Policymakers Boosting Public Health Readiness for Respiratory Illness Season

September 15, 2023 | Maggie Davis

A young girl gets a bandage on the site of her vaccination. ASTHO Health Policy Update banner in the lower leftEach year as autumn approaches—and people begin to spend more time indoors—there is often an uptick of respiratory viruses. Last year, the United States experienced a “tripledemic” with high circulation of three respiratory viruses—COVID-19, Influenza, and Respiratory Syncytial virus (RSV)—straining hospital capacity across the nation. As similar conditions this year could strain hospital capacity if all three diseases peak simultaneously or are circulating more widely than expected, healthcare systems are preparing for an influx of cases. Fortunately, public health leaders are positioned to prevent illness from all three viruses with approved vaccines and preventative antibody treatments.

FDA Approves First Products to Prevent RSV

RSV is a highly contagious virus that, while mild for most people, can be severe for infants and young children and older adults or adults with chronic medical conditions. The high numbers of young children hospitalized with RSV in the winter of 2022 led Oregon’s Governor to declare a public health emergency to support public health authorities and healthcare systems to respond to the increase of pediatric RSV infections and hospitalizations. Similarly, Colorado’s governor amended the COVID-19 disaster declaration this past fall to incorporate RSV and flu infections.

This year, FDA approved its first vaccines to prevent RSV in infants (Abrysvo given to pregnant persons between 32-36 weeks gestation) and in adults 60 years and older (Arexvy). Additionally, FDA approved Beyfortus, an injectable monoclonal antibody to prevent RSV in neonates younger than eight months or some older babies with underlying health conditions. On August 3, the Advisory Committee on Immunization Practices (ACIP) voted to recommend the preventative antibody Beyfortus for children up to 19 months old.

During the 2023 legislative sessions at least four state legislatures (Georgia HR 531, Illinois SR 136, Louisiana SR 101, and Michigan SR 50) passed resolutions supporting ACIP’s inclusion of the RSV preventative antibody product to the Vaccines for Children (VFC) program. In August 2023, ACIP voted to include the RSV preventative antibody product to the list of products provided by the VFC program, becoming the first non-vaccine product included under VFC.

Federal Policies Supporting COVID-19, Influenza, and RSV Immunization

ACIP further recommends all people older than six months receive a seasonal influenza vaccine and a single dose of the COVID-19 vaccine regardless of previous COVID-19 vaccination status. Under the Affordable Care Act, most insurance providers are required to fully cover ACIP-recommended immunizations. Similarly, Medicare Part B covers COVID-19 and influenza vaccines without cost-sharing and Medicare Part D recipients have their routine immunizations provided without needing to pay additional fees.

After more than two years of procuring and distributing COVID-19 vaccines, the federal government is transitioning all COVID-19 medical countermeasures to the commercial market. Medicare, Medicaid, and most employer-based or private health insurance plans will continue to provide the COVID-19 vaccine free of charge for in-network care 15 days after ACIP’s recommendation. This inclusion is faster than other ACIP recommended vaccines, which require coverage within the next plan year after an ACIP recommendation, because Section 3203 of the CARES Act requires plans to cover COVID-19 vaccines as they are available rather than within the next coverage year.

To prepare for this change, CMS issued a letter to Medicaid, Medicare, and private insurance payors alerting them of the requirements to cover the COVID-19 vaccine without cost-sharing. To provide access to the approximately 30 million uninsured adults, CDC established a Bridge Access Program that will provide free COVID-19 vaccines to uninsured adults through December 2024.

Traditionally, the federal government operates two programs to help states vaccinate children and uninsured or underinsured adults. First, Section 317 of the Public Health Service Act enables the federal government to purchase vaccines to support state and local public health vaccination efforts. This law enables CDC to enter into an Immunization Cooperative Agreement with jurisdictions to provide vaccines, with 64 state, territorial, and local jurisdictions participating in recent years. While immunizations for influenza and COVID-19 are generally covered by insurance without cost-sharing, insurance coverage for the RSV vaccines has been less clear. Optional Medicare Part D—which provides prescription drug coverage—covers the RSV vaccine while the more common Medicare Part B covers influenza vaccines.

Second, the VFC program provides vaccines to registered VFC providers to help children receive their recommended vaccines regardless of their parent’s ability to pay. VFC already covered COVID-19 and influenza seasonal vaccines, and with the inclusion of the new RSV preventative antibody product the program support preventative measures for all three illnesses.

In addition to leveraging federal programs to supply needed vaccines before respiratory illness season kicks off, states and territories are working to ensure there is an adequate and accessible vaccine supply for everyone in their jurisdiction. One mechanism many jurisdictions use to acquire vaccines is MMCAP Infuse, a national cooperative group purchasing organization operated by Minnesota.

State and Territorial Policies Supporting Increased Vaccine Uptake

All states, territories, and Washington, D.C. have routine childhood vaccination requirements, meaning that for a child to be enrolled in school or childcare center they must have certain immunizations. Although many states rely on ACIP’s expertise to establish the appropriate schedule and dosage of required immunizations (e.g., Idaho and Guam incorporate ACIP’s vaccine administration schedule by reference), state and territorial leaders establish which vaccines are required for enrollment.

Requiring routine childhood vaccinations to enroll in school is an evidence-based policy to increase vaccination rates, with higher vaccination coverage for diseases like measles, mumps, and rubella in jurisdictions that have adopted ACIP guidelines. As of March 2023, five states require children enrolled in Pre-Kindergarten or a childcare center to receive an influenza vaccine and no states require the flu vaccines for K-12. No state or territory currently requires the COVID-19 vaccine to enroll in childcare centers, pre-kindergarten, or K-12 schooling.

Reducing barriers to vaccines through state law is another evidence-based strategy to increase vaccination rates. Expanding the number of healthcare provides authorized to give vaccines is a common way states reduce access barriers. Under the Eleventh Amendment to the PREP Act for COVID-19 medical countermeasures, all state-licensed pharmacists are provided liability protections to administer COVID-19 and seasonal influenza vaccines through December 31, 2024.

Over the course of the COVID-19 pandemic, states rapidly shifted scope of practice laws to expand the vaccination workforce enabling pharmacists and other professions to provide more vaccines to more people. During the 2023 legislative sessions, at least 19 states considered bills to expand the scope of practice of professions including dentists, optometrists, and midwives to include administering vaccinations.

West Virginia enacted HB 3141, allowing dentists and dental hygienists to administer vaccines during declared public health emergencies. New Hampshire enacted SB 200, expanding optometrists’ scope of practice to include administration of FDA-approved influenza, COVID-19, and shingles vaccines. Additionally, New Hampshire enacted SB 35 to authorize pharmacists and pharmacy interns to administer the newly-approved RSV vaccine to adults. Virginia enacted HB 939, authorizing midwives to administer vaccine medical countermeasures under a Board of Health emergency order to limit the spread of a disease outbreak.

States are also lowering the cost of vaccines by purchasing them through federal programs. Under VFC, providers are authorized to charge an administrative fee but must waive the fee if the family is unable pay. In May 2023, Colorado enacted SB 23-260, which provides state protections for people accessing publicly funded vaccines (purchased through VFC or 317 programs) by allowing people to receive a publicly funded vaccine without showing proof of health insurance or a government-issued identification card and prohibiting providers from denying a patient the vaccine based on their ability to pay the administrative fee.

ASTHO will continue to monitor and provide updates on this important public health issue.

Special thanks to Kim Martin, director, immunizations at ASTHO for her contributions to this Health Policy Update.