Although it’s safe and recommended to co-administer these shots, research finds a reduction in flu vaccine uptake the following year.
There are good reasons to co-administer the shingles and influenza vaccines: patients get protection from 2 viruses in a single trip, and pharmacists get a chance to increase vaccine uptake. However, co-administration has a possible pitfall that pharmacists need to be aware of.
The CDC strongly recommends adults aged 50 years and older get 2 doses of recombinant zoster vaccine (RZV) (Shingrix), in addition to immunocompromised adults aged 19 years and older.1 They note that this vaccine, which is more than 90% effective, is the only way to prevent shingles and accompanying postherpetic neuralgia.1
The Advisory Committee on Immunization Practices (ACIP) says co-administration is safe and recommended, and advises that both recombinant and adjuvanted shingles vaccines can be given with the flu shot, in different arms.2 “Concomitant administration of RZV with Fluarix Quadrivalent (influenza vaccine) (QIV) has been studied, and there was no evidence for interference in the immune response to either vaccine or safety concerns,” ACIP reports.2
There is a catch, revealed by a study by Benjamin M Rome, MD, MPH, of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital and of Harvard Medical School, in Boston, Massachusetts, and colleagues. The researchers reported that less than 50% of adults get the flu shot, and side effects play a major factor in patients avoiding vaccinations. Between August 1, 2018, and March 31, 2019, Rome and colleagues studied a cohort of 89,237 patients aged 50 years and older who either received the shingles and flu shot at the same time or separately for the 2018-2019 flu season. Women made up 58.3% of the group; 85.7% had at least 1 comorbidity; and 70.1% were white. They then tracked the number of flu vaccinations for the following flu season and found “uptake in 2019-2020 was lower among 27,161 individuals who received concurrent influenza and zoster vaccines compared with the 62,076 individuals who received the vaccines on separate days (87.3% vs 91.3%; adjusted odds ratio, 0.74; 95% CI, 0.71-0.78; P < .001). Results were similar across subgroups.”3
Brigid Groves PharmD, MS, senior director of practice and professional affairs at the American Pharmacists Association (APhA) in Washington, DC, spoke with Drug Topics® on the reduction of flu vaccination the year following the co-administration of shingles and flu shots. Pharmacists can prevent the drop-off in flu vaccine uptake the following year by counseling patients on expected side effects from each type of vaccine before administering shots, Groves said. “Flu vaccines reactions are typically localized to the injection site and consist of pain, redness, or swelling. Shingles vaccine reactions can be more systemic in nature, including fatigue, headache, or muscle aches,” she noted.
Groves advised clarifying these side effects with patients. “Explain that the shingles vaccine is known to have a greater likelihood of systemic reaction, which is less likely to happen with a flu shot. The patient may notice a greater reaction when getting both together. Emphasize that it is safe and recommended to get the flu and shingles vaccines together.” Groves added that if a patient prefers it, pharmacists may consider administering the flu and shingles vaccines on separate visits to accurately relate reaction, if any, to the specific vaccine.
“Consider giving the flu shot in the patient’s left arm (using L alliteration) and the shingles vaccine in the right arm to separate location and easily remember which side,” Groves advised. “Deliver a strong recommendation and endorsement for getting an annual flu shot,” she said.
1. What everyone should know about the shingles vaccine (Shingrix). Reference. CDC. Updated May 24, 2022. Accessed November 20, 2022. https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
2.Dooling KL, Guo A, Patel M, et al. Recommendations of the advisory committee on immunization practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67(3):103-108.doi:10.15585/mmwr.mm6703a5.
3. Rome BN, Feldman WB, Fischer MA, Desai RJ, Avorn J. Influenza vaccine uptake in the year after concurrent vs separate influenza and zoster immunization. JAMA Netw Open. 2021;4(11):e2135362. doi:10.1001/jamanetworkopen.2021.35362.