This fall, several vaccines and therapeutics will be available to prevent illness caused by influenza, SARS-CoV-2 and respiratory syncytial virus. How should these vaccines be classified, treated and received — and on what time scale? Are there advantages to receiving vaccines simultaneously, or is it better to space vaccines out over time? Here’s what to consider.
What’s available
Influenza and COVID-19 vaccines will be available for all individuals 6 months of age and older. RSV vaccines will be available for individuals 60 years of age and older, as well as pregnant individuals at 32-36 weeks’ gestation. Finally, nirsevimab is recommended by CDC’s Advisory Committee on Immunization Practices for all infants 8 months of age or less who are about to enter their first RSV season. Nirsevimab is also recommended for infants and young children 8 to 19 months of age who are at increased risk of severe RSV disease and who are entering their second RSV season.
Special considerations/classifications for nirsevimab
Unlike the other influenza, COVID-19 and RSV vaccines available during this fall/winter season, nirsevimab is a monoclonal antibody, classified as a drug by FDA. It is “vaccine-like” in that it is an “immunization” recommended by CDC’s ACIP and covered under the Vaccines for Children program. However, it is “drug-like” in that potential adverse events occurring after nirsevimab administration should be reported to FDA (through MedWatch or the FDA Adverse Event Reporting System), not the Vaccine Adverse Event Reporting System. (If children receive any non-nirsevimab vaccine simultaneously with nirsevimab, any potential subsequent adverse events should be reported both to MedWatch/FAERS and VAERS.) CDC’s Immunization Safety Office and FDA’s Center for Drug Evaluation and Research are working together to ensure continuous and robust safety monitoring of nirsevimab.
When it may be best to administer vaccines simultaneously
Simultaneous administration of these vaccines is likely the best option for most patients. CDC guidance states that influenza, COVID-19 and RSV vaccines can all be given at the same time to eligible individuals. For infants between 6 and 8 months of age, CDC recommends simultaneous administration of nirsevimab and COVID-19 vaccine.
Simultaneous administration ensures that individuals who may have difficulty accessing care or may experience several barriers in coming to the clinic are fully protected. Conversely, scheduling multiple vaccination visits is consistently associated with missed visits and/or attrition.
Patients receiving multiple vaccines during the same clinic visit may be more likely to experience reactogenicity associated with vaccines, such as fever, headache and pain or swelling at the injection site(s). However, simultaneous administration of vaccines does not negatively affect the immunogenicity or effectiveness of those vaccines.
Managing pain and discomfort
To minimize pain and discomfort associated with multiple vaccines given simultaneously, providers should, where possible, administer vaccines in different arms or at different injection sites. If patients request the same arm or same vaccine site for multiple vaccines, or if it is not feasible to deliver vaccines in different limbs, it is helpful to separate injection sites by 1 inch or more where possible, to reduce the potential for swelling and pain at injection sites.
For patients concerned about pain or who have anxiety relating to needles, providers may consider the use of topical anesthetics. These can reduce pain associated with a needle penetrating skin and can reduce underlying muscle spasms, especially in the case of multiple injections. However, prophylactic use of antipyretics (acetaminophen or ibuprofen) before or at the time of vaccination is not recommended; there is no evidence that these serve to relieve pain, and their use could result in an unwanted suppression of the immune system response to vaccination.
For infants or young children, several strategies exist to minimize discomfort during vaccination. These strategies are important to consider especially when administering multiple vaccines. Strategies include:
Inject the vaccine that is thought to be the most painful last; when multiple injections are being administered, this can reduce the pain associated with the injections.
For children 2 years or younger, being breastfed or bottle-fed before, during and after vaccination is thought to decrease pain by multiple mechanisms, including feeling skin-to-skin contact and providing a distraction.
Children 2 years or younger who are not breastfed during vaccination may benefit from a sweet-tasting solution (such as sucrose or glucose) given shortly (1-2 minutes) before the injection. This measure is believed to have an analgesic effect lasting approximately 10 minutes. (Parents should be counseled that this measure is for the purpose of reducing pain associated with vaccination and should not be used regularly at home.)
Scenarios where spacing between vaccines could be considered
Because administering multiple vaccines at the same visit may result in an increased likelihood of reactogenic events, providers may consider spacing vaccines out for individuals who are concerned about pain, swelling or other similar events. Providers may also want to consider this option for individuals with a history of reactogenic events after vaccination, such as severe swelling or induration. Additionally, individuals who are immunocompromised may wish to consider spacing vaccines out to maximize vaccine-mediated protection and prevent intra-season waning of vaccine effectiveness.
In such cases, it may be feasible to space out vaccines if the patient has another scheduled visit or visits with the provider in the near future; however, it will be important to confirm the future scheduled visit is not so late during the winter respiratory virus season so as to leave the patient unprotected during a time when there is community circulation of respiratory virus. Providers should keep in mind that the timing of seasonal respiratory virus epidemics is difficult to predict and can vary substantially by geography. If vaccines are planned to be administered at separate visits, it will be important to schedule those visits before the start of the respiratory virus season.
Specific timing considerations for influenza vaccines
For older adults and people who are in the first or second trimester of pregnancy, influenza vaccine would be ideally received in September or October. However, if this schedule is not feasible, it is possible to receive influenza vaccination as early as July or August. Individuals in their third trimester of pregnancy in July or August can receive influenza vaccine during that time to maximally protect their infant; transfer of vaccine-mediated antibody across the placenta is maximized in the third trimester of pregnancy.
Specific considerations for RSV vaccines for older adults
RSV vaccines for older adults are covered under Medicare Part D, whereas influenza and COVID-19 vaccines are covered under Medicare Part B. Depending on the clinic environment and insurance status of the patient, the patient may be required to go to a different location (e.g., a pharmacy) to receive RSV vaccination under Medicare Part D. This could result in RSV vaccination occurring on a different day than influenza and COVID-19 vaccination even when same-day administration of multiple vaccines is intended or planned.
Summary
For most patients, it will be the most convenient to receive all eligible vaccines during the same clinic visit. The effectiveness of vaccines is not affected with simultaneous administration. For those patients, separate vaccines should be given in different arms (where possible), and other strategies to reduce pain or discomfort should be considered, including topical anesthetics or, for infants, breastfeeding during vaccination.
Some patients may want to discuss the possibility of scheduling vaccines at different times with their provider, depending on their immunocompromised status or history of reactogenic events after vaccination. For patients who may benefit from this approach, it is important to ensure the patient has the support needed to return to the clinic or pharmacy for all vaccines scheduled.