine. With rare exceptions, the committee recommends that everyone in this population receive this year’s influenza vaccine as well.
In past respiratory virus seasons, COVID-19 infections have peaked between January and March. Patients are advised to get vaccines in the fall or winter and should know that it’s safe to receive both at the same time.
Pharmacists can prepare for the upcoming flu and COVID-19 season by bringing themselves up to date on recommendations and knowing why patients might push back against or decline vaccines.
“Pharmacy personnel should anticipate vaccine fatigue and hesitancy among the American public,” said Brigid Groves, PharmD, vice president, professional affairs, at APhA. “Trying to overcome that and get patients interested in receiving flu and COVID vaccines this fall may be one of the biggest challenges for pharmacists.”
Updated COVID-19 vaccines
ACIP unanimously recommended that anyone age 6 months or older get an updated COVID-19 vaccine this year. Updated vaccines will be available from Pfizer, Moderna, and Novavax. They protect against serious illness and hospitalization from COVID-19 including Omicron variants KP.2, KP.3, and JN.1, which are among those currently causing the most infections in the United States.
“They are all part of the same strain,” said Litjen “L.J.” Tan, PhD, chief policy and partnerships officer at Immunize.org and co-chair of the National Adult and Influenza Immunization Summit. “If you think of them like a tree, JN.1 is the trunk and KP.2 and KP.3 grow off the trunk.”
The updated vaccines also reduce risk for Long COVID, which can develop during or after acute infection.
“It doesn’t matter which one you get,” said Gretchen Garofoli, PharmD, associate professor at West Virginia University School of Pharmacy. “Patient preference and whether patients have had more or fewer side effects after one vaccine or the other is what’s driving patient decisions.”
At this time, ACIP has not recommended additional booster doses for members of the general population who’ve previously been vaccinated.
Pfizer and Moderna updated COVID-19 vaccines
Pfizer and Moderna offer mRNA vaccines, marketed under the respective brand names, Comirnaty and Spikevax, which are made with the same technology used since the vaccines were first launched nearly 4 years ago in 2020. mRNA vaccines do not contain deadened virus. Rather, they contain mRNA that directs cells to produce the spike protein such as the one on the surface of the coronavirus. The immune system then recognizes the foreign protein and produces antibodies against it.
These vaccines are approved for anyone 6 months or older with specific recommendations for the following groups:
- Children ages 6 months to 4 years: At least one dose of the updated vaccine after the initial series is complete.
- Everyone ages 5 to 64 years, including those who are pregnant, breastfeeding and who might become pregnant: One dose.
- Adults ages 65 years and older: Two doses at least 4 months apart.
- Anyone who is moderately or severely immunocompromised: One dose of updated vaccine; more depending on the number of previous doses received.
- Adults over age 65 years who are immunocompromised: An additional dose at least 2 months after the first.
Novavax updated COVID-19 vaccines
The Novavax vaccine, marketed under the brand names, Nuvaxovid and Covovax, is the fourth COVID-19 vaccine to be available in the United States (after the Johnson & Johnson vaccine, which is no longer available). As a protein adjuvant vaccine, it’s easier to make and easier to store than its mRNA counterparts. Where the mRNA vaccines inject the instructions for making the spike protein, Novavax’s protein adjuvant vaccine injects bits of the spike protein itself.
Novavax is approved for anyone 12 years or older.
These are the specific dose recommendations for those who choose Novavax:
- People aged 12 to 64 years who have had a COVID-19 vaccine before: One dose.
- People aged 65 years and older who have had a COVID-19 vaccine before: Two doses, 4 months apart.
- People aged 12 to 64 years who have never received a COVID-19 vaccine: Two doses, 4 months apart.
- People aged 65 years and over who have never had a COVID-19 vaccine: Two doses, 4 months apart, followed by one additional dose of any COVID-19 vaccine.
- People who are immunocompromised: At least one dose, possibly more depending on their COVID-19 vaccine history. Those who are not previously vaccinated start with two doses, 3 weeks apart. People who are immunocompromised, unvaccinated, and over 65 years old need another dose at least 2 months after their first.
Updated influenza vaccines
ACIP recommends an updated influenza vaccine for most people aged 6 months or older. This season’s vaccines are trivalent and protect against H1N1, H3N2, and B/Victoria strains of the virus and also include a new A(H3N2) strain.
The committee recommends high-dose inactivated (HD-IIV3) and adjuvanted inactivated influenza vaccines as options for solid organ transplant recipients ages 18 to 64 years.
People who have severe, life-threatening allergies to any ingredient in a flu vaccine, other than egg proteins, should not get the vaccine. People who have had a severe allergic reaction in the past should not get that flu vaccine again and may not be able to get other flu vaccines.
Access barriers widen
While the pandemic presented new, additional, or more challenging barriers to vaccine access for members of minority groups and certain other demographics, the end of the pandemic did not mean the end of access challenges for these underserved groups. It’s important for pharmacists to know that vaccine equity is an ongoing challenge independent of the COVID-19 pandemic.
“If anything, I would say the access problems have gotten worse,” said Jacinda “JAM” Abdul-Mutakabbir, PharmD, assistant professor of clinical pharmacy at University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, “now that the urgency of the pandemic has tapered off.”
With the exception of Asian Americans, people of color are significantly less likely to receive influenza vaccines. More than half of white people and Asian Americans get vaccinated. In comparison, about 43% of Black adults received a flu vaccine last season and 37% of American Indians, Alaska Natives, and Hispanic adults did.
As for COVID-19 vaccines, vaccine uptake among Black people trails any other group. But, Abdul-Mutakabbir said, this discrepancy underscores problems with access to vaccines, not attitudes toward vaccines.
“It’s not a matter of folks not wanting them,” she said. “A lot of those easy ways that folks had to get the vaccines just don’t exist anymore. It’s not that they don’t want them. They can’t get them.”
Geography presents a barrier to accessing vaccines, too. In rural areas, about 40% of adults get flu vaccines compared to 48% of urban- and suburban-dwelling adults. This disparity, according to CDC, is widening.
“Some folks who live in rural communities don’t have a pharmacy for miles and miles and some of these folks may not have cars,” Abdul-Mutakabbir said. Bringing vaccines to churches and other places that rural residents know and can easily access, she said, “makes all the difference.”
As of May 2024, 22.5% of U.S. adults received an updated 2023–2024 COVID-19 vaccine. Those rates directly correlated with urbanicity. Among city dwellers, 24% got the updated immunization, while 22.7% of suburbanites and 17.9% of rural residents had.
Abdul-Mutakabbir advises pharmacists who formed relationships with underserved communities during the first wave of COVID-19 vaccination to continue to leverage those partnerships to bring vaccines to those populations. She stresses that it may not be necessary to convince people to take the vaccine, but rather the real need may be to get the vaccine to them.
As the CDC’s Bridge Access program ended in August, it will become harder to deliver COVID-19 vaccines to low-income and uninsured patients. Some states may purchase vaccines for distribution to uninsured adults. In those states, health departments may offer free or low-cost vaccines to some populations.
If you need to refer patients for free or low-cost flu vaccines, Tan said, “Look for health fairs, churches, synagogues, community centers, and free clinics that might offer free or subsidized flu vaccines.”
He added that some pharmacies offer discounted flu vaccines to patients enrolled in a program with them. Some offer discount vouchers to patients who get vaccinated with them. Urgent care facilities may offer a discount on flu shots for cash-pay, uninsured patients. Discount programs such as GoodRx have offered discounted flu and COVID-19 vaccines in the past and may do so again this year.
Because 90% of the U.S. population lives within 5 miles of a pharmacy, and flu and COVID-19 vaccines are conducive to administration in the pharmacy, all pharmacists can play a critical role in vaccine access.
“We can go very far by inquiring as to whether someone would like a vaccine, making a strong recommendation, and providing factual information on how vaccines work to prevent illness,” said Abdul-Mutakabbir. “We are by far the most accessible health care provider. We need to lean into that.”
Anticipate patient concerns
Pharmacists can plan how they might address common questions, concerns, and pushback against vaccines.
Some data suggest that people are requesting and accepting flu vaccines at lower rates than they were before the COVID-19 pandemic. “The flu somehow got pulled into all the negativity around the COVID vaccine and people stopped looking for the influenza vaccine,” Tan said.
Pharmacists should be aware, Tan continued, that they may need to be more proactive about offering vaccines this year rather than waiting for patients to ask for them.
“If you have patients in particular who have diabetes, heart conditions, or obesity, you need to be advocating to get them vaccinated because they don’t seem to be asking to be vaccinated as much as they used to.”
Pharmacists can also expect to hear, “I’ve already had enough COVID shots and/or COVID infections.”
Pharmacists can stress that previous COVID-19 vaccines protected against previous variants of the virus. “This virus is a superior mutator,” Tan said. “It doesn’t matter if someone’s been vaccinated or infected before. Those vaccines don’t do as well against these new strains.”
Pharmacists may also point out that immunity wanes after vaccination or infection. “Talk about how long the vaccines last,” Garofoli said. “These aren’t one-and-done vaccines that protect you for the rest of your life. We need it every season.”
Patients may also say, “I always get the flu/COVID shot, and I get sick anyway.”
If patients are referring to adverse effects felt immediately after the vaccine, Garofoli said, “Never brush off a patient’s complaints that they feel crummy after getting the vaccine. Remind them that side effects are their body’s way of building up a response.”
As for patients who get vaccinated and contract COVID-19 or the flu after the vaccine has taken effect, Garofoli said, “Let them know that infections in vaccinated people are likely milder and that the vaccine protects them against hospitalization and death.” ■