​Influenza​ Implementation Guidance 

Updated September 2020


While influenza (flu) starts circulating sometime between September and February, flu vaccine preparation begins much earlier. Preparing for the added work of flu vaccine scheduling is an important first step. Whereas flu vaccine may be available starting in August, recent data (mostly in adults) suggests that very early vaccination (July or August) might be associated with suboptimal immunity before the end of the influenza season. Although the evidence is limited in children, recent reports raise the possibility that early vaccination might contribute to reduced protection later in the flu season. The AAP and Centers for Disease Control and Prevention (CDC) recommend that flu vaccination is completed by the end of October. Preparing your patient lists and schedules beginning early in the summer will help you organize your office and educate your staff prior to the influx of vaccine-only visits.

The AAP recommends all people 6 months and older be vaccinated against seasonal flu. During the coronavirus disease 2019 (COVID-19) pandemic and while severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is circulating, influenza vaccination is especially important to prevent respiratory disease and to avoid overtaxing our health care system. Children and adolescents with underlying medical conditions remain at increased risk of complications due to influenza and should receive influenza vaccine, see Table 2 in the AAP influenza policy statement, p 61. While universal influenza vaccination is recommended for everyone starting at 6 months of age, emphasis should be placed in ensuring that people in high-risk groups and their household contacts and caregivers receive an annual influenza vaccine. Pediatricians, pediatric medical subspecialists, pediatric surgical specialists, and parents can work together to make sure these children receive seasonal influenza vaccine as soon as it is available and ensure that there is a plan in place to treat them early if they develop influenza-like illness.

A pediatric medical subspecialist or surgical specialist might see a child more often than the primary care pediatrician. If so, the specialist can add a note to reports that are sent to the child's medical home: "Because of his/her neurologic (or other) condition, Name is at high risk for severe complications from the flu and therefore it is extremely important that he/she receive a yearly influenza vaccine."

Scheduling a large number of patients can be a daunting task for many physicians' offices, especially as it usually coincides with the beginning of the school year and an increase in acute care visits. This year, special precautions should also be considered because of the COVID-19 pandemic. Check out interim guidance from the AAP on providing pediatric well-care during COVID-19. Below are some additional tips to get your practice through the season:

  • Begin advertising flu vaccine as soon as it is available. When you are ready to start administering flu vaccine, you can make your patients aware by posting signs in the waiting areas and exam rooms, sending out flyers via email/text (must have email/text waiver signed by parent/patient), and posting updates on the practice's Web and social media sites. Include information about special processes, such as cloth face coverings and physical distancing to outline expectations.  

  • Prepare early. Set up a separate nurse-only or flu shot schedule as soon as you decide when to start administering flu vaccine. These appointments should be shorter in length and set up for when you either have extra staff or on traditionally slower days to facilitate physical distancing. Schedule plenty of days for after-school appointments. Having a separate schedule allows you to have sufficient staff and to keep track of vaccine supply. Using a separate appointment type such as "flu shot" allows you to continually track how many patients still need appointments. Also, it is much easier for patients and families when they can get immunized quickly and efficiently.

  • Have adequate personal protective equipment (PPE) on hand recommended for use for flu vaccine administration. For administration of inactivated influenza vaccine, a surgical mask should always be worn as well as eye protection. For administration of live attenuated influenza vaccine (LAIV), gloves are recommended in addition to use of a medical facemask and eye protection. Refer to AAP Interim Guidance on the Use of Personal Protective Equipment (PPE) for Pediatric Care in Ambulatory Care Settings During the SARS-CoV-2 Pandemic and CDC Vaccination Guidance During a Pandemic for more information.

  • Consider offering after hours appointments or Saturday flu shot clinic days. This can allow a practice to vaccinate a much larger group of patients more efficiently and prior to the start of influenza virus circulation. Read about a successful flu clinic.

  • Run a report from your electronic health record (EHR), Practice Management System, and/or immunization information system to identify children who need to be called into the office ("recall") for influenza vaccine.

    • Run a report for all children in your practice with any asthma diagnosis, diabetes diagnosis, and other chronic conditions or illnesses for the past 2 years. Prioritize these children for vaccination upon receipt of your flu vaccine inventory  as these are the children at higher risk for complications due to influenza infection.

    • Run a separate report of all other active patients, excluding those scheduled for well-child exams in the months of August, September, and October. Those patients scheduled for well-child exams should receive their flu vaccine during that visit. Excluding these groups from the report will help lighten the recall process.

  • Consider a service that can set up a "phone (call or text) blast" or "email blast." The blast can simply advise parents of your healthy patients without well-child exams in August, September, and October, that the flu vaccine is in stock and they should call at their earliest convenience to schedule their child's flu vaccine.

  • Advise staff as soon as vaccine arrives and review appointment procedures. Advise your physicians, nurses, front office staff, and anyone who will have contact with patients that flu vaccine is in stock and to either offer vaccine to those in the office or schedule appointments for those who call. Physicians should offer the vaccine to all patients at any visit (not just well visits). If a patient does not have true contraindication, he or she should receive the flu vaccine (whatever age-appropriate vaccine is in stock) when in the office.

  • Offer vaccine to siblings. Physicians and nurses should offer vaccine to siblings who are patients and who may be in the office, whether they are scheduled for an appointment or not. Clinics should be flexible, when necessary, to meet the needs of patients. "Never miss an opportunity" to vaccinate should always be the office mantra, but especially once the flu vaccine has been delivered.

  • Follow up with children who need 2 doses and those who haven't scheduled an appointment. At the end of each month starting when your first shipment of vaccine is received, run a follow-up scheduling report of all active patients; excluding  those scheduled for well-child exams through October and those already scheduled for a flu-shot appointment. These remaining patients may require extra outreach. A follow up call/text/mailing/email is likely necessary. Also consider asking parents of children who need 2 doses to schedule an appointment for the second dose while they are in the office for the first dose.

  • Continue to vaccinate throughout the season (through June 30th). Influenza is unpredictable, may have multiple peaks, and can occur any time.

Scheduling Plan

Consider options available for scheduling and create a plan for the season. Some ways to schedule include:

  • Implement recommendations on vaccinating during a pandemic, such as scheduling well visits and sick visits at different times of the day, using specific exam rooms for well visits and immunization only visits, minimizing time in the waiting room, or conducting outdoor vaccination clinics.

  • Schedule patients for flu vaccine early or late in the day (eg, if practice is open 8am-5pm, schedule between 7am and 8am or between 5pm and 6pm).

  • Schedule patients for flu vaccine anytime the office is open, but assign a maximum number of appointments per day or half day. Otherwise, office staff could have more patients than they are able to manage.

  • Train those who answer the office phones to tell patients/parents who call (whether to ask a question or to schedule any type of appointment), that flu vaccines are available and offer to schedule an appointment for siblings who are patients in the practice to be vaccinated, as well.

  • Schedule children who need a second dose at the time they get their first dose. Offer a reminder card listing the appointment information before they leave the office.

  • Have flu clinics on Saturdays—this is helpful for children who need a second dose of flu vaccine.

    • Saturday clinics eliminate crowding in the office once the high-volume fall season starts. It also keeps "well" kids from sitting in the waiting room with "sick" kids (if you don't have regularly scheduled office hours).

    • Designate a "flu clinic organizer" to do the prep work needed to make your flu clinic run smoothly. Here are some suggested duties:

      • Ensure adequate PPE is available.

      • Prepare a sign-up list for staff to work during each flu clinic and explain the need for staff to sign up.

      • Post signs in the office announcing flu vaccine availability, send an electronic communication, and/or post a notice on the office's Web or social media site.

      • Prepare a scheduling document with columns of different kinds of appointments—one column for patients 6-35 months, one for patients who are 3+, 4+, or 5+ years depending on the brand used, etc.

      • Make sure that there is adequate vaccine supply to correlate with the number of patients scheduled in each of the columns, for both Vaccines for Children (VFC) vaccine and private stock.

      • Assign staff to perform the following roles:

        • Check patients in

        • Escort patients to room

        • Obtain consent/signature and answer questions

      • Assign one staff person to administer vaccine to patients in each "column" of scheduled patients, (eg, one staff member to the 3 or 4 yrs+ column).

      • Gather and copy necessary paperwork including consent forms, Vaccine Information Statements (VISs), second dose reminder cards, etc.

      • Check patient insurance coverage.

      • Place reminder calls to scheduled patients.

      • Ensure staff (especially new staff) are adequately trained to work the clinic—all staff working the clinic should be appropriately (re)trained the week of the clinic.

      • Prepare vaccine vials. If you have a separate fridge, pull certain lots to the front—some lots expire sooner than others.

      • Prepare the building for the clinic (eg, open the office and exam rooms, turn on computers, etc.). 

      • Manage patient flow in the clinic.

      • When using exam rooms, ensure they are appropriately cleaned and disinfected between patients.

      • Make sure personnel (staff) documents the vaccines they administered at the time they are given or no later than before the end of the day.

      • Document any vaccine errors incurred on the day of and report to VAERS on the following Monday (eg, VFC vs private, wrong dose administered, expired lot used, etc.)

      • Prepare the building for closing following the clinic (eg, shut down exam rooms, turn off computers, check refrigerator temperature and make sure refrigerator doors are closed, lock up the office, etc.). 

Tools and Resources

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