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The Dose Transcript for October 19, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Last winter, me and my ER colleagues saw lots of older patients with RSV who needed to be admitted to hospital. Public health experts say we might see a repeat of that this winter. Now, we have a vaccine recently approved in Canada for older adults. But many Canadians, depending on where you live, you can't get it for free. So this week, we are asking, what do we know about the new RSV vaccine, especially its cost? Hi, Anne. Welcome to The Dose.

ANNE SUMMACH: Hello, Brian. Thanks for having me.

BRIAN GOLDMAN: Nice to talk to you. Have you had any requests for the new RSV vaccines or questions about it?

ANNE SUMMACH: I have had maybe one question in my clinic regarding whether it was available and whether I thought it was valuable. And I think that's all. Though it has just been approved, so people are just catching up.

BRIAN GOLDMAN: Yeah. And, you know, that's my sense as well, that I haven't heard, you know, in my community, of course, as an emergency physician, people aren't going to be asking me about that. They're going to be asking for treatments for the ailments that they have that they've presented to the ER with. So I haven't heard a lot. So maybe that's a really good thing about us having this conversation right now. So we're going to have it. But before we begin, can you give us a Hi, my name is? Tell us what you do and tell us where you do it. Just adlib.

ANNE SUMMACH: Sure. Hi, my name is Anne Summach and I am a nurse practitioner. I primarily work at the University of Alberta, teaching other nurse practitioners and coordinating their program. But I also work in primary care in Edmonton, Alberta, with an under-resourced group of individuals of all ages, many newcomers, many seniors, and many folks who have limited financial resources.

BRIAN GOLDMAN: And we're going to get to that because that's really an important part of this conversation. But before we talk about the cost of the RSV vaccine, for people listening to us who don't know what RSV respiratory syncytial virus is, can you explain what it is and the disease it causes?

ANNE SUMMACH: So respiratory syncytial virus is a common virus. It's not uncommon. It's primarily common in causing illness in younger children. And we see many infants and young children hospitalized with RSV each year. However, since COVID and since many of us have become less connected with those around us, we as older people have not had as much opportunity to contact people with RSV. And so our immunity to that is waned. And for older people, respiratory syncytial virus can lead to pneumonia and fairly severe lower respiratory tract infections down in the lungs, which can end up with them in hospital and can even cause death.

BRIAN GOLDMAN: So we know last year, we had the so-called triple-demic or the tri-demic, depending on what you call it. It was the combination of COVID and the Omicron and influenza and RSV, and that certainly was responsible for a lot of hospitalizations. Do we know yet if this fall and winter will be as bad for RSV cases as it apparently was last winter?

ANNE SUMMACH: I think it's a little hard to predict, though we have seen elevated cases in other places in the world. So we are usually next on the chopping block when we see that happening in other areas of the world where they tend to move into that respiratory virus season earlier than us. Last year, RSV was up 26% compared to previous pre-COVID levels. So I don't imagine that there has been much change really in the status of the public in that intervening time. So I think our risk is likely just as high.

BRIAN GOLDMAN: And so let's review some of the common symptoms. Wheezing, shortness of breath, cough, what else?

ANNE SUMMACH: Yeah, yeah, shortness of breath, reduced oxygenation because individuals aren't getting the breath that they need, extra strain on their heart because that supplies is supplied by oxygen from the lungs, weakness, fever.

BRIAN GOLDMAN: Which adults are most at risk of getting really sick?

ANNE SUMMACH: The adults that are at greatest risk are individuals who have pre-existing health conditions. So especially older people that have heart failure, COPD lung disease that pre-exists, individuals who aren't very mobile, who can't expand their lungs well or are at greater risk of developing pneumonia when they do get sick. And of course, just being older by itself, unfortunately, is a risk factor for severe disease, which is why vaccination in this category is being recommended so that we can prevent RSV from being passed around within older adult populations.

BRIAN GOLDMAN: So now, we have this vaccine from GlaxoSmithKline. It's a vaccine that's supposed to protect those aged 60 and older. It's called Arexvy. What can you tell us about Arexvy?

ANNE SUMMACH: It is a vaccine that's intended to help an individual mount a response to a trigger, a piece of a virus that helps us to identify the virus in real life when we encounter it. So if you get a vaccine, then your immune system responds to that and creates antibodies to that particular virus so that when you do encounter it, you have a better resistance to the disease.

BRIAN GOLDMAN: How well does the vaccine work based on the studies that were presented prior to approval?

ANNE SUMMACH: The Arexvy vaccine in testing in subjects and in research studies shows that for younger individuals with chronic conditions for whom the vaccine would be indicated, have about a 96% effectiveness, which is very high. For older adults who are in that higher age group, for those individuals, the recommended or the demonstrated effectiveness is around 82%.

BRIAN GOLDMAN: And I understand from my reading that the vaccine is less effective in older adults.

ANNE SUMMACH: Yes.

BRIAN GOLDMAN: What do we know about that?

ANNE SUMMACH: Well, most vaccines are less effective in older adults, and older adults have a less strong, a less robust immune system. And so as we age, our ability to fight disease reduces just as a normal part of ageing because our cells don't reproduce as well. They don't produce energy as well. They don't function quite as well when we're older as they do when we're younger. And so that's what makes… part of what makes older people more susceptible. But it also means that your immune system doesn't respond as strongly as a younger person would. So for example, in the past, we've had two kinds of flu vaccines, one of a normal strength and one sort of a super-sized strength for older people, intended to give them a bigger boost on their immune system. And so for the RSV vaccine, it's not unexpected that the older people that were tested had a slightly reduced efficacy or effectiveness of that vaccine because they just don't mount as strong of a response.

BRIAN GOLDMAN: What do we know about the safety of Arexvy?

ANNE SUMMACH: I mean, it's generally safe as far as I'm aware. I mean, the risks of any kind of vaccine are that we trigger a result, trigger an abnormal result where our immune system responds in a more aggressive way than it should. Of course, whenever you're fighting something off, you are going to have the feeling like you're fighting something off. So I always tell people, you might feel like you're coming down with something. That's because it is your system initiating that immune response to the vaccine. And so the most common side effects include tiredness and your muscle aching and a bit of a headache or maybe your joints aching. And those are the same types of symptoms you might feel if you were fighting off a disease because your body is doing that. It's fighting off the disease. But those are not serious responses. Those are expected minor side effects from any kind of vaccine.

BRIAN GOLDMAN: How important is this particular vaccine when it comes to protecting seniors against RSV?

ANNE SUMMACH: When it comes to protecting against RSV, it's certainly important. It's a very valuable tool in the toolbox that can be used to prevent seniors from ending up in hospital. And we know that older people, when they suffer an acute illness, you know, they become really sick with something like the flu or COVID or RSV, that they become deconditioned, weaker very quickly. In fact, when people are ill or on bed rest, they may lose up to 1% of the strength of their muscles, their muscle mass, the actual cells in their muscles every week that they're sick. And so that can have a real impact down the road on an older persons resilience to future issues that they might encounter. And having vaccinations clearly is demonstrated to reduce the onset of frailty, which is a medical condition where an individual, an older person becomes increasingly weak and unable to manage their activities of daily living. And that can be prevented by using techniques and tools such as the RSV vaccine.

BRIAN GOLDMAN: There would certainly be the hope as well that administering this vaccine to seniors would reduce hospitalizations and deaths.

ANNE SUMMACH: Absolutely, because if we can prevent people from catching the virus or developing illness from the virus, then we prevent them from succumbing to greater illness as a result of that virus.

BRIAN GOLDMAN: Okay. So we've talked about the benefits, We've talked about the safety. Let's talk about the cost. Most of the provinces, including Alberta, are not covering the cost of the vaccine. So first of all, how much does the vaccine cost?

ANNE SUMMACH: So in Alberta, it costs near $300.

BRIAN GOLDMAN: Wow! That's a lot.

ANNE SUMMACH: That’s a lot. It's a big investment for individuals where, you know, cost is a real concern. Seniors are often on fixed incomes and they just can't necessarily afford to pay for huge drug costs that aren't part of their regular monthly costs they're already paying for medications.

BRIAN GOLDMAN: So how much do you think, and I know I'm putting you on the spot by asking you to speculate, but you know what this is? This is a podcast and we get to talk about this kind of stuff on The Dose. So how much do you think the cost, this near $300 cost per dose of Arexvy could be a barrier to people actually rolling up their sleeves and getting it?

ANNE SUMMACH: I would… So for the group of population, the population I work with primarily and have worked with in the last years in downtown Edmonton, those seniors are often on minimal financial supports. These are people who might have very limited pensions and get a guaranteed income supplement from the federal government, have no personal pensions or RRSPs and are living on, you know, 16 or $1700 monthly. And out of that, they have to pay for their medications, their groceries, which are increasing in costs all of the time, and housing, which is increasing in cost also across many jurisdictions in Canada. And so those individuals are going to prioritize other things. I would expect that if they were going to choose something to be vaccinated for that they had to pay for, they might choose a more dramatic illness to avoid shingles, for example, because they might have known someone or seen somebody who has had shingles. But RSV to them is a black box. What does it even mean? And so I imagine most of them will not choose to pay for it or have the capacity to.

BRIAN GOLDMAN: Hmm. So if they can't pay, what are you telling your patients?

ANNE SUMMACH: Hmm. Call your MLA, call the Ministry of Health, advocate for your own rights at the provincial level, call Blue Cross, the Blue Cross program for seniors. Alberta Blue Cross for seniors is the decision body who decides what medications, what vaccinations are on their formulary, which can be received. And so they need to let those individuals in authority, in power know that the choices that are being made are not in the best interests of older people.

BRIAN GOLDMAN: Of course, as you probably know, the province of Ontario is providing Arexvy free of charge to eligible Ontarians who are residents in the province. Would you expect, therefore, that the uptake of the vaccine would be higher in a province that's paying for the vaccine compared to a province that isn't?

ANNE SUMMACH: I think there's the potential for the uptake to be higher. But when we look at the last number of years, vaccination, immunization fatigue has really set in for many people. Recently, there have been increased numbers of vaccines recommended for older people, including the new pneumonia vaccine, the new updated shingles vaccine, as well as multiple different kinds of COVID vaccines over the last while and influenza. And so many older individuals, if they don't have a good understanding of the impact of these illnesses on their potential future health, they might just be too tired. And I know a lot of what will need to be done to increase uptake even in provinces where they pay for the vaccine is an adequate education campaign about the risks of RSV, the benefits and safety profile of a vaccine, and what that actually means to people personally in their lives. What does this mean for your ability to function and be independent? Because that's what older people want. They want to be functional and independent. And so we need to somehow draw a line between achieving that, maintaining that and taking advantage of vaccines when they're available.

BRIAN GOLDMAN: And just to be clear, by comparison, they won't have to pay for COVID 19 and seasonal flu shots. Have I got that right?

ANNE SUMMACH: Yes, correct. They could, in Alberta, receive the first of two or depending on how you space them out, one of the two pneumonia vaccines would be covered and COVID and flu. But RSV and another pneumonia vaccine and shingles vaccine are not covered. So we are already… we've already asked seniors to choose their priorities and to choose what they'll pay for. And we're adding just another brick on the pile of things that they have to choose and prioritize financially, and I don't think it's fair.

BRIAN GOLDMAN: So we're living in the real world as it is with all the conditions therein. What are you advising people? What's your bottom line advice then, given the current climate and given the fact that you work and treat patients in a province that isn't paying for the Arexvy RSV vaccine?

ANNE SUMMACH: Mm hmm. So I will do my best to advocate for those individuals who I feel should be covered. That might mean as clinicians, we need to step out, write letters on behalf of specific people in order to advocate for that vaccine with the insurer. And I think I will advise the patients that I see to definitely choose the vaccines that they can afford, that are free. So definitely receive the influenza seasonal flu vaccine as well as the COVID vaccine when they're eligible because those are free. So let's get people at least double vaccinated for things that are going to be a risk for this fall. And then I will encourage people to consider it. And at the same time, as I encourage to consider the RSV vaccine. And for those who are able to afford it, I'll just remind them of the benefit that it brings. And if they have money, the relatively small financial investment in their health that it might be for them. For people who do not have the finances to proceed, then how can I help with that? And that might be connecting individuals with social work to confirm that their finances are optimized. It might be doing a medication review to see if the medications they currently pay for are still warranted for their use. Maybe we need to deprescribe something to provide a bit more space in their medication budget to pay for an RSV vaccine if it's appropriate.

BRIAN GOLDMAN: And finally, you know, there are, as you've already mentioned, there's a lot of vaccines. Just talking about RSV, COVID vaccines and seasonal flu, how can seniors keep track of when they're supposed to be getting their vaccines?

ANNE SUMMACH: There are some… for those seniors who are really technologically literate, there is an app called CANImmunize, C-A-N Immunize. And it's an app where you can input and track vaccines with recommendations. It's a nice little app for those who are able to use it. Otherwise, there are electronic medical records being implemented in most clinics. I know in Alberta, we have a major rollout of Connect Care, which is intended to connect as many primary care and acute care facilities as possible within one medical record. So having that up to date, and it will then provide cues or recommendations if those cues are turned on to clinicians that they meet with so that that clinician is reminded to remind them that this is an important next step. But also, I think we need public health to step up and increase the marketing and promotion of these vaccines as much as they're able to do so that even individuals who don't attend a clinic regularly will have an understanding of the benefits of vaccination in preventing decline and helping them be as independent as possible in the future.

BRIAN GOLDMAN: Anne Summach, lots of great practical information and advice there. Thank you so much for coming on The Dose to share your insights on the new RSV vaccine and how it might help people and how they might be able to get it.

ANNE SUMMACH: Thanks, Brian. It's lovely to be here. Thanks for having me.

BRIAN GOLDMAN: Anne Summach is a nurse practitioner and assistant teaching professor in the University of Alberta's nursing department. Here's your dose of smart advice. RSV is a contagious virus that causes infections of the lungs and breathing passages in people of all ages. In older adults, it can cause life threatening pneumonia, requiring hospitalization. In August, Health Canada approved Arexvy, the first vaccine for RSV for adults age 60 and over. In that age group, the vaccine has been shown to be 82% effective at preventing lower respiratory tract infections caused by RSV. Experts say the vaccine is effective at reducing both the likelihood of getting RSV and the severity of RSV if infected. Arexvy is less effective in seniors than it is in younger people. The most common side effects of the vaccine are pain at the injection site, tiredness and muscle aches and pains. Arexvy costs upwards of $250. So far, Ontario is the only province we’re aware of to provide the vaccine free of charge. The province is also rolling out its first publicly funded vaccination program for those aged 60 years and older living in long term care homes, elder care lodges and for some retirement homes. Canadians who reside in other provinces must pay for the vaccine out of pocket. For people who live in provinces in which people must pay for the vaccines, it means that those who can afford Arexvy may enjoy better health and a lower rate of hospitalization. But it's too soon to tell how the vaccine's cost might affect how many eligible seniors roll up their sleeves. Overall, experts recommend that eligible Canadians get Arexvy,, but they also say it's more important for people to get this year's seasonal flu shot and the latest COVID vaccine. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Stephanie Dubois. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do we know about the new RSV vaccine, especially its cost? - Transcript

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