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A summary of presentations from the weekly Summit partner webinars

September 2, 2021 – The latest Summit summary

INFLUENZA VACCINATION AND CO-ADMINISTRATION WITH OTHER VACCINES – ANDREW KROGER (CDC)

Andrew Kroger, MD MPH, Medical Officer, Communication and Education Branch, Immunization Services Division, Centers for Disease Control and Prevention, gave a presentation on the updates to the ACIP influenza vaccine statement, and the co-administration of COVID-19 vaccines with other vaccines, including influenza vaccines.

Revisions to the ACIP Influenza Vaccine Recommendations 2021–2022

There are four primary revisions to the ACIP influenza vaccine recommendations for this season, aside from the COVID-19 vaccine co-administration recommendations. The revisions include:

Changes to the strains in the vaccine for the 2021–22 season
Changes to the vaccine formulation
Changes to the timing of vaccine administration
Changes to the contraindications and precautions to the vaccines

2021–2022 Strains

All Influenza vaccines are quadrivalent this year, and each has two type A strains and two type B strains. Type A circulates as two subtypes: H3N2 and H1N1. There are also 2 lineages of type B influenza: the Victoria lineage and Yamagata lineage. The two subtypes don’t change very much on a regular basis, however, specific strains within the subtypes and in the lineages go through a process of drift mutation. Because of this, the World Health Organization (WHO), in partnership with other agencies, look at the surveillance data from the previous year to determine the specific strains for the upcoming year.

This year’s flu vaccines include the following strains:

Egg-based Vaccine

A/Cambodia/e0826360/2020 (H3N2-like)
A/Victoria/2570/2019 (H1N1-like)
B/Washington/2/2019 (Victoria)
B/Phuket/3073/2013 (Yamagata)

Cell-culture and Recombinant Vaccine

A/Cambodia/e0826360/2020 (H3N2-like)
A/Wisconsin/588/2019 (H1N1-like)
B/Washington/2/2019 (Victoria)
B/Phuket/3073/2013 (Yamagata)

This year changes were made to the H3N2 and H1N1 strains. The H3N2 strain is the Cambodia strain, and for the cell-culture and recombinant vaccines, the H1N1 strain carries the Wisconsin name. The H1N1 strain name differs in the egg-based vaccines, which is based on the way the vaccines were manufactured and not related to the seasonal drift.

The Victoria and Yamagata lineages are the same as last year and the same in the egg-based vaccine, cell-culture vaccine, and recombinant vaccine.

Formulation Updates

This year the FDA broadened the age group indication for Flucelvax (ccIIV4), the cell-culture quadrivalent inactivated vaccine. Previously the vaccine was approved for people age four and older. Now the vaccine is approved for people age two and older.

Timing of Influenza Vaccination

The vaccine can become available as early as July every year, however, it’s not available at every location that offers the flu vaccine. The optimal timing is for everyone to be vaccinated by the end of October, as has been recommended in previous years.

The changes to the timing of influenza vacation this year includes the recommendation of the people who should be vaccinated earlier than others:

Children age 2–8 years who require two doses of the vaccine should get their first dose as early as possible. This is so that children can be fully vaccinated (receive 2 doses at least 28 days apart) prior to the end of October.
Individuals in their third trimester of pregnancy. This is because the baby has a reduced risk of influenza up to 6 months after birth if the mother is vaccinated while pregnant.

Healthcare workers should continue to vaccinate throughout the influenza season, which typically lasts until April.

Contraindications/Precautions to Influenza Vaccine

A contraindication is a condition that increases the risk of an adverse reaction, such as a severe allergic reaction (anaphylaxis) and the vaccine should be withheld.

A precaution is based on a milder safety concern, a concern with vaccine effectiveness, or a concern with diagnosis of a new-onset medical condition. In the case of a precaution, the provider must make the clinical decision whether to give the vaccine based on the risk-benefit of giving the vaccine vs. the disease, i.e., they should consider the risk versus benefit of vaccination.

Often, one flu vaccine can be substituted with another flu vaccine that poses a lower risk.

Contraindications to Egg-based Inactivated Influenza Vaccines

There’s one common contraindication to all egg-based vaccines, and that is the history of a severe allergic reaction (anaphylaxis) to any component of the vaccine (any valency) or to a previous dose of any influenza vaccine (IIV, ccIIV, RIV, LAIV) (any valency).

Contraindications to Cell-culture Influenza Vaccine

The contraindication to cell-culture vaccine is a history of severe allergic reaction (anaphylaxis) to a previous dose of any cell-culture vaccine (any valency) or any component of the cell-culture vaccine (any valency).

Contraindications to Recombinant Influenza Vaccine

The contraindication to the recombinant vaccine is a history of severe allergic reaction (anaphylaxis) to a previous dose of any recombinant influenza vaccine (any valency) or any component of recombinant influenza vaccine (any valency).

Contraindications to Live-attenuated Influenza Vaccines

Contraindications to live-attenuated influenza vaccines include:

A history of severe allergic reactions (anaphylaxis) to any component of the vaccine (any valency) or to a previous dose of any influenza vaccine (any valency)
Associated aspirin or salicylate-containing therapy in children and adolescents
Being a child age 2-4 years with a diagnosis of asthma, or whose parents or caregivers report that a health care provider has told them during the preceding 12 months that their child had wheezing or asthma, or whose medical record indicates a wheezing episode has occurred during the preceding 12 months.
Altered immunocompetence
Anatomic and functional asplenia (e.g., sickle cell disease)
Close contacts and caregivers of persons requiring care in a protected environment
Pregnancy
CSF leak
Receipt of influenza antiviral medications within the previous 48 hours (oseltamivir/zanamivir), 5 days (peramivir), or 17 days (baloxavir) before the vaccine

Precautions to Egg-based Inactivated Influenza Vaccines

Precautions to egg-based flu vaccines include moderate or acute illness without a fever (this is a precaution to every recommended vaccine), and a history of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine (a precaution for all influenza vaccines).

Precautions to Cell-culture Influenza Vaccines

Precautions to cell-culture influenza vaccines include moderate or acute illness without a fever and a history of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine. A new precaution added for this year includes a history of severe allergic reaction to a previous dose of any other influenza vaccine (IIV, RIV, or LAIV) (any valency).

Precautions to Recombinant Influenza Vaccines

Precautions to recombinant influenza vaccines include moderate or acute illness without a fever and a history of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine. A new precaution added for this year includes a history of severe allergic reaction to a previous dose of any other influenza vaccine (IIV, ccIIV, or LAIV) (any valency).

Precautions to Live-attenuated Influenza Vaccines

Precautions to live-attenuated flu vaccine (LAIV) include moderate or acute illness without a fever and a history of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine. Unique (not new) precautions to live-attenuated vaccine include asthma in people age five years and older, and those with other underlying medical conditions that might predispose to complications after wild-type influenza infection (e.g. chronic pulmonary, cardiovascular except isolated hypertension, renal, hepatic, neurologic, hematologic, or metabolic disorders including diabetes mellitus).

In nearly every circumstance, healthcare professionals are able to give any other flu vaccine to people with one of these precautions to LAIV, so there’s no need to delay vaccination.

Influenza Co-administration

Standards for Adult Immunization Practices

Healthcare providers need to follow the Standards for Adult Immunization Practice , and General Best practice Guidelines for Immunization to identify which vaccines are needed. There are four steps that should be followed at every encounter with a patient: assess immunization status of the patient, recommend the vaccine, administer the vaccine, and document the vaccine.

Timing and Spacing of Vaccine Doses

The general rule is that two different vaccines may be given simultaneously, which means at the same visit on the same day. However, some exceptions exist for certain vaccines and risk groups. The vaccines PCV13 and Menactra should not be co-administered to those with asplenia and HIV infection. Menactra and DTaP should not be co-administered to those with asplenia, HIV infection, or complement component deficiency. Most injectable live vaccine pairs, including LAIV, should be separated by 28 days. If giving the yellow fever vaccine with another live vaccine, it needs to be separated by 30 days.

The flu vaccine can be given simultaneously with other vaccines, if needed. Some providers feel uncomfortable giving an adjuvanted vaccine like Shingrix with Fluad, and if that’s the case, any other flu vaccine appropriate for the person’s age and medical conditions can be administered.

Best Practices for Multiple Injections

When giving more than one vaccine in a visit, always label the syringe and separate the injection sites by one inch or more, if possible. When administering the COVID-19 vaccine simultaneously with other vaccines if the two vaccines are likely to cause local reactions, give in different limbs, if possible.

Visit the Resource Library for more.

Vaccines Most Likely to Cause a Local Reaction

Adjuvanted vaccines are more likely to cause a local reaction. The vaccines more likely to cause localized reactions include: HepB, DTaP, Tdap, Td, aIIV (Fluad), HPV, Zoster (RZV), MenB, Pentacel, Pediarix, Quadracel, Kinrix, Twinrix, and Vaxelis. In addition, high-dose influenza vaccine and the tetanus-toxoid containing vaccines can be more reactogenic.

If the vaccines are unable to be spaced out to two different limbs, healthcare personnel should not miss an opportunity to vaccinate; the two vaccines should be spaced at least an inch apart if given in the same limb.

Communication with Patients

These guidelines are not specific to COVID-19 vaccines only, but they do help make a strong vaccine recommendation. For more on making vaccine recommendations and how to communicate with patients, CDC has the following resources:

QUESTIONS

Question

Seniors have been saying they are worried about waiting until late September/early October to be vaccinated because they are worried that the high dose vaccine supply will be gone. What are your thoughts on the timing for seniors and whether supply might be constricted?

Andrew Kroger

The recommendation has traditionally been to get the flu vaccine by the end of October. If concerned about waning vaccine immunity, then they should not get the vaccine in July or August. If they do, the protection might not carry though February or March when the season typically peaks. The data and supply constraints are challenging.

LJ Tan: The manufacturer responded during the webinar that they are not anticipating supply constraints on the high dose vaccine for this upcoming season.

Question

Can we get vaccines slightly later due to waning antibodies? Is September too early?

Andrew Kroger

We don’t know when influenza activity is going to peak, so just be sure that you are vaccinated. It’s hard to rationalize waiting on the basis of what happens in the spring. It’s hard to tell if breakthrough sickness is due to waning or due to the drift of the virus later in the season, which we can’t do anything about, anyway. If you are a healthcare worker, get it earlier [September] to protect yourself and your patients.

Question

Given recent announcements on the COVID-19 booster effort and concerns of the potential for a difficult influenza season, what is the CDC doing this season to communicate the importance of being vaccinated for both and the guidance around simultaneous vaccination for both?

Andrew Kroger

Today we don’t have a particular booster recommendation for those that are not immunocompromised. We do have recommendations that cover co-administration and also recommendations for COVID-19 disease. It’s impossible to say what will happen with respect to the boosters. All of these things will be discussed at a future ACIP meeting.

Question

How soon after recovering from COVID-19 can you receive the influenza vaccine?

Andrew Kroger

If you have COVID-19 you need to finish the isolation period before you can be vaccinated, as to not infect others. We are not concerned about the impact of COVID-19 on getting the vaccine; that is not a contraindication to getting the vaccine. It’s also not a contraindication to getting the flu vaccine. We consider it a precaution.

Question

The federal Vaccine Finder tool on Vaccines.gov is currently COVID-19 vaccine specific, and I saw a newsletter sent by CDC a few days ago that mentioned flu vaccine will be added back to the site by an expected date of the 24th of this month. Do we know if the Flu Vaccine Finder search tool widget for webpages will be functional at that time as well?

Andrew Kroger

This is something I will have to follow up on at a later date.

Question

A mild fever of 101°F (38°C) or so is not an uncommon side effect of the flu shot. In this era of COVId-19, how should providers handle a mild fever should a patient present with fever after vaccination?

Andrew Kroger

A lot revolves around when the fever is recognized. If the fever is happening at the time of the vaccination visit, and it’s assumed to be suspected COVID-19, then we aren’t sure. We have to look at how the patient is feeling and whether or not they are acutely ill. The provider can decide the best action for their patient. Today there have been not changes in the ACIP recommendations. It’s up to the provider’s discretion.

ANNOUNCEMENTS

L.J Tan (IAC)

The Immunization Action Coalition (IAC), with funding support from Seqirus, is offering a limited quantity of FREE Flu Vaccine buttons and stickers in English and Spanish to support your flu vaccine promotion efforts this season. To receive these supplies at no cost, please PRE-ORDER your buttons and stickers now. Delivery (also at no cost) is anticipated by early October.

Order the flu buttons and stickers.

The Immunization Action Coalition (IAC) will be holding two interactive webinars in September to emphasize vigilance in preventing influenza in the midst of the COVID-19 pandemic:

IAC will host a webinar titled The Continued Threat of Influenza and How to Sustain Influenza Vaccination Efforts on September 9 at 1:00 p.m. (ET). Topics will include:

Influenza surveillance in U.S. and worldwide
Changes in circulation of other common respiratory pathogens, e.g., RSV
Changes in influenza vaccine strains and changes in influenza ACIP recommendations
Communication issues providers may face regarding perceptions of the need for influenza vaccination
A public perspective on the importance of influenza vaccination and advocacy for vulnerable populations (chronic issues)

These topics will be addressed by speakers:

Alicia Budd, MPH, Influenza Division of CDC’s National Center for Immunization and Respiratory Diseases (NCIRD)
Robert H. Hopkins Jr., MD, University of Arkansas for Medical Sciences
Gary Stein, MBA, Families Fighting Flu

IAC will host the second of two webinars titled Translating COVID-19 Strategies to Improve Influenza Seasonal Flu Vaccination Efforts. This 1.5 hour interactive webinar will take place on September 20 at 1:00 p.m. (ET).

The topics will include:

Information to improve influenza immunization for underserved populations and improving vaccine equity
Strategies to reach small communities from a public health perspective
Making a strong recommendation for influenza vaccination this season
Pharmacists and pharmacies lessons learned for improving vaccine access and vaccine equity for vulnerable populations

These topics will be addressed by speakers:

Laura Lee Hall, PhD, President, Center for Sustainable Health Care Quality and Equity, National Minority Quality Forum (NMQF)
Amy Callis, BA, MPH, Principal and Owner, Devi Partners
Sarah Price, Director of Public Health Integration, National Association of Community Health Centers (NACHC) and Jennie McLaurin, MD, Specialist, Child & Migrant Health, Bioethics, Migrant Clinicians Network
Mitchel Rothholz, R.Ph, MBA, Chief of Governance & State Affiliates and Executive Director, American Pharmacists Association (APhA)

Following these presentations there will be an opportunity for you to ask your questions. This live question and answer session will include additional experts from the Immunization Action Coalition joining the speakers to answer your questions.

Both webinars are supported by IAC and a vaccine education grant from Seqirus, Inc.

We would like to welcome having more NAIIS member organizations to add their support to the Call to Action on adult immunization. Access the call to action and click on the top righthand button to add your organization.