Q&A: Timing of flu vaccination in patients with COVID-19
Experts have expressed concern about a surge in COVID-19 cases during influenza season.
We asked Infectious Disease News Editorial Board Member Raghavendra Tirupathi, MD, FACP, medical director for Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine. about the clinical considerations in vaccinating patients with COVID-19 for influenza.
Q: If doctors are not sure when to offer the influenza vaccine to patients with COVID-19 and there is no real clear guidance, what action would you recommend they take?
A: This is unknown. However, it is anticipated that SARS-CoV-2 and influenza viruses will both be active in the United States during the upcoming 2020-2021 influenza season. On Aug. 21, MMWR published 2020-2021 guidance for influenza vaccination during the COVID-19 pandemic. Guidance regarding the optimal vaccine type to be used in hospitalized patients with COVID-19 is limited because of lack of data elaborating the same. Clinical experience with influenza vaccination of persons with COVID-19 is limited. The optimal timing of the influenza vaccination is also being debated in ID circles. Should it be administered on resolution of acute symptoms, on discontinuation of isolation, or should we wait until after the convalescence period of 3 weeks?
Q: What are the other considerations when vaccinating patients with COVID-19?
A: The other considerations would be the impact of the COVID-19 therapeutics on the vaccine immunogenicity and efficacy. Questions to be asked would be, “What is the optimal time duration between the receipt of antiviral medication, remdesivir and influenza vaccination?” We know from prior experience that high-dose steroids can blunt immune response to vaccines. What is the optimal time duration between administration of dexamethasone for COVID-19 and the influenza vaccine? Would convalescent plasma have any impact on the vaccine efficacy if given in close proximity? The other concern I would personally have is that any clinical deterioration that would happen in these fragile patients with COVID-19 after influenza vaccination may be blamed on the vaccine, even though it could all be due to underlying COVID-19 infection. It may be hard to distinguish COVID-19-related deterioration from a reaction to the influenza vaccine in some situations. This may contribute to bad press and further vaccine hesitancy.
Infection prevention considerations for administering a vaccine to patients with COVID-19 are a big issue as an outpatient but may not be as big a challenge for inpatients, given that they are already in isolation. Patients are being recommended to wait until the resolution of symptoms and discontinuation of isolation and quarantine as an outpatient. When scheduling or confirming appointments for vaccination, patients should be screened for COVID-19 symptoms and recent exposure.
Q: Are there data or is there a precedent to guide this decision?
A: We will need to look for precedent with patients with influenza infection. My quick PubMed search did not bring up studies looking at optimal timing of influenza vaccination for patients recovering from influenza. The usual clinical practice is to wait and defer vaccination until resolution of symptoms in sick patients.
Q: When do physicians offer the influenza vaccine to other hospitalized patients?
A: To avoid missed opportunities, current practice in most U.S. hospitals is to administer the influenza vaccine at the end of hospitalization with resolution of acute symptoms. This has been a safe practice for several years now. Hospitalized patients who received the influenza vaccine had no increased risk of outpatient visits or hospital readmission, fever or clinical evaluation for infection within 7 days of discharge, according to a Kaiser Permanente study published in Mayo Clinic Proceedings.
The study also found that 74% of those who miss the opportunity to vaccinate before or during hospitalization remained unvaccinated throughout the season. This study further consolidated the belief that giving patients the influenza vaccine while they are hospitalized is convenient and, most importantly, safe. However, with COVID-19, new questions about administering the vaccine in the hospital have been raised. We need to be mindful of missing the opportunity to vaccinate (as highlighted in this study) especially this year given the stakes are so high with risk of a “twindemic” of COVID-19 and influenza.
Q: Going forward, what research developments or clinical improvements should be made to ensure safe influenza vaccination for patients with COVID-19?
A: Research of the optimal timing of vaccination in hospitalized patients with COVID-19 similar to the above mentioned Mayo Clinic study needs to be pursued.