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Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by CSL Seqirus. Here’s your host, Dr. Dogrhramji.

Dr. Doghramji:
Welcome to Clinician’s Roundtable on ReachMD. I'm Dr. Paul Doghramji, and joining me to discuss how we can help our patients combat the flu is Dr. Marci Drees, who's the Chief Infection Prevention Officer and Hospital Epidemiologist at ChristianaCare in Wilmington, Delaware. Dr. Drees, thank you for being here today.

Dr. Drees:
Thank you very much for inviting me.

Dr. Doghramji:
Dr. Drees, to start us off, what do we need to know about our patients’ risk of flu exposure during the flu season?

Dr. Drees:
Well, I mean, I think as everyone's well aware, we've been through several very strange flu seasons the past few years with the pandemic. You know, there was nearly no flu at all in the 2020-2021 season. And then the 21-22 season was overall pretty mild, but very late, going well into May, which has almost never been seen before. And then the 2022-23 season was very early, it really came and went in the fall and is still kind of petering out since then.

So, I mean, I think what I often say is the only thing predictable about flu is that it's unpredictable. And certainly this past year, RSV hit around the same time, COVID was still present. So, there's just a lot going on. But I think we're certainly seeing more flu in this past year, because all the things that we were doing for COVID kind of went away. Things are open again, and people are traveling again. People aren't masking in public like they were required to do at one point during the pandemic. And so, I think it's certainly not surprising that that leads to more exposure to flu and other respiratory viruses.

Dr. Doghramji:
Now, what does the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommend for keeping our patients safe during the flu season?

Dr. Drees:
So, there are some longstanding recommendations as well as some newer recommendations. The longstanding recommendation is that everyone who's 6 months or older, is recommended to be vaccinated unless they have a specific contraindication to all available flu vaccines. And that includes immunocompromised persons as well as pregnant women.

What's happened over the past couple of seasons is that all flu vaccines are now quadrivalent, meaning they have two strains of flu A and two strains of flu B. And the decision of which strains are included in each Fall’s vaccine for the Northern hemisphere is typically made in February of each year.

One thing that's relatively new is around the timing of vaccine. The CDC used to say just start getting it as soon as it’s available in the community. But what we're seeing now is sometimes in community pharmacies, it's available by late July, early August. And they've clarified that really, for most people, September, October is really the ideal timing to get the flu vaccine. And that's especially true for people who are 65 and older because we know that their immunity wanes a little bit sooner. So, we want that vaccine to last for a good six months that will get them through the flu season. There is no recommendation to revaccinate later in the season.

There are a few populations that should try to get that vaccine really as soon as it becomes available. So, one is pregnant women that are in their third trimester. You want to try to get them before they give birth so that they have some time to develop antibodies that they can pass on to that infant who will then be protected during the first six months of their life where they can't themselves be vaccinated and they're going into flu season.

The second one is for younger children under 8 who are getting their first round of flu vaccines. They are recommended to get two vaccines that first season. So, you want to get that first one in as quickly as possible so that you have time to give them the second one before the flu really hits in the community. However, if you are seeing other children in August, say because they have their pre-sports physicals, and you're giving them other vaccines, or especially when you don't think they're going to come back for another visit, it is certainly okay to give them their flu vaccine that early just to make sure that they don't miss it altogether.

And then the other new recommendation that was for the 2022-23 season was around which vaccines to give to older adults, meaning those 65 and older. So, the ACIP now has a preferential recommendation for those three special vaccines. One is the high-dose vaccine, one is the adjuvanted vaccine, and one is the recombinant vaccine. So, any of those three are recommended over the standard flu vaccine for people 65 and older. And the reason for that is that they've been shown to either have better protection against flu illness, or at least have higher antibody levels generated after vaccination compared to the standard flu vaccine. And we know that older people are less likely to respond to flu vaccines in general, so this is a way to give them a little bit extra protection. And again, they're the higher risk population for getting severe disease. That said, if they're there for flu vaccine and you don't have one of those special vaccines, and especially if you don't think they're going to come back to get a special vaccine, it is certainly okay to give them the standard flu vaccine.

Dr. Doghramji:
For those just tuning in, you're listening to Clinician’s Roundtable on ReachMD. I'm Dr. Paul Doghramji, and I'm speaking with Dr. Marci Drees to discuss patient counseling tips on safeguarding against the flu.

Given the risks and recommendations, Dr. Drees, can you tell us why it's so important for our patients to get vaccinated against the flu?

Dr. Drees:
Well, I think a lot of people just have the attitude of, ‘Oh, it's just the flu. You know, it's no big deal.’ And I think as all clinicians know that the flu kills anywhere between 12,000 and 48,000 people on average, and that's just your typical flu seasons, not those terribly severe flu seasons. The majority of these are older adults 65 and older and children under 2. So, I think it's important for people to realize that even if they still get the flu after they're vaccinated, the idea is that their illness will be less severe, and they're much less likely to die or be in the hospital or be severely ill.

And the other thing I think people don't realize it's not always illness caused directly because of the flu. The flu can exacerbate other chronic medical conditions chronic heart disease, diabetes, asthma. So sometimes it's not that people got the flu and got better, but then they have a heart attack a couple of weeks later, and we have more data now that supports that the flu just kind of exacerbates a lot of other medical conditions. So obviously, avoiding that flu illness in the first place can help reduce some of those risks as well.

Dr. Doghramji:
With all that in mind, how can we counsel our patients on protecting themselves from the flu and tailor our approach to meet their needs?

Dr. Drees:
So I think it's really important to just meet people where they are. As a country, we've talked a lot lately about anti-vaxxers or the vaccine-hesitant. But I think it's important to understand that vaccine acceptance is an entire continuum. You have the very eager, like, ‘give it to me as soon as it's available’, to the ‘no way, never’ crowd. And true, what we call anti-vaxxers, whose beliefs maybe stem from a number of different places, from disinformation, conspiracy theories, their political views, whatever. You may be unlikely to change their beliefs based on anything that you tell them. I don't necessarily ignore the topic with those people, but, you know, I acknowledge their beliefs, but respectfully agree to disagree. And state something along the fact of, ‘I still recommend the vaccine,’ it's always their choice whether to accept that recommendation or not. But I wouldn't otherwise spend a bulk of time on that very small subgroup of people, because you're probably not going to get very far.

But most people are really in the middle. You know, they might have some misinformation that you can correct. Or they might feel like they're not at high enough risk to make the vaccine worth it, which is why I'd bring up some of the things I just talked about. Or maybe they've gotten sick after getting the vaccine in the past and they either think it was from the vaccine. So, there might be some concepts that you can clarify there about the vaccine only protects against the flu. They might have had another virus, or they might have had like just a robust immune response to the flu vaccine that made them feel bad for a day or two, but that's actually not necessarily a bad thing.

So, I think there's a lot of ways you can start to work with people. And I never really give up, even the patients that I have that every year they've refused a flu vaccine. I always bring it up at least once in the flu season. And often they're like, ‘oh, yeah, I know, I know.’ And then, you use humor and say, ‘okay, you know, I'll get off my soapbox now.’ But you've at least made the point that you think it's important and that you warned them that they're probably going to get the next speech next year.

Dr. Doghramji:
Well, as a quick follow-up to that, are there any tools or resources we can provide our patients to help them combat the flu?

Dr. Drees:
So I mean, I think we've learned a lot from COVID about how to prevent the flu, right? So, we've learned masks are really effective, and even more effective in preventing flu perhaps than preventing COVID, because the flu is just not quite as contagious as COVID is. So you know, especially if you're at higher risk, I think it's much more culturally acceptable now to go out in a mask if you're at the grocery store or someplace, just to protect yourself. Washing your hands frequently, of course.

But if you do get the flu, I mean, most people are just going to need symptomatic treatment. They need rest, they need fluids, you can use acetaminophen for fever or pain. Of course, there are antiviral medications available. But ideally, you want to start them within the first two days of illness. So, everyone should, even before they get sick, should have a plan, like, ‘Okay, if I get the flu, do I call the on-call doctor, do I go to the urgent care?’ Like, ‘what's my plan to decide if I need to get tested? Do I need to get medication?’ So that's something that you can talk about with your patients year-round is what is your practice’s plan to manage patients. The antiviral medications are helpful for people that are at higher risk. So certainly, people with other comorbidities, people who are over 65, pregnant women, those are the people I really try to target with antiviral medication. An otherwise younger, healthy person, they may feel better a day or two sooner, if they start antiviral medication, but otherwise, it's not going to make a big difference for them. And of course, all medications have cost, and they have the potential for side effects. So, it becomes kind of a case-by-case decision.

But as a practice, you want to make sure that, again, your practice has a plan, you have a way to get testing. Once flu season is well established, you may not even need to test, you can just treat empirically, and kind of have a discussion among your partners, or whoever you're working with, so everyone's managing it the same way so it's not confusing.

Dr. Doghramji:
Well, finally, Dr. Drees, do you have any key takeaways you'd like to share with our audience?

Dr. Drees:
I think the most important part is that multiple studies have shown that the most influential thing that helps people decide to get a flu vaccine, or any vaccine for that matter, is a strong recommendation from their doctor. And that's especially true if you can actually also offer it to them at that visit, as opposed to maybe making them go somewhere else to get it.

So how you frame it is really important. It's not, ‘Okay, so do you want your flu shot today?’ versus, ‘Hey, it's time for your flu shot,’ or, ‘It's time for your child's flu shot.’ So, the way that you frame it can be really important. And I think if there's other vaccines that the child needs, or if you're giving a T-DAP to a pregnant woman, and you can bundle the flu vaccine in with other vaccines, that tends to help acceptance as well.

The CDC actually has a whole, they call it the Fight Flu Toolkit that people can use. It has Q&A sheets, it has patient handouts, it has social media widgets and buttons, email templates, it has a ton of tools that all offices can use, that helps encourage flu vaccination.

And I think overall, if you can create a culture of immunization in your practice so that all of your staff are educated, they feel empowered to discuss flu vaccine with patients, you have a standing order so it doesn't even have to go through you for people to get their flu shot, and just make it that much less likely that it'll get missed. And I think every visit really between September and March of every year is an opportunity to get a patient vaccinated against the flu.

Dr. Doghramji:
Well, with those final thoughts in mind, I want to thank my guest, Dr. Marci Drees, for joining me to talk about helping our patients protect themselves against the flu. Dr. Drees, it was great having you on the program.

Dr. Drees:
Thank you so much.

Announcer:
This episode of Clinician’s Roundtable was sponsored by CSL Seqirus. To access this and other episodes in this series, visit ReachMD.com/CliniciansRoundtable, where you can Be Part of the Knowledge. Thanks for listening!