• ACIP Updates Flu Vaccine Recommendations for 2020-2021

    Report Includes Guidance for Patients With COVID-19

    September 9, 2020, 1:45 pm Michael Devitt — The AAFP has reviewed and agrees with the Advisory Committee on Immunization Practices' recommendations for the 2020-2021 influenza season, which — among other things — call for all patients ages 6 months and older who have no contraindications to be appropriately immunized. 

    patient receiving immunization

    The CDC's Aug. 21 Morbidity and Mortality Weekly Report summarizes the recommendations and enumerates the many vaccine products on the market this season. They include several inactivated influenza vaccines, a recombinant influenza vaccine and a live attenuated influenza vaccine. With one exception, these products will be quadrivalent; MF59-adjuvanted IIV is expected to be available in both quadrivalent and trivalent formulations.

    The report also provides guidance on administering the influenza vaccine to individuals with COVID-19. Family physicians are invited to review the report and additional information on seasonal influenza from the CDC, including an upcoming webinar on testing for and treating influenza during the COVID-19 pandemic.


    In addition to recommending routine annual influenza vaccination for everyone 6 months and older who does not have a contraindication, the CDC advises that vaccines be administered by the end of October, although vaccination should be offered as long as influenza viruses are circulating locally and unexpired vaccine is available.

    There are no preferential recommendations for one vaccine over another for patients for whom more than one licensed, appropriate product is available.

    Pamela Rockwell, D.O., of Ann Arbor, Mich., the Academy's liaison to the ACIP, told AAFP News that clinicians should seize every opportunity to vaccinate patients when they are seen in the office for routine or urgent care.

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    "Children aged 6 months through 8 years who require two doses of vaccine should receive their first dose as soon as possible after the vaccine is available to allow the second dose (given four or more weeks later) to be received by the end of October," she noted.

    Updates for 2020-2021

    The MMWR report includes two primary updates.

    First, the composition of the 2020-2021 U.S. influenza vaccines includes revisions to the influenza A(H1N1)pdm09, influenza A(H3N2) and influenza B/Victoria lineage components, with all egg-based influenza vaccines containing hemagglutinin derived from one set of updated viruses and all cell culture-based inactivated vaccines and the recombinant influenza vaccine containing hemagglutinin derived from a different set. Quadrivalent vaccines will include an additional influenza B virus component from the B/Yamagata lineage, which is unchanged from that included in the quadrivalent vaccines used during the 2019-2020 influenza season.

    The second primary update is the licensure of two new influenza vaccines:

    • a high-dose, egg-based quadrivalent IIV, Fluzone High-Dose Quadrivalent (which is expected to replace the previously available trivalent formulation of Fluzone High-Dose) and
    • a standard-dose, egg-based, adjuvanted quadrivalent IIV, Fluad Quadrivalent.

    Both vaccines are licensed for patients 65 and older and are expected to be available in the United States for the 2020-2021 season.

    Additional updates include the following:

    • Contraindications and precautions for LAIV4 now address anatomic and functional asplenia; active communication between cerebrospinal fluid and oropharynx, nasopharynx, nose, ear or any other cranial cerebrospinal leak; and cochlear implant.
    • Additional measures for patients with a history of severe egg allergy (i.e., vaccination in a medical setting supervised by a health care professional who is able to recognize and manage severe allergic reactions) are needed only if a vaccine other than cell culture-based IIV4 or RIV4 is used. No postvaccination observation period is recommended specifically for egg-allergic patients, but the ACIP recommends that vaccine providers consider observing them (seated or supine) for 15 minutes after vaccine administration.
    • Although specific data on LAIV4 vaccination in the setting of influenza antiviral use are not available, antiviral medications may interfere with the action of LAIV4 because it contains live virus.

    "For those patients receiving influenza antiviral medications for treatment or chemoprophylaxis, it is acceptable to administer any IIV or RIV4 vaccine concomitantly," said Rockwell. "Influenza antivirals may interfere with LAIV4 if initiated within two to 17 days of vaccination, depending on antiviral product, and up to two weeks after vaccination with LAIV4. Therefore, persons on antiviral medications who have received LAIV in this time period are recommended to be revaccinated with an age-appropriate IIV or RIV4 two weeks after receipt of LAIV4."

    Rockwell also pointed out that the ACIP recommends that for seven days after vaccination, health care personnel who receive LAIV should avoid providing care for severely immunosuppressed patients.

    Influenza Vaccination and COVID-19

    The 2020-21 influenza season is expected to coincide with continued or recurrent recirculation of SARS-CoV-2 throughout the fall and winter.

    "This circumstance highlights the importance of a strong recommendation to vaccinate, with distribution of influenza vaccine to as many persons possible this season -- more than any previous influenza season," said Rockwell.

    The report notes that given the limited data available, for patients who have acute illness from suspected or confirmed COVID-19, clinicians may consider delaying influenza vaccination until the patients are no longer acutely ill. If vaccination is delayed, however, patients should be reminded to return for vaccination once they have recovered from the acute illness.

    Rockwell told AAFP News that depending on state and local COVID-19 case levels, some influenza vaccination programs may need to modify their timing to accommodate stay-at-home orders and social distancing strategies.

    "These circumstances might necessitate consideration of starting vaccination campaigns earlier to allow sufficient time to vaccinate the population and avoid some persons going unvaccinated for influenza," Rockwell said.

    The report directs clinicians to the CDC's guidance on vaccination during a pandemic for more information.

    It should be noted that earlier this month the Academy published an FAQ document for members to help answer questions from patients about influenza and COVID-19.

    Additional Comments

    Although COVID-19 has captured the public's attention for much of the year, Rockwell noted that influenza also should be taken seriously.

    "Not only is influenza disease an important cause of missed work or school and decreased productivity, it may cause serious illness and need for hospitalization, resulting in significant morbidity and mortality, particularly among older adults, very young children, pregnant women and persons of all ages with certain chronic medical conditions," she said.

    Rockwell also noted that effective influenza vaccination programs could produce benefits beyond decreased disease prevalence.

    "By reducing the prevalence and severity of influenza illness through vaccination, we can reduce symptoms that might be confused with those of COVID-19; reduce outpatient visits, hospitalizations and ICU admissions; and alleviate stress on the U.S. health care system during the ongoing pandemic," she said.