Overcoming Barriers to RSV Vaccination in Adults

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AJMC®: How has limited awareness of respiratory syncytial virus (RSV) infection risk impacted vaccination rates of adults in the long term–care setting?

FELTNER: There is a widespread misconception that RSV vaccinations are only for the pediatric population. However, with the recent approval of RSV vaccines for adults, and particularly those 60 years and older, awareness is increasing.

In my practice at long term–care facilities, we encounter numerous respiratory illnesses including peri-influenza, COVID-19, and RSV infection. It is crucial to protect against these illnesses along with pneumococcal disease by educating our residents on the benefits of RSV vaccines and implementing measures to prevent the spread of these diseases within our facilities and the broader community.

The challenge lies in overcoming the misconception that RSV is solely a pediatric concern. Education and awareness are key to improving vaccination rates among adults.

AJMC: How can pharmacists and providers contribute to identifying at-risk adults for RSV vaccination?

FELTNER: Pharmacists can play a crucial role in identifying at-risk adults for RSV vaccination by implementing a comprehensive vaccination program. Engaging the entire pharmacy team, especially in a retail setting, is essential. Pharmacy technicians and clerks can help identify patients who regularly pick up medications for conditions like diabetes, heart failure, or immunocompromised states and make it easier to pinpoint those eligible to receive an RSV vaccine.

It’s important to educate the entire pharmacy team about the safety and efficacy of the RSV vaccine to assist in identifying at-risk patients. Pharmacists can then discuss the vaccine’s benefits with eligible patients. Retail pharmacies often create data exports to identify patients on specific medications and reach out to them, which has proven beneficial. Additionally, promoting vaccine awareness through hanging posters, handing out flyers, and providing community outreach is key.

RSV vaccines are primarily covered under Medicare Part D, and pharmacies are pivotal in vaccine administration. Collaborating with local health care providers and promoting the pharmacy as a vaccine provider can significantly enhance vaccination rates among at-risk adults.

AJMC: With the recent expansion of 1 RSV vaccine indication to include adults aged 50 to 59 years with comorbidities,¹ what are the considerations for identification and vaccination of these individuals?

FELTNER: Identifying and vaccinating this population will be critical. Staff at pharmacies and long term–care facilities must focus on recognizing these at-risk individuals.

However, several challenges must be addressed, particularly those concerning insurance reimbursement. Currently, under the Patient Protection and Affordable Care Act, Part D vaccine submissions often result in a zero-dollar co-pay for those 65 years and older. For patients aged 50 to 59 years, especially those with private insurance, there may be shared costs.

Pharmacists will need to stay informed to effectively navigate reimbursement issues and ensure that eligible patients receive the vaccine without having to deal with undue financial burden.

AJMC: How do pharmacists use guidance from the Advisory Committee on Immunization Practices (ACIP) for adult RSV vaccination?

FELTNER: The ACIP, which is an arm of the CDC, serves as the essential guide for pharmacists regarding adult vaccinations. Clear and concise ACIP recommendations are crucial for pharmacists to effectively administer vaccines.

The ACIP’s 2023 recommendations,² which involved shared decision-making between patient and provider, could be challenging in retail pharmacies, especially when no collaborative agreement was in place allowing pharmacists to vaccinate without a prescription. Pharmacists often had to collaborate with medical providers to secure vaccination authorizations, which led to missed opportunities to vaccinate eligible patients.

The ACIP’s June 2024 recommendations are much more straightforward. Adults who are 75 years or older and adults aged 60 to 74 years who live in nursing homes or are at increased risk of severe RSV infection should be vaccinated.³ This simplifies the vaccination process and is likely to improve immunization rates.

Ultimately, clear ACIP guidelines enable pharmacists to better protect adult patients from RSV disease by streamlining the vaccination process and ensuring broader, more effective immunization coverage.

AJMC: How did last year’s ACIP guidance for RSV vaccination in older adults² influence vaccine coverage in this population?

FELTNER: In my practice within long term–care facilities, we primarily administer RSV vaccines to individuals over 65 years old and bill their Medicare Part D plans, which typically cover the vaccine at no cost. The ACIP’s 2023 guidance did not significantly impact us, but it did affect the retail pharmacy sector.

In retail settings, if patients aged 50 to 64 years do not have Medicare Part D and must use private insurance, some costs may be passed on to them. This could lead to patients declining the vaccine, increasing the risk of RSV in the community. Although RSV vaccine efficacy is not 100%, it can reduce the severity of the disease, which is crucial.

RSV disease is underreported in the US, with only 12 states having mandatory reporting programs. There are over 170,000 hospitalizations and up to 14,000 deaths annually from RSV infection in older adults. Accurate data are essential, but current reporting is insufficient. In long term–care and skilled nursing facilities, we frequently see RSV infection alongside COVID-19 and influenza. Therefore, vaccination remains a critical strategy in preventing severe RSV disease.

AJMC: What challenges have arisen in administering RSV vaccines to older adults, and how might these be overcome?

FELTNER: Until June of this year, the major obstacle with administration of RSV vaccines had been the shared decision-making process recommended by the ACIP involving pharmacists, patients, and medical providers. This approach often led to missed vaccination opportunities. The ACIP’s recent age-based recommendation for patients 75 years and older will likely increase immunization rates and reduce missed opportunities for this population.

The new risk-based recommendations for patients aged 60 to 74 years are more straightforward than the ACIP’s previous shared-decision-making recommendation. However, it is less straightforward than an age-based recommendation would be. We saw this with the influenza vaccine. When administration of influenza vaccines involved risk-based recommendations, pharmacists had to check each patient’s condition before vaccinating, which was cumbersome and less effective. When the recommendation changed to include everyone 6 months and older, immunization rates improved. Similarly, a clear age-based recommendation for RSV vaccines in younger adults would streamline the process and enhance coverage, benefiting both pharmacists and medical providers.

AJMC: How can health systems effectively collaborate with pharmacies and health care providers to identify and vaccinate at-risk individuals?

FELTNER: Health systems should collaborate with local pharmacies to ensure that at-risk patients receive vaccinations. When health systems cannot directly bill Medicare Part D plans, they should refer patients to local pharmacies that can handle the billing and vaccination process.

To build effective partnerships, health systems need to understand pharmacy processes. Providers can send electronic prescriptions to pharmacies; staff will then manage insurance verification, discuss any co-pays with patients, and follow up to ensure vaccinations are administered.

Pharmacy staff, in turn, should communicate with health systems to outline their services and referral processes. In states without collaborative agreements allowing pharmacists to vaccinate independently, referrals from health care providers are crucial.

For example, in Nebraska, collaborative agreements permit pharmacists to vaccinate eligible patients automatically based on ACIP recommendations. In states without such agreements, strong cooperation between health systems and pharmacies is essential to ensure that patients receive necessary vaccines.

AJMC: What strategies can pharmacists employ to mitigate uncertainty about insurance coverage and improve uptake?

FELTNER: Uncertainty about insurance coverage is a significant obstacle to RSV vaccination. If an older adult doesn’t have a Medicare Part D plan (which typically covers the vaccine at no cost) and instead has private insurance with an associated cost, they are much less likely to get vaccinated. In most cases, if there is a co-pay, especially a high one, the patient will decline the vaccine.

This situation mirrors past experiences with the herpes zoster vaccine for individuals aged 50 to 64 years. High out-of-pocket costs deterred many from getting vaccinated. As pharmacists, we must effectively communicate the vaccine’s value, safety, and efficacy to overcome these financial barriers.

Clear and concise recommendations are crucial. Any confusion or lack of clarity can lead to patients declining the vaccine. Based on my 25 years of experience in retail and long term–care pharmacy, providing straightforward, understandable information is key to improving vaccination rates among older adults.

AJMC: How can insurance coverage for RSV vaccines for younger adults be optimized?

FELTNER: Insurance coverage for RSV vaccines for patients aged 50 to 59 years could be optimized by ensuring no out-of-pocket costs for eligible patients as per ACIP recommendations. Importantly, the ACIP recognizes that disease from RSV constitutes a public health problem for patients in this population who are at risk for severe disease.⁴ It’s more cost-effective for insurance companies to cover the vaccine than to pay for the treatment of RSV-associated disease, which the vaccine could prevent.

Economically, investing in vaccination leads to higher immunization rates and reduces overall health care costs. Insurance companies should view the RSV vaccine as a preventive service and fully cover it to encourage widespread uptake. This approach is essential for preventing vaccine-preventable diseases and promoting public health.

AJMC: How can providers encourage early RSV vaccination?

FELTNER: Encouraging early RSV vaccination is crucial, especially as the RSV season shifts earlier in the year and hospitalization rates rise. During the early stages of the influenza season—typically August to September—patients should be educated about the importance of RSV vaccination alongside administration of influenza and pneumococcal vaccines.

Currently, RSV vaccinations are typically administered as a 1-time dose, but future guidance from ACIP may recommend a different schedule. With 3 manufacturers in the market, ongoing evaluation of efficacy, safety, and postmarketing data will shape future immunization schedules. Stay tuned for updates on RSV vaccination recommendations as more information becomes available.

AJMC: How do you educate patients and staff on the importance of preseason RSV immunization?

FELTNER: In our long term–care pharmacy, patient interaction is limited, so our focus is on educating medical providers in our facilities. We work closely with over 50 medical directors and serve 2500 residents in Nebraska to ensure that they are updated on ACIP’s RSV recommendations.

To identify eligible patients, we prioritize vaccination upon admission. Since RSV vaccines became available, they have been given year-round alongside influenza and COVID-19 vaccines. When a new resident arrives, we ensure that they’re informed about the benefits and safety of RSV vaccination, empowering them to make an informed choice.

We’ve also expanded RSV vaccination availability facility-wide, and we actively educate patients and their families about this service. By collaborating with medical providers and promoting awareness among residents, we aim to maximize RSV vaccination rates, especially among high-risk populations.

AJMC: How might postmarketing data influence recommendations for the frequency and administration of RSV vaccines?

FELTNER: Given the ongoing evaluation of postmarketing data from all 3 manufacturers, the possibility of RSV vaccines transitioning to an annual immunization remains uncertain, since the ACIP currently is advocating for a 1-time-only dose. As we navigate this evolving landscape, it’s imperative to stay abreast of ACIP’s changing recommendations, which may include age-specific approaches such as considering different schedules for high-risk patients aged 50 to 59 years and individuals aged 60 to 74 years.

AJMC: How do pharmacists mitigate vaccine fatigue and hesitancy among eligible patients?

FELTNER: Overcoming vaccine fatigue is imperative in the retail pharmacy sector, where pharmacists play a crucial role. They must not only be knowledgeable about RSV vaccines but also effectively communicate their safety and efficacy to patients. It’s vital to address the misconception that RSV vaccines are solely for the pediatric population and to emphasize their importance for older adults as well. Educating patients and health care teams about the value of RSV vaccination is essential amid vaccine hesitancy and especially in the context of the COVID-19 pandemic. By involving patients in the decision-making process and fostering a collaborative approach, pharmacists can help mitigate vaccine fatigue and promote RSV vaccination uptake.

AJMC: How do pharmacists effectively combat misinformation surrounding RSV and RSV vaccination among patients, particularly considering the proliferation of vaccine-related misinformation observed during the COVID-19 pandemic?

FELTNER: When addressing misinformation about RSV or RSV vaccination with patients, it’s essential for pharmacists to provide supplementary materials to guide them toward informed decisions. Transparency about potential risks and adverse effects associated with any vaccine or medication is paramount for fostering trust between health care providers and patients. Effective communication involves speaking to patients with empathy and clarity and emphasizing the importance of vaccination for their health and well-being. Pharmacists should be knowledgeable about the benefits and safety data of RSV vaccines, as well as the distinctions among different manufacturers’ products, to best serve their patients in the pharmacy setting.

As our population ages, the health and economic impact of RSV disease will persist, underscoring the importance of educating health care teams, patients, and communities about the benefits of RSV vaccinations. As health care providers, we need to make sure that we educate our teams, our patients, and our community on the benefits of RSV vaccinations. Vaccine-preventable diseases are only preventable if we vaccinate.

REFERENCES

1. Arexvy. Prescribing information. GlaxoSmithKline; 2024. Accessed June 12, 2024. https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Arexvy/pdf/AREXVY.PDF

2. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801. doi:10.15585/mmwr.mm7229a4

3. CDC updates RSV vaccination recommendation for adults. CDC. June 26, 2024. Accessed June 27, 2024. https://www.cdc.gov/media/releases/2024/s-0626-vaccination-adults.html

4. Britton A, Melgar M, Roper L. Evidence to recommendations framework (EtR): RSV vaccination in adults aged 50–59 years, 60–74 years, and 75 years and older. CDC. June 26, 2024. Accessed July 3, 2024. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2024-06-26-28/11-RSV-Adult-Melgar-Roper-Britton-508.pdf