SPEAKER_00 0:19

Hello and welcome to Impatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. I was at the pharmacy the other day and noticed Halloween candy on the shelves. It reminded me of what Dr. Wynn Williams would tell us in residency on VA Wards, and that was when you see Halloween candy on the shelves, it's time to start offering your patients the flu vaccine. Since that time, I've gotten out of the habit of routinely vaccinating my hospitalized patients, and I think that is a mistake. We see flu, pneumococcal pneumonia, RSV, COVID in our patients in the hospital and we treat it. But are we doing as much as we should as hospitalists to prevent those illnesses from occurring for our patients? So as we enter respiratory virus season and we're hearing murmurs of new vaccine guidelines, new available formulations, I'm delving into the guidelines and the data to try and answer for the hospitalists who should we be offering vaccines to? What vaccines should we be offering? And is it even safe and appropriate to be vaccinating someone who's sick and admitted to the hospital? What is the evidence and what are the guidelines in this realm? And can we trust them? Much of my renaissance in prioritizing vaccination in my patients came from a trial that I came across specifically looking at patients hospitalized with heart failure. I'm going to play you a clip of my conversation with Dr. Emily Reams about that trial. If you're a regular listener to the show, you've heard this before, but I think it's worth another listen because it looks specifically at the benefits of vaccinating a hospitalized patient, and the outcome is so impressive. Emily and I certainly thought so. So, Dr. Reeves, how often do you have someone on your service who has congestive heart failure?

SPEAKER_03 2:22

Every day.

SPEAKER_00 2:23

Every day. What if I told you, at least in folks with moderate to severe, that there was one single medicine you could give people that would reduce both their mortality and their readmission over the year with a number needed to treat of 17. What would you think that medicine was?

SPEAKER_03 2:43

I would think that that might be-I would think that might be a beta blocker. Yeah, right? Entresto.

SPEAKER_00 2:49

Ooh, entresto. The cardiologists love entrusto.

SPEAKER_03 2:52

Yeah.

SPEAKER_00 2:53

Um, so actually, it's a one-time medicine. You've taken it this year. I've taken it this year.

SPEAKER_03 3:02

Plus, I can't go to work, yes. Exactly.

SPEAKER_00 3:04

So the flu shot.

SPEAKER_03 3:05

Shocking.

SPEAKER_00 3:06

I so this is one that I didn't go to the heart failure session, but I was talking to a colleague in the hall who did Rahula Hoosia, and he mentioned a few of the stuff. And I was like, oh, that sounded like that was a better session than I thought, or it just it wasn't the one I picked. Um, so I looked back at the slides and I was like, it just saw the slide. If you remember one thing, give your flu shot to everyone you admit with heart failure. And I just I looked into it a little more and looked at the slides some more. Um, I was like, whoa. This is super cool.

SPEAKER_05 3:40

Yeah.

SPEAKER_00 3:41

Um, just a flu shot and 17 patients, which takes like what, you know, two weeks on service? Two weeks on service.

SPEAKER_03 3:49

Maybe.

SPEAKER_00 3:50

And you've saved a life andor readmission within the next year. The flu shot is a powerful thing. This trial, PANDA 2, was published in the Lancet in 2025. It randomized hospitals in China to offer free flu vaccination before discharge or usual care. These were patients admitted with acute heart failure and had NYHA class three or four symptoms. The primary outcome they looked at was death or readmission within the year. And that occurred 41.2% of the time in the free vaccine group and 47% of the time in the control group. That gave us a number needed to treat of about 18 for the composite outcome. This effect we're looking at belongs to the heart failure population in this specific study in these specific hospitals. But it was a wake-up call for me of just how powerful the flu shot can be in preventing illness and sickness and hospitalization and death in patients that are already sick in the healthcare system. The CDC guidance is annual flu vaccines for nearly everyone. And so for my adult patients who haven't received a seasonal dose already, if clinically appropriate, I will be offering them a flu vaccine, emphasizing doing this in September or October, if possible. So there are a couple of other respiratory illnesses that have vaccinations that you do not on an annual basis, but often with just a one-time dose. The guidelines on these have changed recently, and if you like me aren't keeping your ear to the ground of everything going on in primary care, you may have missed it. And that's RSV and the pneumococcal pneumonia vaccine. Before I get into the specific guidelines here, I think it's worth at this point touching on ACIP, what it is, the CDC, and how recommendations are formulated. This is something that's been dynamic that I'll talk about more going forward. Like any medication, we as clinicians offer and recommend to our patients. Vaccines have both risks and benefits. Our job as clinicians is always to look at our patient and decide: do we think the benefit of this medication outweighs the risk for our patient? When it comes to vaccines and their guidelines, it gets even more complex and even trickier because we're recommending these medications to broad swaths of the population. Because of that, we rely on data and experts that interpret it to come up with guidelines that we can recommend to the general population. And then we take those guidelines to each of our patients and apply them if appropriate. There's been recent changes in the structure the CDC uses to give recommendations for vaccinations. But I'm going to talk here about the historic process because of the important new guidelines for these respiratory infections I mentioned. So ACIP, the Advisory Committee on Immunization Practices, advises CDC on who should receive vaccines and when. Under its established process, work groups review disease burden, vaccine effectiveness, safety, and how certain the evidence is. Then the committee deliberates and votes publicly. The question isn't whether a vaccine has zero risk, it's whether its expected benefits outweigh its harm for a particular group of patients. That's the work that's behind these recommendations. I watched some of those public votes in committee meetings, and it's about like watching Wednesday morning C-SPAN as they deliberate how quickly it takes paint to dry. But I'm gonna play you some snippets from those. And I think the value here is just getting a glimpse into seeing how much priority the people behind these vaccine recommendations were putting on the evidence and were putting on impartiality when they made these recommendations. So here's ACIP presenting and voting on proposed RSV expansion and guidelines for the CDC in April 2025.

SPEAKER_08 8:43

We can have the language for the RSV motion. ACIP recommends adults 50 to 59 years of age who are at increased risk of severe RSV disease receive a single dose of RSV vaccine. CDC will publish clinical considerations that describe chronic medical conditions and other risk factors for severe RSV disease produced in this risk-based recommendation. At this time, RSV vaccination is recommended as a single dose only. Persons who have already received RSV vaccination are not recommended at this time to receive another dose. An RSV vaccine can be administered with any product licensed in the age group.

SPEAKER_05 9:25

Edwin Asturias, no conflicts for his vote. My vote is yes.

SPEAKER_04 9:34

George Cashel, no conflict, but in view of uh uh brief consulting about a decade ago, I will be abstaining.

SPEAKER_08 9:41

Okay, thank you. Dr. Lair.

SPEAKER_10 9:44

Jamie Lair, no conflicts.

SPEAKER_08 9:47

I have 14 yeses, zero no's, and one abstain, so the motion passes. Would anyone like to comment on this motion or vote?

SPEAKER_00 9:55

And then lots of people want to get in there.

SPEAKER_11 9:57

I yes, this is Rob Schechter. I just to um yes, Oliver Bruce. I would like to echo what Dr. Scheckter said regarding the uh low tigers.

SPEAKER_07 10:08

But yeah, I'm also echoing what was said and just reinforcing that the you know.

SPEAKER_03 10:13

Dr. Dalbut, I don't think I can say it enough, but more studies in moderate to severe immunocompromised patients who are at highest risk for RSV disease, a call to action.

SPEAKER_08 10:23

Yes. Test the vaccine in the population that needs it the most.

SPEAKER_00 10:32

So you can hear there just how conscientious, deliberate, and focused on the science and what will be best for patients that these people are as they are formulating these recommendations. But for us going forward, more importantly, the guidelines. The takeaway general rule one dose at age 75 or older for any patient for RSB. Patients 50 and older, if they have any qualifying comorbidities, also vaccinate them. That could be asthma, COPD, coronary artery disease, diabetes, heart failure. And there's good evidence to back up the value of this vaccine. There's a new randomized trial, the expanded Dan RSV trial, published in August in New England Journal of Medicine Evidence. It found about 70% fewer RSV-related respiratory hospitalizations with vaccination. Next pneumococcal vaccination, because this has expanded as well, and you may have missed it. Here's ACIP again in October 2024, discussing reducing the age threshold.

SPEAKER_09 11:52

ACIP recommends a pneumococcal conjugate vaccine for all PCV naive adults aged greater than equal to 50 years. Um, and we'll start off with Dr. Brooks.

SPEAKER_10 12:05

Oliver Brooks, uh no conflicts, yes.

SPEAKER_09 12:13

Dr. Brewer, yeah.

SPEAKER_05 12:15

No brewer and no conflicts.

SPEAKER_09 12:21

So I have 14 yeses and one no. And the motion passes. So the motion passes.

SPEAKER_00 12:33

So now all adults 50 and older are recommended and qualified for vaccination. And for the rest of adults, 19 and up, it doesn't take much to have one of the qualifying conditions that puts you in the bucket that we recommend vaccination as well. Diabetes, cigarette smoking, alcohol use disorder, asthma, COPD, heart failure. There are some nuances here because there are different formulations of the conjugate vaccine. And so make sure you take a good history from your patient and coordinate with pharmacy of what you have available, what they've gotten in the past to know what's appropriate. So finally, COVID-19. As you're aware, this is where it all really comes to a head. The anti-vaccination sentiments, the fear of complications and side effects, the politics, the skepticism are all really at their most extreme when it comes to this specific vaccine. And that's had implications on the recommendations. So briefly, let's talk about what's changing the CDC. The recommendation process itself changed in 2025. HHS dismissed all 17 ACIP members, the ones you heard from earlier, and also released some recommendations about COVID vaccination specifically through a different workflow. So the AAFP objected both to the dismissal and to COVID policy changes made outside the usual review process. Then follows that with its own physician review and approval process. That goes specifically into their current process for their vaccination recommendations. But I'm going to share with you a clip from a previous episode of the Inside Family Medicine podcast where the AFP's Dr. Margot Savoy discusses the nuances between how a recommendation and shared decision making fit together. This is from the IFM podcast from September 2025.

SPEAKER_06 16:11

They changed the recommendation to be what they call shared decision making. And when CDC says shared decision making, what they mean is that the parent and the and the physician should have a discussion. And after hearing the risks and the benefits, the parent should decide what they would like to do going forward. Now, don't misunderstand me. Like the AAFP thinks that every um health decision is a shared decision-making opportunity. And we view all immunization conversations as shared decision-making conversations, and so we're not suggesting to you that your um your your new task is to go force people into getting vaccines that don't want vaccines. That's that's not what we're saying. We just distinguish between um shared decision-making and a recommendation. So a recommendation should be you standing on evidence, all ten toes down, telling them what you believe to be the best advice for them, and then you have a shared decision-making conversation to allow them to make the decision for their family the way they want to make it. And so we do recommend having a shared decision-making conversation with all of these vaccines. However, we think that the recommendation should be evidence-based and and parents should have access to the best information.

SPEAKER_00 17:19

And a bit of evidence on this vaccine for you. The vision trial published this June in JAMA Network Open showed last season's vaccine was associated with 53% protection against COVID hospitalization in immunocompetent adults 65 and older. So that trial was on last year's formulation of the vaccine. But also hot off the presses, we've got new formulation for COVID vaccine this year. The FDA approved Pfizer's 2026-2027 formulation on August 27th. So you may be able to be offering your patients the new COVID vaccination to get their annual vaccine now. Check your pharmacy to see if it's available. Now back to one of the bedrock questions we started with. Is an acute hospitalization an appropriate time to be vaccinating patients? Here's CDC pre-ACIP gutting in 2014 discussing just that.

SPEAKER_01 18:35

Thank you very much for this opportunity to uh present the unfinished business for general recommendations on immunization. And so the proposal uh is to connect those two passages that I showed you earlier with a bridging statement uh about the fact that current, recent, or upcoming anesthesia surgery or hospitalization is not a contraindication to vaccination. So this is how it would look. It would fit right between those two uh the two passages that I showed you earlier, the evidence statement, which is in italics, uh, and then where it starts current recent, you can see I've I've I've placed that sentence in there, followed by the action statement that efforts should be made to ensure vaccine administration during hospitalization or at discharge.

SPEAKER_00 19:26

That recommendation remains in CDC's current guidance. Hospitalization itself is not only not a contraindication to vaccination, but is an opportunity to vaccinate clinically appropriate patients. Do keep in mind that if your patients are having active, moderate, or severe illness, it may not be the right time to vaccinate. For me, this is something I'm thinking about within 24 hours of discharge. Once the patient's well and ready for the ambulatory setting, I'm thinking, should I be giving flu, COVID, RSV, or pneumococcal pneumonia vaccines in these patients? One important point about these vaccines is none of them are live attenuated vaccines. So my takeaway from this and what I'm going to try to do going forward, I'll be focusing on trying to get, when appropriate, flu, COVID, RSV, and pneumococcal vaccines for my patients. From when Halloween candy hits the shelves to when they're taking Valentine's candy off, I'll be offering flu vaccines to any patients, if clinically appropriate, that haven't already been vaccinated that season. For COVID, similarly, if new formulation is available and the patient hasn't gotten an annual vaccination yet, for my adult patients, I'll be offering vaccination when clinically appropriate. Then for any adult patient over the age of 75 who hasn't already gotten an RSV vaccination, the hospitalization is a great time to offer that. And patients 50 and up that have qualifying comorbidities can get offered that RSV vaccination as well. Anyone 19 and up who has qualifying comorbidities, I'll be offering a pneumococcal pneumonia vaccine if they haven't already gotten it. And any patient 50 years or older, I'll be offering this vaccine too as well if they haven't already gotten the vaccine. One thing to keep in mind is there are other vaccinations that many adults need that could be considered in the hospitalization. Shingles is a huge one, but hepatitis B, TDAP, and other vaccines are also indicated too. I'm just focusing on our respiratory illness vaccinations here. But again, a huge takeaway here is to be making sure a vaccine history is taken on patients hospitalized and appropriate vaccinations are given to that patient. So let the Halloween candy be the reminder that we have patients in front of us and an opportunity to improve their health going forward. So be thinking about vaccinations and all your patients, admitted to the hospital or not.