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August 20, 2021 – With the first COVID-19 vaccinations continuing and the plan to offer booster shots to most Americans starting next month, what are the considerations for getting vaccinated against COVID-19 and flu at the same time?
Medscape / WebMD sought advice from Andrew T. Pavia, MD. He is the head of the Division of Pediatric Infectious Diseases at the University of Utah, Salt Lake City, Utah, and a fellow of the Infectious Diseases Society of America.
Q: With COVID-19 cases on the rise, is it a good idea to get a flu shot early this season?
Pavia: I don’t think there is an urgency to do it in August, but it’s a good idea to get the flu shot this season. The consequences of contracting the flu while the COVID is circulating are serious.
Q: What are the implications?
Pavia: There are some that we know and others that we do not know. If you develop flu-like symptoms, you will need to get tested. You are going to have to stay home a little longer if you get a [positive COVID-19] test than you simply would with flu symptoms. In addition, you are likely to be absent from work when your workplace is very stressed or your children are stressed by the circulation of COVID in schools.
The part we know less about is the implications of the flu and COVID combination. There is reason to believe that if you bring them together, the disease will be more serious. We see it with RSV [respiratory syncytial virus] and parainfluenza and COVID co-infections in children. They seem pretty harsh.
“We don’t know of any reason why you can’t do both shots together.”
But for the flu, we just don’t have the data yet. This is because there has really been no co-circulation of COVID and flu except for parts of China for a brief portion of February and March.
Q: Will the scheduled COVID-19 booster vaccine delivery this fall affect how many people get the flu shot or how it’s distributed?
Pavia: This creates a lot of logistical challenges, especially for hospitals and other places that need to vaccinate large numbers of their employees against the flu and will need to give COVID reminders around the same time. It also creates logistical challenges for physician offices.
But we don’t know of any reason why you can’t have it both ways together.
Q: Is it possible that the flu season is more severe because we isolated ourselves and wore masks etc. last winter? A science behind it?
Pavia: The more you study the flu, the less you can predict, and I’ve been studying the flu for a long time. There are reasons that could suggest a severe flu season – there has been limited immunity, and some people don’t wear masks effectively and they band together again. These are things that we think protected us from the flu last season.
But we have yet to see the flu emerge. Normally, we look to Australia, New Zealand, and South Africa during their winter – which is our summer – to get a sense of what’s on the horizon for the northern hemisphere. Influenza activity in Australia has been very modest this year.
It could mean that the flu may not appear for a while, but I would hate to make a prediction.
Q: What are the chances that we will witness a flu epidemic like the one we see with RSV, which is normally a winter illness?
Pavia: The fact that we had a summer flare-up of RSV just gives you an idea of how the normal epidemiology of viral infections has been disrupted. This means anything can happen with the flu. It could appear in late summer or fall or wait until next spring.
We really don’t understand how these interactions work. When a new strain of flu appears, it often ignores traditional behavior and appears in the spring or fall. It happened during the 2009 pandemic, it happened in 1918.
The only thing I can predict safely about the next flu wave is that it will surprise us.
Q: Do you hope that the combination vaccines being developed by a number of companies, such as Moderna, Novavax and Vivaldi, will be effective?
Pavia: It is starting to look like COVID will be with us for the foreseeable future – perhaps as a seasonal virus or perhaps as an ongoing pandemic. We are going to have to protect [ourselves] simultaneously against influenza and COVID. One shot is a great way to do it – no one wants two needles; no one wants two trips to get the vaccine.
An effective combination vaccine would be a very good tool.
We have to wait and see what science shows us, because these are quite different viruses. We won’t know if a combination vaccine works well and has acceptable side effects until we do these studies..
Q. Do you know at this point if the side effects of two vaccines would be additive? Is there a way to predict this?
Pavia: There is no way to predict. There are so many things that go into whether someone is having side effects that we don’t understand. With fairly reactogenic vaccines like mRNA vaccines, a lot of people have no side effects and others are really uncomfortable for 24 hours.
Influenza is generally a better tolerated vaccine. There are still people who have muscle aches and very sore arms. I don’t think we can predict whether getting two vaccines will be additive or just the same as getting one vaccine.
Q: Besides the convenience and benefit for people with needle phobia, are there any other benefits of combining them in one shot?
Pavia: Logistics alone is enough to justify having an effective product if we can make one. This should reduce the overall cost of administration and reduce downtime from work.
Combination vaccines administered by pediatricians have been very successful. They reduce the number of needles for children and make it much easier for parents and pediatricians who administer them. The same principle should apply to adults, who are sometimes less courageous than children for needles.
Historically, combination vaccines in general have worked as well as vaccines given alone, but there have been exceptions. You just have to see what the products look like.
Q: At the moment, the flu vaccine and the COVID-19 vaccine are unique products. If you get them separately, is it better to put some time in between?
Pavia: We do not know. There are studies that probably won’t come out in time to make a decision in September. They are looking to see if you get an equivalent immune response if you give them together or separately.
For now, I would say the benefit of bringing them together is that if you experience any side effects you will only experience them once a day to suffer. It is also a visit to the doctor.
“I will get my flu shot as soon as it becomes available. If I am to receive a COVID booster then, I would probably do them together.”
The potential benefit of separating them is that this is how we developed and tested vaccines. If you react to it, the side effects might be milder, but it will be on two separate days.
I would recommend doing whatever works so that you get both vaccines on time.
I’ll get my flu shot as soon as it’s available. If I am to receive a COVID reminder at that time, I would probably do them together.
Q: Do you foresee a time in the future when the predominant strain of SARS-CoV-2 will be one of the components of an influenza vaccine, like we did in the past with H1N1 etc. ?
Pavia: It really remains to be seen … but it is highly conceivable that it could happen. The same companies that developed the COVID-19 vaccines are working on flu vaccines.
Q: Do you have any other advice for those concerned about getting the COVID-19 and flu shots in the coming months?
Pavia: There is no side effect of the vaccine that begins to approach the risk you face for either disease. One of the best things you can do to protect yourself is get vaccinated.
In the case of influenza, the vaccine is only modestly effective, but it still saves tens of thousands of lives each year. The SARS-CoV-2 vaccine is a much better vaccine and a more deadly disease.
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