Interim Guidance for Routine and Influenza Immunization Services During the COVID-19 Pandemic

This interim guidance is intended to assist healthcare personnel in a variety of clinical and alternative settings for the safe administration of vaccines during the COVID-19 pandemic. This guidance will be continually reassessed and updated based on the evolving epidemiology of COVID-19 in the United States. This guidance focuses primarily on reducing the transmission of SARS-CoV-2, the virus that causes COVID-19, in vaccination settings: outlining circumstances in which it is safest for people to come to a vaccination setting (particularly since any time a person leaves home there is an increased potential for exposure or transmission of SARS-CoV-2), or when it is safest for people who are already in healthcare or congregate settings to be vaccinated. Additionally, when deciding when to vaccinate individual patients, healthcare personnel should consider factors, such as presence and severity of acute illness which might be a precaution for vaccination, presence of underlying risk factors that might predispose a person to severe vaccine-preventable illness, likelihood that the person can or will return for vaccination at a later date, and the degree to which vaccine-preventable illnesses (such as influenza) are occurring in the community. Healthcare personnel who administer vaccines should also consult guidance from state, local, tribal, and territorial health officials and the respective vaccination statements from the Advisory Committee on Immunization Practices (ACIP).

Efforts to reduce transmission of SARS-CoV-2, such as stay-at-home and shelter-in-place orders, have led to decreased use of routine preventive medical services, including immunization services. Ensuring that routine vaccination is maintained or reinitiated during the COVID-19 pandemic is essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks. Routine vaccination prevents illnesses that lead to unnecessary medical visits, hospitalizations and further strain the healthcare system. For the 2020-2021 influenza season, influenza vaccination will be paramount to reduce the impact of respiratory illnesses attributed to influenza in the population and resulting burdens on the healthcare system during the COVID-19 pandemic. Communicating the importance of vaccination to patients and parents/caregivers as well as the safety protocols and procedures outlined in this guidance can help provide reassurance to those who may otherwise be hesitant to present for vaccination visits.

Routine vaccination is an essential preventive care service for children, adolescents, and adults (including pregnant people) that should not be delayed because of the COVID-19 pandemic. Because of COVID-19-related reductions in people accessing vaccination services, it is important to assess the vaccination status of all children and adolescents at each patient visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up. All vaccines due or overdue should be administered according to the recommended CDC immunization schedules during that visit, unless a specific contraindication exists, to provide protection as soon as possible as well as minimize the number of healthcare visits needed to complete vaccination.

• Children and adolescents: Healthcare personnel should identify children who have missed well-child visits and/or recommended vaccinations and contact parents to schedule in-person appointments, starting with newborns, infants and children up to 24 months, young children, and extending through adolescence. Additional guidance is available for the prevention of mother-to-child transmission of hepatitis B during COVID-19-related disruptions.
• Pregnant people: If administration of the recommended maternal vaccines (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and influenza) has been delayed because of reduced or deferred in-person prenatal care visits, pregnant people should be scheduled for follow-up and receive vaccination during the next in-person appointment.
• Adults: Healthcare personnel, whether they administer vaccines or not, should take steps to ensure that their patients continue to receive vaccines according to the Standards for Adult Immunization Practice. If vaccination is deferred, older adults and adults with underlying medical conditions who subsequently become infected with a vaccine-preventable disease, are at increased risk for complications.

Annual influenza vaccination is recommended for all persons aged 6 months and older to decrease morbidity and mortality caused by influenza. Healthcare personnel should consult current influenza vaccine recommendations for guidance around the timing of administration and use of specific vaccines.

During the COVID-19 pandemic, reducing the overall burden of respiratory illnesses is important to protect vulnerable populations at risk for severe illness, the healthcare system, and other critical infrastructure. Thus, healthcare personnel should use every opportunity during the influenza vaccination season to administer influenza vaccines to all eligible persons, including:

• Essential workers: Healthcare personnel, including staff in post-acute and long-term care facilities, as well as pharmacy staff, and other critical infrastructure workforce
• Persons at increased risk for severe illness from COVID-19: Including adults aged 65 years and older, residents in post-acute and long-term care facilities, and persons of all ages with certain underlying medical conditions. Severe illness from COVID-19 has been observed to disproportionately affect members of certain racial and ethnic minority groups
• Persons at high risk for influenza complications: Including infants aged 6 months and older and young children aged <5 years, children with neurologic conditions, pregnant people, adults aged 65 years and older, and other persons with certain underlying medical conditions

It is important to counsel the patient about the risk of self-limited side effects after influenza vaccination, including local reactions, such as redness, pain, or swelling at the injection site, and systemic reactions, which include fever, chills, headache, and body aches. If they occur, such side effects normally resolve within 72 hours after vaccination.  Because of concerns about COVID-19, if a vaccine recipient develops fever after vaccination, they should stay home until they have been fever-free for 24 hours without the use of fever-reducing medications. Influenza vaccination does not cause respiratory symptoms common in COVID-19, such as cough or shortness of breath. If the vaccine recipient develops new symptoms of COVID-19 (e.g., cough or shortness of breath), or if fever does not resolve within 72 hours of vaccination without the use of fever-reducing medications, the recipient should contact their healthcare provider. If the patient develops emergency warning signs for COVID-19, emergency medical care should be sought immediately.

There are no data to inform optimal timing of influenza vaccination in persons with COVID-19 or who are recovering from COVID-19 with regards to influenza vaccine effectiveness. Additionally, some patients with COVID-19 are treated with medications that can suppress the immune system (e.g., IL-6 inhibitors, high dose steroids).  It is possible that these medications may diminish immune response to influenza vaccination, but the ideal time to vaccinate after discontinuation of these medications is not known. These persons might also be at increased risk for severe illness due to influenza as a result of immunosuppression. Timing of vaccination for these individuals should be guided by considerations of the individual’s underlying risk of medical complications due to influenza, and the degree of influenza circulation in the local community.

Visits for routine vaccination should be deferred for asymptomatic and pre-symptomatic persons who have tested positive for SARS-CoV-2, the virus that causes COVID-19, for 10 days from their positive test result. For symptomatic persons with suspected or confirmed COVID-19, visits for routine vaccination should be deferred until criteria have been met for them to discontinue isolation: at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving, AND the person is no longer moderately to severely ill. Consider further deferring (postponing) the vaccination visit until the person has fully recovered from acute illness.  Persons who have had a known exposure to a person with COVID-19 should not seek outpatient care solely for vaccination until their 14-day quarantine period has ended. Vaccination visits for all of these individuals should be postponed to avoid exposing healthcare personnel and other patients in the vaccination setting to SARS-CoV-2. When scheduling or confirming appointments for vaccination, patients should be instructed to notify the provider’s office in advance if they currently have or develop any symptoms of COVID-19, or if they have had any known exposures to a person who has tested positive for COVID-19 in the past 14 days.  However, if patients with symptomatic COVID-19 seek care in a healthcare setting and are still under isolation criteria, deferral of vaccination may be warranted, depending upon the degree of illness and other individual factors. Moderate to severe illness with or without fever is a precaution to vaccination for all vaccines.  Additional considerations regarding influenza vaccination of persons who are already in healthcare or congregate settings are discussed below.

Vaccination in the medical homeexternal icon is ideal to ensure that patients receive other preventive services that may have been deferred during the COVID-19 pandemic. However, vaccination at locations outside the medical home may help increase access to vaccines in some populations or situations, particularly when the patient does not have a primary care provider or when care in the medical home is not available or feasible. Regardless of vaccination location, best practices for storage and handling of vaccines and vaccine administration should be followed. In addition, information on administered vaccines should be documented (e.g., through the state-based immunization information system [IIS], patient’s electronic medical record, client-held paper immunization records) so that healthcare personnel have accurate and timely information on their patients’ vaccination status and to ensure continuity of care in the setting of COVID-19-related disruptions to routine medical services.

The potential for asymptomatic transmission of the virus that causes COVID-19 underscores the importance of applying infection prevention practices to encounters with all patients, including physical distancing, respiratory and hand hygiene, surface decontamination, and source control while in a healthcare facility. Immunization providers should refer to the guidance developed to prevent the spread of COVID-19 in healthcare settings, including outpatient and ambulatory care settings.

To help ensure the safe delivery of care during vaccination visits, providers should:

• Minimize chances for exposures, including:
  • Screen for symptoms of COVID-19 and contact with persons with possible COVID-19 prior to and upon arrival at the facility and isolate symptomatic patients as soon as possible.
  • Limit and monitor points of entry to the facility and install barriers, such as clear plastic sneeze guards, to limit physical contact with patients at triage.
  • Implement policies for the use of a cloth face covering in persons over the age of 2 years (if tolerated).
  • Ensure adherence to respiratory hygiene, cough etiquette, and hand hygiene.
• Ensure all staff adhere to the following infection prevention and control procedures:
  • Follow Standard Precautions, which includes guidance for hand hygiene and cleaning the environment between patients.
  • Wear a medical facemask at all times.
  • Use eye protection based on level of community transmission:
    • Moderate to substantial: Healthcare personnel should wear eye protection given the increased likelihood of encountering asymptomatic COVID-19 patients.
    • Minimal to none: Universal eye protection is considered optional, unless otherwise indicated as a part of Standard Precautions.
  • Additional considerations for vaccine administration:
    • Intranasal or oral vaccines:
      • Healthcare personnel should wear gloves when administering intranasal or oral vaccines because of the increased likelihood of coming into contact with a patient’s mucous membranes and body fluids. Gloves should be changed between patients in addition to performing hand hygiene.
      • Administration of these vaccines is not considered an aerosol-generating procedure and thus, the use of an N95 or higher-level respirator is not recommended.
    • Intramuscular or subcutaneous vaccines:
      • If gloves are worn during vaccine administration, they should be changed between patients in addition to performing hand hygiene.
    • Ensure physical distancing by implementing strategies, such as:
      • Separating sick from well patients by scheduling these visits during different times of the day (e.g., well visits in the morning and sick visits in the afternoon), placing patients with sick visits in different areas of the facility, or scheduling patients with sick visits in a different location from well visits (when available).
      • Reduce crowding in waiting areas by asking patients to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment.
      • Ensure that physical distancing measures, with separation of at least 6 feet between patients and visitors, are maintained during all aspects of the visit, including check-in, checkout, screening procedures, and postvaccination monitoring using strategies such as physical barriers, signs, ropes, and floor markings.
      • Utilize electronic communications as much as possible (e.g., filling out needed paperwork online in advance) to minimize time in the office as well as reuse of materials (e.g., clipboards, pens).

Guidance has been developed for the administration of vaccines at pharmacies, temporary, off-site, or satellite clinicspdf iconexternal icon, and large-scale influenza vaccination clinics. Other approaches to vaccination during the COVID-19 pandemic may include drive-through immunization services at fixed sites, curbside clinics, mobile outreach units, or home visits.

The general principles outlined for healthcare facilities should also be applied to alternative vaccination sites, with additional precautions for physical distancing that are particularly relevant for large-scale clinics, such as:

• Providing specific appointment times or other strategies to manage patient flow and avoid crowding.
• Ensuring sufficient staff and resources to help move patients through the clinic flow as quickly as possible.
• Limiting the overall number of attendees at any given time, particularly for populations at increased risk for severe illness from COVID-19.
• Setting up a unidirectional site flow with signs, ropes, or other measures to direct site traffic and ensure physical distancing between patients.
• When feasible, arranging a separate vaccination area or separate hours for persons at increased risk for severe illness from COVID-19, such as older adults and persons with underlying medical conditions.
• Remind persons who have had close contact to a person with COVID-19 in the past 14 days or who are positive for COVID-19, that they should not visit a pharmacy solely for vaccination or a temporary, off-site, or satellite vaccination clinic:
  • until their 14-day quarantine period has ended (for persons with close contact to a person with COVID-19 in past 14 days)
  • until their 10-day isolation period ends (for asymptomatic or pre-symptomatic COVID-19 patients)
  • until at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving AND they are no longer moderately to severely ill. Consider further deferring the vaccination visit until the person has fully recovered from acute illness (for symptomatic COVID-19 patients)
• Selecting a space large enough to ensure a minimum distance of 6 feet between patients in line or in waiting areas for vaccination, between vaccination stations, and in postvaccination monitoring areas (the Advisory Committee on Immunization Practices recommends that providers consider observing patients for 15 minutes after vaccinationpdf icon to decrease the risk for injury should they faint).

Vaccinating patients who are already in a healthcare setting (e.g., patients in outpatient settings, including:  urgent cares, outpatient clinics, or community influenza vaccination events; patients presenting at an emergency department; or hospital inpatients in acute care) does not necessarily introduce additional risk to healthcare personnel or other patients. In the healthcare setting, assuming proper infection control precautions can be taken, healthcare personnel should take advantage of opportunities to vaccinate patients to the extent possible, with the following considerations:

• Patients who have no known recent exposure to a person with COVID-19 are recommended to receive influenza vaccine.
• Patients in quarantine due to close contact to a person with COVID-19 in the past 14 days can receive influenza vaccine, particularly if they might not have another opportunity to be vaccinated; however, if there are concerns that post-vaccination symptoms might cause diagnostic confusion, vaccination can be deferred until quarantine has ended.
• Patients with suspected or confirmed COVID-19 who are asymptomatic or pre-symptomatic, or who have recovered and are now asymptomatic, can receive influenza vaccine, even if criteria for discontinuation of isolation are not yet met. For example, an asymptomatic person being discharged from the hospital can receive influenza vaccine before discharge, since they might not have another opportunity to be vaccinated once they are discharged.
• For patients with suspected or confirmed COVID-19 who are symptomatic, healthcare personnel should consider deferring (postponing) influenza vaccination for at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving AND no longer moderately to severely ill. Consider further deferring vaccination until the patient has fully recovered from acute illness.

CDC recommends that these facilities offer influenza vaccine to all residents and healthcare personnel throughout the influenza season. In post-acute and long-term care settings, group homes, mental health inpatient facilities, or inpatient substance use disorder treatment centers where direct exposure and transmission of SARS-CoV-2 can occur repeatedly for long periods of time, residents with close contact to someone with COVID-19, as well as asymptomatic and pre-symptomatic residents infected with SARS-CoV-2 in isolation, can be vaccinated. In these settings, healthcare personnel are already entering residents’ rooms to deliver medications or conduct health assessments, so administering influenza vaccine should not result in additional exposures. However, for residents with suspected or confirmed COVID-19 who are symptomatic, healthcare personnel should consider deferring (postponing) vaccination until criteria for discontinuing isolation are met (i.e., for at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving), AND the person is no longer considered moderately or severely ill.  Consider further deferring vaccination until the person has fully recovered from acute illness.

CDC recommends that correctional and detention facilities offer influenza vaccine to all incarcerated/detained persons and staff throughout the influenza season, especially those who are at higher risk of severe illness from influenza. Influenza vaccination is always important in congregate settings where large numbers of persons are in close contact for prolonged periods of time without opportunities for physical distancing. During the COVID-19 pandemic, influenza vaccination will be even more critical to maintain population health and help reduce pressure on healthcare resources.

For incarcerated or detained persons who are under quarantine precautions because of exposure to a person with COVID-19 in the past 14 days, healthcare personnel should consider deferring (postponing) influenza vaccination until after the quarantine period ends. Delaying vaccination until the end of the quarantine period prevents the quarantined persons from potentially exposing people in other parts of the facility in the event that receiving vaccination would require them to leave the quarantine area, and prevents possible mild vaccination side effects from being mistaken for COVID-19 symptoms which has broader implications in this type of setting. Note that if a person is in routine, administrative quarantine that happens either at intake before being assigned housing with the rest of the facility’s population, or before transfer or release (rather than quarantine because of exposure to someone with COVID-19), they can be vaccinated during this period.

For incarcerated or detained persons in medical isolation as confirmed or suspected COVID-19 cases with symptoms of COVID-19, healthcare personnel should consider deferring (postponing) vaccination until criteria to discontinue isolation are met (i.e., for at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving), AND the person is no longer considered moderately or severely ill.  Consider further deferring vaccination until the person has fully recovered from acute illness. Persons in medical isolation for COVID-19 who are asymptomatic or pre-symptomatic can be vaccinated if it can be done without leaving the isolation area (e.g., so they do not potentially expose people in other parts of the facility to SARS-CoV-2). Vaccination should only occur under circumstances when healthcare personnel providing vaccination are wearing recommended PPE.

Sometimes incarcerated or detained persons in quarantine or isolation are transferred to other facilities during their quarantine or isolation period. In addition, some persons may be released from the facility into the community during their isolation or quarantine period, since they cannot legally be held in the facility beyond their release date. In these instances, the decision to vaccinate prior to transfer or release should be left to the facility’s discretion.*

Shelters and homeless service providers should consider ways to provide access to influenza vaccine for people experiencing homelessness, as well as staff, throughout the influenza season, especially those who are at higher risk of severe illness from influenza. Influenza vaccination is always important in congregate settings where large numbers of people are in close contact for prolonged periods of time with limited opportunities for physical distancing. During the COVID-19 pandemic, influenza vaccination will be even more critical to maintain population health. 

For people experiencing homelessness who are under quarantine precautions because of exposure to a person with COVID-19 in the past 14 days, healthcare personnel should consider deferring (postponing) influenza vaccination until after the quarantine period ends. Delaying vaccination until the end of the quarantine period prevents the quarantined persons from potentially exposing people in other parts of the shelter in the event that receiving vaccination would require them to leave the quarantine area, and prevents possible mild side effects from vaccination from being mistaken for COVID-19 symptoms which has broader implications in this type of setting.

For people experiencing homelessness with suspected or confirmed COVID-19 who are symptomatic, healthcare personnel should consider deferring (postponing) vaccination for at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving, AND the person is no longer considered moderately or severely ill.  Consider further deferring vaccination until the person has fully recovered from acute illness. People in isolation for COVID-19 who are asymptomatic or pre-symptomatic can be vaccinated, if the process of accessing vaccination does not compromise their ability to isolate (e.g., having to travel to a healthcare facility solely to be vaccinated). When deciding whether to vaccinate persons who are asymptomatic for COVID-19 in these settings, facilities should consider the availability of healthcare personnel to provide vaccination on-site, in addition to the availability of PPE for these healthcare personnel, and the degree to which influenza is circulating within the facility and in the community. Vaccination should only occur under circumstances when healthcare personnel providing vaccination are wearing recommended PPE.

With reduced vaccine administration during the COVID-19 pandemic, unvaccinated or undervaccinated patients are susceptible to preventable illness and communities are at risk for outbreaks. Thus, implementation of strategies to promote adherence to the vaccination schedule and ensure catch-up vaccination is important, especially for children. Reminder and recall systems should be implemented to identify patients who are due for or who have missed vaccine doses. Immunization Information Systems and electronic health records may be able to support this work. In addition, the vaccination status of all patients should be assessed at every healthcare visit to reduce missed opportunities for vaccination. Use of standing ordersexternal icon may further improve efficiency of catch-up vaccination.

• Interim CDC Guidance on Handling Non-COVID-19 Public Health Activities that Require Face-to-Face Interaction with Clients in the Clinic and Field in the Current COVID-19 Pandemic
• Repository of Resources for Maintaining Immunization during the COVID-19 Pandemicexternal icon
• Resources for Hosting a Vaccination Clinic
• Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic
• Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmissionpdf icon
• Vaccine Recommendations and Guidelines of the ACIP
• Community Preventive Services Task Force – Findings for Increasing Vaccinationexternal icon
• Vaccine Finderexternal icon
• Vaccines for Children program
• Vaccine information statements
• Vaccinate with Confidence
• Immunization Information Systems
• Epidemiologyand Prevention of Vaccine-Preventable Diseases, 13^th ed
• Vaccine administration Resource Library