Shingles vaccine In line with general advice about co-administration of inactivated vaccines, the non-live shingles vaccine, Shingrix, can be given concomitantly with inactivated influenza vaccine. Initially, a seven day interval was recommended between Shingrix and adjuvanted influenza vaccine because the potential reactogenicity from two adjuvanted vaccines may reduce the tolerability in those being vaccinated. Interim data from a US study on co-administration of Shingrix with adjuvanted seasonal influenza vaccine is reassuring. Therefore, an appointment for administration of the seasonal influenza vaccine can be an opportunity to also provide shingles vaccine, although the latter should be offered all year round, rather than purely as a seasonal programme. The live shingles vaccine, Zostavax, can also be given at the same time as inactivated influenza vaccination. COVID-19 vaccine Flu vaccines can also be given at the same time as the COVID-19 vaccines where it is clinically indicated, operationally feasible and where the patient is content for this to happen. Where co-administration does occur, patients should be informed about the likely timing of potential adverse events relating to each vaccine. If the vaccines are not given together, they can be administered at any interval, although separating the vaccines by a day or two will avoid confusion over systemic side effects. RSV vaccine for older adults There is some data which shows that in older adults, administering the RSV vaccine, Abrysvo, at the same time as seasonal influenza vaccine may reduce the immune response to the RSV vaccine. There is also data that suggests that the response to the influenza A(H3N2) component of seasonal influenza vaccine (the influenza subtype which most severely affects older adults) may be diminished when RSV and seasonal influenza vaccine are co-administered to older adults.   The clinical significance of any reduced response is unknown, but influenza immune response is known to correlate with protection against infection, and there is emerging data that RSV immune response also correlates with clinical protection. It is therefore recommended that these vaccines should not routinely be scheduled to be given at the same appointment or on the same day. No specific interval is required between administering the vaccines.   If it is thought that the individual is unlikely to return for a second appointment or immediate protection is necessary, the RSV vaccine Abrysvo can be administered at the same time as the influenza vaccine.  RSV vaccine for pregnant women For pregnant women, the RSV vaccine Abrysvo can be given concomitantly with inactivated influenza vaccine. Similarly, there are no safety or effectiveness concerns around giving Abrysvo to pregnant teenagers who are due or who have recently had a live attenuated influenza vaccine nasal spray.  General guidance about co-administration If other vaccines are given at the same time as flu vaccines, the vaccines should be given at separate sites, preferably in different limbs but if given in the same limb, they should be given at least 2.5cm apart and the site of each should be recorded in the patient’s record. Because of the increased risk of local reaction following aQIV, this vaccine should be administered in a separate limb to any other vaccines that need to be given at the same time. If any new vaccines are introduced during the flu vaccination season, please ensure you follow the specific guidance given as to whether concomitant administration is possible for these. Administering an inactivated influenza vaccine after a first dose of LAIV
In the event that all LAIV stock expires before children scheduled to receive a second dose are able to do so, a suitable inactivated injectable flu vaccine should be offered as an alternative, allowing a 4 week minimum interval period between the 2 doses Administering LAIV
LAIV is administered by the intranasal route and is supplied in an applicator that allows 0.1ml to be administered into each nostril (total dose of 0.2ml). Clear diagrams showing administration are provided in the SmPC. Administration of LAIV by healthcare staff in clinical risk groups In theory, healthcare workers may have low level exposure to live attenuated influenza vaccine viruses during administration of the vaccine and/or from recently vaccinated patients. The vaccine viruses are cold-adapted and attenuated and are unlikely to cause symptomatic influenza. In the USA, where there has been extensive use of LAIV, no transmission of vaccine virus in healthcare settings has ever been reported and there have been no reported instances of illness or infections from the vaccine virus among healthcare professionals inadvertently exposed. The US Centers for Disease Control and Prevention (CDC) has considered that the risk of acquiring vaccine viruses from the environment is unknown but is probably low. As a precaution, however, very severely immunosuppressed individuals should not administer LAIV. Other healthcare workers who have less severe immunosuppression or are pregnant, should take reasonable precautions to avoid inhaling the vaccine and ensure that they themselves are appropriately vaccinated. Administering LAIV when the patient has a blocked or runny nose There are no data on the effectiveness of LAIV when given to children with a heavily blocked or runny nose (rhinitis) caused by infection or allergy. As heavy nasal congestion might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration until resolution of the nasal congestion or use of an appropriate alternative intramuscularly administered inactivated flu vaccine should be considered. Administration of both half doses in the same nostril It is recommended that LAIV be administered as 2 divided sprays (0.1ml into each nostril) to maximise the vaccine’s contact surface area of epithelial cells within the nasopharynx. No clinical trials have been conducted using a single-nostril administration. However, there is no need to repeat immunisation as each half dose (0.1ml) contains enough viral particles to induce an immune response. Administering LAIV with other vaccines LAIV can be given at the same time as, or at any interval before or after other currently used vaccines, including live vaccines. If any new vaccines are introduced during the flu vaccination season, please ensure you follow the specific guidance given about concomitant administration for these. LAIV nasal spray vaccine can be given at the same time as COVID-19 vaccines where required for eligible children. LAIV triggers an immune response in the nasal mucosa. This is unlikely to interfere with the body’s response to COVID-19 vaccines. Similarly, it is unlikely that the response to LAIV will be affected by the immune response to COVID-19 vaccine. Side effects of the nasal flu spray are very mild and short-lived and are unlikely to be in any way affected by the COVID-19 vaccine. Administering LAIV with antiviral agents against flu There is a potential for flu antiviral agents to lower the effectiveness of LAIV. Therefore, flu antiviral agents and LAIV should not be administered concomitantly. LAIV should be delayed for at least 48 hours after cessation of treatment with flu antiviral agents. Administration of flu antiviral agents within 2 weeks of administration of LAIV may adversely affect the effectiveness of the vaccine and an additional dose of vaccine may be required. Administering LAIV to children with cochlear implants Children with cochlear implants can be given LAIV safely although ideally it should not be given in the week prior to implant surgery or for 2 weeks afterwards, or if there is evidence of on-going cerebrospinal fluid leak. Children with unrepaired craniofacial malformations Unrepaired craniofacial malformations including cleft palate may occasionally be encountered by vaccinators immunising children of an age eligible for LAIV. The Summary of Product Characteristics notes that there is no data on use in this patient group. From first principles, there would be an expectation that adequate vaccine would be absorbed by the intranasal route to establish an immune response. If there were specific reasons to consider that the patient’s unrepaired craniofacial malformation was associated with a potential portal of entry to the brain / central nervous system, or particular concerns around absorption, then an inactivated influenza vaccine injection should be given instead. The child’s specialist team should be consulted if advice is required regarding the malformation and its potential impact on the suitability of LAIV.