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Exploring the Continued Need for COVID-19 Vaccines and Boosters - Episode 9

Considerations When Selecting COVID-19 Vaccines

Expert panelists highlight special considerations when selecting COVID-19 vaccines.

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Mitchel Rothholz, RPh, MBA: Let’s talk about the 2 authorized bivalent vaccines on the market. Some of these recommendations may change, depending on when you’re watching this program, because the ages are under consideration for lower ages. Let’s talk about what we have available to use. Jeff, what are the 2 products and what are the differences in terms of their use?

Jeff Goad, PharmD, MPH: We have Comirnaty by Pfizer and Spikevax from Moderna. Those are our 2 mRNA [messenger RNA] products. Those products come in the 2-dose primary series. The primary series hasn’t changed over the years. The same recommendations are largely still there. The booster dose is where the recommendations have changed over the span of the pandemic. For people in the age group indicated—the Moderna product is for 18 years old and over, whereas Pfizer is 12 and up—those will likely change. As you mentioned, we still have the monovalent booster for some populations in which the EUA [emergency use authorization] of these vaccines came up. That’s the other thing to realize. Even though the vaccine itself may have FDA approval, EUA is still an important process to add new boosters and new uses for the vaccine that the CDC [Centers for Disease Control and Prevention] can’t do on its own.

We still have the recommendations in place looking at very young children vs where we are with adults. By following those recommendations and keeping up with the changes, the bivalent booster will eventually be available to all populations and will likely become the primary series. It isn’t right now. It’s still monovalent for the primary series. But once we understand more about how the bivalent works in a population and look at its real-time effectiveness, there isn’t any reason why it shouldn’t become the primary series as well, making it easier for providers to have 1 vaccine to use for primary and booster, as we do for other vaccines.

Mitchel Rothholz, RPh, MBA: The important message to providers is you still need the monovalent vaccine in stock because you’re going to have people who haven’t gotten their primary series yet or are going to need a monovalent based on their age, and then you’ve got the bivalent. We’ve had that question pop up several times from providers as well. “Do I need to have all this stock?” They were looking to reduce the potential for errors. Part of the practice operation that’s also important is to make sure your shelves, refrigerators, and freezers are labeled appropriately and have safeguards, and double check as you’re pulling vaccine. Jeff, in terms of the makeup of the Moderna and Pfizer vaccines, how is it broken down? Is it equal parts of the original and the bivalent? How does that work?

Jeff Goad, PharmD, MPH: The excipients in each vaccine is a little different. In other words, the immune enhancers, the delivery vehicles to get the mRNA into cells, varies between the Pfizer and Moderna vaccines. But the antigen composition—the ancestral strain mixed with the BA.4-5 variant strain—is the same. That’s why the CDC for the longest time has had that ability to interchange those vaccines outside the primary series for booster doses. We have no reason to believe that you wouldn’t be able to do that for these 2 bivalent as well.

Mitchel Rothholz, RPh, MBA: For patients coming in to get their boost that fits within the age recommendation for the vaccine, it doesn’t matter which vaccine they get, correct?

Jeff Goad, PharmD, MPH: That’s right.

Mitchel Rothholz, RPh, MBA: We’ve got the 2-month duration between your last vaccination and these new bivalent vaccines. Let’s say a pharmacist has a patient in front of them who has gotten their primary and needs a booster. Which booster do they get?

Jeff Goad, PharmD, MPH: How old are they?

Mitchel Rothholz, RPh, MBA: Thank you.

Jeff Goad, PharmD, MPH: It depends on their age. Let’s say we’re dealing with adults, like most pharmacists. The booster that they’re going to get now is the new bivalent. If they’ve already been through their primary series and they’re adults, we’re asking pharmacies and others to get rid of the old booster and use the new booster. We’re hoping we don’t see a lot of errors of people given the monovalent when they should have gotten the bivalent. We’re going to have to come up with all kinds of new clinical guidelines to deal with these situations that are going to happen when you still have legacy vaccine sitting in the refrigerator or freezer when we have the newer version of the vaccine.

As with the flu vaccine, the FDA and CDC will eventually step in to give us better labeling guidelines to help do this as well. They’ve tried to do a good job of labeling something as a booster dose or primary dose to make it fairly obvious. Making vaccines expire artificially has been a strategy used in influenza to make sure you don’t use last season’s strain for this season. There will be different strategies going forward to help providers minimize the chance of error.

Mitchel Rothholz, RPh, MBA: [Let’s say] you have a patient who’s still contemplating whether to get the bivalent vaccine. What’s your sound bite when you’re talking to them about why they should get the bivalent vaccine?

Jeff Goad, PharmD, MPH: The messages that we use for flu might resonate fairly well, which is that we change the flu vaccine every year to match those strains. You don’t want a flu vaccine that matched the strain 10 years ago. You want this year’s [to protect against] what’s coming your way. The bivalent vaccine is better matched to what’s in the environment, so you want the new vaccine. People like things that are new and improved. Commercial marketing and science don’t always mix together, but having this at your fingertips, you can say, “This vaccine is better suited for the variants that are circulating in our environment. Why wouldn’t you want the new vaccine, the one that’s going to handle the disease that’s out there in the community?”

Mitchel Rothholz, RPh, MBA: But then the patient says, “I got the last booster, and I still got COVID-19. Why should I get vaccinated again?”

Jeff Goad, PharmD, MPH: I always say there’s that little bubble over every provider’s head that says, “Yes, but you’re still here to complain about it,” meaning that it kept them out of the hospital and kept them from dying. We’ve done the same thing with the pneumococcal vaccine and people still getting community-acquired pneumonia. That isn’t what it’s designed to protect against. It’s the same thing here: we help them understand that it helps manage the disease. You might have seen relatives or friends or people in the media or on TV who have gone into the hospital and didn’t make it out. Almost all the time you saw that, they were unvaccinated. The numbers help us in the messaging that vaccination, resetting your immune response, and getting it back up to what it was before or as close as we can works. Even though you still might get the disease, we also know that the disease plus vaccine equals even better immunity. We aren’t suggesting people go out and get COVID-19, but for those who have, we know that this hybrid immunity also produces very robust immune response.

Transcript edited for clarity.

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