Vaccines, variants, and trends for respiratory virus season

Get prepared for respiratory virus season with an informative discussion on what every physician should know about this year’s flu, COVID, and RSV vaccines. In this episode of PermanenteDocs Chat, guest Connie Park, MD, clinical flu lead for The Permanente Medical Group and chief of Infectious Diseases, Greater Southern Alameda Area, joins host Dr. Alex McDonald of the Southern California Permanente Medical Group to discuss vaccine strains and practical strategies for addressing vaccine hesitancy and misinformation.

Guest

• Connie Park, MD, Clinical Flu Lead, The Permanente Medical Group; Chief, Infectious Diseases, Greater Southern Alameda Area

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello everybody. Welcome to today’s PermanenteDocs Chat. I’m your host Alex McDonald, and this week we are discussing vaccines variants and trends for the 2024 respiratory virus season with our guest Dr. Connie Park. Dr. Park, thank you so much for joining us today.

Connie Park, MD: Thank you so much for having me. I’m excited to be here.

AM: We’re excited to talk to you. Dr. Park is our clinical flu lead at The Permanente Medical Group [and] chief of Infectious Diseases for the Greater Southern Alameda area. We have lots of juicy topics to discuss today. As always, put your questions in the Q&A box early and often. We’re going to jump right in. Dr. Park, in your own words, tell us who you are and what you do.

CP: I’m a practicing adult infectious disease physician. That basically means I see a variety of patients for a variety of infections in an office and hospital setting. I’m a Northern California Kaiser Permanente physician, so I’m based out here in the East Bay and San Leandro. But I recently also took on this regional clinical lead role for our Northern California’s seasonal mass vaccination program. I serve primarily as a clinical consultant to this longstanding, large-scale vaccine program. We administer millions of flu and COVID-19 shots a year to all of our Northern California members and many times to our non-members. So in a nutshell what I’m doing in my professional time.

AM: Awesome. So just a small project is what you’re telling us.

CP: Just a tad.

AM: I used to think about fall being a flu vaccine season, however now we have flu, we have COVID, and starting last year, we have RSV vaccines. So I started shifting my language and my thinking to respiratory virus vaccination season, if you will, starting in the fall. Can you tell us any key updates this fall and any differences this year moving into upper virus respiratory infection or cold and virus season compared to prior years?

CP: There’s a lot of things that we can talk about in terms of updates. I’ll start with the influenza vaccines. We’ve now broadened our minds to encompass the season as a global respiratory viral season because that’s more accurate than just flu season.

AM: I have to admit, cold and flu season always didn’t sit well with me. Those are very different things. So that’s another issue.

CP: Exactly, I appreciate everyone getting the idea that these viruses tend to circulate. There’s a multitude of them and fortunately we have vaccines for [many] of the ones that can cause severe disease. A few updates, when it comes to influenza vaccines, this is the first year we’ve gone to a trivalent vaccine. So, not hugely impacting in a day-to-day way, but for the last 10 years or so it had been a quadrivalent formula. There were two influenza B strains that were included along with two influenza A strains, but one of the strains hasn’t really been circulating. One of the influenza B strains hasn’t really been circulating since 2020, so that was recommended to be removed. As a reminder to the audience, the World Health Organization recommends which flu strains to include for the upcoming season as early as January [and] February.

This year, it targets two influenza strains, H1N1, H3N2, and then one influenza B strain. Another interesting update that folks might’ve heard about is that the FDA did approve the flu mist, a nasal spray vaccine. It’s currently approved for individuals 2 to 49, administered in a health care setting by a health care provider. They updated that to be a vaccine that can be self-administered or administered at home by a caregiver. This isn’t actually going to roll out until the 2025-26 season, but it’s an exciting new development to look forward to.

Back in June, the COVID vaccine was recommended to be updated to include the more up-to-date circulating variants, which [included] the JN1, and then later KP.2 and KP.3 variance. The idea is that the virus does continue to mutate, it mutates at a rate about 2 times faster than the flu. And we do think that the variants do meaningfully differ in terms of how well they can trigger antibody formation. So we do know that the vaccine has some waning protection around the 4-month mark. We see that there are some effects that have waned. So the idea that it’s best for people to get updated shots annually. And what I was trying to say is although the effectiveness wanes, the general population [still has] baseline protection, so this is really incremental protection above that baseline.

AM: I’m hearing you say that we should all make sure we get our updated COVID vaccines this fall because it’s a new updated variation compared to prior vaccines. There’s a lot of COVID vaccine fatigue that I’ve seen [and] what I’m hearing you say is even if you’ve had X number of COVID vaccines prior, this fall update is really important to match the circulating strains, correct?

CP: Yes, exactly. Everyone 6 months and older is recommended to get an updated 2024 -25 COVID-19 vaccine. We have preliminary efficacy data, it does show the vaccine offers additional 40 to 60% additional protection against severe disease, depending on how soon after you get the vaccine that that protection is measured. So, take home message, everyone 6 months and older is eligible for an updated vaccine, it offers a little bit of a boost in how well you form antibodies against the variants that are circulating now and also for protection against severe illness, especially for those that are a little more susceptible to that.

AM: And we’ll get to RSV in a second. But I guess a question popped in my brain, which I’ve been getting a lot from patients is does it matter what kind of flavor of COVID vaccine, if you will, Moderna, Pfizer, the Novavax? Is there a specific difference? Is there one you recommend versus another?

CP: Bottom line, there isn’t really a meaningful difference. I think it’s whichever one is being offered and whichever one you’ll take. Anecdotally some people have a little bit more side effects with the mRNA vaccine, a little bit more lingering pain in the arm or more muscle aches, and so prefer to get the protein-based Novavax vaccine. But it’s really probably the same across the board. I would just say just get which one you are offered or is available.

AM: I got my flu and COVID vaccine about 2, 3 and a half weeks ago and my nurse gave it to me, my arm was sore for a couple days and then someone asked me, oh, what type of COVID vaccine did you get? And I realized I didn’t even know. So I went back and asked, turns out I got the Pfizer version, what was available.

CP: I think that’s what the attempt is in terms of the COVID vaccine is, making it routine from the seasonal vaccine point of view, much as we think about flu vaccines.

AM: Lastly, tell us about RSV vaccines, this is the second season that we’ve had this available for our patients 16 and older who are a little bit higher risk of severe RSV disease.

CP: No meaningful updates with the RSV vaccine in and of itself, aside from the fact that there’s a new manufacturer and new product. Moderna’s mRNA vaccine made it through all of their trials and is available now for use. That’s the only new update. It did get an update in recommendations from the CDC and ACIP committee, so that [made] it easier for clinicians to comply with the recommendations. Basically anyone 75 years and older should get one RSV vaccine and individuals 60 to 75 years old with certain immunocompromising conditions are recommended to get the vaccine. And pregnant women who are 32 to 36 weeks gestation between September and January are recommended to get the vaccine. It’s a one and done shot, so if you’ve already gotten one, there’s no need for an updated one. This is considered once in a lifetime vaccine for now.

AM: It’s funny you should mention that. I’ve had a lot of patients who I’ve been taking care of for 10-plus years and I’ve trained them to come in to get their flu vaccines and now their COVID vaccines. I had a patient who came in to get her annual RSV vaccine, [and I told her] you got it last year so you actually don’t need it. She was very excited. So, I think there’s still some education to be done regarding physicians and patients regarding how frequently we need that RSV vaccine.

CP: Very true, yes.

AM: Let’s take a step back here. Can you talk about the vaccine program in Northern California and your innovative approach to how you’re dealing with distribution and administration? And then we’ll go into vaccine hesitancy and education in the coming questions.

CP: If it’s okay Alex, [I’d like to] look into my crystal ball and predict the future in terms of what I anticipate the season will look like. These are all best guesses and we’re going with the information that we have, but I want to say the CDC did come out and forecasted with moderate confidence that our upcoming flu season should be similar or maybe even milder than last year’s season. I thought was welcome news. Obviously this depends on a number of circumstances, including how much infection are we seeing, what type of subtypes of influenza are circulating, how much population immunity there is, and also vaccine efficacy. Some of that remains to be seen for this season. We did get preliminary vaccine efficacy data from the southern hemispheres experience that was released earlier this month. Unfortunately it showed a decrease in efficacy compared to last year, about a 35% efficacy in reducing risk of hospitalizations among at-risk groups. That was young children, people with preexisting conditions in older adults, and, for clarity, vaccinated people in these groups were 35% less likely than unvaccinated people to get sick enough to go to the hospital due to influenza complications. For context, last year’s vaccine efficacy was about 51%, although this is within the typical range of efficacy. We’ve seen around 20 to 60% for flu vaccine performance. So one reason for this decreased efficacy, it’s possible there was less H1N1 circulating, they did detect more of the H3N2 influenza A, and historically the vaccines have performed less well against H3N2.

That’s one hypothesis, although there was less vaccination, only 21% of adults were vaccinated. Obviously more disease spreading can hide vaccine effectiveness. Overall, the flu season did seem on par in the southern hemisphere with their average influenza year, but there were pockets in some countries like Chile, Uruguay that did see unusually high severe flu hospitalizations. So take that for what it’s worth, but it seems like we’re on track for a middle-of-the-road season, but some things remain to be seen, especially if we have similar vaccine performance up here in the northern hemisphere.

AM: So the bottom line is no vaccine is perfect, but it can give you some protection and that some protection can be enough to prevent severe disease or overwhelmed medical system.

CP: Yeah, I think that’s a great reminder that the role of vaccines often [is to] protect from infection, but even with infection in that group of individuals in that prelim data, it did show that those who were vaccinated [had] a lower risk for hospitalization or influenza -elated complications [than] those who weren’t vaccinated. We forget that there is a role in attenuating the immune system a little bit to help make things not as bad as they could have been.

AM: I appreciate you looking into the crystal ball there, but we won’t hold you to any of those predictions. Obviously it’s an educated guess when it comes to predicting the epidemiology of different viruses and illnesses. Walk us through the vaccine program that you helped oversee in Kaiser Permanente Northern California and describe any innovation approaches to that program.

CP: I’m really excited to share this program. Our organization has really leaned into prevention is key to health. The gist of the program is if you want a vaccine, we try to make it as easy as possible for you [to get the vaccine]. We set up more than 70 standalone seasonal vaccine clinics throughout all of our Northern California ecosystem so that you can get them as easily as possible wherever you might be getting your care. There’s clinics, and one of my personal favorites, our drive-through clinics.

I have five young children, ages 11 and younger. So, drive-through clinics are super, make it streamlined for me. I got mine a couple weeks ago through our location in Union City. The seven of us pile into my minivan. The line was short, even though I was prepared to wait with books and movies and we were ready to chill in line. But we got there, we pull up, and of course when they see there’s seven of us, they call a few other people. We usually get one or two other staff members and my husband and I go first. We roll up our sleeves, no problem. By this time my boys are crawling up to the front to watch because they’re fascinated with needles.

And so they’re just watching the injection happen and my oldest daughter is reading her book and she can barely be bothered to lift her head up. And my five-year-old is totally shrieking, but nobody cares because her cries just get dissolved into the wind. And then after all is said and done, my 2-year-old, I think she kind of watched the whole thing unfold, just gets it and doesn’t even make a peep. So that was our experience this year and super easy. We just roll up our windows and then drive away. So that’s definitely my personal favorite and I really appreciate the effort that people go through to set those up for us. But yeah, we basically try to make it as easy as possible. We take walk-ins, no appointments, we offer appointments for those because some people do like to be more scheduled standing orders, so just really easy to walk in and get it done, try to remove any barriers that we can.

AM: I know one thing, one problem that I’ve had as a parent is sometimes getting my kids to different locations to get vaccinated. So just piling into the car, I love that. Or having it available at multiple different locations without an appointment. That’s so helpful. I know when I walk in through the lobby here to my own office building, there’s always a table there with a nurse offering flu vaccines. And anytime I walk past I see people and I tell ’em to get their flu vaccine as I walk out to the parking lot.

CP: And that’s kind of our second part is for those, the people who want the vaccine, they’ll find it, but it’s really those who are kind of contemplated or maybe just haven’t and they’re not as motivated. We really try to make it hard for you to miss us. So yeah, we’re in the front entrances of your facility, so you see us whether you’re coming to get your prescriptions or seeing your doctor, we stock specialty clinics, so even if you’re there for your GI consult, you could get your flu shot. We’ve got nurses with carts that are roving around to capture people in waiting rooms or even our own employees who kind of can’t get to the lines in time. We’ve got pop-up reminders in our EMR to tell people like, Hey, this patient’s due for their shot, can you offer it to them? We send millions of outreaches via text and emails reminding all our patients where and when they can get their shots. So I think that’s kind of the gist of the program is we’re just kind of ubiquitous. We want to be everywhere all at once to try to make it as easy as possible to get as many people their vaccines.

AM: Yeah, no, there’s definitely those 20% of people that are going to actively seek out the vaccine and do whatever they can, and then there’s 20% that will not get it vaccinated no matter what you do. And those 60% are the movable middle of those that we try to make it easier for and less barriers. And I really appreciate all the work that we do. Again, again, I’m a primary care physician. My job is to keep you healthy and I think vaccines are a really big part of that.

CP: Absolutely.

AM: So let’s switch gears here to sort of that conversation for those people who are unsure who have questions about the various vaccines this fall. There’s been lots of information and misinformation circulating even before covid, but then obviously Covid sort of put some of those concerns on hyperdrive. And what recommendations or advice do you have for physicians who are counseling their patients about vaccines? What works, what doesn’t work? What insights can you provide?

CP: Yeah, this is a big topic and I think all of us are scratching our heads about what is the best way to get to the unreachable. And I guess I was just reviewing, especially when it came to covid-19 vaccine hesitancy, just reviewing the research and it does seem a few themes come out. Obviously misinformation and disinformation like you mentioned, I think is really huge and it’s playing a really big role. It was helpful for me to understand there’s misinformation, which is people sharing misleading information without any malicious intent. And then there’s disinformation, which is an actually coordinated orchestrated effort to deliberately mislead and to change behavior. And usually most things it’s motivated by profit and the campaigns are a real legitimate business now. So I think, and obviously social media and AI give it more legs. So I think that is playing a huge role.

And I think the evidence does show there’s a link between misinformation and evidence for contributing to vaccine hesitancy. So this does really affect and change real world behavior. I think when it came to COVID-19 vaccines too, the concerns about safety and side effects I think continues to be a major deter for people. People are scared about side effects, people don’t want side effects. People want things to be safe, and if there is any echo that it isn’t or suggestion like nervous and whether it’s legitimate or not, these are kind of really barriers to people being willing to take up the vaccine. And then I think unfortunately, I think we did suffer some distrust. We meaning public health entities and healthcare in general. I think there was some eroding trust in us as a group. And it’s hard because I was there in the middle of the pandemic and saw how things were changing.

We were asked to act on information that was already a day old. And I think there were well-intentioned steps that led to a little bit that ultimately led to some mistrust. But I think one example, my non-medical husband always likes to point out about how we were telling people early on that masks don’t work or don’t use masks only to reverse course and then double down on masks. And he always said, you guys should have just leveled with people from the beginning and said, Hey, listen, we really need, these are for healthcare workers right now and please don’t use them because that’s what we really need them for instead of doing this reverse phase. So I think it’s hard criticism for me to swallow, obviously being part of the medical community, but I do think that is playing a factor in people’s willingness to take this up.

And I think finally, personal beliefs and values still play a huge role when it comes down to it. People have different value systems and I think covid, especially accentuated how people value life and liberty, and these are a little bit more esoteric topics, but I think our policy scientific data is objective obviously when done well. But we do forget that policy does incorporate objective scientific data, but also our subjective values and worldviews and so well-intentioned policies like mask and vaccine mandates, which does utilize both science and kind of value systems got presented as the scientifically right choice and didn’t acknowledge the tradeoffs that happen, like economic burden or infringement on freedom. And I think that made science take a credibility hit. So I think that’s all what’s ruminating in the background when people are thinking about COVID-19 vaccines. So how does one actually overcome that?

It’s hard. I think it’s going to take a lot of work. I don’t think these efforts are necessarily easily scalable. This is done through clear transparent communication, building rapport with your patients, asking open-ended questions, avoiding judgmental language, being empathetic with your patients. But one thing I thought was really effective or that I heard that I thought was really helpful is a lot of times it doesn’t end up coming down to the facts or the data, it’s more about people’s values and identity. And I think finding a way to connect with people about values that they hold, what do they hold as important and finding a way to connect about those versus trying to introduce a new world order into their thinking. I think those are going to be in the long run, the more effective way to build bridges between these two groups. So

AM: I completely agree with you, and again, as a primary care physician who takes care of whole families for over years or even decades sometimes I have found that building that trust doesn’t always happen in one visit. And you sort of, Hey, do you want to get your flu vaccine and do you want to get your covid vaccine? No, not today. Great. Well, we have ’em available, stop by anytime. Right? And then the next year, same thing, and you sort of have the same conversation over and over again. And as a physician you build trust by doing, by showing and by listening. I think one of the greatest pieces of information I ever had was when you offer someone their vaccine and they say no, you ask why, and they’ll often say something and then asking permission to give them your perspective, your medical opinion, essentially rather than just sort of jumping into the science or jumping into the tirade, you ask them why, and then you ask permission to give your kind of opinion as it relates to whatever their why is and really tailor that conversation, that message to each individual patient. So it really takes every single physician, every single time, even if it’s just 20 seconds, can all collectively add up and make a big difference. But that’s my own 2 cents.

CP: No, I think that actually that pans out too. I think tailoring messages to specific concerns, again, I’m bringing that back to the side effects just because that’s such a big concern for people, but talking openly about them and letting them know actually those do occur. Most of them are mild, most of them aren’t permanent, and last just a few days at most, it’s actually a sign that your immune system is working, just kind of tailoring your message to some of the specific concerns. But yeah, I agree. I also provide primary care in the HIV setting, and so a lot of my patients are very reluctant and sometimes it’s just it’s not going to happen that year, but you come back to it every year, I let

AM: Them know.

CP: Yep, that’s totally fine. Just to let you know, I’ll probably ask you each time that we get together and just let me know if you have any questions or I really like your idea of, could I just tell you what I think or would that be okay if I shared my own beliefs about why this is effective? Just small strategies like that. But yeah, it’s not going to be something that we can just quickly snap our fingers and turn things around.

AM: Yeah, my favorite is to take a picture of my own vaccinations and post it on social media to kind of publicly show people that, Hey, look, I’m a physician. I am getting vaccinated to protect my family, to protect my patients. And so I think leading by example is really powerful as well. Oh my gosh, this is amazing. We’ve covered a ton of information. We both speak pretty quickly, so it’s been helpful. We’re going to try to wrap this up just because we do try to keep these high yield. Maybe we’ll have to have a part two because there’s so much information here. So last question. What makes you most proud to be a Permanente physician?

CP: Yeah, I think we talked about, I’m a transplant from the Midwest and East coast and sort of been practicing in a lot of different care models, but it’s really the care model that I think, I believe in that Kaiser Permanente practices, which is that we’re here and we’re in the business of trying to treat patients and keep them healthy and well. And that’s just never rung true to me. As I’ve gotten older, I’ve seen my parents and my family age, I’ve seen how health really is such a determinant to your quality of life. And I think that the mission of really trying to get people holistically well, trying to prevent illnesses before they happen, and just that model of investing really before illness and trying to take care of people and keep them healthy and well, it is just something I think that resonates with me. So I’m glad to be practicing in a system that practices and preaches that. And so hopefully, and yeah, I think that’s what makes me really excited and happy to be part of the Permanente Medicine Group.

AM: Amazing, amazing. Thank you so much for your time today, Dr. Park. And thank you for all your work, kind of helping coordinate vaccines and helping prevent respiratory illnesses this winter.

CP: Thank you. Thank you for having me.