Advances in medicine are continuously emerging, challenging all members of the interprofessional team to remain aware of important updates and how they may improve clinical practice. This is particularly true for the prevention and treatment of infectious diseases. However, increasing demands on the time and resources of healthcare practitioners make it difficult to stay up to date on the latest clinical research and guidelines, as well as the implications for patient care. This article highlights recent advances in our understanding of infectious diseases and strategies to prevent and treat these illnesses.

SHOULD LONG COVID PATIENTS GET THE FLU, RSV, AND NEW BOOSTER SHOTS?

Seasonal COVID-19 influenza vaccines are important for the prevention of respiratory infections.^[1] Indeed, influenza vaccines have been available for decades and are considered integral to decreasing the health burden associated with the flu.^[2] Similarly, respiratory syncytial virus (RSV) is a key cause of acute respiratory disease,^[3] and preventive therapy is recommended for infants and older adults.^[4,5]

The first thing up on the Dartmouth Hitchcock Medical Center website^[6] in late August was a question: Are you up to date with your vaccines?

For people living with long COVID and other chronic conditions, the answer may not be so clear.

Three shots are coming online this fall, including a new vaccine for RSV. With flu season approaching, as well a pending update to the COVID-19 shot, people with long COVID will have to make some choices.

The Centers for Disease Control and Prevention (CDC) advises everyone to get the COVID vaccine and a flu shot.^[7,8] The RSV vaccine is recommended for those over 60 and with weakened immune systems, and federal health experts suggest younger individuals, pregnant women, parents, and others talk to their clinicians about the pros and cons of receiving the RSV vaccine.^[9]

But the CDC is not specifically saying whether long COVID patients should get the new COVID boosters, flu shots, or RSV vaccines. A CDC spokesperson said the agency could make no one available to discuss whether long COVID patients should get a COVID vaccine, and the Food and Drug Administration (FDA) referred similar questions to the CDC.

Last fall, federal health officials urged people to get their COVID booster and flu shot at the same time — but in separate arms.

In terms of vaccine guidelines, some professional medical groups, like the American Academy of Family Physicians, defer to the CDC.^[10,11] The FDA’s label for the RSV vaccine makes no mention of long COVID.^[12] Long COVID is not on the CDC’s list of vaccine contraindications.

Despite the lack of clear guidelines from the CDC, some experts and healthcare organizations say people with long COVID should get the new COVID booster and the flu shot, and should talk with their clinicians about whether the RSV vaccine is right for them.

Paul Sax, MD, clinical director of the infectious disease clinic at Brigham and Women’s Hospital in Boston, Massachusetts, acknowledged an absence of clinical trial data on vaccines for people with long COVID. But he said the COVID and flu shots may benefit people with the condition.

"People with long COVID may be susceptible to postinfectious, prolonged fatigue illnesses, and these are more likely with the severity of the illness," he said in an email. "Since the vaccines reduce disease severity (and initially prevent infection), anything that mitigates disease severity would be beneficial to them."

On the RSV vaccine,^[9] he agrees with the (FDA)^[13] that this is a shot that benefits "shared decision making" — a clinician and a patient weighing risks and benefits before proceeding. He would only recommend RSV to "people at the extremes of older age, immunocompromised, or with multiple other medical problems," he wrote.

Jeffrey Parsonnet, MD, co-director of Dartmouth Hitchcock’s Post-Acute COVID Syndrome Clinic in Lebanon, New Hampshire, said nothing in the medical literature raises concerns about vaccines for people with long COVID. However, he said it is reasonable for some people to be cautious and to talk to their clinicians about the pros and cons before making a decision.

He tells those already vaccinated to skip the current boosters if they had a bad reaction in the past. The vaccines are great at preventing death and hospitalization, he said. "I’ve had every vaccine right on time and I’ve had it twice," he said.

If the new vaccine booster proves effective, he said, he would be likely to recommend the shot.

The fall COVID-19 vaccines are an improvement on the exiting vaccine, but the virus is mutating quickly. In late August, President Joe Biden called for another update.

For anyone who is vaccine hesitant, Parsonnet advises a wait-and-see approach on RSV. Until recently, RSV was considered a childhood disease, he said, but a growing death rate among older adults led to a vaccine. He said he qualifies by age and will be getting it.

His general advice: "I think doctors should follow the recommendations of our public health authorities,"^[24] he said. "That’s what I would do."

Advocates for people with long COVID and other chronic health conditions have complained that there is little research into how vaccines impact their health.^[25] For years, people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is common among people with long COVID, have been reporting both improvement and declines after vaccines or infections.^[26]

A recent Mayo Clinic study of about 500 patients found that vaccination lowered the risk for long COVID and reduced the severity when it did occur. Vaccinated patients are less likely to report loss of smell, chest pain, dizziness, numbness, shortness of breath, and weakening.^[27]

Herman, with Oregon Health and Science University, noted that most people get their vaccines from primary care clinicians, which is why OHSU’s long COVID program created a guide for primary care clinicians who need help treating a new condition.

"The OHSU Long COVID-19 Program generally recommends that patients experiencing chronic COVID-19 symptoms obtain all preventative vaccinations (including flu, COVID, and RSV) for which they are eligible, while also recommending that patients directly discuss any questions or concerns they may have about vaccination with their health care provider," he said.

STUDY: UNEXPECTED VAGINAL BLEEDING RISES AFTER COVID VACCINATION

Recent data have shown that COVID-19 vaccination or infection can impact the menstrual cycle. Indeed, one study found that disturbances in uterine bleeding occurring following vaccination and the next anticipated menstrual period, with abnormalities similar to those seen among women who were infected with COVID-19.^[14] A new study evaluated the association between COVID-19 vaccination and unexpected uterine bleeding in groups including post-menopausal women, peri-menopausal women and non-menstruating pre-menopausal.^[15]

The researchers used an ongoing population health survey called the Norwegian Mother, Father, and Child Cohort Study, Nature reported. They examined more than 21,000 responses from postmenopausal, perimenopausal and non-menstruating premenopausal women. Some were on long-term hormonal contraceptives.^[15,16]

The study found that non-menstruating women were more likely to experience unexpected vaginal bleeding after receiving COVID-19 vaccinations. Researchers suggested it could have been connected to the SARS-CoV-2 spike protein in the vaccines. The study was published in Science Advances.^[15]

After vaccinations became widely available, many women reported heavier menstrual bleeding than normal. Researchers at the Norwegian Institute of Public Health in Oslo examined the data, particularly among women who do not have periods, such as those who have been through menopause or are taking contraceptives.

They learned that 252 postmenopausal women, 1008 perimenopausal women and 924 premenopausal women reported having unexpected vaginal bleeding.

About half said the bleeding occurred within four weeks of the first or second shot or both. The risk of bleeding was up 3 to 5 times for premenopausal and perimenopausal women, and 2 to 3 times for postmenopausal women, the researchers found.

Postmenopausal bleeding is usually serious and can be a sign of cancer, Nature wrote.^[16] "Knowing a patient's vaccination status could put their bleeding incidence into context," said Kate Clancy, a biological anthropologist at the University of Illinois Urbana-Champaign.

NO NEED TO RESTRICT HEP C DAA THERAPY BASED ON ALCOHOL USE

Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). It is transmitted via the blood of an infected individual, for example by shared needle use. While some people may experience short-term illness, others may develop a chronic HCV infection that causes significant liver damage.^[17] Evidence has historically indicated that consuming alcohol impacts the effectiveness of medication used to treat HCV, as well as adherence to treatment.^[18] However, a new study has found otherwise.^[19]

TOPLINE:

Alcohol use at any level, including alcohol use disorder (AUD), is not associated with decreased odds of a sustained virologic response (SVR) to direct-acting antiviral (DAA) therapy for chronic HCV infection. Therefore, DAA therapy should not be withheld from patients who consume alcohol.^[19]

METHODOLOGY:

• The researchers examined electronic health records for 69,229 patients (mean age, 63 years; 97% men; 50% non-Hispanic White) who started DAA therapy through the US Department of Veterans Affairs between 2014 and 2018
• Alcohol use categories were abstinent without history of AUD, abstinent with history of AUD, lower-risk consumption, moderate-risk consumption, and high-risk consumption or AUD
• The primary outcome was SVR, which was defined as undetectable HCV RNA for 12 weeks to 6 months after completion of DAA treatment

TAKEAWAY:

• Close to half (46.6%) of patients were abstinent without AUD, 13.3% were abstinent with AUD, 19.4% had lower-risk consumption, 4.5% had moderate-risk consumption, and 16.2% had high-risk consumption or AUD
• Overall, 94.4% of those who started on DAA treatment achieved SVR
• After adjustment, there was no evidence that any alcohol category was significantly associated with decreased odds of achieving SVR. The odds ratios were 1.09 for abstinent without AUD history, 0.92 for abstinent with AUD history, 0.96 for moderate-risk consumption, and 0.95 for high-risk consumption or AUD
• SVR did not differ by baseline stage of hepatic fibrosis, as measured by Fibrosis-4 score ≤ 3.25 vs > 3.25

IN PRACTICE:

"[A]chieving SVR has been shown to be associated with reduced risk of post-SVR outcomes, including hepatocellular carcinoma, liver-related mortality, and all-cause mortality. Our findings suggest that DAA therapy should be provided and reimbursed despite alcohol consumption or history of AUD. Restricting access to DAA therapy according to alcohol consumption or AUD creates an unnecessary barrier to patients accessing DAA therapy and challenges HCV elimination goals."

SOURCE:

Emily J. Cartwright, MD, of Emory University School of Medicine, Atlanta, Georgia, led the study, which was published online September 26 in JAMA Network Open.^[19]

LIMITATIONS:

The study was observational and subject to potential residual confounding. To define SVR, HCV RNA was measured 6 months after DAA treatment ended, which may have resulted in a misclassification of patients who experienced viral relapse. Most participants were men born between 1945 and 1965, and the results may not be generalizable to women and/or older and younger patients.

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