COVID, Flu, RSV: How the Tripledemic Impacts Your Practice

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Summary and Key Highlights

Medscape kicked off its new series, Medscape Masters, with a conversation about the “tripledemic” — COVID-19, RSV, and influenza. Eric Topol, MD, Medscape's editor-in-chief, and Manisha (Mo) Patel, MD, chief medical officer for CDC’s National Center for Immunization and Respiratory Diseases (NCIRD) and a captain in the US Public Health Service, addressed some of the most pressing questions facing healthcare providers right now as COVID numbers rise and the colder months approach. Neha Pathak, MD, an internal medicine physician and a member of WebMD’s editorial team, moderated the conversation.

What’s behind the rising COVID-19 numbers?

According to CDC data, hospitalizations due to COVID-19 have been increasing for a while now. But Topol noted that, while this may be in part due to the spread of new COVID variants, it’s also because we have waning immunity to the virus as a population.

“We also haven't used mitigation practices that we know about, like high-quality masks and avoiding indoor, crowded gatherings, particularly without ventilation and air filtration,” Topol said. “So, we're set up for the virus to evolve further, and that, of course, could make for a tougher October and November. But it's hard to predict.”

Clinical guidance on the new COVID-19 vaccine:

The official recommendation from the CDC is that everyone over age 6 months should get the COVID vaccine and a flu shot.
For the flu shot, adults over 65, Patel said, should get a different formulation: either an adjuvanted, recombinant vaccine or a high-dose inactivated vaccine so that their immune response is stronger.
For the new COVID shots, children between the ages of 6 months and 4 years, as well as those with weakened immune systems, should get some additional doses of the updated vaccine.
Patel noted that healthcare providers should work individually with immunocompromised patients to determine what path is best for them.

What about the RSV vaccines?

Nirsevimab, a recombinant monoclonal antibody product, is recommended for all infants younger than 8 months when RSV season is approaching, or even during the season.
Patel said that infants who are at higher risk for RSV, like premature babies on oxygen or diuretics, can get nirsevimab between the ages of 8 and 19 months.
Adults 60 years or older may get the RSV vaccine, but Patel encourages doctors to have in-depth conversations with their patients about whether they might be at higher risk for RSV and thus should be immunized.

Vaccine timing, sequencing, co-administration, and more

Both Topol and Patel noted that healthcare providers shouldn’t advise patients to wait for the new Novavax shot, which is expected to be available soon, as the vaccines that are on the market now are still effective at providing sufficient protection.
Those who have just recovered from a recent bout of COVID can wait up to 3 months before getting vaccinated.
It’s acceptable for physicians to administer all three vaccines — for flu, RSV, and COVID — at one time, especially because that might be the only time they see that individual patient all season long.
If physicians decide that it's best to co-administer the COVID and flu shots and delay the RSV vaccine, that’s acceptable too, as long as they encourage the patient to come back for their third immunization. There is no recommended delay period between these vaccines.

How much will this cost my patients?

Since the COVID state of emergency ended, the cost of getting a COVID vaccine has risen significantly, particularly for the uninsured. Even for the “pseudo-insured,” Topol said, insurance companies will still insist that the individual pay this cost, claiming that it will go toward their deductible.

“It’s still in the early days,” Topol said. “But unfortunately, the companies — namely Moderna and Pfizer — have increased the price more than fivefold what they were charging the government. That’s atrocious, in my view.”

Most insurance plans are required by law to cover CDC-recommended vaccines, which include COVID-19 vaccines, with no cost-sharing involved. The practical implementation of this, though, is “very convoluted,” said Patel.

The CDC has a Vaccines for Children program for the uninsured and underinsured, which has provided immunizations to half of the children in the United States, according to Patel. For adults, there is the Bridge Access Program, which would provide COVID-19 vaccines to adults at no cost.

Precautions going forward

“A lot of people think the pandemic is over,” said Topol. “Maybe the emergency phase is over, but we still have this virus, and we’ll have this virus for many years to come.”

That’s why, in Topol’s opinion, we shouldn’t let precautions, like masking and avoiding congregating indoors without proper ventilation, fall by the wayside.

Patel explained that healthcare providers have a respiratory disease toolkit, which includes vaccines, antivirals, testing, physical distancing, and more. This kit can and should be tailored to each patient.

“It's a really exciting place to be, to have these additional new and updated immunizations available for the public,” she said.