As we enter the third flu season of the COVID-19 pandemic, getting needles into arms is becoming more challenging than ever. The situation is exacerbated by enduring vaccine hesitancy amongst some and a possible flu surge. Clinicians will likely need to intensify their flu prevention efforts this fall to make sure their patients get the vaccines they need.
To learn more, we spoke with William Schaffner, M.D., professor of preventive medicine in the department of health policy at the Vanderbilt University School of Medicine. He shares seven things clinicians should do before a new flu season begins.
1 | Acknowledge vaccine hesitancy...
It's no secret that COVID-19 vaccine rates vary widely across the United States. For example, 84% of Rhode Islanders were fully vaccinated as of mid-July, compared with 51.5% of Wyoming residents.1
Researchers at UCLA have found a link between COVID-19 vaccine hesitancy and acceptance of flu vaccines. During the 2021-2022 flu season, flu vaccination rates dropped by 4.5% in states with below-average COVID-19 vaccination rates and rose 3.8% in states with the highest uptake of COVID-19 vaccines.2
Against that backdrop, Dr. Schaffner thinks clinicians need to become vaccine insisters instead of vaccine 'suggesters' this fall.
"We don't say, 'Charlie, you've got diabetes. You know, you ought to think about getting that treated.' We don't say that," he says. "No, we begin to prescribe treatment. The same thing with high blood pressure, etc., etc. Why are we so wishy-washy with vaccines?"
2 | ... and vaccine fatigue
Even among those who've been fully vaccinated, there is significant vaccine fatigue. That's no surprise, considering that 107 million people have received one booster dose and 19 million have received two.3 On top of that, another variant-specific shot, which Dr. Schaffner dubs "COVID vaccine 2.0," is due out this fall, just in time for flu season.4
"It may well be that we'll be asking many adults, at the very least, to roll up both sleeves: get their flu vaccine in one arm and their updated COVID vaccine in the other," he says. "This is not going to be, as we say, an easy sell. We will have to work very hard, because there's so much vaccine fatigue out there already."
Acknowledging that fatigue may be an important step in this year's flu prevention campaign.
"A vaccine deferred is very often a vaccine never received. I think it's a 'bird in the hand is worth two in the bush' situation, and so you've got to vaccinate while the patient is right there."
3 | Aim for co-administration
The Centers for Disease Control and Prevention (CDC) has stated that both flu and COVID-19 vaccines can be administered at the same time (assuming a patient is due to receive both). However, since each vaccine can cause local reactions like soreness, redness and swelling, the agency recommends administering them in different limbs, if possible.5
"There's no accumulation of either minor or more serious side effects, and your immune system can handle both simultaneously," Dr. Schaffner says. "That's been well established, and the CDC's recommendations about that are very clear."
Of course, some patients may choose to defer one vaccine or the other, perhaps over fear of side effects. Dr. Schaffner encourages clinicians to push patients to get both when they see their doctor this fall. "A vaccine deferred is very often a vaccine never received," he says. "I think it's a 'bird in the hand is worth two in the bush' situation, and so you've got to vaccinate while the patient is right there."
So what should you do if a patient insists on deferring one vaccine or the other? Dr. Schaffner recommends considering local conditions. "If there's a flu outbreak in your community while you're vaccinating, then give the flu vaccine," he says. "If your community is having high rates of COVID, then you might want to give the COVID booster first."
4 | Improve your flu prevention follow-up
If a patient promises to come back later for a vaccination they missed, Dr. Schaffner believes your practice has an obligation to follow up. "What happens if the patient doesn't show up in a month?" he says. "What are you going to do to follow up with that patient?"
You may even have to come up with a new process. "Most doctors don't really have a built-in system to do that via email or social media or telephone, and that takes more work," Dr. Schaffner adds.
A good way to start is by leveraging pre-drafted communications to follow up with patients. McKesson's patient engagement toolkit includes email and letter templates, voice and text messaging scripts and more to help simplify the process of staying in touch with patients regarding vaccinations.
"Figure out a way that's more comfortable for you to at least get your patients vaccinated against influenza, even if they're pretty rigid in not wishing to get vaccinated against COVID. At least get one needle in an arm."
5 | Choose your battles
Dr. Schaffner knows that some patients may balk at getting a flu shot if they're suspicious of COVID-19 vaccines. "Figure out a way that's more comfortable for you to at least get your patients vaccinated against influenza, even if they're pretty rigid in not wishing to get vaccinated against COVID," he says. "At least get one needle in an arm."
He recommends acknowledging patients' concerns – and then pushing for the flu shot. For example, a doctor might say something like this:
"Everybody who works here gets vaccinated against flu each year, and we want that benefit of protection to extend to absolutely every one of our patients. And you, Charlie, are next in line."
"I'll bet that kind of persuasiveness will get you another 20%," he says. "It won't be 100%, but you could increase the rate of influenza immunization in your office by 20% by having a conversation like that."
6 | Steer older adults to quadrivalent flu vaccines
In June, CDC Director Rochelle P. Walensky, M.D., adopted a recommendation from the Advisory Committee on Immunization Practices (ACIP) that all adults 65 and older receive specific quadrivalent vaccines. The vaccines cited in the recommendation are the Fluzone® high-dose quadrivalent, Flublok® quadrivalent and FLUAD® quadrivalent shots.6
Dr. Schaffner says 80% of older adults were already getting one of those vaccines, but he believes the CDC emphasis is still important. "Having this as a distinctly preferential recommendation focuses the attention of all providers that they should be trying to have at least one of these vaccines available for their patients age 65 and older," he says.
7 | Don't be surprised if you're surprised
Finally, Dr. Schaffner says, don't expect this (or any other) flu season to follow a predictable pattern. For example, the 2021-2022 season began normally, but soon deviated from the norm. The incidence of infection dropped dramatically after the first of the year and then slowly rose during the spring, lasting into May with high activity in some states.7
"That was very unusual, and it persisted much longer than it typically does," Schaffner says. "It persisted past March, into April, into May, and it was only in June that it really started to go down again."
Another important indicator is flu activity in the Southern Hemisphere during the early summer months, which typically models trends for the U.S. Countries below the Equator experienced an early resurgence of flu that exceeded the 5-year average. This could mean a busy flu season for the U.S.8
If history repeats itself, you may need to promote flu shots in March and April as aggressively as you do in October and November.
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