The Evolving Landscape of Influenza Immunizations - Episode 9

Navigating Concerns Around Influenza Vaccination and Adverse Events

Vaccination discussion continues with a focus on navigating patient concerns and potential adverse effects to vaccine administration.


Mitchel Rothholz, RPh, MBA: In terms of vaccination and concomitant administration of the flu vaccine with the COVID-19 and other vaccines, are there any concerns from a practitioner perspective? Do you have any guidance to give pharmacists about addressing the concomitant administration concerns that a patient may have?

Jeff Goad, PharmD, MPH: I don’t know if any confusion is still out there, but when COVID-19 vaccines first came out, it was recommended to not give them with other vaccines. Sometimes I still hear a little of that filtering around. Try to put COVID-19 and flu and the other vaccines back in the context of general recommendations. For adults, there are no contraindications to simultaneous administration.

Sometimes, if I’m giving patients 5 or 6 vaccines at a time for travel, they’ll say, “Why don’t I come in tomorrow or the next day and space it out?” I say, “Do you want your arm to hurt for a week or for 2 days? Because either way, your arm is going to hurt for a couple of days.” Let them know that that’s the most common adverse event from the vaccine. Certainly, there are other adverse events that you need to counsel them on, but that’s the one they home in on. Coax them to understand that your arms are going to hurt for a couple of days but then you’re going to be protected against both diseases.

Mitchel Rothholz, RPh, MBA: As far as administering multiple vaccines, what are your recommendations for locations and making notations?

Jeff Goad, PharmD, MPH: There’s still a soft recommendation to do them in different arms when you’re giving COVID-19 vaccines, but technically, general recommendations could override that and say that you could give 2 intramuscular vaccines in the deltoids. There’s nothing to prohibit that. It’s more of a soft recommendation to space it into the 2 arms. There isn’t a lot of science behind it.

Mitchel Rothholz, RPh, MBA: If you do it in the same arm, remember to do it an inch apart, right?

Jeff Goad, PharmD, MPH: Yes, absolutely.

John Beckner, RPh: Jeff, how far away are we from a combination COVID-19 and flu vaccine?

Jeff Goad, PharmD, MPH: If you could get COVID-19 to stop mutating, we might get one. If you look at some of the FDA hearings and the CDC [Centers for Disease Control and Prevention] talking about it, as soon as they’re formulating the BA.2.12.1, here comes BA.4 or BA.5. BA.4 is out, and BA.5 is in. Then here comes the new subvariant of BA.2. I don’t know that we can get to a combination vaccine in the near term. Maybe we could get to something like that once it stabilizes and isn’t mutating as often, more like a flu vaccine, but I’m not optimistic in the short term.

Mitchel Rothholz, RPh, MBA: It’s being worked on. But as Jeff said, it’s fluid.

Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: We’re going to be highly recommending getting both vaccines at the same visit if they’re getting a COVID-19 vaccine and the flu vaccine. It’s a discussion with the patient and finding out what they feel comfortable with. You’re right: they’re going to have a sore arm regardless if we wait, and it could be a longer period of time because you’re just extending it. We tell patients that you’re going to have a sore arm no matter what. Especially when we looked at COVID-19 [vaccines], some people had some significant sore arms for a longer period of time.

Anecdotally, we’d say to patients, “One of these vaccines may hurt your arm more than the other vaccine. Which preference do you have for which arm?” Let them know that. I still have patients who say, “I’d rather have just 1 sore arm that’s going to be really sore.” Have that conversation with the patient. But the most important conversation is about getting both vaccines at that same visit.

Mitchel Rothholz, RPh, MBA: There’s another COVID-19 booster available this fall. Some patients were saying, “I’ll wait until that vaccine is out, and I’ll get them both at that time.” How do you recommend pharmacists answer that question if that pops up?

Jeff Goad, PharmD, MPH: It was a legitimate question [because we didn’t know] when the next vaccine was coming out. It’s like a series vaccine. When we talk about hepatitis B, you’d say, “You don’t have to restart the vaccine for a lapsed interval.” Let’s say you didn’t complete your third dose and you waited 5 years to get your third dose. We skip the third dose. But between dose No. 2 and No. 3, you were at risk for disease. You could have gotten hepatitis B because you didn’t have full protection. It’s the same argument. We protect against what we can protect now. If you have the booster dose, you’re still eligible to get the second booster dose or maybe your third booster dose, depending on your schedule so far, in the fall or early winter. People should get the vaccines available now.

John Beckner, RPh: Somebody asked me that same question the other day, and that’s what I told them. I feel much better now.

Mitchel Rothholz, RPh, MBA: The standard answer is that you should get what’s available to you. Jeff, to reiterate the point you made: you want to be protected now and not expose yourself.

Transcript edited for clarity.