Influenza Vaccination With SARS-CoV-2 mRNA Booster Shots


Drs Jacinda Abdul-Mutakabbir, Madeline King, Rodney Rohde, and expert nurse practitioner Wendy Wright provide insight on receiving the influenza vaccine concurrently with the SARS-CoV-2 booster shot, and comment on data on immune responses from the Moderna and Pfizer/BioNTech vaccines.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: In our clinic, we separated the Moderna and Pfizer vaccines and do Moderna Mondays and Pfizer Fridays. Because there are so many idiosyncrasies to the different dosing, our fear is giving the wrong dose to the wrong person. I want to talk to all of our pharmacists here, because in many states, pharmacists can’t vaccinate every age group. A lot of primary care providers are saying, “This is way too much work. We aren’t taking any of these on. You need to go to the pharmacy.” Pharmacists are just as burdened as we are with all the workload, if not more. As a country, it’s most important that we all work within our systems to create novel ways to get these vaccines on board.

Jacinda Abdul-Mutakabbir, PharmD: From the pharmacist standpoint, we’re vaccinating most age groups at this point due to special pandemic orders. Over 70% of individuals who have received vaccines have received them from pharmacists. I’m in the community, and I vaccinate. I only vaccinate with Pfizer. When I go into the community, I only take Pfizer with me. Moderna has a ton of doses in the vial, and the climate of uptake is changing, so I don’t feel comfortable wasting the number of doses that I would waste should I take Moderna with me into the community.

I explain this to the community members, and then I offer that information in terms of heterologous vaccination. Can you receive 2 different vaccines? Can you receive a different booster? I consistently have that conversation. I consistently discuss the study in which 400 individuals enrolled. Individuals got Pfizer-Pfizer, or received Moderna, Johnson & Johnson or Pfizer, and they wanted to see their immunogenicity. We saw similar responses with the mRNA vaccines but a lower response with J&J, which is why it’s recommended that those who had J&J get the booster with the mRNA vaccines. That’s the conversation I have with my patients.

We talked about dumbing the science down, but I believe in making them a community stakeholder. I explain, “This is how this goes.” I want them to know the reason I’m not bringing Moderna, but that I’m not compromising their protection. That’s a good point you brought up, Wendy. We have so many different doses. We have so many different caps at this point: 17 different colors. It becomes a matter of, “How can I do this and maximize the vaccinations? How do we keep it safe?” Then I end up in the community, and patients ask me, “Can I get the flu vaccine? Can I get it at the same time as the COVID-19 vaccine?” It becomes that comfortable place when I have only the Pfizer COVID-19 vaccine. If I bring the influenza vaccine with me, it becomes a bit easier to have to manage only those 2 different types of vaccines.

But then I get asked, “Do I get the vaccines in the same arm?” I explain to them that this is mRNA technology, and you can definitely receive other vaccines because it’s equivalent to an inactivated vaccine. It isn’t live, so you can receive 2 different inactivated vaccines, or a live and an inactivated vaccine. You just can’t get 2 live ones at the same time. I advise to not get them in the same arm. You guys may have different advice, but I usually say to get them in 2 separate arms. I did it in the same arm last year, and I still regret it. I still have phantom pain.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: There are a couple of things I’d add. Heterologous boosting has become sexy. I love talking about that with people. I say, “In Europe, they’ve been doing this for a long time. Let’s mix it up, and you may have some better protection.” We do give 2 live vaccines on the same day. We do MMR [measles, mumps, and rubella] and varicella. They just have to be separated by a month if they aren’t done on the same day. That doesn’t matter with these. People can get other vaccines, but don’t do them in the same arm. We’re giving the flu vaccine in one arm and the COVID-19 vaccine in the other. We say, “You probably aren’t going to like us tomorrow, but then you’re miserable and your misery is over. Take some acetaminophen if you need it, and you’ll be done with your vaccines.”

Madeline King, PharmD, BCIDP: That’s a great point. We’re starting to give our flu vaccines where I work, and a lot of people say, “Just give both to me at the same time. If I’m going to feel bad, I want to feel bad only once.” It’s good to remind people that if they feel bad, it isn’t because they developed the infection. I’ve heard the old adage about people getting the flu from the flu shot. It’s hard to dissuade people from believing that. It’s important to reiterate to people that your arm is going to be sore and you may feel fatigued and a little out of it for a day, but that’s just your immune system waking up and figuring out what it’s doing. Don’t worry that you’ve acquired COVID-19 or influenza from the shot that you’ve gotten. I always try to point that out if I’m giving both vaccines at the same time. You’re going to feel kind of bad, but it’s OK. You don’t have the disease.

Rodney Rohde, SV, SM, MB (ASCP), FACSc: Right on. The hashtag here from Wendy is #MixItUp. Let’s start a new campaign.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Or #HeterologousBoostingIsSexy. That’s the other one.

Rodney Rohde, SV, SM, MB (ASCP), FACSc: That’s a long hashtag. That may not work. It’s interesting. I have a ton of friends who are first responders and firemen. One of the highlights and feel-good moments for me during the past 2½ or 3 years is when people got out there and did their part in helping immunize people. I took my parents to be vaccinated. We drove 60 miles to Brenham, Texas. Both of my parents are immunocompromised. My mom’s a recovering patient with cancer. My dad has some diabetes issues. They’re both older. We drove them into this community, and there were thousands of cars. It was so exciting to see them get their shots. It’s easy to forget that. That wasn’t that long ago. We have to remember how amazing the country responded. We certainly tripped over ourselves sometimes, and we made some mistakes, but overall, we stepped up when we had to.

I’m glad you guys talked about flu and COVID-19. We need to make sure people understand that it’s safe to get both vaccines. I do one in each arm, myself. That helps. Also, if you have issues—I got 4 shots for COVID-19 and had some issues– it’s OK to take a little acetaminophen after you take that vaccine. It might make you feel a little better. Why feel horrible? That’s what medications are for. I tell people all the time, “That’s why you’re taking a vaccine. It’s also why we take medication. You don’t need to suffer. It’s OK if you’re doing it correctly according to the directions, and things will be a little easier for you.” That’s important.

Before I move on, the last point I want to mention and cement what you guys talked about was that mixing and matching became critical, and there are data. With the Johnson & Johnson vaccine, we were desperate to get people vaccinated, so we were looking for a 1-shot option because Moderna and Pfizer were both 2 shots, about 3 to 4 weeks apart. In hindsight, the Johnson & Johnson vaccine should have been a 2- or maybe 3-vaccine series. We learned some lessons, but 1 shot was better than no protection when this thing was raging 2 years ago.

Transcript Edited for Clarity

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