As the COVID-19 pandemic enters another winter, physicians and other health care experts are again concerned with a possible “twindemic.” The combination of the current surge in COVID-19 cases driven by the Delta variant has pushed the health care system to its breaking point. This means that patients who are seeking treatment for other ailments, including influenza, may not be able to find the care they need. That is why it is more important than ever for every patient who is eligible to be vaccinated both against the flu and COVID-19.

Read the latest on COVID-19 vaccines

Get reliable information on developments in the authorization, distribution and administration of COVID-19 vaccines.

These vaccines can be administered at the same visit, as recommended by the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunizations Practices (ACIP). The COVID-19 vaccines—including those made by Johnson & Johnson, Moderna and Pfizer-BioNTech—and flu vaccines have been shown to reduce illness, hospitalizations and deaths.

Here is what physicians need to know about coadministration of influenza and COVID-19 vaccines as discussed during a recent CDC Clinician Outreach and Communication Activity (COCA) webinar.

COVID-19 vaccines may be administered without regard to timing of other vaccines. This means COVID-19 vaccines can be co-administered with the influenza vaccine during the same visit. Giving all vaccines for which a person is eligible at the same visit is a best practice as it increases the probability people will be up to date on recommended vaccines.

But there are a few rare exceptions to the allowance of simultaneous vaccination. These instances generally involve children who have conditions such as asplenia, complement component deficiency or HIV infection. This is limited to PCV13 and Menactra vaccines, according to the CDC COCA webinar.

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Then there is nonsimultaneous vaccine administration, which is when a prior vaccine was given more than one full day ago. This is not a problem either.

However, there are some exceptions such as with non-live vaccines Menactra and DTaP—again they apply risk groups such as patients with asplenia, HIV infection or complement component deficiency.

Most injectable live vaccine pairs that are not given on the same day need to be separated by 28 days, which includes the live, attenuated influenza vaccine. For yellow fever and another live vaccine, administration should be separated by 30 days.

When administering the flu and COVID-19 vaccine together, they should be given in different sites on the arm separated by an inch or more if possible. If a local reaction does occur, the physician can identify which vaccine may have been responsible. But physicians should make sure to document the precise location in the patient’s chart for reference if they are unable to see the patient when they report the adverse reaction.

Additionally, if COVID-19 vaccines are administered at the same time as flu vaccines that might be more likely to cause a local reaction—such as adjuvanted or high-dose inactivated influenza vaccines—they should be administered in separate limbs if possible. The deltoid is the preferred site, but the anterolateral thigh may be used as an alternate site, according to the CDC COCA webinar. CDC has extensive guidance for health care providers on coadministration of vaccines.

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Flu vaccinations should be offered by the end of October. And for children who need two doses, they should receive their first dose as soon as possible after the vaccine is available because they can’t have the second dose until at least four weeks later. The timing of the onset and peak of influenza activity varies from season to season. Within a particular season, this can also vary geographically with localized pockets of activity in some portions of the country are seen before others in any given season.

Over 36 seasons between 1982 and 2018, peak flu activity varied widely. It happened in December and March in 19% of seasons, while it occurred in February in 42% of the seasons. Vaccination should continue throughout the season, as long as influenza viruses are circulating and unexpired vaccine is available.

The AMA has developed frequently-asked-questions documents on COVID-19 vaccination covering safety, allocation and distribution, administration and more. There are two FAQs, one designed to answer patients’ questions (PDF), and another to address physicians’ COVID-19 vaccine questions (PDF).

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