Vaccine Confidence, Waning Protection, and the Next Generation of Respiratory Disease Prevention: Insights from Leading Clinicians

The prevention of respiratory infectious diseases stands at a critical crossroads, shaped by evolving pathogens, waning vaccine protection, and a troubling erosion of public trust in immunization. In two wide-ranging interviews, Donald B. Middleton, a family medicine clinician and influenza (search)Search disease vaccine researcher, and Tina Q. Tan, a national thought leader in infectious diseases and immunization policy, offered candid assessments of where respiratory medicine stands today and what must change to meet emerging threats.

The Waning Shield: Influenza (search)Search disease Vaccine Durability in Older Adults

One of the most pressing clinical challenges is the decline in influenza (search)Search disease vaccine effectiveness (VE) over the course of a single respiratory season. Middleton pointed to research led by Jill Ferdinands, with whom he collaborated on a 2021 VE study. That study demonstrated that the rate of VE waning was notably worse in adults aged 65 years and older, with a decline of approximately 10% every 30 days post-vaccination. "At that rate, influenza VE, which typically begins at around 50–60%, could decline by more than half by season's end," Middleton explained. He noted that it remains unknown what percentage of study participants received an enhanced influenza vaccine, which might reduce this dangerous drop in protection.

Given the 1–2-week delay in effectiveness post-vaccination and the typical November onset of influenza (search)Search disease, Middleton advocates for vaccinating older patients in early-to-mid-October. His guiding principle: "If you are older, wait until it's colder."

Co-Circulation: A Diagnostic and Capacity Challenge

The simultaneous circulation of influenza (search)Search disease, RSV, SARS-CoV-2 (search)Search disease, and bacterial pathogens such as Bordetella pertussis (search)Search disease is not a new phenomenon, but the clinical stakes have risen sharply. Middleton emphasized that the arrival of SARS-CoV-2, with a death rate that eclipsed that of influenza, made the prospect of co-circulation particularly alarming. He noted that multiple viruses, including human metapneumovirus (search)Search disease, now cause significant disease across all ages, often producing prolonged coughing lasting several weeks. "The cough from bacterium Bordetella pertussis tends to get lost in the thought that only viruses can create this problem," he cautioned. His recommendation: all health systems should maintain diagnostic detection capabilities to provide focused treatment whenever possible.

Tan reinforced this perspective from the pediatric vantage point, stressing that recent studies illustrate that respiratory diseases "are serious and not benign, and they can cause serious sequelae that may last a very long time." She urged healthcare practitioners to use vaccination as the most effective tool for prevention.

Antimicrobial Resistance and the "Just in Case" Antibiotic

Tan highlighted the growing challenge of antimicrobial resistance in respiratory infections, pointing to findings regarding the development of resistance to all common oral antibiotics. She warned that this will be most consequential in situations where patients are placed on antibiotics "just in case" they have a bacterial infection when they actually have a viral infection, and in countries where antibiotics are available over the counter. The findings, she argued, underscore the importance of preventing disease through vaccination rather than relying on antibiotics as a fallback.

The Global Threat: Infections Are "Just a Plane Ride Away"

Both clinicians underscored the borderless nature of respiratory pathogens. Tan observed that "infections are just a plane, bus, train, and boat ride away," citing measles, pertussis (search)Search disease, mycoplasma, RSV, influenza (search)Search disease, and COVID-19 as examples of organisms that unvaccinated individuals contract abroad and bring back to the United States. She noted that many countries lack the capacity to vaccinate against all diseases for people of all ages, allowing vaccine-preventable diseases to circulate endemically and increasing risk for the unvaccinated.

Tan recounted her experience giving keynote lectures at the Puerto Rico Infectious Diseases Society Annual Meeting and the Japanese Infectious Diseases Society Annual Meeting, where a massive pertussis (search)Search disease epidemic had just begun. After both lectures, she was "swamped by healthcare providers asking if they should get a pertussis vaccine for themselves and for their families." The takeaway, she said, is that "more vaccine education is needed for adult providers."

Vaccine Hesitancy: The Defining Challenge

Middleton described the failure of public leaders to commit to appropriate vaccination as "deplorable," noting that many individuals incorrectly believe they are immune to infection, that illness will be mild, or that treatment will be readily available. "These opinions are sadly wrong," he stated. His approach with hesitant patients is direct: "I simply tell a hesitant patient that I vaccinate myself and my family, that I like them, and that they need vaccination too."

Tan chairs the American Academy of PediatricsView company profile' Global Immunization Advocacy Pediatric Advisory Committee, which has been working to develop vaccine training for healthcare practitioners in other countries. She reported that this initiative has been "very successful at increasing the ability of healthcare providers to address vaccine hesitancy, discuss the importance of vaccines with parents, and increase vaccination rates."

Middleton identified the restoration of public trust in vaccination science as the major issue facing the field, adding that "a growing number of hesitant medical practitioners need to reaffirm their faith in vaccination."

The Innovation Horizon: mRNA, Monoclonal Antibodies, and Surveillance

Looking to the future, Middleton placed his confidence in mRNA technology. "mRNA vaccines (search)Search drug have great potential to be widely effective," he said, envisioning combined influenza (search)Search disease and SARS-CoV-2 (search)Search disease protection in a single injection, with additional pathogens potentially added over time. He also noted that an mRNA Lyme disease vaccine is under investigation and that many hope for better mRNA cancer vaccines.

Tan expressed excitement about next-generation vaccines and monoclonal antibodies, major advances in rapid diagnostics, and increased development of local, statewide, and nationwide surveillance and precision medicine programs. "All of these will provide increased protection for people of all ages against potentially serious infections," she said.

Both experts agreed that sustainable global respiratory surveillance systems are essential. Middleton emphasized the importance of local education about detection and reporting, including home tests for influenza (search)Search disease and SARS-CoV-2 (search)Search disease, and the critical role of the WHOView company profile in providing warnings and control measures. On the role of artificial intelligence in outbreak prediction, he offered a note of caution: "AI may help to truncate outbreaks, but patients and clinicians first need to explore AI recommendations and second need to have reassurance against errors in advice. AI must also be informed: false anti-vaccine information must not be repeated."

The path forward, as articulated by both clinicians, demands a dual commitment: embracing the next generation of vaccine and diagnostic technologies while rebuilding the foundational trust between the public, healthcare practitioners, and the science of immunization.