November-2023 Newsletter

Welcome to the November 2023 Newsletter for

Santa Monica Primary Care.

In this issue, we will cover our progress with seasonal vaccines, specifically
RSV, Influenza and COVID-19. We will also cover the expected seasonal rise in COVID cases along with their relative severity. Lastly, as we near the end
of the calendar year, we will review some of our progress with our clinical
quality partner, Aledade.

Seasonal Influenza Vaccine & Low Flu Illness Rates Worldwide

Nationally, almost 84 million doses of the 2023/2024 seasonal vaccine have been distributed with a very, very, very small percentage of those being delivered to our office. Generally manufacturers produce about 165-170 million doses for 330 million Americans. While we have had a pretty steady uptake of the flu vaccine, immunization rates nationally are essentially on par with those of last year. About 3.8 million doses have been given to adults 18 and older the week ending September 9th (pretty long data lag) as compared to 4.0 million in 2022.

Globally, the World Health Organization (WHO) is reporting low overall activity of influenza illness (“the flu”) itself. The same holds true for our experience here in Santa Monica.. Specifically, in the northern hemisphere, influenza activity is below expected seasonal thresholds. Predominant strains that have been seen are Influenza A subtypes H3N2 and H1N1 followed by Influenza B. For those that follow my monthly newsletter, we covered the selection process for seasonal influenza vaccine components last month. Indeed, H1N1 as well as H3N2 subtypes are in the 2023/2024 formulation. So it is reassuring to see that the vaccine matches the predominant circulating subtypes. This bodes well for this season’s shot to be effective against infection and in the reduction of severe disease.

COVID-19 Boosters & (Pleasantly) Surprising Uptake in Clinic in Contrast to Disappointing Vaccination Rates Worldwide

We have been administering both Moderna and Pfizer mRNA COVID Booster vaccines for Fall of 2023. Similar to the flu shot, we have had an enthusiastic response to us having such, perhaps because pharmacies have had more difficulty obtaining the vaccine leading to long appointment waiting times. So enthusiastic that we had to reorder!

What we are seeing in our office vis-a-vis COVID booster uptake is substantially different from what is occurring at the national level. Thus far only 12 million Americans (3.6% of the population, have gotten the 2023 booster. By comparison, 17% of the US population received the 2022 booster and it seems unlikely that we will reach that level by season end.

In addition to the well known Pfizer and Moderna mRNA vaccines, the FDA recently approved Novavax’s 2023-2024 formula both as a booster (one shot) and as a primary series (two shots three weeks apart for individuals who have not yet had any COVID vaccination). Unlike the newer mRNA technology which directs cells to create the spike protein seen on the surface of SARS-CoV-2, the Novavax vaccine is protein-based and a vaccine type that has been used for decades (HPV, Hepatitis B and Shingles). The vaccine itself contains a synthetic spike protein and an “adjuvant” ingredient that enhances the immune response. The Novavax vaccine is also stable in standard refrigeration, making storage and delivery easier.

We have had a lot of questions about co-administration of the flu and COVID boosters and have recommended that space them out by 2 weeks or so. We had discussed a study in last month’s newsletter data suggesting that systemic reactions among those who received a flu+COVID co-administration was more than twice as high as compared to those receiving flu only. The FDA commissioner Dr. Peter Marks apparently agreed, stating that he had spaced out his seasonal COVID and flu shots by about two weeks to “minimize the chance of interactions, and minimize confusing side effects from one with the other.” He noted that this could be a good option for people who did not mind multiple trips to the pharmacy or the doctor’s office (I mean who doesn’t, right?) but for those where this was not possible, co-administration was still OK.

On the New RSV Vaccine

The RSV vaccine has been recommended by the FDA for adults 60 years and older. There are no national data published on its uptake, but from informal surveys amongst our patients this seems to be less of a priority than COVID and influenza shots. Approved in May 2023, two RSV vaccines are available in the prevention of respiratory tract disease among older adults – Arevxy (82% effective) and Abrysvo (67% effective). The CDC also recommends the RSV vaccine amongst pregnant women between weeks 32 and 36 of gestation to protect babies from severe RSV disease. To this end, only Abrysvo has been approved, importantly only for pregnancies during September through January as RSV itself is a seasonal illness.

RSV is typically seen from October through March but peaks in January and February. While the COVID-19 pandemic, associated masking and travel restrictions disrupted the virus’ seasonality over the past two years, it does appear that the usual patterns have returned. RSV is a common respiratory illness that infects up to 90% of children in their first two years of life and frequently reinfects both older children and adults. In most cases, RSV infection is typically mild and involves the upper respiratory tract with cough, runny nose and sometimes sinus and ear involvement. Interestingly, infection severity tends to decline after the third infection. However, amongst older adults RSV can involve the lower respiratory tract leading to pneumonia, asthma exacerbation and bronchitis. Illness among older adults can be serious and is associated with
60,000-160,000 hospitalizations and 6,000-10,000 deaths annually in the US among adults aged 65 and older.

Transmission of RSV is primarily by direct contact making handwashing and contact precautions important in preventing spread of the virus, particularly in healthcare environments. RSV can survive for several hours on hands and surfaces. Within families, studies of transmission dynamics have shown that infection of infants often follows infection of older siblings. In our own clinic, infection of older adults can be associated with visiting grandchildren who display typical RSV symptoms.

Adults with certain medical conditions including pulmonary disease, asthma, heart failure, heart disease, diabetes and kidney disease are at particular risk. The risk of RSV-associated hospitalization increases among those 75 and older and severe complications can occur amongst those with compromised immunity – either due to medication or underlying conditions.

The decision to vaccinate against RSV employs ‘shared decision making’ between the patient and physician. One advantage of the RSV vaccine is that it is expected to last multiple seasons – currently at least two – so it would not be something that would need to be given annually, unlike influenza and seemingly COVID boosters. The current RSV vaccine is recommended only as a single dose for individuals 60 years and older in the United States but should be considered in the context of the need for flu and COVID boosters. Those most likely to benefit would be those with pulmonary disease (such as COPD or asthma), cardiovascular disease, moderate to severe immune compromise, and diabetes.

COVID-19 in Our Clinic

COVID cases have typically been low during the Spring followed by a mid-summer surge. Interestingly, this year our clinic saw a late summer surge in cases which has persisted through the fall (Figure 1 below).

Total COVID-19 Cases (Blue) and Repeat Infections (Red) by Month in 2022/2023: Santa Monica Primary Care

The majority of the cases we have seen in August, September and October have been first time infections. Symptoms have generally been mild (7 of 12 cases – congestion, cough, malaise) or moderate (4 of 12 cases – fever, shortness of breath). One patient required hospitalization.

Paxlovid has continued to provide significant symptomatic relief when initiated early (within 5 days) of the start of symptoms. Rebound infection, which is always a risk of Paxlovid administration, has occurred 20% of the time. We have prescribed Paxlovid 121 times and had 24 documented rebound infections.

Quality of Care Measures

As part of our ongoing commitment to maintaining our quality of care, we have continued our partnership with Aledade (https://www.aledade.com/) as an Accountable Care Organization (ACO). Several steps are involved as we focus on performance and quality measures. Primary among such is an emphasis on the Annual Wellness Examination and, as such, you have likely received a phone call from our office reminding you of this important yearly evaluation. Similarly, we have also been focused on transitions of care, following up on Emergency Department visits
and scheduling in-office follow-up after hospitalization.

Additional quality of care measures include breast cancer screening and appropriate evaluation of kidney health. For our Medicare patients, we have continued our monthly outreach that we started during the first months of the COVID pandemic. This regular outreach has been helpful both for patients and for our office as we manage routine preventive care as well as chronic medical conditions.

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