Preparing for the 2022-23 Influenza Season

The AAP influenza policy statement and an accompanying technical report are now available. The policy statement and technical report will be published in the October 2022 print issue of Pediatrics.

The American Academy of Pediatrics recommends annual influenza vaccination for all children without medical contraindication starting at 6 months of age. Any licensed influenza vaccine (injection and intranasal) appropriate by age and health status can be used for vaccination. All health care personnel should receive an annual seasonal influenza vaccine to prevent influenza and reduce health care-associated influenza infections.

Children 6 months through 8 years of age who are receiving influenza vaccine for the first time, or who have received only 1 dose ever prior to July 1, 2022, or whose vaccination status is unknown should be offered vaccination as soon as influenza vaccines become available and should receive 2 doses of vaccine, ideally by the end of October.

Children and adolescents needing only 1 dose of influenza vaccine, regardless of age, should also receive vaccination ideally by the end of October.

Recent data (mostly in adults ≥65 years) suggests that early vaccination (July or August) might be associated with suboptimal immunity before the end of the influenza season, so pediatricians should consider the risks/benefits of early vaccination for the individual patient.

Influenza vaccines can be administered simultaneously with other live and inactivated vaccines (including the available COVID-19 vaccines). Vaccinating as recommended on the Child and Adolescent Immunization Schedule and during a single visit has important benefits of protecting children and adolescents against many infectious diseases and minimizes the number of visits that patients and their caregivers must make to the doctor’s office. Pediatricians can review the latest clinical guidance from the CDC and AAP regarding coadministration. See here for more information from the AAP about COVID-19 vaccine for children.

Per General Best Practice Guidelines for Immunization from the CDC, two different vaccines may be given at the same time and spaced out at any interval (eg, number of days apart). However, there are some exceptions for certain vaccines and risk groups.

Based on extensive experience with other, non-COVID-19 vaccines, we know that the immune response and side effects in both adults and adolescents are generally the same whether vaccines are given together or more spaced out. Current AAP guidance indicates that influenza vaccine can be administered simultaneously with or at any time before or after COVID-19 vaccine administration.

Reactions may occur at the injection site with influenza vaccine and COVID-19 vaccine (eg, pain, redness). Best practices for multiple injections include labeling each syringe, separating injection sites by at least 1 inch (to reduce the chance of local reactions overlapping), and if possible, administering COVID-19 vaccine and vaccines that may be more likely to cause a reaction in separate limbs. See here for more information on proper vaccine administration and visit the CDC Resource Library for vaccine administration job aids.

When co-administering vaccines, precautions and safety strategies should be implemented to avoid errors, particularly mix-ups between the COVID-19 vaccine and influenza vaccine.

The Institute for Safe Medication Practices offers a set of safe practice recommendations, summarized below:

• Provide staffing support. Schedule vaccines for a dedicated block of time each day and ensure adequate staffing.
• Separate vaccination areas. Provide vaccinations in an area away from distractions and interruptions.
• Label the syringes. Clearly label all individual syringes containing vaccines.
• Separate the vaccines. Bring only the intended vaccine(s) for each individual patient to the vaccination area.
• Identify the patient and requested vaccine. Verify with the patient and/or parent/caregiver the vaccine(s) that will be administered. 
• Involve the patient/parent in the checking process. Ask the patient and/or parent/caregiver to read the syringe label to confirm the correct vaccine will be administered. At minimum, the vaccine provider should tell the patient and parent/caregiver which vaccine is being given before administration.
• Document lot number and expiration date. Document vaccine lot number and expiration date prior to administration. Make sure to document vaccine administration afterward in patient’s medical record.
• Scan the barcode. Scan the vaccine barcode to verify the correct product is being administered, to confirm the correct vaccine has been retrieved and prepared.
• Provide the intended vaccine. If a mix-up occurs, ensure it is addressed with the patient and/or parent/caregiver right away and that the intended vaccine is provided.
• Report vaccine errors. Report all vaccine errors internally as well as to the FDA Vaccine Adverse Event Reporting System (VAERS), which is mandatory for errors with the COVID-19 vaccines available under an EUA.

Standard precautions should be used at all times and in all situations in health care. Additionally, transmission-based precautions should be utilized based on anticipated exposures and suspected or confirmed diagnoses.

Children with acute moderate, or severe illness, including COVID-19, may receive influenza vaccine as soon as their illness has improved. Children with mild illness, including low-grade fever, can still be vaccinated.

While mild illness is not a contraindication to influenza vaccination, vaccination visits should be postponed to avoid exposing healthcare personnel and other patients to the COVID-19 virus. When scheduling or confirming appointments for influenza vaccination, patients should be instructed to notify the health care professional’s office or clinic in advance if they currently have or if they develop any symptoms of COVID-19.

Studies have shown high rates of co-infection with SARS-CoV-2 and other respiratory pathogens. Testing may be needed to differentiate the cause of a patient’s respiratory illness.

• Information on testing for influenza can be found in the Recommendations for Prevention and Control of Influenza in Children, 2022–2023, which is now available.
• Complete information on diagnostic tests for RSV can be found in the Respiratory Syncytial Virus chapter in Red Book on Red Book Online (AAP log-in required).
• AAP interim guidance on COVID-19 testing can be found here.

Guidance and resources on treatment for influenza, Respiratory Syncytial Virus (RSV) and COVID-19:

• Antiviral medications are important in the treatment and control of influenza but are not a substitute for influenza vaccine to prevent infection. Refer to the AAP influenza policy statement and technical report for more information.
• The AAP recommends consideration of the use of palivizumab, a monoclonal antibody directed against the fusion protein of RSV, in infants at increased risk of severe disease. Refer to the 2022-2023 updated guidance on the treatment of serious lower respiratory tract infections caused by RSV.
• Information on treatment of COVID-19 can be found in the AAP interim guidance on Management Strategies in Children and Adolescents with Mild to Moderate COVID-19 (aap.org).

An in-office influenza vaccination clinic can be an efficient and expedient way for your practice to provide vaccines and improve vaccination rates. Information and resources on how to plan and implement a vaccination clinic in your practice are available here.

The AAP has developed a vaccine policy white paper, Policies to Preserve the Vaccine Delivery System for Children, outlining our vaccine advocacy priorities, including critical policy changes needed for the Vaccines for Children (VFC) Program such as prioritizing the delivery of influenza vaccine to VFC providers.

The AAP is currently not aware of delays in manufacturing or supply issues associated with influenza vaccines. Please contact the AAP with information about any delay your practice is experiencing.

See here for information and resources from the AAP on office strategies for improving immunization rates and other best practices. Additional resources for immunizing during COVID-19 include the following:

• AAP Guidance on Providing Pediatric Well-Care During COVID-19
• CDC Resources for Encouraging Vaccinations During COVID-19 Pandemic
• CDC Vaccination Guidance During a Pandemic

The AAP and CDC have resources that pediatricians can use to promote vaccination and to address questions related to vaccine hesitancy from patients and caregivers. These resources can be found here:

• AAP Flu Toolkit
• HealthyChildren.org - Flu Subsite (English)
• HealthyChildren.org - Gripe Subsite (Spanish)
• AAP Communicating with Families and Promoting Vaccine Confidence

For more information, see Frequently Asked Influenza (Flu) Questions: 2022-2023 Season from the CDC.