RSV and Vaccine Hesitancy: Overview of Respiratory Vaccines and Delivery for the Clinician

Podcast Transcript

Respiratory Exchange Podcast Series

Release Date: May 8, 2024

Expiration Date: May 7, 2026

Estimated Time of Completion: 40 minutes

Overview of Respiratory Vaccines and Delivery for the Clinician

Trate DeVolld, PharmD

Kaitlyn Rivard, PharmD

Description

Welcome to a special series by the Respiratory Exchange Addressing the Impact of RSV and Vaccine Hesitancy.  In this series, we explore the efficacy of RSV vaccines and discuss preventive strategies aimed at reducing the occurrence of severe RSV respiratory illness in infants, children and older adults.  

In this episode, Dr. DeVolld and Dr. Rivard will present a comprehensive analysis of the various types of vaccines available, highlighting their safety and efficacy. Additionally, they will shed light on the crucial role that pharmacists play in vaccine delivery, emphasizing their ability to assess a patient's eligibility for the vaccine and report it into the state's immunization registry to prevent any duplications. 

Learning Objectives

• Evaluate the importance of pharmacists in vaccine delivery, including their ability to administer vaccines, educate patients, and ensure vaccine safety.
• Identify the different types of vaccines available, such as protein-based, mRNA, and prefusion vaccines, as well as passive immunization through the administration of antibodies.

Target Audience

Geriatricians, infection disease physicians, intensivists, nurse practitioners, nurses, obstetricians/gynecologists, pediatricians, pharmacists, physician assistants, primary care physicians, pulmonologists, and other prescribing and non-prescribing providers. 

Accreditation

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation 

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.75 ANCC contact hours.

• American Academy of PAs (AAPA)

Cleveland Clinic Center for Continuing Education has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.75 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.

• Accreditation Council of Pharmacy Education (ACPE)

Cleveland Clinic Center for Continuing Education designates this knowledge-based activity for a maximum of 0.75 hours. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion.  Universal Activity Number List:

- Pharmacist UAN: JA0000192-0000-24-467-H06-P

Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

Cleveland Clinic Planning Committee for Addressing the Impact of RSV and Vaccine Hesitancy Series

Cecile Foshee, PhD
Co-Activity Director
Director, Office of Interprofessional Learning

Steven Gordon, MD
Co-Activity Director
Chairman, Infectious Disease Department

Kaitlyn Rivard, PharmD
Co-Activity Director
Department of Pharmacy 

Nichole Brown, MSN, RN, CHSE-A, PhD(c )
Nursing Institute

Neal Chaisson, MD
Department of Critical Care Medicine
Department of Pulmonary Medicine 

Frank Esper, MD
Pediatric Infectious Disease
Cleveland Clinic Children’s Hospital 

Debra Kangisser, PA-C
Director of Education
Physician Assistant Services

Aanchal Kapoor, MD, Med
Department of Critical Care Medicine
Department of Pulmonary Medicine

Steven Kawczak, PhD, CHCP, FACEHP
Co-Medical Director, Center for Continuing Education

Neil Mehta, MBBS, MS
Center for Technology-Enhanced
Knowledge and Instruction
Associate Dean of Curricular Affairs, Cleveland Clinic Lerner College of
Medicine

Anne Vanderbilt, APRN
Senior Director, Advance Nursing Practices
Center for Geriatric Medicine

Hannah Wang, MD
Director, Molecular Microbiology & Virology

Faculty

Trate DeVolld, PharmD, AAHIVP
Department of Pharmacy
Cleveland Clinic

Kaitlyn Rivard, PharmD
Infectious Disease Clinical Specialist
Department of Pharmacy
Cleveland Clinic

Host

Steven Gordon, MD
Cleveland Clinic Chairman of Infectious Disease Department

Agenda

Overview of Respiratory Vaccines & Delivery

Trate DeVolld, PharmD, AAHIVP

Kaitlyn Rivard, PharmD, BCIDP

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest: 

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Nichole Brown, MSN, BSN, 
Trate Allen DeVolld, PharmD, RPh, Cecile M Foshee, PhD, Steven Mark Gordon, MD, Debra Kangisser, PA-C, Aanchal Kapoor, MD, Steven Kawczak, PhD, Neil Mehta, MD, and Anne Vanderbilt, APRN. 

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC, AAPA, ACPE Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: http://cce.ccf.org/ccecme/process?site_code=main&activity_session_code=EHCE05703

to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Acknowledgement: 

The Cleveland Clinic Center for Continuing Education acknowledges an educational grant for support of this activity from ModernaTX, Inc.

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Podcast Transcript

Dr. Dweik:

Hello, and welcome to the Respiratory Exchange Podcast. I am Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today as well as the patients of tomorrow. I hope you enjoy today's episode.

Dr. Gordon:

Welcome to another special edition of the Respiratory Exchange, my name is Steven Gordon. I am the Chairman of the Department of Infectious Disease at the Cleveland Clinic, and it is a pleasure for me to have two of my brightest colleagues who have helped me out innumerably. We have Katie Rivard, whom I have known for a longtime, and we will discuss some of that in terms of our pandemic issues, who is an infectious disease pharmacist, as well as Trate Devolld, who is relatively new to the team. But I am pleased to have you both, and welcome.

Dr. Devolld:

Thanks.

Dr. Rivard:

Thanks, Dr. Gordon.

Dr. Gordon:

I think to start it would be helpful for our audience to hear a little bit about each of your backgrounds in terms of how you got to the position that you are in now, a little bit about your narrative. So, Katie, we want to start with you.

Dr. Rivard:

Yes, of course. I became a pharmacist over 10 years ago and did my first year of residency training in Michigan, and really wanted to specialize in infectious diseases because I found it to be such an interesting and dynamic specialty. So, I did my second year of residency here at Cleveland Clinic actually, and then was fortunate enough that a position was available when I graduated, so I could stay on in the role of the pediatric infectious disease pharmacist, since immunizations are so important in children. When I took this position, I also started to lead a lot of our vaccine initiatives in the pediatric space. And when the pandemic started, it was a natural progression for me to help lead our COVID-19 vaccine initiatives. And through that, we realized that it is probably best to have a pharmacist involved, not only for pandemic vaccines, but for all vaccines. So very recently, my role transitioned, and I now oversee vaccine operations for the health system.

Dr. Gordon:

Well, thank you. Thank you. And Trate?

Dr. Devolld:

Yeah, thanks for having me. I am actually on the other side of my career, and just getting started. I graduated from Ohio Northern University in 2022 with my Doctor of Pharmacy.  I interned for the clinic for about six years and decided that I was not done with my journey here. So, I stayed on last year as a first-year pharmacy resident, completed my training, and stayed on this year to specialize in infectious diseases and work more closely with this team. My interest areas in pharmacy school surrounded public health and infectious diseases as well. And so, lot of my research as a student surrounded the relationship between pharmacists and medical providers, in developing public health initiatives and the way that we are training those pharmacists and those medical students in order to become a public health advocate in that space. So that research became the foundation of my interest and got me interested in RSV and other vaccination-based principles for preventative diseases as well.

Dr. Gordon:

Well, thank you, Trate. And that is a great segue to the focus of today's problem, which is really about the evolution of vaccine delivery, new vaccinations in terms of what we would say a post-pandemic world, where everyone got a shock course in terms of immunizations and delivery. But I want to go back a little bit, Katie, I have been here a little bit longer than you and it is interesting to see the role evolve of pharmacists in clinical practice, in the hospital. And I wonder if you can give a little bit of life in the day in terms of how that practice has evolved. And maybe how it differs from the retail pharmacists that many people may be used to seeing in their local stores.

Dr. Rivard:

Yes, absolutely. I definitely think that the world of hospital pharmacy is an unknown to many people. In fact, my parents know I am an infectious disease pharmacist, but they think that that means that I dispense antibiotics and that is it. So really, what our role in the hospital is that we support the physicians in their specialty, taking care of patients. For example, I round most days with the pediatric infectious diseases team, and really help them to make sure that they're selecting the most optimized antibiotic therapy for each patient that we see, keeping in mind things like safety, drug interactions, the specific way patients should be taking medications, making it as easy as possible for parents to give the medication to their patients. And that is a big part of my job. 

And then we also are able to be consulted for independent practice as well. We are able to collaborate with physicians and other licensed, independent practitioners to be delegated responsibilities including prescribing of certain medications. I also help to cover our pharmacist led travel medicine clinic, where we are able to independently see patients, provide them with all their counseling needs for travel, and then actually prescribe their vaccines as well as their prophylactic medications to prevent infection while they are traveling. So that is a very unique component of pharmacy practice that's emerging in our world.

Dr. Gordon:

Well, thank you. And this goes along with our focus on patient centered care, team of teams, high reliability, and high standards. And I wonder, Trate, I know that you have rotated on the organ transplant services, where there is a lot of complications or potential issues going on. I wonder if you can expound a little bit about that team of team approach in terms of your experience.

Dr. Devolld:

Yes, absolutely. And I think that as a learner, I have a unique perspective because I am interacting with other types of learners in an academic setting. But as a student, we also rotate through different academic institutions. And I have gotten perspectives from outside of institutions, from our institution, and even within our hospital, different departments. And I think the one thing that is consistent amongst all of those are just those direct lines of communication and having that open communication to ask questions.

I think that is one of the biggest benefits in being in an academic center, is that you are expected to ask questions. You are expected to test the waters and see the way that you can optimize those patients' care by collaborating with people who have different experiences than you. And I have had a wonderful experience on all those teams, our oncology teams, our solid organ transplant teams, and our interactions with infectious diseases, but more specifically with pharmacists and really understanding what roles we can play and how we can optimize those patients' care throughout the hospital stay.

Dr. Gordon:

Well, we appreciate that. And that speaks to what we like to say, the psychological safety, where any member of the team should be able to ask a question without being worried about consequences. The ability and the courage to be vulnerable because often these are things that maybe are not in the physician’s line of sight or something that has been overlooked. And it hearkens to me, as I said, going back to that, the first Institute of Medicine report, To Err is Human, which talked about errors in medicine. And the one thing they really highlighted that was very actionable was the polypharmacy issue in having this electronic pharmacy record, so that if all these clinicians are ordering things, you have at least a central way of someone saying, “Wait a minute. Here’s a drug interaction.” Or “Wait a minute, this dosing may be optimized or may be a contraindication.” 

I know I have learned; I love getting those messages from whatever pharmacist it is, in terms of, "Hey, Dr. Gordon, just heads-up on this." Or "I think this would be a better way." And my response to that is always, obviously, “Thank you." So, it is very, very appreciated. 

I wonder if we can pivot now towards one of the things you all are trained to do, and which was implied is also about vaccinations, administration, in terms of dosage, in terms of sequencing. There is a science to that. And I think we all agree, in the infectious disease world, that we would rather prevent something than treat it. And vaccines are still way up there in terms of preventive activities on a global spectrum, as well as when we are talking about things like SARS-CoV-2. 

Katie, I am wondering if you can help us now in terms of honing down on vaccines, and particularly the respiratory vaccines in terms of how the pharmacists are helping us execute this policy for one patient at a time, but for also populations here.

Dr. Rivard:

Yes. Absolutely. So, the pharmacy, especially our community pharmacies, and your corner retail pharmacy are really the cornerstone of vaccine delivery, particularly for adults post-pandemic. There was an interesting study that came out evaluating vaccine delivery in 2021 and 2022 that found that over 90% of COVID vaccines were administered to adults in the pharmacy setting.  Just showing the scope and the availability of pharmacists to contribute to such an important initiative for our health. And it has been about 20 years, now, that pharmacists have had the authority to administer vaccines in the community pharmacy setting. And I think that is so important for access. It's much easier to be able to go to your corner pharmacy and get that vaccine, than it is to maybe make an appointment with your medical provider, have to take off work, or have to wait weeks to months to get into that appointment, depending on how busy your primary care provider is. Whereas pharmacies have nights and weekends that are open and able to accommodate schedules for patients and be much more convenient, as well as continuing to deliver that safe care. Pharmacies are able to administer pretty much any vaccine to an adult. They are able to ensure that a patient is eligible for the vaccine. All states have an immunization registry, so when you receive a vaccine, it is reported into that registry so that your primary care provider sees that you got the vaccine to prevent duplications as well. Because we want to make sure that ultimately, the provider who is the primary care provider knows what is happening in the pharmacy and outside of their office.

Dr. Gordon:

Well, thank you, Katie. Trate, to follow up along that, we now look to see the position of the patient and what is frictionless or best from them? I mean, people are used to now getting tested at home or delivering things at Amazon. And again, the neighborhood pharmacist is often also a trusted area as well. I wonder if you can speak, especially post-pandemic now, in terms of for many patients that delivery of care system, in terms of trust in the pharmacist and also education of the patients at the pharmacy level, in terms of vaccine preventable illness.

Dr. Devolld:

Yes. Katie alluded to this as well. But community pharmacists are the most accessible healthcare providers in the United States. There is some recent data that shows that around 90% of Americans have a community pharmacy within five miles of their home. And when we talk about meeting the patients where they are at and bringing that information that data on safety and how well these vaccines work for them, and the prevention of preventable diseases, we are meeting them where they are at. And I think meeting patients where they are is what really builds that rapport, is what builds that trust, and helps them relate to you on a one-to-one level that, they might not experience in the same capacity in the clinic setting. 

And so, I think having that relationship building, also filling their prescriptions on a month-to-month basis, you get to know these patients. They quickly become people. You know their kids and their families. And I think based on that, they learn to trust you as an expert, both as a person, but also as a clinical specialist. And I think later, as we start to discuss RSV specifically, there's recommendations surrounding shared clinical decision making. And the CDC has specifically called out pharmacists as one of those providers who should be included in the shared clinical decision-making process for these patients. And I think based on that, we should really be having these conversations with our patients, who we know could benefit from them in providing the rationale for why we think it might be an effective option for them specifically. 

Dr. Gordon:

Well, thank you for that. Those are important points. We will continue to explore those. I wonder, Katie, we can pivot back to the children, because as you mentioned, if I look at the vaccine schedule for our kids and our small kids, and now I am fortunate enough to have two young grandchildren, so I am acutely aware of that. But that is a lot of immunizations relatively in sequenced time. And that's time to allow the visits for the pediatricians whom really own this. And I wonder if you can talk about the differences with the pediatric patient population, and the adults, and the adolescents.

Dr. Rivard:

Sure. So, certainly, there are a lot of immunizations we give in the first year of life, as that primary immunization series. And they do correspond to the appropriate time intervals that a pediatrician or family medicine provider need to see the child, not only for vaccines, but also for other developmental milestones, sleep safety, car seat safety, all the things that are important for a pediatrician to be monitoring for their patients. And I think it makes a lot of sense for those initial immunizations to be owned by the pediatrician, because there are other reasons why patients need to be seen in the office, and so that it does become more seamless for them to be able to do all of those in their visits with their pediatricians.

But what is interesting is we do see a significant drop off in immunization adherence and staying up to date as children transition from being a child to an adolescent, because they are less often seeing their providers. It may now only be annually instead of multiple times per year. And the last touchpoints that those patients are having with their provider, the less opportunities there are for vaccination. And that is really, again, where the community pharmacy can play a role. It is challenging, our pharmacy state laws, do vary. And the scope of a pharmacist to immunize children really depends on the state that you live in. Some states are purely adults only; some states pharmacists can vaccinate down to a certain age. And then, in others, it is quite open. So, it is variable. 

What was interesting is during the pandemic, the PREP Act, actually gave pharmacists federal scope to vaccinate down to three years of age, which has since been reversed. And so many states now are revising their legislation to put that back into their state laws to allow pharmacists to vaccinate down to age three. That just passed the Ohio Senate in December and is now going to the House for a vote. So, we could see that even here in our home state of Ohio very soon. 

Then, of course, as patients continue to age into adulthood, immunization rates continue to drop. It is a lot harder to keep up with adult immunizations because it is not as well-oiled as the pediatricians are. And so again, a great opportunity for pharmacists to have those interventions as patients are coming in to get their medications, we're able to see their immunization history, and know based on their medications, what they may be at risk for. So maybe if they are immunocompromised, we know that based on the prescriptions that we are filling. And we can say, "Hey, I see here that you’re on this medication which affects your immune system. Would you like to discuss the shingles vaccine today?"  and that provides a nice opportunity for the pharmacist to make that touchpoint. And even if the patient does not agree in that moment, it is in their mind. They can discuss it with their provider and can come back and get that vaccine in the future.

Dr. Gordon:

As you mentioned, documentation, challenge for series vaccines, the one that require more than one for completion to get that patient back. But Trate, I wonder if you can comment on how our electronic health record can work both ways to remind not only the provider but the patient, and also be a source of empowerment, so if you need to get your immunization records for whatever reason, school, camp, or a job, it should be a part of what the patient has access to. "It's not the clinics or my provider, it is my records."

Dr. Devolld:

Yes, absolutely. I think I might be one of the last generations that had all their vaccinations documented on papers that my mom carried around and kept in our safe, for safekeeping, which were then passed on to me, eventually, when I went to college. And I still have those at home as well. I think that has changed a lot. And when we talk about empowerment of the patient, things like MyChart, which are accessible patient records has gone even beyond the scope of just vaccinations where they can see test results. They can see the comments that providers are able to make on those. It is streamlined care for sure, but I think it is empowered patients to ask questions and to feel like they are a part of that shared clinical decision, across the scope of their care.

And then when we are talking about the inpatient electronic medical records, I think that we can capitalize on a lot of the technology that we have available to ask for both safety as well as for direction for providers to select appropriate agents or to select an agent at all. So that can be through triggering reminders in patient charts that a vaccine might be eligible for that patient. They have not received their influenza vaccine that year, and we can be reminded to continue to ask about that and consider initiating a prescription for that or giving that in-office.

And then on the safety side, we can also have alerts or flags if we accidentally ordered the product that might not be approved in that patient. I think that we can talk a little bit more about that as its own section of safety of these vaccines because there is some confusion with the RSV products available, and for the products that are approved in specific populations. 

Dr. Gordon:

That is very enlightening. I think all of us remember that through many things like the vaccine monitoring, that many of us got messages on our phones. And I think to hit a certain population, if it is not going through the phone, you are probably not going to get them in using TikTok, and messaging, and things of this nature. But how effective that can be for reminders and getting some feedback. And that is a good segue to respiratory viruses. It is not your father’s respiratory viral season anymore, Katie. It is not that we have a new player with SARS-CoV-2, but we also have some new interventions. And I am wondering if you can scope out, now, as we are in 2024, just the changes that means in terms of vaccine preventable in some of the things we begin to think about in respiratory viral season?

Dr. Rivard:

Absolutely. So, 2023 was an exciting, and for me, personally, very busy season, as we were able to launch not only the updated COVID vaccine, the annual flu vaccine, but also two major healthcare miracles, I’ll say, with the RSV vaccines, and then the RSV antibodies, which also created a lot of confusion we’ll say. So, for those unaware, there are two things we can now do to prevent RSV. There are the vaccines, the names are Arexvy (RSVPreF3) and Abrysvo (RSVpreF). They are two separate products that are approved for adults to prevent RSV infection. 

One specifically, Abrysvo (RSVpreF), is also approved in pregnant people to prevent RSV in their newborn. Those are very different products from the RSV antibodies, which is more of a passive or antibody mediated immunization that we give to newborns and infants to help protect them, because they are one of the most vulnerable populations to RSV. 

And so now that we have these kinds of multimodal ways of preventing RSV, there is, of course, as Trate mentioned, a risk for error because it is a lot when multiple things come out at once. And one thing that we are keeping a very close eye on, in the vaccine safety community, is the number of errors that are occurring. And there was just a report that there are 25 children who inadvertently received the adult RSV vaccine, and then about 128 pregnant women who received the RSV vaccine not indicated in pregnancy. 

Fortunately, none of those events led to adverse outcome in those patients, but it really highlights the importance of implementing medication safety strategies to prevent those errors. The Institute for Safe Medication Practices just published a best practice with 10 recommendations that medical providers do to help prevent these errors. And I think it is definitely worth any clinician pulling that up in Google and doing a gap analysis to see what your office or your clinic could be doing to prevent these errors. 
 
 Now that we have all of these, this will hopefully be an annual practice. Right now, we don't know whether adults will need subsequent RSV vaccines. It is looking like the vaccines protect for more than one season, but I envision boosters will be needed. I envision we will continue to have annual COVID and flu. So really, it's going to be that bundle of respiratory vaccines that we're able to get each season instead of just flu, which I think is ultimately really exciting to be able to prevent these viruses. While in most people may cause an annoying cold, can be very serious for certain populations.

Dr. Gordon: 

Thank you for that overview. I think that becomes important on the pediatric side, the most common cause of infectious admissions during that first year of life has been RSV. In the elderly, obviously, although it is not as frequent as influenza, usually more severe in the most recent studies, especially in the elderly who are immunosuppressed. So, it is something that the respiratory syncytial virus is a new lexicon. From the clinical side, I will tell you that as a clinician it would be very hard for me to distinguish between SARS-CoV-2, RSV, and influenza. So, without me knowing what the local epi is, so the importance of testing, obviously, but also the importance of prevention. 

Trate, I am wondering with patients coming in, how do you talk about what is the safety of giving potentially three vaccines? Do we do that all at once? Or do you space those out? What are the recommendations when it is indicated? Because right now, obviously, the majority of people, anyone over six months should get their annual flu shot. RSV is not a universal vaccine, but it is still a high percentage of patients may be indicated for that. And SARS-CoV-2, obviously, also recommended for most people.

Dr. Devolld: 

Yes, absolutely. This is dependent on the patient as well as dependent on where you are at in seasonality. And I think that when we are talking about RSV specifically, it might not follow the same seasonality of our other respiratory viruses might. And we have seen some shifts in RSV seasonality in specific areas in the United States, like Florida, for example, which might not follow the other states in the country. And so, I think it is important to consider what your current rates of infection are and be able to prioritize that if you need to with those patients. 

Now, these are all safe to give at the same time. And so, if we are able to do that, recommending that in patients and doing it is probably best practice. But when we talk about patients being able to be a part of that decision and empowering them. They might not be comfortable receiving three vaccines, and they might want one in each arm that day. These are conversations that we have as pharmacists in the community setting almost every single day. And being able to weigh that patient's own concern with their ability to tolerate those vaccines is important. Having that conversation and then also having the science behind it to help educate them that this will not decrease the effectiveness of these vaccinations. But also, being able to prioritize and pivot a little bit when they do have those concerns.

Dr. Gordon:

Well, thank you. We are using the term immunization as a process and vaccine interchangeably, but Katie, all these vaccines there are different types of vaccines. So, I am wondering if we begin to talk about, maybe we can use flu, RSV, and COVID as different examples of the types of vaccine. So, I am wondering if you can mention to that and then we can get into some safety.

Dr. Rivard:

Absolutely. There are many types of vaccines available. And they all work a little bit differently. But essentially the way a vaccine works is that the vaccine contains some component of the infection. We call it the antigen. And it is able to tell our immune system how to fight future infection from that antigen. Things like influenza are protein-based vaccines. They contain protein from each of the influenza strains that we include each season. Something like COVID, the most common vaccine that we see are the mRNA vaccines. mRNA stands for messenger RNA that is something that teaches our cells how to create the protein, a piece of the spike protein from COVID and our body is able to create antibodies against that spike protein. mRNA does not stick around in the body. After our cell follows the instructions, the mRNA degrades and is removed from the body. And then we are able to have that protection for COVID. 

And then RSV, is a prefusion vaccine. So essentially what it does is, it is a component of the RSV virus, the component is what connects the virus to our cells to enter and cause infection. And by creating antibodies to that component, we are preventing RSV in the future from entering our cells to cause infection. So those are how the respiratory virus vaccines typically work. But there are many other vaccines. We have live vaccines which contain a weakened version of a virus that triggers our immune system to create that response. Those types of vaccines do have certain people who can't get them, like people who are immunocompromised. So that is important to keep in mind and something that your pharmacist or health provider can help you with as a patient if you are making vaccine decisions.

And then there are immunizations like the antibody I mentioned for RSV. And these are a little bit different. So, the RSV antibody, the brand name is called Beyfortus, is what we call passive immunization. So rather than administering something that triggers the body to create, the antibody response, we are administering antibodies. So, it skips that middle step. And we are able to provide that direct protection to the patient. So that is how it is a little bit different than the adult RSV vaccines. And why it is so important to distinguish them as true vaccines with the adult products versus a passive immunization with a pediatric product. 

Dr. Gordon:

That is an excellent overview. And if I can add, Katie, it was interesting, because I know there was a shortage of the monoclonal antibody, which may be another reason, aside from taking the jab from the baby, that a mother might decide to get during that third trimester of pregnancy, to go ahead and get the RSV vaccine that's indicated for pregnancy as opposed to waiting for the monoclonal antibody. Although both have been efficacious. I know that.

Dr. Rivard:

Yes, exactly. The shortage was definitely challenging and disappointing this year. It was hard to tell families that we did not have enough product, that we were not able to immunize their child. But we are fortunate in that it appears that was a one-off type of shortage due to a manufacturing issue that has since been resolved. 

So, we are looking forward to the future, that next season, we should have ample supply of both the vaccine for pregnant people as well as the antibody for infants. Everybody who wants it should be covered. And even despite that shortage, a very recent publication from the CDC showed that 40% of infants, eligible infants, were able to receive the antibody, which is actually very high for a very new product. And shows that there is less hesitancy with an antibody versus a vaccine, which I think is an interesting phenomenon. And I am excited to see how that plays out again next season.

Dr. Gordon: 

Oh, thank you. Well, Trate, I think that pivots to the next is safety, because aside from efficacy, what we are preventing, most patients' top of mind we hear about is, "Doc," or the pharmacist, "Is this safe?" And so how do you approach that question in terms of where do you turn, to give that information for the patients?

Dr. Devolld:

Yes, absolutely. I think that having a conversation with the patients about both what might be in the studies, but also based on the guidance that is provided from ACIP and from the CDC. I think that also giving perspective to patients is probably the key in having them relate to past vaccinations to have a better understanding of the way that those rates of adverse events or side effects in the studies might compare to previous studies with things like influenza. And so, explaining to patients that the side effects that were seen in these studies might be very similar to what they experience with an influenza or a COVID vaccine, typically being fatigue or myalgias, having that kind of relatability to past experiences can help comfort the patient despite it being a relatively new product. 

And so, I try to compare those rates and discuss that with patients, because I think it is easier for them to understand that than these specific scientific terms surrounding studies. And also comforting them with these accrediting bodies and these guidance providers that are putting this together as specialists in the industry that have recommended these for specific populations, supported by data of thousands of patients who went through these clinical trials. These are not small clinical trials with a couple of hundred patients, which we utilize every day in practice. These are seven to 10,000 patients that we are pulling this data from to have a better idea of what those adverse events could look like.

Dr. Gordon:

Think that's very helpful, Trate. I think is important, one thing we have learned is to listen to the patients' concerns, even though you are coming in with our own unconscious bias about the vaccines. Some of the things I think the more common, we would say, "myths" are, "Well, I've never gotten the flu before, so therefore, I don't think I'm going to get it." 

Again, and as we know, people's identification of influenza ranges from diarrhea, enlists it to things that are not flu. The second is "When I get the flu shot, I get the flu." And as Katie explained, these are not live vaccines. It does not mean it is going to necessarily 100% prevent, but it is not going to give you the flu. And then of course, the association. So, "I got the vaccine, and then I heard, my uncle got this vaccine, and then something happened."

Yes, and so I think what we are learning is don't be dismissive. And then Katie, I wonder if you can talk about strategies. Because explaining the difference between vaccine resistance and vaccine hesitancy, and then trying to have that conversation, it is persuasion, but it is a joint decision making to try to get patients to at least reconsider or consider.

Dr. Rivard:

Yes. Absolutely. Vaccine hesitancy is more prevalent in the United States than perhaps vaccine resistance. Meaning that somebody may be willing to receive a vaccine, but they have some hesitation, some reservations, and really want to have that full conversation with a healthcare provider to understand the risks versus benefits before proceeding. And the most important thing is really having that empathy for the patients. And especially as a pediatric pharmacist, empathy for the parents. Nobody teaches you how to be a parent. And you are trying to make the best decision for the little human that you are taking care of. And I can understand how that can be very scary and wanting to make sure that you are doing the right thing. So, I think actively listening to the concerns of the parents, letting them really speak what they are saying. And even true of an adult patient pursuing vaccine for themselves, before jumping in, and having a rebuttal to everything they're saying, really letting yourself sit with what they're saying and making sure that when you're responding, you're responding to their actual concern and not just spouting off, as Trate said, the data from the literature which they're not going to care as much about. 

I think that has been the most successful strategy for me first, is being empathetic and actively listening. And then starting with motivational interviewing techniques as well, helping to dive into why if there is a concern that isn’t scientifically valid where is that coming from? Providing them with information, asking them again, "Does that change your perspective? Does that help make you feel more comfortable?" And then also being comfortable with getting a no in the moment but being willing to have that conversation again. Because somebody may need some time to think about it and then come back for vaccination rather than agreeing right in the moment. 

I think as a pharmacist who is very passionate about vaccines, it can be frustrating internally when I am like, "Come on, these are great interventions." But remembering that not everybody knows everything that I know about vaccines, and meeting, as Trate has said, meeting patients where they are, and giving them time, I think is really important. 

Dr. Gordon:

Well, that is very helpful. Trate, I think for many of the learners, we say, "They have grown up in a vaccine era, so vaccine preventable illness is maybe something they haven't seen a lot of chicken pox, they haven't seen the mumps, and the measles." Unfortunately, looking, as Katie said, I think there has been some vaccine hesitancy, the levels of vaccination of our children have remained very high. But it is something that we cannot take for granted. I am wondering you are a generation below. Tips for messaging in terms of for your generation that you have found helpful, as opposed to old gray hairs like myself? 

Dr. Devolld:

Yeah. You alluded this early on in our conversation as well, is there might be a shift in the idea that if we do not see these diseases, that we do not need to be protecting ourselves from them any longer, they are eradicated. In reality that might be what we see in the United States. But we have people coming from all over the world into our country, and we are visiting other countries so often, that these are transmittable diseases that we can get again. And staying vigilant in our preventative care is really important. And I think meeting the younger generation on where they are. I've highlighted that several times throughout our conversation today, so whether that be finding them in their communities. That's probably not where you're going to have the biggest effect on somebody who's in middle school or high school, and being able to start those conversations, and starting to empower them to make those decisions as well. 

So, I think the strategies change significantly. I know that when I was in middle school, we had people come in from the health department to try to explain some of these differences and relate to our science classes. And make those conversations more curious to us, so that we felt empowered to think about those things on our own and have those conversations with our parents. And I think in more modern times, using social media to supply a platform of education has become important. But it has also become a little bit risky in that there's also mass media that can give misinformation. And so being able to find reliable sources of information is important. Looking at a TikTok or an Instagram influencer or might be one way to get your information. But what are their credentialing? And what is their background in this information? And do they truly understand it? I think we must be selective, and we must be curious, and look for those opportunities. But we also need to make sure that this is backed by valid information.

Dr. Gordon:

Those are all great points. And I can't help but think we can't be fortress America, right? We are in a global world. And there are many examples. So shortly after the pandemic was waning, we saw monkeypox. And obviously, that was a global migration, but also people vulnerable in the States. And another vaccine preventable. And again, some of the lessons learned in the pandemic, I think were helpful in terms of getting a vaccine campaign up and fortunately, we had a vaccine ready. 

But I think this will continue to challenge us. We are going to see, hopefully, more vaccine development, maybe different ways of also vaccination to either decrease the amount you need, or obviously combining vaccines, which has been done in pediatrics because we, we understand a lot of people still don't like needles. That is fair to say. But I think the role of pharmacy in terms of the healthcare team, in terms of the vaccine delivery, the vaccine education, the protocols, the safety in the supply chain, it has been tremendous. And as you said, it is a front door to many people, to get healthcare. When you travel in Europe and everything, I think many people, or in other parts of the world, the pharmacist is also providing a lot of primary care, and is their trusted provider, and it is the same in the States. So, this has been wonderful. 

I wonder if we can wrap up, if any concluding thoughts, Katie, that you might have for the audience?

Dr. Rivard:

I think what I would say is my career as a pharmacist has been very surprising, and where I thought I would be and where I am is very different. And I am very thankful for my profession, and the work that we do to support and provide care to patients. And I am excited to see how the field of pharmacy continues to evolve, particularly as we continue to see more vaccine platforms and the hopefully expanded scope of the pharmacist in what we are able to provide to patient care. 

Dr. Gordon:

Trate, any comments for the audience that you want to leave in conclusion?

Dr. Devolld:

Yeah, I think that going off that, there has been a huge shift in education in healthcare right now. There is a mass shortage of healthcare providers. There is also a mass exodus of providers as well because of burnout. And I also want to highlight as a learner, and then as somebody moving into my career, as well, this need for wellness and balance, and really highlighting that this is something that, as a system, we are kind of encouraging. But we have to really support and continue to support our learners in actually finding that balance and also motivating them to continue to grow as people, and then also growing as a collaborative group, as a healthcare team. 

Dr. Gordon:

That is very thoughtful and, and prescient. And again, I think gratitude to you both and to our pharmacists everywhere in terms of health and prevention, and service. And finally, I will put you on the spot, just one last thing. Is there any book that you would recommend to the audience? It does not have to be about vaccine delivery or things that you have recently read that you might recommend to the audience. Katie?

Dr. Rivard:

I can't think of its title. It is vaccine related. It was written by Dr. Peter Hotez, who is a vaccine scientist who has a daughter with autism. I believe the book is called Vaccines Did Not Cause Rachel's Autism. And it is a really interesting book that goes back and forth between his journey as a vaccine scientist and then his journey as a parent with a, a child with autism. 

And, and how in the '90s there was that concern about, about autism stemming from vaccination. And he provides really nice information about, about how, as a parent with an autistic child, he can understand how people wanted to make that connection. But then as a vaccine scientist, he explains how there really is not that biological plausibility. So that book has always stuck with me as a pediatric pharmacist, and I recommend it to all the medical residents that I work with and pharmacy residents. 

Dr. Gordon:

Well, thank you. Trate?

Dr. Devolld:

Mine is maybe a little bit more niche, but I am actually in the middle of a book by Your Financial Pharmacist, Six Figure Pharmacist. And this isn't about becoming a millionaire as a pharmacist. It is about financial literacy. But I think it's highlighted a lot of points for me about how much we don't learn in school, as medical professionals about financial literacy and preparing yourself for both loans as well as to go in after residency and make a large amount of money, and how do you really manage that, to prepare yourself for the longevity of your career and your retirement. So, a little bit less exciting maybe, but also just equally as important, I think.

Dr. Gordon: 

Well, thank you for sharing that. And again, Steve Gordon, your host, for this Respiratory Exchange on focusing on our pharmacists and vaccine delivery, and the new RSV vaccines. And I want to thank our guests today very much and wish you all a very happy day. Thank you. 

Raed Dweik:

Thank you for listening to this episode of the Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.