On behalf of the Advisory Committee on Immunization Practices (ACIP), Neil Murthy, MD, MPH, from the US Centers for Disease Control and Prevention in Atlanta, and colleagues break down the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2024.

The authors note that changes to the 2024 adult immunization schedule include new COVID-19 vaccine recommendations, including that all adults should receive at least one dose of the updated vaccine. Respiratory syncytial virus vaccination is a new addition to the adult immunization schedule, with routine use of Abrysvo (Pfizer) recommended during pregnancy (at 32 to 36 weeks of gestation); for older adults (aged 60 years and older), shared clinical decision-making is recommended for vaccination with either Abrysvo (Pfizer) or Arexvy (GlaxoSmithKline).

“The CDC’s Advisory Committee on Immunization Practices’ Recommended Adult Immunization Schedule, United States, 2024 confirms ACIP’s competence in preparing current, evidence-based vaccination recommendations,” Scott C. Ratzan, MD, from City University of New York’s Graduate School of Public Health and Health Policy in New York City, and colleagues write in an accompanying editorial. “However, it also demonstrates that CDC has not moved sufficiently beyond merely providing information to clinicians and the public to persuasive communication.”

Abstract/Full Text

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Increasing COVID-19, influenza and respiratory syncytial virus vaccination rates in older adults is going to require a village to battle vaccine reluctance in the form of misinformation, hesitancy and fatigue, according to senior living experts.

The Centers for Disease Control and Prevention recently released two reports on vaccination coverage and treatment for respiratory viruses. The agency found that vaccine fatigue, inaccurate health information and vaccine hesitancy contributed to lower vaccination rates in older adults. 

A significant challenge is that many people now tend to equate COVID-19 with catching a cold, Argentum Vice President of Government Relations Paul Williams told McKnight’s Senior Living. 

“We need to continue to emphasize how serious these respiratory viruses can be for our residents, who tend to have multiple comorbidities and chronic conditions, putting them at greater risk for serious complications, and even death,” Williams said. “At this point, so many people have made up their minds on vaccination, and trying to get folks to reconsider is an uphill task.”

Many people are “done with COVID” and any discussion of vaccines, he added.

“Vaccine fatigue is real, even though it remains a threat to the older adults we serve,” Williams said.

Raising vaccination rates

According to the CDC, uptake of the updated COVID-19 vaccine is approximately 37% in adults aged 75 or more years, compared with the national average of 19% among all adults. The statistics aren’t much better for the flu and RSV vaccines — only 34% of adults aged 65 or more years had received the flu vaccine as of Oct. 28 and only 17% of adults aged 60 or more years reported receiving an RSV vaccine as of Dec. 23.

Nursing homes have national reporting requirements for resident and staff member vaccination rates, making statistics more readily available than in assisted living, which does not have such requirements. And not all states are mandating or tracking vaccination in senior living community staff members for COVID, RSV or flu.

Williams said that Argentum is hearing that communities with strong leadership often have higher vaccination rates, and that staff members who trust and respect community leaders are more receptive to calls for vaccination and the importance of helping to protect residents and colleagues in the community.

“Communities that involve trusted nurses and clinicians to educate residents and answer questions on the risk and benefits of vaccines have higher rates,” he added. “The use of toolkits and talking points have proven to be helpful but the main barrier to increasing compliance remains ‘vaccine fatigue.’”

Challenges of vaccine reluctance

The challenge in battling vaccine reluctance is not unique to senior living or nursing home providers; it is systemic among the US population at large, according to the American Health Care Association / National Center for Assisted Living.

“As a country, we face significant challenges with vaccine reluctance that require a collective endeavor by public health officials, other healthcare providers and the public,” an AHCA/NCAL spokeswoman told McKnight’s Senior Living. “Assisted living providers remain persistent in talking to family members and residents about their vaccine concerns and appreciate the partnerships of the larger healthcare system to help reinforce the importance of the vaccines.”

Last week, US Department of Health and Human Services Secretary Xavier Becerra met virtually with representatives from LeadingAge and AHCA/NCAL to express concerns about low vaccination rates among residents of nursing homes, which are supported by federal dollars through the Medicare and Medicaid programs. LeadingAge said in a statement after that meeting that it had urged HHS to help ease logistical issues that have slowed vaccination rates and to encourage hospitals to offer vaccines on discharge. 

David Gifford, MD, MPH, chief medical officer of AHCA/NCAL, writing in a column in McKnight’s Senior Living sister publication McKnight’s Long-Term Care News last week, discussed the need for the nation to collectively combat vaccine reluctance. He opined that strides in the right direction since the pandemic have been taken with vaccines, especially in the long-term care industry, but much collective work remains to be done by the healthcare profession to combat widespread hesitancy.

Vaccine fatigue and hesitancy, Gifford said, are “rampant,’ but especially so when it comes to COVID-19 and RSV vaccines. And although vaccine uptake in skilled nursing facilities is higher than in the general community (a number easier to know for nursing homes due to federal reporting requirements), he called for a doubling down on efforts to increase those numbers.

Gifford called for the ready availability of vaccines for residents through on-site vaccine clinics, provider reimbursements and consistent public health messaging. He said many new admissions arrive at an assisted living community or nursing home without being offered or having received the vaccine during visits with physicians in other healthcare settings.

AHCA/NCAL created a #GetVaccinated website last year with resources for providers to secure and administer vaccines on site, as well as resources to help encourage residents and staff members to receive vaccines.

Hannah E. Reses, MPH, from the CDC in Atlanta, and colleagues examined COVID-19, influenza and RSV vaccination coverage among US nursing home residents during the 2023 to 2024 respiratory virus season. The researchers found that 33.1% of nursing home residents were up to date with COVID-19 vaccination as of Dec. 10, 2023. Coverage with influenza and RSV vaccines was 72.0 and 9.8%, respectively, among residents at 20.2 and 19.4% of facilities that elected to report.

Carla L. Black, PhD, from the CDC in Atlanta, and colleagues used data from the National Immunization Survey-Adult COVID Module for adults aged 18 years and older to monitor influenza, COVID-19 and RSV vaccination coverage. The researchers found that an estimated 42.2 and 18.3% of adults aged 18 years and older reported receiving an influenza and updated 2023 to 2024 COVID-19 vaccine, respectively, by Dec. 9, 2023; 17.0% of adults aged 60 years and older had received an RSV vaccine. There was variation noted in coverage by demographic characteristics.

“Although influenza, updated COVID-19 and RSV vaccination has slowed for the 2023 to 24 respiratory season, vaccination is recommended to continue while viruses are circulating, and many unvaccinated persons continue to report intent to be vaccinated,” Black and colleagues write.

Abstract/Full Text – Reses

Abstract/Full Text – Black

Eleanor Wilson, MD, from Moderna in Cambridge, MA, and colleagues conducted a randomized, phase 2 to 3 trial in which adults aged 60 years of age or older were randomly assigned to receive one dose of mRNA-1345 (50 μg; 17,793 participants) or placebo (17,748 participants).

Participants were followed for a median of 112 days. The researchers found that vaccine efficacy was 83.7 and 82.4% against RSV-associated lower respiratory tract disease with at least two signs or symptoms and against the disease with at least three signs or symptoms, respectively. Vaccine efficacy against RSV-associated acute respiratory disease was 68.4%. Protection was seen against RSV subtypes A and B and was mainly consistent across subgroups defined according to age and coexisting conditions. Compared with those in the placebo group, participants in the mRNA-1345 group had a higher incidence of solicited local adverse reactions (58.7 versus 16.2%) and of systemic adverse reactions (47.7 versus 32.9%); most reactions were mild-to-moderate and transient. Overall, 2.8% of each trial group had serious adverse events.

“This phase 2 to 3 efficacy trial showed that a single 50-μg dose of the mRNA-1345 vaccine in adults 60 years of age or older was efficacious against a spectrum of RSV-confirmed respiratory disease,” the authors write

The study was funded by Moderna, the manufacturer of the mRNA-1345 vaccine.

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Vaccine uptake by senior living residents is being hampered by barriers to access, vaccine fatigue and misinformation, according to two providers.

During a LeadingAge policy update call on Monday, industry representatives discussed issues related to vaccine access, operations, reimbursement and trust.

The nation is entering an “unprecedented vaccine season” with the availability of vaccines for the three viruses most responsible for hospitalizations among older adults: influenza, COVID-19 and respiratory syncytial virus, or RSV. With the privatization of the COVID-19 vaccine, however, arranging vaccination clinics is becoming more difficult for senior living providers.

Carol Williams, an infection preventionist with continuing care retirement / life plan community operator Rockwood Retirement Communities, based in Washington state, recounted her struggle to schedule an on-site COVID-19 vaccination clinic after the Food and Drug Administration and the Centers for Disease Control and Prevention approved the updated vaccines in mid-September. 

Williams said she contacted private companies, area pharmacies, the local health department and the community’s long-term care pharmacy, only to run into a “stalemate” due to vaccines being on backorder, the need to update policies, and concerns about reimbursement.

“There were a lot of barriers in the beginning,” she said. “No one could give me a date, and every person reminded me it was private now and not for free any more.”

Rockwood is offering its first vaccine clinic this week after working with a private company, but Williams said that struggles with reimbursement limited the number of vaccines the company was willing to provide at its first clinic. Approximately 30 independent living residents are still waiting for an upcoming clinic, she said.

“I’m disheartened that with all of the resources that we have, that the people who are most at risk for getting very ill at the time hospitalizations and death rates were going up from COVID, who wanted a vaccine, were unable to have access to that,” Williams said. “Staff that wanted a vaccine were able to go to a local pharmacy and get one at the end of September, but most at-risk residents were not able to get one until this week.”

Access barriers aside, Williams said that another challenge she faced was vaccine hesitancy, mostly from staff members. 

Although residents have trust and confidence in the vaccines, she said, Williams said that she is seeing vaccine fatigue with the introduction of updated COVID-19 shots and this year’s new RSV vaccine. She added that she also has encountered confusion about the RSV vaccine for older adults. 

“There is a little bit of a gap in knowledge going out, not only to the general public, but also healthcare providers,” Williams said. “I had to do a lot of education about what these vaccines are, who recommended it, who they’re recommended for and where to find answers to questions.”

Workarounds for new problems

Nina Tan, a regional supervisor for California-based nonprofit senior living provider HumanGood, said she ran into similar roadblocks initially, being told by one pharmacy that it was going to cost an affordable housing community $600 to host an on-site clinic.

“That never happened before,” Tan said. So she turned to another local vaccine provider, only to find that it only had the flu shot available in September. And a local health plan created further challenges by no longer offering on-site community vaccine clinics, necessitating transportation for residents with mobility issues to that provider’s vaccination sites.

Tan said she decided to wait until the flu shot, COVID-19 vaccine and shingles vaccine all were available, adding that the first vaccine clinics for the communities she oversees are scheduled for next week.

Tan said that whenever she schedules a vaccine clinic, she and her team initiate the resident paperwork and deliver it to the vaccine provider ahead of time to gain insurance approvals.  The extra time on the front end creates a smooth process during the clinics, not only for the nurses administering the vaccines but also for the residents, she said.

Prioritizing long-term care

Wiliams said she’d like to see long-term care residents prioritized in the future when it comes to vaccines.

“I would like to see a way for long-term care contracting pharmacies to have priority access to vaccines to immunize those most vulnerable people, not later than everyone else who has access to it,” she said. “Have our pharmacy have access to it as soon as it’s approved, and that’s not what happened.”

National long-term care advocates met with White House administrators last week on partnership efforts to increase vaccination uptake in long-term care settings. In that meeting, industry advocates detailed some of the same concerns, adding in workforce shortages and opportunities to improve communication about access to federal resources.

Earlier this year, LeadingAge distributed grants to senior living and other long-term care providers to promote education about and increase COVID-19 vaccination uptake via the US Department of Health and Human Services’ We Can Do This public education campaign. And last December, LeadingAge launched its All Hands on Deck campaign to support the White House’s COVID-19 Winter Preparedness Plan to increase long-term care residents’ uptake of updated COVID vaccines. 

The association also partnered with the CDC’s Vaccine Equity and Awareness Program to raise awareness and access to vaccines in older adults. More recently, LeadingAge partnered with HHS and the US Department of Housing & Urban Development to create a portal, open to all aging services providers, for free access to COVID-19 test kits.

Kristine Du, from the Cumming School of Medicine at the University of Calgary in Alberta, and colleagues examined the occurrence of influenza A (IAV), influenza B (IBV), and respiratory syncytial virus (RSV) RNA in WW treatment plants (WWTPs) in Alberta’s largest city and the correlation with clinical disease. Twenty-four-hour composite WW samples were collected weekly from three WWTPs in Calgary between March 2022 and April 2023. WW was concentrated and RNA was extracted. Viral RNA was quantified using a commercial TaqMan assay. A composite city-wide metric for each target was created using flow rates at each WWTP.

The researchers observed peaks in IAV, IBV and RSV in Calgary’s WW for November to December 2022, February to April 2023, and November 2022 to February 2023, respectively. There was a positive correlation seen for the composite IAV signal with weekly confirmed clinical cases within the Calgary Zone, which was seen regardless of influenza typed as H3N2 or H1N1 or untyped. Across the entire province, specimen test positivity rates correlated with Calgary’s WW measured IAV. Across the entire province, the IBV WW signal correlated with clinical cases and test positivity rates. Across Alberta, Calgary’s RSV WW correlated with clinical cases and test positivity rates.

“Knowing what viruses are coming down the pike can help prepare individuals and communities appropriately,” Du said in a statement.

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Fiona P. Havers, MD, from the CDC in Atlanta, and colleagues examined characteristics of 3,218 adults aged ≥60 years who were hospitalized with laboratory-confirmed RSV infection during July 2022 to June 2023. The researchers found that 54.1% of a random sample of 1,634 older adult patients with RSV-associated hospitalizations were aged ≥75 years. Obesity, chronic obstructive pulmonary disease, congestive heart failure and diabetes were the most common underlying medical conditions. Overall, 18.5% of patients aged ≥60 years had severe outcomes: 17.0, 4.8 and 4.7% were admitted to an intensive care unit, required mechanical ventilation and died, respectively.

Diya Surie, MD, also from the CDC, and colleagues characterized RSV-associated severity among 5,784 adults aged ≥60 years hospitalized with acute respiratory illness and laboratory confirmed RSV, severe acute respiratory syndrome coronavirus 2, or influenza infection (5.3, 81.8, and 12.9%, respectively) from 25 hospitals in 20 US states during Feb. 1, 2022, to May 31, 2023. The researchers found that compared with those hospitalized with COVID-19 or influenza, patients hospitalized with RSV were more likely to receive standard flow oxygen, high-flow nasal cannula or noninvasive ventilation, intensive care unit admission, and invasive mechanical ventilation.

“Healthcare providers and older adults should consider RSV disease severity when making a shared clinical decision about RSV vaccination,” Surie and colleagues write.

One author from the Havers study disclosed ties to Merck. Several authors from the Surie study disclosed ties to the pharmaceutical industry.

Abstract/Full Text – Havers

Abstract/Full Text – Surie

The results of the National Foundation for Infectious Diseases’ 2023 national survey of attitudes about influenza, COVID-19, respiratory syncytial virus and pneumococcal disease are raising concerns among infectious disease experts. There are implications for residents and workers in senior living.

The NFID hosted its annual news conference on the topic on Thursday, with experts presenting survey results as well as vaccine recommendations for the upcoming respiratory season and information on final influenza vaccine coverage data for the 2022-2023 US respiratory season,.

The Centers for Disease Control and Prevention urges everyone 6 months and older to get vaccinated against flu and COVID-19 this season. Any adult 60 and older or at higher risk for severe disease should discuss the new RSV vaccine and pneumococcal vaccine with a healthcare professional, according to the agency.

And according to this year’s survey, almost two-thirds of US adults (65%) agree that vaccination is the best preventive measure against flu-related hospitalizations and deaths. But 43% said they do not plan to or are unsure whether they will get vaccinated against the flu.

Among older adults, 72% said they plan to get a flu vaccine, compared with only 52% of adults aged 18 to 64.

Similarly, only 40% of adults said they plan to get vaccinated against COVID-19 with the updated vaccine, and among adults aged 60 or more years, only 40% said they plan to get vaccinated against RSV.

Attitudes around RSV were even more concerning, the experts said. Among older adults, only 40% said they plan to get an RSV vaccine.

The NFID survey found that only 40% of US adults at higher risk for pneumococcal disease, including older adults and those with certain chronic health conditions, had been advised by a healthcare professional to get a pneumococcal vaccine. Among those advised to get vaccinated, 79% did so, underscoring the importance of a strong vaccine recommendation from a healthcare professional, said William Schaffner, MD, former NFID medical director and past president.

“This year, we have an extraordinary opportunity,” Schaffner said. “Vaccines may not be perfect in preventing every infection, but they turn a wild infection into a milder one. They keep us out of the hospital.”

Concerns about side effects (32%), distrust of vaccines (31%) and the belief that vaccines do not work well (27%) were the top reasons survey respondents cited for not getting vaccinated. In addition, 27% said they were worried about getting sick from vaccines. 

Only 38% of US adults indicated that they would get the flu and COVID-19 vaccines at the same time, if offered, even though experts say the vaccines can be co-administered.

The speakers said that the survey findings reinforce the importance of raising awareness and addressing misconceptions about flu, COVID-19, RSV and pneumococcal disease, as well as the need for healthcare professionals to provide strong vaccine recommendations for patients. 

A ‘thrilling’ time

Despite concerns related to the survey results, the experts said Thursday that with the availability of vaccines to protect against the flu, COVID-19 and RSV, it’s a “thrilling” time for those who work to prevent diseases.

“This is a thrilling year for those of us who work in the vaccine business and look at prevention of diseases,” NFID President Patsy Stincheield, RN, MS, CPNP, said during the group’s annual news conference. “This is a year we have all been waiting for.”

Last year

According to CDC data released Thursday, last year’s flu season was moderately severe, with an estimated 31 million cases reported, 14 million medical visits, 360,000 hospitalizations and 21,000 flu-related deaths. 

The CDC estimates that only 47% of US adults received a flu vaccine during last year’s respiratory season, down from 49% in 2021-2022. As in previous years, older adults were more likely than younger adults to receive a flu vaccine — 70% of adults aged 65 and older were vaccinated last year, compared with 50% of adults aged 50 to 64 and 35% of adults aged 18 to 49.

Although uptake of COVID-19 vaccines initially was high, staying up to date with vaccine recommendations has been more challenging. More than half (57%) of older adults did not get the bivalent vaccine, leaving them at increased risk for severe outcomes, including hospitalization and death, according to the NFID.