Key Message
For the 2023-2024 respiratory virus season, new or updated vaccines are available for influenza, COVID-19, and RSV viruses. This Health Alert Network (HAN) message will briefly address the clinical guidance surrounding the use of these products.  Of note, simultaneous administration is allowed for all three vaccines and may be preferable in situations where returning for a separate appointment may be difficult.

Influenza Vaccine
Influenza vaccination is recommended each year for persons 6 months and older with rare exceptions. New for this season, people with egg allergy may get any vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status. Beginning with the 2023-2024 season, additional safety measures are no longer recommended for flu vaccination of people with an egg allergy beyond those recommended for receipt of any vaccine, regardless of the severity of previous reaction to egg. All vaccines should be given in settings where allergic reactions can be recognized and treated quickly.

All of this season’s flu vaccines are quadrivalent and contain the following: (A/Victoria/4897/2022 (H1N1)pdm09-like virus; (Updated), A/Darwin/9/2021 (H3N2)-like virus; B/Austria/1359417/2021 (B/Victoria lineage)-like virus; and B/Phuket/3073/2013 (B/Yamagata lineage)-like virus. Consistent with last season’s recommendations, Fluzone High-Dose, Flublok Quadrivalent, and Fluad are preferentially recommended for those 65 years of age and older. 
Data collected on the 2023-2024 flu vaccine used in the Southern Hemisphere’s 2023 winter season showed that these vaccines performed well against circulating strains of influenza virus. Flu vaccine will be given at all county health department clinics.  

Like COVID-19, treatments are expected to be widely available, although supply shortages may be experienced during times of high circulating flu activity.

Influenza activity reports can be found at https://www.cdc.gov/flu/weekly/index.htm and https://www.alabamapublichealth.gov/flu/data.html.  

COVID-19 Vaccine
The Advisory Committee of Immunization Practices has approved updated 2023-24 COVID-19 mRNA vaccines for all Americans 6 months and older who have not received a vaccine in the past 2 months.  These monovalent vaccines are focused on the Omicron sublineages that are currently in circulation and are expected to provide enhanced protection, especially among high-risk individuals. The updated vaccines are not expected to produce any adverse reactions beyond what has been seen with previous mRNA vaccines.

Those at risk for severe disease, hospitalization and death include:
- Adults 50 years and older, with risk increasing with age.
- People with certain medical conditions, including chronic lung disease, heart disease, and immunocompromising conditions or treatments. Additional groups include persons that are overweight or obese and pregnant persons.

The updated monovalent COVID-19 vaccine is now available at county health departments.  For persons with health insurance, most plans cover COVID-19 vaccine with no copays if patients are using their in-network providers. Insured individuals are being encouraged to visit vaccines.gov to find the nearest pharmacy location that offers COVID-19 vaccine rather than county health departments, where supplies may be limited. Children eligible for the Vaccines for Children (VFC) program can also receive the vaccine at no charge from a participating provider in that program. 

The Alabama Department of Public Health (along with certain retail pharmacy chains and other government-funded health clinics) is participating in the Centers for Disease Control and Prevention’s (CDC) Bridge Access Program (https://www.cdc.gov/vaccines/programs/bridge/index.html) which offers free vaccine to people with:

- No health insurance (ages 64 and younger)
- Ages 64 and younger who
   - Have insurance that does not cover vaccines
   - Are American Indian, Native Alaskan, Native Hawaiian, Pacific Islander

Treatments for COVID-19 remain free and widely available. Consider these treatments for qualifying high-risk individuals based on their individual risk and potential drug-drug interactions.

Please visit the CDC’s updated Clinical Considerations page for more details, including vaccination recommendations for those with moderate-to-severe immunocompromise:
https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html

COVID-19 activity reports can be found at https://covid.cdc.gov/covid-data-tracker/#datatracker-home.

RSV Vaccine
New for this season, RSV vaccines and immunizations are available for certain groups of individuals.  

Pfizer’s bivalent RSVpreF vaccine (Abrysvo) is recommended and available for people who are 32-36 weeks pregnant to protect their babies from severe RSV through passive maternal antibody transfer. The vaccine should be provided only immediately before or during the RSV season. Those providing care to these persons should review the information provided by CDC and be prepared to discuss the vaccine’s risks and benefits, as the infants of these mothers will not be eligible for the new monoclonal antibody product after birth (nirsevimab/Beyfortus).  

Nirsevimab (Beyfortus) is a long-acting monoclonal antibody to protect babies and some toddlers from severe RSV.  The recommendations include 1 dose of nirsevimab for all infants younger than 8 months born during or entering their first RSV season and 1 dose of nirsevimab for infants and children 8–19 months old who are at increased risk for severe RSV disease and entering their second RSV season.  Although not a vaccine, nirsevimab was voted to be included in the VFC program.

Palivizumab (Syanagis) continues to be available, but is limited to children under 24 months of age with certain conditions that place them at high risk for severe RSV disease. It must be given once a month during RSV season. Please see AAP guidelines for palivizumab (https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-for-use-of-palivizumab-prophylaxis-to-prevent-hospitalization/).

RSVPreF3 (Arexvy, GSK) and RSVpreF (Abrysvo, Pfizer) are RSV vaccines that are licensed for use in adults aged 60 years and older in the United States. These vaccines carry a recommendation for shared clinical decision making, taking factors into consideration such as risk for severe RSV disease, clinical judgment, and patient preference. However, these must be balanced with the possible risks associated with the vaccines seen in clinical studies such as inflammatory neurologic events and atrial fibrillation.  The numbers of events were small and ongoing monitoring will be needed to determine if these events were truly associated with the RSV vaccines.

More information can be found at https://www.cdc.gov/vaccines/vpd/rsv/index.html and at http://www.alabamapublichealth.gov.