On The Cover
Loren Bonner
We averted the “twindemic” last year, but as hospitalizations from the COVID-19 Delta variant have increased, experts are feeling certain the country could be in for a difficult influenza cycle that could strain the health care system.
Although it’s impossible to predict any given influenza season, some health officials said flu cases this year could hit sooner and harder than last season.
COVID-19 prevention measures such as masking and social distancing have been loosened, which has left the public more vulnerable to influenza—especially since those same policies prevented people from building up natural immunity ahead of the coming cycle. Because so little of the influenza virus was in circulation last year, researchers also had less data to help determine which annual strains should be used in this season’s vaccines.
Officials hope a high rate of flu vaccinations will help alleviate any risk, and CDC is asking Americans to get a flu shot by the end of October. The agency also announced that both the COVID-19 and flu vaccines can be administered simultaneously, reversing earlier recommendations that they be given separately.
“If a patient is due for both vaccines, providers are encouraged to offer both vaccines at the same visit,” said CDC. “Coadministration of all recommended vaccines is important because it increases the probability that people will be fully vaccinated. It is also an important part of immunization practice if a health care provider is uncertain that a patient will return for additional doses of vaccine.”
Providers should administer vaccines in different arms, space vaccinations by at least 1 inch if injecting more than one vaccine in an arm, note which vaccine was administered in which location, and discuss potential post-vaccination symptoms and how to manage them with the patient.
Coadministering vaccines
Pharmacists can expect patients to come into the pharmacy for both their third dose of the COVID-19 vaccine as well as the flu vaccine.
In August 2021, CDC approved an additional dose of the mRNA Pfizer and Moderna COVID-19 vaccines for individuals who are moderately or severely immunocompromised. In September 2021, CDC recommended a single Pfizer COVID-19 vaccine booster dose for specific individuals (see sidebar) at least 6 months after completing their Pfizer–BioNTech primary series.
Both the COVID-19 and the flu vaccines are generally well-tolerated by the body, and giving 2 vaccines—or more—at the same time is not a new concept, according to Andrew Kroger, MD, MPH, a medical officer in CDC’s National Center for Immunization and Respiratory Diseases. The MMR vaccine that is given to children, for example, is a cocktail of 3 vaccines.
“The immune system definitely has the capacity to handle the multiple vaccines,” said Kroger during a CDC webinar on September 9, 2021.
“Coadministration may need to occur so individuals are caught up on vaccine doses they may have missed,” said Kroger. “Every clinical visit might be an opportunity to vaccinate.”
On August 19, 2020, the U.S. Department of Health and Human Services (HHS) authorized pharmacists to provide all Advisory Committee on Immunization Practices (ACIP)–recommended vaccines to children aged 3 to 18 years during the COVID-19 public health emergency, regardless of state laws and regulations.
CDC reported earlier this year that rates of childhood immunizations had sharply declined nationwide as a result of the pandemic.
Through this newly granted authority, which was part of the PREP Act, HHS understands that pharmacists can help increase access and administration of these vaccines at a time when individuals and communities need protection from vaccine-preventable diseases.
Kroger noted, however, that adults might be the ones who have missed doses since they don’t see a provider as often as children do.
“Attention has to be given to assessing the immunization status at every encounter,” he said. “We don’t want to miss an opportunity to vaccinate.”
According to Kroger, there are only a few exceptions where it is not permissible to administer vaccines to individuals simultaneously. This includes some rare conditions in children, HIV status, and certain vaccines (e.g., PCV13 and Menactra). Otherwise, providers should feel comfortable coadministering recommended vaccines; and they need to make a strong recommendation to vaccinate, said Kroger. Vaccination coverage rates can increase by as much as 50% with a provider recommendation.
Flu vaccination updates
This year, 9 flu vaccines are available, and pharmacists and other health care providers should know that the composition of the vaccines has been updated to protect against 4 different virus strains. As in years past, annual flu vaccination is recommended for everyone 6 months and older, with rare exceptions.
Other important updates include the recommended timing of flu vaccination for some groups, such as pregnant people in their third trimester (but can be given in any trimester), and children who need 2 doses (e.g., babies 6 months old). CDC has also updated guidance concerning contraindications and precautions for the use of Flucevax Quadrivalent and Flublok Quadrivalent.
“Similar to last year, [flu vaccines] should be offered throughout the season as long as flu is circulating,” said CAPT Lisa Grohskopf, MD, MPH, medical officer, CDC’s ACIP lead for influenza, during the September 9 CDC webinar.
She said providers should continue to check CDC’s website for updates.
According to CDC, best practices for administering more than one vaccine, including COVID-19 and influenza vaccines
When preparing more than 1 vaccine, label each with the name and dosage (amount) of vaccine, lot number, the initials of the preparer, and the exact beyond-use time, if applicable.
Always inject vaccines into different injection sites. Separate injection sites by 1 inch or more, if possible, so that any local reactions can be differentiated. Each muscle (deltoid, vastus lateralis) has multiple injection sites. Preference is that providers administer in different arms if giving 2 doses at the same time.
If administered at the same time, COVID-19 vaccines and vaccines that might be more likely to cause a local injection site reaction (for example, high-dose and adjuvanted inactivated influenza vaccines) should be administered in different limbs, if possible.
Inject vaccines rapidly without aspiration, since aspiration is not recommended before administering a vaccine.
Documenting every vaccine administered into the immunization registry is also critical.
CDC answered some important questions providers might have about flu vaccination this season
Will there be changes to how and where flu vaccines are given this fall and winter?
You can get your flu vaccine as you normally do, whether that’s through your local pharmacist or other health care provider. CDC has been working with health care providers and state and local health departments on how to vaccinate people against flu without increasing their risk of exposure to respiratory viruses, like the virus that causes COVID-19, and has released Interim Guidance for Immunization Services During the COVID-19 Pandemic.
Should a flu vaccine be given to someone with suspected or confirmed COVID-19?
No. Flu vaccination should be deferred for people with suspected or confirmed COVID-19, whether or not they have symptoms, until they have met the criteria to discontinue their isolation.
While mild illness is not a contraindication to flu vaccination, vaccination visits should be postponed to avoid exposing health care personnel and other patients to the virus that causes COVID-19.
When scheduling or confirming appointments for flu vaccination, patients should be instructed to notify the health care professional’s office or clinic in advance if they currently have or develop any symptoms of COVID-19.
When can someone who recovered from COVID-19 receive a flu vaccine?
Flu vaccination should be deferred until a patient is no longer acutely ill. This may be different for patients who are already being cared for in a medical setting than it is for patients who are isolating at home. In a medical setting, the timing for vaccination is a matter of clinical discretion.
In general, patients who are isolating at home should wait until they meet criteria for leaving isolation (even if they have no symptoms) to come to a vaccination setting in order to avoid spreading COVID-19 to others.
Is there guidance for safely administering vaccines during the COVID-19 pandemic?
CDC released Interim Guidance for Immunization Services During the COVID-19 Pandemic. This guidance is intended to help vaccination providers in a variety of clinical and alternative settings with the safe administration of vaccines during the COVID-19 pandemic.
This guidance will be continually reassessed and updated based on the evolving epidemiology of COVID-19 in the United States. Health care professionals who give vaccines should also consult guidance from state, local, tribal, and territorial health officials.
What steps can health care personnel take to safely give flu vaccine during the COVID-19 pandemic?
Applying infection prevention practices to all patient encounters is very important, including physical distancing (at least 6 feet) when possible, wearing masks, hand hygiene, surface decontamination, and source control while in a health care facility.
The potential for asymptomatic spread of the virus that causes COVID-19 underscores the importance of these practices. Immunization providers should refer to the guidance developed to prevent the spread of COVID-19 in health care settings, including outpatient and ambulatory care settings.
Is there guidance for giving flu vaccine in settings other than a doctor’s office (e.g., pharmacies, temporary, off-site, or satellite clinics, and large-scale influenza clinics)?
Yes. Guidance has been developed for giving vaccines at pharmacies, temporary, off-site, or satellite clinics, and large-scale influenza clinics. Other approaches for vaccination during the COVID-19 pandemic may include drive-through immunization services at fixed sites, curbside clinics, mobile outreach units, and home visits.
The general principles outlined for health care facilities should also be applied to alternative vaccination sites, with additional precautions for physical distancing that are particularly relevant for large-scale clinics in communities with high levels of COVID-19 transmission. Read more in the Interim Guidance for Immunization Services During the COVID-19 Pandemic.
What is CDC’s recommendation regarding drive-through influenza vaccination clinics?
Curbside and drive-through vaccination clinics may provide a good option for staff and patient safety during the COVID-19 pandemic in communities
with high transmission. Read CDC’s guidance on drive-through vaccination clinics.
Burnout a big concern for pharmacists this flu season, especially in retail settings
Chris Phung, RPh, who manages 12 independent pharmacies for Adams Drugs in the Montgomery, AL, area said he expects a 10% increase in the number of flu shots they will give this year compared to last.
Early this year when COVID-19 vaccines began rolling out, Phung anticipated the demand for COVID-19 shots and set up after-hours clinics where pharmacy employees working in those clinics were paid overtime. The arrangement allowed pharmacy staff to continue their work uninterrupted during normal work hours.
“With the anticipation of the COVID-19 booster shots, if it gets to the point where it’s chaotic, we might consider after-hours clinics and pay employees more,” said Phung.
But they can be nimble in an independent pharmacy setting, according to Phung, which is a relief.
“If something is not working, we can go to plan B and can make those decisions without having to go through so many hoops,” he said.
Workload increases
The case in retail pharmacy settings appears to be different right now. Jason Opritza, RPh, a former pharmacy manager at a chain pharmacy in Ohio, said retail pharmacies do not have adequate staff to handle all the extra work that COVID-19 has demanded. He said that in all his 25 years in retail pharmacy they were always short-staffed, but this worsened over the last decade. As the work brought on by COVID-19 increased, their labor could not keep up, and in many cases, was further reduced.
“It was COVID shots, COVID testing, and anything other than prescriptions was our focus,” said Opritza, who was recently named to the Ohio Board of Pharmacy workload taskforce. His store was constantly behind on prescriptions without adequate staff to help them catch up, let alone get through a normal workday.
He said it’s as if the metrics being used in the retail pharmacy setting are not based on reality. “As our workload increased, and staff budget decreased before COVID—even with advanced knowledge that COVID shots and tests were coming—no chain retail outlet added staff,” said Opritza. He and others believe burnout among pharmacists and staff is a patient safety issue right now.
“There is no way we can do this work with the staff we have and then give flu shots on top of it,” he said. “It’s only gotten worse because we have COVID-19 walk-ins, which pulls us away [from other work].”
With an unbearable workload and upper management only demanding more, many pharmacists like Opritza have left the retail pharmacy setting. Big chains are now in a desperate situation to find more help as flu season approaches, with some even offering special bonuses to pharmacists and pharmacy technicians who are certified to administer flu and COVID-19 vaccinations.
Pharmacy techs, students can relieve pressure
When the frenzy subsided after the COVID-19 vaccine push earlier this year, Phung said they shifted vaccinations back into their daily workflow and saw patients via appointment.
Adams Drugs also partners with schools of pharmacy. Phung said it is helpful to have student pharmacists help with immunizations, especially during busy times.
“Students will come at the end of September,” said Phung. “Because we know we will have extra help during that time, we will send out automated calls letting patients know they can come in and get their flu shot during that time.”
In the PREP Act, HHS also expanded COVID-19 vaccination authority not only to pharmacists, but also to pharmacy technicians, student pharmacists and interns, and retired or inactive pharmacists and interns across the country.
Phung said, in general, their pharmacy technicians will only vaccinate in a mass clinic or off-site clinic setting.
Sara Dreyer, who works as a certified pharmacy technician (CPhT) at Towncrest Pharmacy in Iowa City, thinks her pharmacy will schedule more clinics this flu season instead of having walk-ins come through the pharmacy all day long.
In July 2021, pharmacy technicians in Iowa were granted authority to administer all vaccinations.
“That was a big relief,” said Dreyer. “Maybe the pharmacists were most relieved. It’s just rewarding to relieve stress [of] other people. Even though giving a vaccination doesn’t take long, being pulled away is hard. I think it’s easier for a technician to pause what they are doing versus a pharmacist.”
Pfizer COVID-19 vaccine booster criteria
CDC estimates that pharmacies are administering about 70% of COVID-19 vaccinations at this time. President Biden has said that booster injections are available at more than 40,000 pharmacy locations nationwide.
Eligible individuals for the Pfizer COVID-19 vaccine booster, which is now recommended for specific individuals at least 6 months after completing their Pfizer primary series, include:
- People 65 years and older
- Long-term care facility residents
- People aged 50 to 64 years of age with underlying medical conditions
The following individuals may receive a booster dose:
- People aged 18 to 49 years with underlying medical conditions based on their individual benefits and risk
- People aged 18 to 64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting, based on their individual benefits and risks. This includes health care workers, teachers, and other essential workers.
At press time, this recommendation only applies to the Pfizer COVID-19 vaccine. The booster dose should be administered as a 0.3 mL intramuscular injection, which is the same as the first and second doses. Pharmacists should continue to check CDC’s webpage, specifically the Interim Clinical Considerations for the Use of COVID-19 Vaccines, for updates. Approval of Moderna and Johnson & Johnson additional doses are pending.