Flu shots and adult immunizations and COVID vaccines...oh my!

With the second flu season of the pandemic upon us, pharmacies are gearing up for another challenging winter. Although last year had an abnormally low number of influenza detections across Canada (69 cases, compared to the annual average of ~50,000),¹ experts predict a more significant flu season this year, due to the ease in restrictions and the reduction in natural immunity from the lack of exposure to influenza virus this past year. Although many pharmacy teams may now be well-versed at providing vaccines during the pandemic, we review some recent updates and considerations below that will be important in offering optimal protection for your patients this season, while keeping your pharmacy teams safe.

Influenza Vaccines

There are several types of influenza vaccines available in Canada this flu season. The High-Dose (HD) Quadrivalent vaccine (Fluzone® HD) is now publicly funded in each province, although distribution to pharmacy and program restrictions may vary between provinces.² Pharmacies in Ontario, for example, will have access to all three options for patients aged 65 and over: Fluzone® HD Quadrivalent, Fluad® Adjuvanted Trivalent, and Standard Dose Quadrivalent (multiple products).³

If only one type of vaccine indicated for the patient is available in your pharmacy, the overarching recommendation would be to not delay the flu shot and to give that available vaccine, as all products are safe and effective for their indicated ages.⁴ If given the option between the three types of vaccines for a patient who is 65+, however, the recommended course of action would be to prioritize the High-Dose quadrivalent vaccine (Fluzone® HD), followed by the adjuvanted trivalent vaccine (Fluad®), and if neither of those options are available, the standard dose quadrivalent vaccine.^3,4

Coadministration with COVID-19 & other vaccines

Since the start of COVID-19 vaccinations, limitations around co-administration with other vaccines have been a barrier to providing routine and recommended adult immunizations. Thankfully, NACI has updated their recommendations to allow COVID-19 vaccines to be co-administered with any other vaccines, including live, non-live, adjuvanted, and non-adjuvanted vaccines.⁵ Although most provinces follow NACI guidance, there may be some differences between jurisdictions; pharmacists in Alberta will find they are still recommended to wait 14 days between administration of COVID-19 vaccines and live vaccines (e.g., Flumist®, MMR, etc.).⁶

Another combination to look out for this season is the adjuvanted trivalent flu vaccine (Fluad®) and Shingrix®, another adjuvanted vaccine. As there is no data to support the safety and efficacy of using two adjuvanted vaccines together,⁴ it is recommended to avoid co-administering these vaccines. There is no evidence-based interval for optimal spacing, but a reasonable timeline would be to wait at least 1-2 weeks after receiving Fluad® before getting Shingrix®.

Beyond flu and COVID-19 vaccines, screening for other immunizations (pneumonia, meningitis B, shingles, HPV, Tdap) to provide outstanding vaccinations at the same time as the flu shot is recommended by NACI.⁴ Optimizing the vaccination encounter reduces patient trips to the pharmacy (limiting potential exposure to COVID-19) and consolidates workload to allow pharmacy teams to perform screening, consent, and prescriber communication for multiple vaccines at once. When administering multiple vaccines, use different limbs if possible, or separate injection sites by at least 1 inch.⁴

Appointment-Based Model

Similar physical distancing and infection prevention and control procedures as last year are recommended for this flu season.⁷ Offering immunization services on an appointment basis (as opposed to walk-in) can help facilitate distancing and allow pharmacies to maintain control of the workflow.⁷ If a walk-in model is still desired, consider dedicating specific hours for walk-ins, while continuing to offer booked appointments for vulnerable/high-risk patients and families (who may require a longer appointment times) during off-peak times to minimize their risk of potential COVID-19 exposure from other patients.⁷

Where possible, utilize technology to optimize workflow. When booking appointments, integrating screening and consent forms into booking systems, or making forms available online in advance for patients to complete can help reduce the time spent in the pharmacy.

Patient Buy-In

Even if it seems intuitive, it can be helpful to remind patients that flu and COVID-19 are caused by different viruses and the vaccine for one will not protect them against the other. A consideration that may be impactful for patients is the fact that influenza and COVID-19 can present very similarly. At the moment, public health considers the presentation of any of these symptoms as a potential case of COVID-19, necessitating COVID-19 testing and/or isolation. Therefore, it can be helpful to highlight that the flu vaccine can provide protection against the flu, reducing their chances of going through potentially unnecessary COVID-19 procedures. Another way to improve buy-in is to emphasize one's role in the protection of the community, as highlighting family and community duty can be a stronger motivator than solely identifying benefits to the individual.⁸

If you face hesitancy, using motivational interviewing techniques can help patients feel heard.⁹ It is important to ask permission to address the hesitancy/beliefs that the patient expresses, and to be confident while staying respectful and sensitive to cultural or moral values. Check out this helpful resource from the Immunize BC on addressing vaccine hesitancy for more information.⁹

Pharmacy teams have stepped up throughout the pandemic to vaccinate and maintain continuity of care for patients, an act that has not gone unnoticed. Our contributions to our communities have further established our reputation as one of the most accessible and trusted health care providers.¹⁰ If you would like more information on the 2021-2022 influenza program and additional strategies to optimize the vaccination appointment, check out Wholehealth’s “Flu + More!” webinar HERE.

1. Government of Canada (2021, August). Fluwatch report. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2020-2021/weeks-30-34-july-25-august-28-2021.html
2. Immunize Canada (2021, October). Publicly funded seasonal influenza vaccines 2021-2022. Influenza and Pneumococcal Immunization Awareness Campaign | immunizecanada
3. Public Health Ontario (2021, September). Influenza vaccines for the 2021-2022 influenza season. https://www.publichealthontario.ca/-/media/documents/f/2020/fact-sheet-influenza-vaccine-2020-2021.pdf?la=en
4. NACI (2021, May). Canadian immunization guide chapter on influenza 2021-2022. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/vaccines-immunization/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2021-2022/naci-2021-2022-statement.pdf
5. NACI (2021, September). Recommendations on the use of COVID-19 vaccines. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/recommendations-use-covid-19-vaccines/summary-updates-september-28-2021.html
6. Alberta College of Pharmacy. (2021) Seasonal influenza information. https://abpharmacy.ca/seasonal-influenza-information
7. Canadian Pharmacists Association. (2021, September) Suggested best practices for pharmacies. https://www.pharmacists.ca/advocacy/issues/influenza/influenza-2021-2022-suggested-best-practices-for-pharmacies/
8. Krueger, B. S., Hutchison, M. L., Bodo, E. C., Orr, K. K., DeAngelis, J., Caffrey, A. R., & LaPlante, K. L. (2020). Science-based communication to decrease disparities in adult pneumococcal vaccination rates. Journal of the American Pharmacists Association, 60(6), 861-867.
9. Immunize BC (2021) Immunization communication tool. ICT-2021.pdf (bccdc.ca)
10. Canadian Pharmacists Association (2021, September). What do Canadians think about their pharmacists anyway? Turns out, a lot. https://www.pharmacists.ca/news-events/news/what-do-canadians-think-about-their-pharmacists-anyway-turns-out-a-lot/