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AMA Update
CDC changes COVID isolation guidelines and COVID vaccine dose schedule with Sandra Fryhofer, MD
Mar 8, 2024
Featured topic and speakers
CDC COVID vaccine recommendations, COVID dose schedule for seniors, and what to do if you get COVID now.
Our guest is Sandra Fryhofer, MD, AMA’s liaison to the Advisory Committee on Immunization Practices (ACIP) and a member of ACIP’s COVID-19 Vaccine Workgroup. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Sandra Fryhofer, MD, immediate past chair, AMA Board of Trustees; AMA liaison to ACIP
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today, we'll hear the latest from ACIP, the CDC'S Advisory Committee on Immunization Practices, and also talk more about the CDC's new isolation guidelines for COVID. Back with us today to share all the details is the AMA's in-house vaccine expert, ACIP liaison and immediate past board chair, Dr. Sandra Fryhofer in Atlanta. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Fryhofer, it's great to have you back.
Dr. Fryhofer: Hi. Thanks for having me back.
Unger: Well, ACIP had a two-day meeting at the end of February, and it looked like a packed agenda with lots of presentations about many vaccines, including flu, pneumococcal, polio, RSV and a word I never thought I would say—chikungunya. And hopefully, I got that right. Dr. Fryhofer, tell us about some of the highlights from the meeting.
Dr. Fryhofer: Yes, it was a packed agenda, but ACIP's new recommendation for COVID vaccines was the major headline of the week. ACIP voted in favor of an additional dose of the updated COVID vaccine for all adults 65 and older. CDC director Dr. Mandy Cohen agreed and quickly endorsed the new recommendation.
Also last week, CDC also relaxed its isolation guidelines for those testing positive for COVID. You no longer have to isolate for five days. CDC issued a new 25-page guidance for COVID and other respiratory viruses, including flu and RSV.
The new guidance says, stay home while you're sick, but you can return to work when you're feeling better and fever-free for 24 hours without taking fever lowering medications. But do wear a mask and try to physically distance from others for the five days that follow. This is especially important if you're going to be around someone at high risk for severe ... and those 65 and older and those with weakened immune systems. And to repeat, CDC now says everyone 65 and older should get an additional dose of the updated COVID vaccine this spring if and when they're eligible.
Unger: So why don't you tell us just specifically about that word "eligible"? What exactly does that mean?
Dr. Fryhofer: The additional dose for those 65 and older should be given at least four months after the first updated dose. So getting an additional dose implies you've already received a first dose, and many people have not. Uptake of the updated vaccine has been disappointing.
Unger: Dr. Fryhofer, in terms of uptake, what are the numbers looking like right now?
Dr. Fryhofer: Only 13% of children have received a dose of the updated vaccine, and overall, only 22% of adults 18 and older have received the updated shot. This new recommendation only applies to those 65 and older. And nearly 42% of them have already received an updated dose. But that means 58% have not and that's far from ideal.
Unger: Dr. Fryhofer, I think it would be helpful then if you could review the timeline of when the updated vaccine first became available and how this new recommendation fits in.
Dr. Fryhofer: The updated 2023-2024 COVID vaccine is an XBB.1.5 monovalent version. It first became available last fall at the end of September 2023. That's when the updated COVID vaccine received a universal recommendation for everyone six months and older.
Those six months through four years old need multiple doses, including at least one dose of the updated vaccine, to prime their immune system to protect them. For those aged five and older, a single dose was all you needed to be up to date and to protect against serious illness. Back in September, additional doses were allowed for patients with immunocompromising conditions.
They could receive an additional dose at least two months after their last updated dose as well as more doses if recommended by their physician. The additional dose recommendation for those with immunocompromising conditions still applies. This new ACIP recommendation expands access to additional vaccine doses to all adults 65 and older. But the interval is four months after the first dose.
Some of this older age group are now four months out from their first updated dose, so they can get an additional dose now. But others still have not received their first updated vaccine dose, and that's where physicians can really make a difference. Adults who are vaccinated or definitely plan to get vaccinated were more likely to report a health care provider recommended they get a COVID vaccine. This highlights the importance of physician recommendation.
Unger: Absolutely. Question for you, Dr. Fryhofer—Why are additional doses only recommended for adults in the older age group?
Dr. Fryhofer: Well, simply put, this extra vaccine dose will provide additional protection for those at highest risk. Most COVID deaths and hospitalizations are in those aged 65 and older. Risk increases with age. People aged 75 and older have the highest COVID mortality rates.
We're in a much different place than we were in 2020. More than 98% of people have at least some type of immunity from vaccination, from prior infection, or both. Hybrid immunity from both vaccination and previous infection is the most protective, and older patients have tended to isolate more during the pandemic.
So there's a higher prevalence of vaccine-only immunity in older adults as compared to younger adults. We know vaccine-induced immunity tends to fade with time. Additional vaccine doses provide incremental benefit in boosting protection.
Another reality is immunosenescence. Our immune systems don't work as well as we get older. And immunity wanes more quickly in older age groups. This means more frequent vaccine doses are needed to maintain protection in this older population.
Unger: All right. Also a question for you, because it might surprise some people, about having this done in the spring—what about the timing, the spring?
Dr. Fryhofer: Well, this is actually the third year in a row a spring COVID vaccine dose has been recommended. Flu and RSV outbreaks surge in the fall and winter. COVID does, too. We've seen increases in COVID during the respiratory virus season. COVID hospitalizations peaked in late December, early January.
We've also seen COVID surges in the spring and summer. So COVID seems to have year-round transmission. Hospitalizations and deaths due to COVID continue throughout the year, and rates are highest in those 65 and older.
Each week, there are still about 20,000 new hospital admissions and 2,000 deaths due to COVID. And 95% of those hospitalized this past winter with COVID had not received a dose of the updated vaccine. The updated vaccine provides protection against JN.1 and other circulating variants.
Vaccine effectiveness is expected to wane. Additional doses are needed to restore protection. This additional spring vaccine dose can do just that.
Unger: All right. Thank you. Dr. Fryhofer, I understand there was quite a discussion about the precise language that was used in the new recommendation. Can you give us a little background about that?
Dr. Fryhofer: Well, you got that right. Words matter, and there was much debate about whether the recommendations should say older adults "may" or "should" get an additional dose.
Now, for full disclosure, I'm a member of the COVID Vaccine Workgroup, and our workgroup had suggested the softer language, that those 65 and older "may" get an additional dose. This is also called shared clinical decision-making, meaning you and your patient have to discuss and decide.
At the meeting, ACIP voting members went back and forth about "may" versus "should," but after reviewing the most recent data for those 65 and older presented at the meeting, ACIP voting members decided on the stronger wording. Everyone 65 and older "should" get another dose.
Unger: That's clear. Dr. Fryhofer, many older adults have multiple medical conditions. Did that factor come into play in terms of making the stronger recommendation?
Dr. Fryhofer: Yes. Older patients and those with multiple underlying medical conditions are at highest risk of bad outcomes from COVID—heart disease, lung disease, diabetes, neurological conditions and obesity are some of the most common underlying medical conditions in those hospitalized with COVID. And as we know, many older patients have multiple medical conditions.
COVID continues to circulate. And although COVID hospitalizations are down 75% and COVID deaths are down 90% since January 2022, there's still more than 20,000 hospitalizations and 2,000 deaths each week due to COVID. Most are in the 65-and-older age group.
The ultimate decision by ACIP voting members was, everyone 65 and older should get a dose. This stronger language is crystal clear and demonstrates ACIP's confidence in the importance of an additional dose of the vaccine in keeping our most vulnerable Americans protected. And I think it was the right call.
Unger: Thank you. What about the idea of booster fatigue? What role does that play in getting people to agree to vaccination?
Dr. Fryhofer: Well, we're trying not to call them boosters anymore. It's now called the updated vaccine. But sure, we all have vaccine fatigue. People are tired of masks. They're tired of testing.
CDC surveys say less than 50% of people who get sick are testing themselves for COVID. We're all sick and tired of COVID, but the virus is still here. It's still circulating.
Some people are still refusing to get the vaccine. Many have not received a dose of the updated vaccine, but others really want to stay protected. And with this new recommendation, they can. Some people who have not been vaccinated may not like the strong language.
But understand this language is meant to inform, not to offend. COVID is here. It has not gone away. People are still being hospitalized. People are still dying from COVID.
ACIP's strong recommendation for an additional dose is a wakeup call to get a dose now to restore protection for those 65 and older. This new recommendation allows the most vulnerable to restore their protection. Another silver lining of this strong recommendation—if ACIP recommends it, insurance companies have to cover it.
The vaccine is already in pharmacies. All you have to do is sign up and show up, and of course, roll up your sleeve. And there's no shortage of the updated vaccine.
Unger: Well, that's good news. And although it seems like a long way away, the fall will eventually be here. And I'm curious what the plans are for getting ready for next year and thinking about what we might expect this fall season.
Dr. Fryhofer: The virus keeps changing. Last September, when the updated vaccine first became available, the rollout was rushed. It was sort of a mess. No one was ready. Pharmacies didn't have the codes. Insurance coverage wasn't initially updated on a lot of the pharmacy software.
Some who wanted it got turned away. Many became frustrated. We need to do better, and that's why ACIP's review process for the next COVID vaccine, if there is one, will happen sooner.
FDA's VRBPAC will likely meet mid-May to discuss any needed vaccine strain changes. And just like for flu vaccines, updated COVID vaccine strain changes do not require any new human data. ACIP will then meet in June to review and finetune any recommendations.
That's the plan, at least for now. Many of the patients I talked to still don't seem to realize they're supposed to get a dose of the updated vaccine. So having more lead time to develop clearer messaging and communication will be helpful.
Public health officials sort of know what to expect. We now have four years of epidemiological data to predict a likely COVID peak in the winter of 2024-2025. And we need to be ready.
Unger: Absolutely. This has been an amazing amount of information. Dr. Fryhofer, any final thoughts?
Dr. Fryhofer: The updated COVID vaccine continues to be effective against JN.1, which became dominant in January. But the virus keeps changing. For those 65 and older, remember, there's a four-month interval before you can get an additional dose.
Try to get your second dose before June, if you can. That way, if the vaccine is updated again for fall, you won't have to delay getting the most up-to-date COVID shot. This timing issue was actually pointed out by FDA's Dr. David Kaslow at the ACIP meeting.
And finally, don't underestimate the power of physician recommendation. Physician recommendation matters. Our patients listen to us. They trust us. Physician recommendation is vital for vaccination success.
Unger: Absolutely. And thank you, Dr. Fryhofer, for that update. And one of these days, we'll have you come back to talk about how the new ACIP recommendations for the chikungunya vaccine will work.
Dr. Fryhofer: I'd love to come back, Todd.
Unger: And I'll look forward to saying that word again. Dr. Fryhofer, that wraps up today's episode. Thanks again for joining us and keeping us informed. If you want to support important public health information like this, you can become an AMA member at ama-assn.org/join.
We'll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at ama-assn.org/join. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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