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Influenza vaccines can be co-administered with COVID-19 vaccines for both children and adults, according to updated recommendations from the CDC's Advisory Committee on Immunization Practices (ACIP).

In a unanimous 14-0 vote on Thursday, the committee approved language for co-administration of influenza and COVID-19 vaccines, in line with current CDC guidance that says COVID-19 vaccines can be administered with other vaccines, though providers should be aware of increased reactogenicity.

Some ACIP members took issue with the lack of data on co-administration in children, though CDC staff noted there had been one pre-print examining co-administration of influenza vaccine and the Novavax COVID-19 vaccine that showed no changes in antibody titers for influenza vaccine and no safety issues.

ACIP member Matthew Daley, MD, of Kaiser Permanente Colorado, encouraged additional study about co-administration of COVID-19 and influenza vaccines, especially in children and adolescents.

"Most adolescents will be vaccinated [against] COVID-19 in the summer and have their flu vaccination in the fall" this year, but this could become an issue with COVID-19 boosters administered at the same time as influenza vaccine next year, he said.

Other changes to the wording of clinical guidance included a more explicit statement about timing of influenza vaccines, saying non-pregnant adults should avoid influenza vaccine in July and August unless they cannot be vaccinated later, due to concerns about waning immunity.

The language also said children should be vaccinated by the end of October, and pregnant women should be vaccinated in the third trimester as soon as a vaccine becomes available.

Language about severe allergic reactions was updated to more closely harmonize with flu vaccine packaging, and age indications for cell-based vaccine Flucelvax Quadrivalent were updated, as the vaccine is now indicated for individuals ages 2 and older.

Dengue Vaccine for Children in Endemic Areas

The committee also voted 14-0 to recommend the dengue vaccine for seropositive children ages 9 to 16 living in dengue endemic areas of the U.S., such as Puerto Rico. The vaccine was approved for this population in 2019.

CDC staff emphasized the importance of a laboratory-confirmed positive test, indicating prior infection, and stressed the need for highly sensitive and specific testing prior to vaccination.

One option was to recommend the vaccine through shared clinical decision-making, but CDC staff noted insurance companies in the affected areas said if that was the case, parents would have to pay for the test upfront and then submit for reimbursement.

Given logistical challenges, liaison member Yvonne Maldonado, MD, of the American Academy of Pediatrics (AAP), warned that even with a full recommendation, this would not be an "easy process," but that the AAP planned to engage its local chapters to get involved, as well as key public health stakeholders.

"The risks are extremely manageable, albeit there will be a number of administrative obstacles to move through," she said, saying the key issues are the "insistence on having a highly sensitive [lab] test available and the recommendation to only vaccinate those kids."

The dengue vaccine is a three-dose vaccine, administered 6 months apart for children ages 9 to 16 with laboratory confirmation of prior dengue infection only.

Two-Dose Rabies Vaccine OK'd for Kids

In another 14-0 vote, the committee recommended a two-dose rabies vaccine for children younger than age 18 as pre-exposure prophylaxis if they are traveling to a country with potential rabies exposure.

For children with a "sustained and elevated risk" of rabies exposure, they can either have their titers checked 1 to 3 years later, and be boosted accordingly, or receive a booster after day 21 or no later than 3 years after the second shot.

CDC staff noted that a shorter vaccination series would be "easier to implement before travel," though they cautioned there is no data on this vaccine in children beyond 3 years.

Previously, rabies pre-exposure prophylaxis was a three-dose rabies vaccine, but the committee voted in May for the two-dose series in adults who are indicated for rabies vaccine. The vaccine is to be administered on days 0 and 7.

All three votes on flu vaccine, dengue vaccine, and rabies vaccine were also unanimously approved for their respective Vaccines for Children resolutions.

As always, recommendations of the ACIP are not considered final until they are published in the Morbidity and Mortality Weekly Report.

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