Another shot?! That small but unpleasant injection in the arm and its potential side effects strike fear into the hearts of many, so much so that nearly half of all adults avoid getting an influenza (flu) vaccination each year (Centers for Disease Control and Prevention [CDC], 2022). The coronavirus disease-2019 (COVID-19) and the respiratory syncytial virus (RSV) vaccines (for adults over the age of 60) are now also recommended this season. As healthcare providers, we can’t emphasize enough that these potent little pokes can really save lives! Let’s review each of these immunizations and the current recommendations to help you educate your patients, family, and friends.

Influenza (Flu) Vaccine

The flu continues to burden the health care system contributing to millions of medical visits, over half a million hospitalizations, and tens of thousands of flu-related deaths each year (CDC, 2023a). The CDC recommends everyone 6 months and older in the U.S. should get a flu vaccine every season, with a few exceptions. There are several types of flu vaccine available in the U.S. and three types are recommended for people over the age of 65 as outlined in the table below.
 

Flu Vaccines Available 2023-24 Season (CDC, 2023b)
Type of Flu Vaccine	Brand Names	Approved for Use	Recommend for Age 65 and older
Standard dose flu shots (virus grown in eggs)	Afluria Fluarix FluLaval Fluzone (all Quadrivalent)	6 months and over	No
Cell-based (virus grown in cell culture)	Flucelvax Quadrivalent	6 months and over	No
Recombinant (egg-free, uses recombinant technology)	Flublock Quadrivalent (contains three-times the antigen)	18 years and older	Yes
High dose (egg-based)	Fluzone High-Dose Quadrivalent (contains four-times the antigen)	65 and older	Yes
Adjuvanted (made with an ingredient that creates a strong immune response)	Fluad Quadrivalent	65 and older	Yes
Live Attenuated Influenza Vaccine (LAIV)/Nasal Spray (made with weakened live flu virus)	FluMist Quadrivalent	Age 2 years through 49 years	No
Flu Vaccination by Jet Injector	AFLURIA Quadrivalent	18 through 64 years	No

Flu Vaccine Key points (CDC, 2023b):

• All flu vaccines for the upcoming season are quadrivalent vaccines targeting four different flu viruses including two influenza A viruses (H1N1 and H3N2) and two influenza B viruses.
• All vaccines are administered as an intramuscular injection except for the nasal spray and jet injector. The jet injector delivers the vaccine using a high-pressure, narrow stream of fluid to penetrate the skin instead of a needle.
• September and October are the preferred months to get the flu vaccine, ideally by the end of October. After vaccination, it takes about 2 weeks for antibodies to develop to protect against the flu.
• Children receiving their first flu vaccine will need two doses spaced 4 weeks apart.
• Individuals with an egg allergy are no longer required to be vaccinated in  an inpatient or outpatient medical setting; they may receive any vaccine (egg-based or non-egg-based) in settings where allergic reactions can be recognized and treated quickly.
• People who have had a previous allergic reaction to a component of the flu vaccine should not receive the vaccine.
• Pregnant individuals should get a flu vaccine however, they should not get the nasal spray version. 

COVID-19 Vaccine (CDC, 2023c)

While the public health emergency declaration ended last spring, the CDC continues to recommend that everyone 6 months and older get an updated COVID-19 vaccine to help protect against illness, hospitalization, effects of long COVID, and potential death. Like the influenza virus, the coronavirus that causes COVID-19 mutates and evolves to survive. The latest vaccines target the Omicron XBB.1.5 subvariant and will generate an immune response against other strains such as BA.2.86 and EG.5.
 
COVID-19 Vaccine Key points (CDC, 2023c):

• There are three COVID-19 vaccines available in the United States for the 2023-24 season: Pfizer-BioNTech, Moderna, and Novavax; the Johnson & Johnson/Janssen COVID-19 vaccine is no longer available in the U.S.
• If an individual recently developed COVID-19 illness, they still need to stay up to date on their vaccines, however the vaccine should be delayed by 3 months following the first signs of infection.
• Individuals who are moderately or severely immunocompromised should speak to their healthcare provider about the need for additional doses of updated COVID-19 vaccines.
• Children, teens, and adults can get a COVID-19 vaccine at the same time as other vaccines, such as the flu vaccine.
• COVID-19 vaccines will remain free of charge, covered by the U.S. government or by most private insurance.

Respiratory Syncytial Virus (RSV) Vaccine

RSV is a highly contagious respiratory virus that typically causes mild cold symptoms lasting only a week or two. However, RSV can cause serious illness in infants and older adults, resulting in 60,000-12,000 hospitalizations and 6,000-10,000 deaths in individuals 65 years and older (CDC, 2023e). The CDC recommends that “adults 60 years of age and older receive a single dose of RSV vaccine using shared decision making (SCDM)” (CDC, 2023e). In other words, healthcare providers should discuss with their patients the risks and benefits of RSV vaccination to help the patient to make an informed decision.
 
Individuals 60 years and older who are frail, living in a long-term care facility or with any of the following chronic medical conditions are at high risk for severe RSV disease and may benefit from vaccination (CDC, 2023e):

• Cardiovascular disease (i.e., congestive heart failure, coronary artery disease)
• Lung disease (i.e., asthma, chronic obstructive pulmonary disease)
• Kidney disorders
• Liver disorders
• Neurologic or neuromuscular conditions
• Hematologic disorders
• Diabetes mellitus
• Moderate or severe immune compromise

RSV Key Points (CDC, 2023e):

• There are two RSV vaccines approved by the Food and Drug Administration (FDA) available this season in the U.S. RSVPreF3 (Arexvy, GSK) and RSVpreF (Abrysvo, Pfizer). Both vaccines contain a recombinant RSV F protein antigen and are administered by intramuscular injection.
• RSV vaccination should happen before the start of the fall/winter RSV season.
• The RSV vaccine requires only one dose. Each vial contains 120 mcg of antigen that requires reconstitution prior to injection.
• While the RSV vaccine may be given with other adult immunizations, studies have found that flu vaccine effectiveness was higher when administered separately from RSV.
• Adults with minor illness (i.e., cold) can receive the RSV vaccine. Vaccination should be delayed for moderate or severe acute illness.
• Common side effects include pain, redness, and swelling at injection site, fatigue, fever, myalgia, headache, nausea, and diarrhea.
• Length of protection has not yet been determined for either vaccine, but preliminary reports find they provide some protection for at least two RSV seasons.

References
Centers for Disease Controla and Prevention (CDC). (2022, October 18). Flu Vaccination Coverage, United States, 2023-22 Influenza Season. https://www.cdc.gov/flu/fluvaxview/coverage-2022estimates.htm 
 
Centers for Disease Control and Prevention (CDC). (2023a, May 26). 2022-2023 U.S. Flu Season: Preliminary In-Season Burden Estimates. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm
 
Centers for Disease Control and Prevention (CDC). (2023b, August 25). Key Facts About Seasonal Flu Vaccine. https://www.cdc.gov/flu/prevent/keyfacts.htm
 
Centers for Disease Control and Prevention (CDC). (2023c, September 15). Stay Up to Date with COVID-19 Vaccines. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html
 
Centers for Disease Control and Prevention (CDC). (2023d, August 30). Respiratory Syncytial Virus (RSV) Immunizations. https://www.cdc.gov/vaccines/vpd/rsv/index.html
 
Centers for Disease Control and Prevention (CDC). (2023e, August 30). Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html