This talk provides answers to the questions clinicians are starting to hear every day, including how worried to be about current COVID cases, when the latest COVID vaccines will be available, and whether they’ll work better against upcoming variants. Infectious disease specialist Peter Chin-Hong, MD, also explores the query “Will there be another ‘triple-demic?’” and presents valuable information on three RSV vaccines that target specific populations.
Great. So it's, it's such a privilege again to come to this audience and tell you about where we are right now in COVID, uh where we might be going. And of course, talk about RSV, given the fact that the uh RSV vaccine for pregnant persons in the third trimester was FD approved yesterday. And that's really addressing uh that newborn population to protect them for the winter. So a lot of movement uh in all the vaccines and viruses uh this winter and I'll get through uh each of these in turn. So no disclosures. So what I'm gonna do is to talk about seasonality and respiratory viruses again first and then go for a deep dive in each of the three, the big three COVID in influence at RSV with a focus on prevention. Uh We'll talk a little bit about how to put them all together and I'll talk about uh where we're headed and some of the predictions for the winter um in, in particular, um I'll address some of the frequently asked questions that people ask me and of course, um look forward to your questions during the Q and A. So most respiratory viruses are single stranded RN A viruses. And the reason why that is important is because, um, they generally have high mutation rates, uh, compared to DNA viruses like pox is a DNA virus and it doesn't really mutate as much as these respiratory viruses. And they tend to follow seasonal patterns as, you know, most of them show peak incidents in the winter months. Um, there's cooler temperatures, uh, low humidity which makes the viruses kind of uh glob on to fluid a little less easily. So it makes it lighter like dandelions. So they can like float around and, and be more easily transmissible. Also, of course, during the winter period, people are um um more uh apt to be indoors versus outdoors in general. Um Although we've seen that with the heat waves uh over the summer this year that uh and we can talk a little bit about that, that's probably drove a lot of people indoors as well. And uh we saw a spike in many respiratory viruses uh including COVID or seeing a uh a current spike in COVID uh which continues. So, um in these respiratory viruses, uh the lipid layer of the viral envelope is sensitive to heat and humidity. And uh as I mentioned, human behavior is is seasonal. So there are some viruses like Rhinovirus and a virus that detected all year on. And I'll show you a nice graph to illustrate that these tend to be more non envelope viruses. It's the envelope viruses that a little bit more uh temperature sensitive. So it makes sense that influenza, uh and some of the power influenza et cetera are more um uh probable in the winter time in many of these respiratory viruses. Uh, an animal connection is always uh there at the end. Uh influenza, for example, there's a pig, there's a bird, um, pigs tend to get uh infected with human influenza as well as bird influenza and then they could resort in the pig. And that's why um you know, uh bird flu is eventually thought to lead to human transmissions probably through an inter marry pig and a lot of the influenza viruses that are bad right now, uh have some reassortment that happen in the pig influenza B tends to be more human only. So it generally tends to be milder influenza A is generally animal influenza and they tend to be more virulent in general. For respiratory uh viruses. We have drugs but they're not uh really um available. So we have to focus on vaccines, which has been a focus for a lot of respiratory virus prevention. And until this year, we didn't and couldn't do a lot about RSV. But all of a sudden we have all these tools for RSV. You just have to learn about it. So here are the, the virus graphs. So you can see that uh the big uh influenza, first of all, usually peaks in December to February kind of more January February last year. It peaked in November. So it really went an atypical season last year and hit hard, uh, in general. Um, and we're, we're not really sure it will happen this year. RSV is similar to influenza, but of course, RSV has been out of sync for the last couple of years, at least it was two years ago in the summer before winter and then last year, of course, we got really hit hard with RSV, mainly because uh people hadn't seen RSV for a few years, reduce population immunity because some immunity generally carries over the following year. You can see human, there are other viruses in the winter too, like human mea virus. We still don't have a great um therapeutic or vaccine for it although it doesn't cause as much bad disease. Uh but we're getting better at diagnosing it anyway. A no virus all year on Rhinovirus, all year on and then power influenza. We're kind of seeing some power influenza activity now. Uh So this is a U CS F graph for where we are right now. Um You can see that lots of Rhinovirus, um some norovirus and Norovirus is in general been much more prominent this year than in previous years. We can see some ad no virus in the blue here and um and some so the ad no virus or in the green here and, and some power influenza in the blue here. So these are kind of the big viruses apart from COVID and I'll get to COVID uh specifically next. Um So right now we're in the middle of what we, most people are calling a COVID swell. So it's kind of like not a big surge, not a tsunami um of cases but a swell. That's really definitely an increase in cases from where we were before the beginning of July. So before July, kind of like February March till July, we were at record lows and starting in July, beginning of July, we started to increase every week. So now we have, you know, several weeks now, consecutive increase across the country of cases. Um hospitalizations up deaths are slightly up by about 8%. Hospitalization is up by about 20%. And they compared to the month before emergency department visits up by about 20% as well. But because the last few months were so low, a 20% increase of a very low number sounds dramatic, but in absolute numbers, um it's not as bad but, but definitely people are, you know, paying attention a little bit worried. Um at U CS F, for example, to give you some perspective, our kind of average COVID census for both kids and adults across four hospitals is about, I would say about 15 to 20 right now. Um at the low point, it was around 10 and uh in January it was about 100. So that's to kind of give you a perspective of, you know, going from 10 to 15 to 20. Uh, but that 15 to 20 right now is very different from 100 back in January. So this is 1/4 consecutive, uh, COVID summer we had in the US. So a lot of people thought, well, it's COVID just gonna be a winter virus. But it seems now that at least for four consecutive summers and of course, we always had a winter increase in cases. Uh Ever since the pandemic began that, um maybe it's going to be a virus that we're gonna see twice a year. A little bump in the summer and a bigger rise uh in the winter time. And why is this so? Well, like I mentioned, it's very similar to many respiratory viruses but uh right now there's more travel record ts a visits, um More gatherings, uh Taylor Swift Concert Beyonce. Uh All of those things bringing a lot of people together from a lot of different regions. There's a lot of heat waves all over the country except just the County of San Francisco, which is this random bubble. Um But uh that's driving a lot of people indoors. Uh And there's also virologic factors and immunologic factors. So the last time a lot of people got infected interestingly was about six months ago. So that's kind of the time when people's immunity probably wane a little bit for even a mild infection. So that's probably all contributing together. Um The deaths are still relatively low, although there's about an 8% increase, but it's about 3 to 400 deaths a week in the United States as opposed to 2000 deaths a day at the height of the COVID pandemic. Um the new COVID vaccines, um you know, you'll read different things in different places, but it's probably, now, I think most people, I said early October in the slide here where it's most people think now uh late September is the time when they'll be uh available. So the other factor that might be driving um this increase in cases that we've been seeing is some changes in the virus. So the virus continues to shape shift. The changes are not as dramatic from sub variant to sub variant as they used to be in the old days. Like a change from Delta to Omar was huge. It was like 30 mutations. But when you think about changing from the XBB flavors and they're all flavors of XBB. If you look at the graph, even though even eg even though EG five is number one, which is 21% um EG five is still a flavor of XBB and the rest of them that are on the top list are all XBB variants, which itself is a rec combination of two B A variants. They're all Ron. And the reason why that's important is because um when we think about the vaccine, the vaccine was based on another XBB um variant called 1.5. But because it changes between 1.5 and this current er, or EG five is so small. I think it's just like one or two mutations in the spike pro uh protein that the vaccine monovalent vaccine is expected to work. Um unless we get something that's completely very, very different. So what might be different? Although there's no evidence that it's going to be a huge threat. Um Yet is this new uh sub lineage of Ron called B A 2.86. And the name letters and numbers are not that important. But the important thing is that there's something that's been detected now in three continents, including the United States, the first case in Michigan where I told you like from one XBB one Ron to another Ron these days and for the whole year, so far, there's just been changes of like one or two mutations. Well, this, this one raised eyebrows in a lot of people because they are 36 mutations that are different from XBB 1.5 which the new vaccine is gonna be based on. There's no evidence that it's gonna run wild. And my feeling is even if it runs wild, um you know, we have so much immunity built up in the population right now that uh most people will still be well protected against serious disease, hospitalization and death, including the pediatric population. So how can you protect yourself? I, well, I think it's really hard these days because we don't have a day to day changes in the number of cases by region. And there's been a decrease in funding all over the country in terms of not only looking at case rates. Um, people are not doing as much testing. Um There's wastewater surveillance and the CDC is only looking by certain sentinel sites rather than um multiple data points. But the CDC did, does do an update of hospitalization rates, um which is a lagging indicator because, you know, you look at this map, it looks so green, which is the best indicator of uh COVID risk for hospitalizations. But of course, you know, uh COVID is going around very um commonly right now, a lot of people have COVID. Um and uh it's not, but they are not going to the hospital, which I think is another interesting feature as opposed to the early days. Um You know, the latest time I looked at the wastewater epidemiology in the Bay area, it's about 200% increase from the one month ago. Um But again, the hospitalizations are not increasing that much even with many weeks of sustained COVID transmission. So I'm crossing my fingers and holding out hope that that um again, with this build up immunity that most people are not going to go to the hospital. But some people are and we have to still be aware of that. Um That fact and of course, we can talk about long COVID as well, uh which risk is decreasing over time. But there are still, there are still people who are getting uh chronic symptoms. So in the CDC, more up new updated maps um that are color coded by three red, yellow and green and they give guidance about masking and of course, this is kind of more crude guidance. Um and we can talk about, you know, more nuanced recommendations as well. But when it's red, everyone masks in population one, it's yellow and there, there's more and more yellow over the last few weeks. Um high risk populations masks. So there's a lot more uh COVID increase in hospitalizations occurring in the Southeast right now compared to California, for example. So what can you do? Well, I think uh you can look at hospitalizations is generally kind of lagging. You can look at wastewater epidemiology, which is sometimes hard to interpret. You can see what's going around uh anecdotally, which seems weird that we're at that point now. Um But I think um using a well quality, high well fitted mask, high quality well fitted mask is still uh something that is always a good idea, particularly if um you are all your family members or people who live with are at high risk of getting seriously ill. Like right now I'm visiting my mom. So uh in the week before I was going to visit her. I was really making sure that I wasn't going to be exposed because she's uh elderly and I don't want her to get COVID for me. So, even though I, I'm up to the on vaccines, I'm not gonna get seriously ill. Uh, I still was taken, uh, very conservatively. I had to fly on a plane so I was wearing my mask on the public transit. Um, the Jetway is going up onto the plane and off. I had in my pocket, if somebody is coughing around me, I put it on, uh, even though the ventilation plane is good. So that was just my way of reducing risk. Um I know it's not 100% but uh I was just trying to do the best I can. Um, there's more guidance now or some recommendations that most people have gotten their last by Vient booster about, um, in the fall, at least when it first came out, uh, which is many months ago and some people haven't gotten it for more than a year. Only 17% of the American population has gotten the booster. So at least a lot of people who haven't even gotten it in the last year. So, should you get the booster now or should you wait for it? Um, I would say given what we're seeing now in numbers if like my mom, for example, um, uh, she's elderly, she's, she, um, you know, I would say get that booster for her right now. Um, because even though I know it's coming the end of September early October, I'm not really sure when she'll actually go to the pharmacy to get it and, you know, if there will be any barriers. So, you know, for immune compromise and those over in 65 given what's going on around now, it might be, it certainly wouldn't be dangerous and it's more convenient. Um, you know, uh try to get it if you can, but if you, even if you don't get it, um having a pack plan uh is probably a great thing to advise uh you know, uh those who are eligible and which is all pretty much everybody except for, but particularly those who are older than 65 and immune compromise or um so when they get COVID and then being kind to people who wear masks, I think it's like the opposite of the early days in the early days, there's a lot of mask, non mask shaming. So people didn't wear a mask, everyone look at them really. Um Strangely, but now if you're wearing a mask, it's the opposite. Everyone looks at you like if you're, you have three eyes or something like that. So I think being kind to each other um is going to be really important in this era. So this new COVID vaccine uh is going to be available uh at the end of September early October. It's based on only one type. It's not gonna be by villains. It's just XBB 1.5 which is an um flavor XBV. 1.5 is not even around anymore. In high numbers. It's this new um EG five which is called Harris, but it's still an XBV flavor and it's very similar to XVV 1.5. So the idea is that they'll only be incremental changes until the end of the year. So this new vaccine will be a, a much better fit than the previous vaccines which are based on if you ever remember B A four and B A five, which is like early um flavors. There are three companies that are gonna make the new vaccine Pfizer are doing a new vaccine. They already started making it. Uh Currently, the FD advisory board unanimously approved uh the vaccine. Um We're still waiting for FDA formal approval which will come any minute now and CDC guidance as to who should get it, but it's anticipated I'll be available to everyone and including pediatrics. Um But the priority group will be 65 and old and immune compromise of any age. Um However, um you know, for, for kids, two and above you land, you'll get, I mean, we'll wait for the formal guidance but it's expected it'll be one shot monovalent uh guidance and uh 6 to 23 months um continues to have the, the two or three shots. Uh depending on, on the age and the manufacturer. So, um, that is kind of what you'll expect, um, for the end of September, early, um, October. Um, so what about, uh influenza? So, so far, what we know about influenza, we always look at the southern hemisphere to give us ideas about what might happen in influenza in the United States and North America and Europe. Um, it doesn't always work that way, but it's kind of always interesting to see what happens, particularly in these COVID times when the world generally has uh the same sort of uh susceptibility because uh people have protected the, the themselves in the same way and uh have not been exposed in the same way in general. So this year in Australia, um in their winter, uh they had an earlier than expected influenza season and Children are disproportionately affected at the beginning of the Australian flu season. About 80% of the admissions to, to uh hospitals are actually pediatric populations. Um There's no guarantee that that's what will be happening here. But again, I I just bring this up as something that happened um in the southern hemisphere for their winter. Some of the reasons why uh so many kids went to the hospital in Australia were hypothesized to be, maybe the final analysis is still being done, but they might have been more H one N one this year. Um And that might have a little bit more proclivity to pediatric populations as opposed to last year, which was more an H three and five and there was a little bit more influenza B which affects kids a little bit more than adults. But one of the biggest reasons why the Australians thought the kids were more or disproportionately affected early in the flu season. This year is because of substantially lower vaccination rates in kids uh compared to the regular times. So I think in general, in Australia, the pediatric population was about uh close to 50% uptake. Uh this year was in the 20% range. So I think, you know, I think that's a wake up call to us that I think parents and the sort of vaccine hes been seen in the population may be uh much lower this year than in even last year or previous years. And we kind of have to be ready for that or to have, be ready to have conversations with uh parents and, and kids about about that when we look back at the influenza season in the United States for last year, it was a kind of, it was a bad year actually. So to give you perspective, a typical flu season is about 35,000 deaths. Uh last year was about 60,000 deaths, uh which is kind of in the bad flu season um realm and it made sense. Lots of things were bad last year. RSV influenza, uh COVID. Uh and that's because again with these non COVID viruses, uh it's, you know, lack of population immunity, uh and et cetera and then, you know, um vaccine, some vaccine hasn't c last year, we also had an abnormal um cadence of influenza. So, rather than peaking later in January, February, it peaked in December and started earlier like in uh September, October. But the good news is despite all of that, the, the prediction of the vaccines were a good match for last year. Um And um it, it's pretty much mimicked this year with uh one minor exception, which I'll mention in a second. So what will we expect for influenza vaccines in 2023? Well, they're already available as you know, uh it's available for everyone six months and older. Um, you can get flu miss or for the injectables, uh six months to eight year, eight years, um, two shots one month apart of flu timer or one shot in general for most people, priority groups, uh five and under over 65 and older immune compromise. Um, but everybody uh is, is hopefully gonna get, uh is eligible for flu shot and, and should get it. Um The current flu shot for this year is uh two influenza Aids and wanted two influenza bs depending on the shot, the manufacturer, but the two influenza is uh uh very similar to last year. So there's H one N one which again I mentioned was hypothesized to be one of the drivers of increased uh pediatric hospitalizations in Australia this year, uh they updated a little bit to mimic something that was more towards the end of last season because it changed a little bit. Um But they continue the same H three N two, which is, which causes more serious influenza, um but primarily more serious in adults. Um and then 1 to 2 influenza bees which is generally less serious uh in general. So the big question always is when to get it. Um, in general, my feeling is get it when it's convenient because getting it is better than not getting it ever because you forgot to go or couldn't get it, uh administrative put it off and then it's, you know, in the middle of the flu season or after, uh most people say September or October, given the fact that we are not really sure what will happen with the, with um, what the tempo of the viruses will be. Um But, uh, you know, it may take about two weeks to really get on board. Um, may last for, um, you know, 5 to 6 months peak at around month, 4 to 5. So in general, if you can wait and there's not a lot of flu, um, you know, definitely get it before that. Uh Halloween is kind of good advice, but September, October and if again, you're not, you're worried that the person won't come back for the flu shot, getting it now is just get better than not getting it at all. Um In the future, uh these are some of the things that you might see with flu shots. Uh it was supposed to be this year but uh there's been some delay in getting the results. Um but uh there have been uh phase three studies for the MRN A vaccine for flu. And the reason why that's interesting is because you can combine two MRN A vaccines. So there's also studies looking at influenza and COVID combined Mr A shots. So, wouldn't that be great just to have one needle and two vaccines for influenza and COVID. And there's also a recent uh study now looking at a universal MRN A influenza vaccine which uh looks at more epitope, more uh universal uh non changeable parts of the virus. And the idea is that hopefully, if you get one of these to work, uh you don't have to get a flu shot every year and, and you can get it less frequently. So what is uh going on with RSV right now? Well, a lot is going on with RSV. I probably think it's the most change compared to last year in terms of tools that we have, but just to remind you what happened last year, um you know, it was, it was uh terrible as you all know, in terms of uh people getting sick in the community, people coming to offices, not having any tools to manage it. Um hospitalizations. Um uh feeling that it like the pediatric version of March of 2020. Um and I just wanted to review who does worse in RSV. Uh either there's some genetic component but generally infants uh under six months, uh given small airways and the mucus that it gets produced there. Um Those who are under 35 weeks gestation and second hand smoke exposure. Uh those who are Children who have lung and congenital heart disease. Um those who are immune compromise and for adolescents and adults, lung and heart disease and those are immune compromise. Uh RSV causes tens of thousands of hospitalizations every year. Um But uh most of the deaths are in those who are older than 65 which is around 4000 or 5000. And the pediatric population generally less than 1000 deaths a year, generally like 3 to 400. Um So lot of hospitalizations, but fortunately not proportionally, a lot of deaths. But no, you know, we always want to prevent all deaths um in, in, particularly in, in kids. Um 100 hours we present. Um again, most people will get a flu like syndrome or a cold like syndrome, more likely with localized rhea hepatitis mania cytic a group. Um you can get a cough, some people will get pneumonia, uh particularly those who are immune compromised or at risk of serious disease. And then uh people may get a low grade fever systemically um, but the clinical syndromes as you know, vary by host in infants. We think about bronchialis, pneumonia and apnea in Children and young adults. Otitis media and uris and the elderly and immune compromise. Uh, that's really when you're getting a lot of pneumonias and probably what's driving a lot of deaths in that population until this year. Um, you know, we still don't, I mean, we still don't have great treatment for RSV. Um It's generally supportive rehydration, respiratory support. There's less evidence for antibiotics. There's less evidence for ribery in most people. Um uh inhale hypertonic Celine used by some uh some people may benefit from steroids but most people won't. Some people use uh IVIG but there's less evidence for that. Um And bronchodilators as well. How do we until this year? This was all we had to in the menu of RSV prevention which was masks, washing hands, staying home and sick, avoiding secondhand smoke. Um uh getting your, your COVID and influenza shots because of co infections and poly poliza uh which is uh targeting this F protein, which the new proper vic vaccines are targeting. Uh it's monoclonal antibody preventing hospitalization in high risk groups. Um And currently recommended for bronchopulmonary dysplasia, prematurity under 29 weeks and others. And the dosing is once a month for five doses max. But now we have uh the first time uh where we have three vaccines now available for RSV. Uh So it's the first time the vaccines are available for COVID influenza and RSV uh all at the same time. That also leads to a lot of questions. So let's take them one by one. So um the first vaccine that was uh FD approved was one for uh babies or infants. Uh This is called the for A N I uh made by uh Sino and astrazeneca. It's a monoclonal antibody. So not a typical uh protein vac sub vaccine or MRN A vaccine like you used to, but a monoclonal antibody um and in clinical trials was shown to be e efficacious against serious disease and as well as clinic visits by as close to 80%. Um Right now, it's uh recommended for those under eight months of age and for those who are eight months and 19 months, uh if you're immune compromised lung disease, uh Alaska uh indigenous or um or American Indian, the second RSV vaccine. And right now, I think uh people are still working on payment for this vaccine, this mono an body. I think it's a little bit different because it's not really automatically in the vaccines for Children program. But uh i it's been approved, it's just a matter of getting it formally um on there. So I think in this transition period, um I think the payment still will be uh something that people are working on working out for the new RSC vaccine. Number two. This is in pregnant persons which is meant to protect newborns. This will probably be easier to get. Um uh and this is as you know, it's common practice to vaccinate pregnant persons to protect the newborns via antibodies that develop in the mom that cross the placenta. We've seen in COVID with uh moms who are vaccinated, protecting particularly those kids under six months old, who can't make their own antibodies. Um breastfeeding uh in T A influenza, this all uses this strategy. So this urrc vaccine uh made by Pfizer is a traditional protein subunit vaccine. And the studies uh was given to 7400 pregnant people and infants. Um And for the pregnant people's uh arm of the study, the moms got this bivalent uh RSV vaccine that's protein based and they were found to have an 82% decreased risk. The infants were found to have 82% to decrease risk of serious RSV infection in three months defined by rapid breathing low oxygenation and IC U visits. And there's also uh a cutting off of outpatient visits by about 50%. So that's vaccine number two. So we talked about monoclonal antibody in infants under eight months, primarily uh vaccines RSV vaccine for pregnant persons in the third trimester to protect the the newborns. And uh the third is the RC vaccine, old adults uh because you might get questions about that. And these are two companies that are making RC vaccines for older adults that have been FDA approved one by pfizer and one by GSK, they're both protein subunit vaccines. So, non MRNH sort of traditional vaccines right now, it's FDA approved for those who are 60 older. And um it's in studies shown to be effective at preventing lower respiratory symptoms, cough, shortness of breath, wheezing by close to 9 85 to 90%. Um The interesting thing is uh they were studying, studying this from, you know, two seasons ago. So they were able to have data to look at the second season of RSV. And the people who got vaccines compared to placebo and they found that the vaccine lasted in these adults for a second season. So right now, the thinking is um you can give the vaccine at least, you know, it's gonna last for two years. So you don't have to give it every year for at least for the adults. We don't have enough information about the uh given in pregnancy at part. But I think people will continue to follow that. And um the, the not seen in the pediatric populations, either with the monoclonal bodies or with the vaccine in pregnant people in the older adults who got the vaccine. There were 20 cases of atrial fibrillation and six cases of neurologic complications including Guillain Barre, um didn't stop the FDA from improving it. It was thought to be low enough and not too different in placebo where they're going to continue to follow this very closely. Um But right now, I think it probably was the reason why it was not automatic approval for older adults. Uh But the CDC guidance is that older adults engage in a conversation with clinicians to talk about risks and benefits. And it's really because it's a relatively new vaccine and because of the 20 cases of a fib and 66 cases of neurologic complications. So, um we talked about the three new vaccines for RSV and babies, monoclonal bodies, pregnant persons, third trime and old adults older than 60. But coming in future right now, they are ongoing studies in high risk Children, 2 to 18 years old and high risk adults, 18 to 60 years old. So uh right now it's really just uh immune com uh age cut-off for older individuals and the age cut off for younger folks. So I immune compromised individuals like ages two to 60 are um you know, there's no data or FDA clearance for supporting vaccines in that population yet. So, what are some of the frequent questions that I get um about putting all these vaccines together? What vaccines to prioritize? I think, you know, it depends on who you are. Um You know, I think in general, I think the the biggest two killers are still um COVID and influenza. So I'd probably uh prioritize those. Uh the RSC vaccines are relatively new, but they will make a, have the promise of making a big dent in the huge amount of hospitalizations we've seen last year. Um So right now, um you know, that's, that's the way I think about but, but really uh giving three vaccines, if you can get them in to people would be uh the best uh intervention I would recommend when to get vaccines. We talked about that. Um September October is a general guidance. You don't want to give it in August. Um And that's really because you want antibodies to peak around the time when uh you would need it the most when you're expecting things to release there. The only exception is about what's going on with COVID right now for those who are all in 65 and immune compromise. Um But uh you know, that's kind of the, the timing of the guidance. The only other tweet to that is if somebody is, is pregnant and they're going to uh deliver soon, you might wanna give them their vaccines like the flu and um and uh COVID right now rather than, and wait so that there could be some protection for the newborn. Can I give vaccines together? Uh Right now, the there's most data for flu and COVID together. Um There's no evidence that giving the RSV at the same time would be uh any different. Um But uh you know, this theoretical evidence of the RSV vaccine given together at the same time may decrease the antibodies in uh the COVID vaccine. But that that hasn't really worn out all that, but it is still high enough where people haven't really, um um, you know, modified recommendations around that. So I guess I would take that as convenience trumps everything uh for the time being are the vaccine safe. Um, I would say that uh for the pediatric population, pregnant persons, uh generally, yes, I mean, the, there hasn't really been any serious adverse effects seen in any of the RSC vaccines for, for that age group. Uh in pregnant persons, there was a non statistical increase in preterm birth, but again, it was non statistical. So people are just gonna follow that more closely. Um And um but for right now, uh the recognition is as it stands for COVID, there's no new uh safety profile or, or adverse effect expected with a new vaccine and, and influenza. It's the same um as previous, the only other tweak and influenza guidelines for this year is that people with egg allergies can pretty much get any vaccine. Um And that's because I guess the CDC has looked at the data safety profile even though there's an egg free vaccine. Um the guidance is here is that you don't have to like go out of your way to look for that if, if people have egg allergies, but you, you might wanna uh review that as well with, with a patient, if you can get an egg allergy, an egg free vaccine, of course, uh get it. Uh but patients may still be a little bit worried about that. And again, like the million dollar question is who pays for the vaccine against the moving target in California? At least for by law. Uh Everybody has to be covered until the end of no, until November. Um The Biden administration is trying to process this bridge program that will um uh cover everyone again for COVID vaccines. Um And of course, the vaccines for Children program should cover the rest and that's with COVID for influenza. It's the same as in the years past. Uh We don't anticipate any change. I think the main question is really about the RSC vaccines, they're so new. Um And people are still trying to figure out uh distribution and payment um for the RSV vaccines. Uh I, I know a lot of people working pretty hard in that. Unfortunately, I don't have any details uh about the RSV vaccine rule out uh for the time being. So, where are we headed? Um I think, you know COVID is gonna be something that's here to stay as we talked about, it's probably gonna e eclipse uh you know, flu and pneumonia, at least in terms of morbid immortality for the next few years. Um But flu is definitely, as I mentioned with last year's numbers. Um and at least the abnormal keens that we saw with since we've been in lockdown and post lockdown. Um But it is interesting that we have this new player on the block that wasn't there um before you know, 2020 year. So what to expect this fall and winter. I think you may see abnormal timing on vi viruses. Um Flu may come earlier this year. It may hit kids earlier that like it did in Australia, it may not. Um the vaccine are likely going to be a good match for it. Um RSV may come early like last year. Um People, I think it will still uh cause a lot of people to get sick this year unless the VACC people take the vaccines and they may have a dent COVID. We're expecting that this um swell will go down a little bit and then come back up in the winter time at a higher number. So we may end up having another triple dem but hopefully with less RSV going around because of the new vaccines, uh it may moderate things a little bit. But again, what we don't know about is how many people will actually take vaccines. Would they get paid for some of the new ones like RSV? Or? Um there's a lot of misinformation, disinformation. I feel like more than ever before. Although an interesting Kaiser Family Foundation study showed that even though only 17% of the American population took the new vein booster that close to 50% say they would take the new monovalent updated shot in the fall if we're available and part of it is, I think it was just really confusing four months here, six months there. Uh when you get the last one who's getting four shots, five shots, the CDC is just hoping to just make things better for people by simplifying everything. Everybody just think about it at least once a year around the same time as they the vaccines. And hopefully that will be how the goes, it will be unclear right now, whether or not with a summer surge again, if it happens every year, whether or not or an increase in cases, I wouldn't really call it a surge whether or not some groups will have vaccines twice a year for COVID. And despite all of this, I think there's a lot of confusion, you know, so I think as we get more information, boiling it down for patients prioritizing things, taking that patient situation um into consideration as to what will give them the biggest bang for the buck if they got COVID a bunch of times, uh maybe you might wanna prioritize influenza and RSV because they will still have some immunity that might take it on and come back to COVID afterwards. So I think it's very dynamic. Parents are very um on edge. There's so many politics that continues to be even more profound in science. So, you know, I would say, hold on and um support each other as we navigate uh this season. Um So when to refer hospital wise, I think in general, uh you know, some of the criteria um any time you have a question, I think uh getting in touch with uh with, with um a 90 folks or, or um somebody else who, who might be a champion in your group around vaccines. Um But these are some of the criteria for RSV that we think about because sometimes they're new um uh including social support and then um Lauren shared the slide already, but we're always happy to have your patience here and she's everything and he's just can. And uh there are two kinds of people when going back to school. So, thanks a lot uh for your attention and I'll be happy to take any questions.