It is estimated that the COVID-19 vaccine prevented 19.8 million deaths globally between December 2020-December 2021. COVID-19 remains the leading cause of death from respiratory viruses in the U.S.

Due to viral mutation, it is important to get updated vaccines for COVID-19 as they become available to continue to be protected against serious complications and long COVID. For adults, the more vaccines you get, the less likely you are to get long COVID. This is called a dose-response relationship – one dose of vaccine reduces risk by 21%, two doses by 59%, and three or more doses reduces risk by 73%.

Updated COVID-19 vaccines are effective in preventing infection, boosting immunity and providing sustained protection against severe disease.

Influenza, also known as flu, occurs seasonally from early fall through late spring, peaking during winter. It may lead to hospitalization or death, and the best way to prevent the flu is to receive an annual vaccination. The Centers for Disease Control and Prevention (CDC) estimates that 70-85% of seasonal flu deaths are attributed to those 65 years and older.

During the 2019-2020 flu season, flu vaccination prevented an estimated 7.09 million illnesses, 3.46 million medical visits, 100,000 hospitalizations and 7,100 deaths. The Healthy People 2030 goal is to increase the proportion of persons aged six months and over who are vaccinated annually against seasonal influenza to 70%.

In the 2020-2021 flu season, however, 49.8% of persons aged six months and over were vaccinated against seasonal influenza. The CDC’s Seasonal Influenza Vaccination Resources for Health Professionals includes toolkits, videos and flyers that can be used within your organization.

Getting vaccinated decreases risk of flu illness by up to 60%.

Pneumonia is an infection of the lungs that can be caused by bacteria, viruses or fungi. Older adults and those with chronic conditions are at an increased risk of developing complications from pneumonia. A common cause of pneumonia are viruses, such as influenza, respiratory syncytial virus (RSV) and SARS-CoV-2 (the virus that causes COVID-19). Approximately 1 million individuals 65 years and older are hospitalized each year with pneumonia and infection occurs year-round, peaking in winter.

Pneumonia vaccines are effective and pneumococcal disease rates have decreased significantly with the use of preventative vaccines in children and adults – learn more.

RSV can be serious in adults with risk factors, including those who reside in long-term care facilities. Complications can include bronchiolitis, pneumonia, hospitalization and death.

In clinical trials, the RSV vaccine provides protection for up to two years.

After someone is infected with Chickenpox, the virus remains dormant and often settles near nerves which can later be reactivated and cause shingles. A common complication is nerve pain, known as postherpetic neuralgia (PHN), which can be permanent in some cases.

The shingles vaccine is highly effective (97% in patients aged 50-69, 91% in patients 70 and older and between 68-91% in immunocompromised patients) and is the only way to prevent shingles.

Booster doses of Td or Tdap are recommended for most adults every 10 years. Diphtheria and pertussis are spread from person to person, whereas tetanus enters the body through cuts or wounds. Tetanus is serious and often fatal, and diphtheria causes damage to the heart, kidneys and nervous system and can be deadly. Pertussis can increase the risk of pneumonia along with other complications.

The tetanus, diphtheria, and pertussis vaccine protects virtually everyone who is fully vaccinated but wanes over time. It is important to get booster doses as recommended by the Advisory Committee on Immunization Practices (ACIP).

The CDC recommends the SHARE method.

S: SHARE the reasons why a vaccine is right for the patient/resident given their age, health status, lifestyle, occupation or other risk factors.

H: HIGHLIGHT positive experiences with vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in vaccination.

A: ADDRESS patient/resident questions and any concerns about vaccines including side effects, safety and vaccine effectiveness in plain and understandable language.

R: REMIND patients/residents that vaccines protect them and their loved ones from serious illness and other complications.

E: EXPLAIN the potential costs of becoming infected including serious health effects, time lost (such as missing work or family obligations) and financial costs.

Motivational Interviewing (MI) strategies can be beneficial when initiating conversations to boost vaccine acceptance. The CDC has a quick 4-step guide to apply motivational interviewing in as little as one minute. These vaccine hesitancy tips from the American Academy of Family Physicians provide strategies and sample questions, as well as links to helpful resources.

Using Best Practices to Address COVID-19 Vaccine Hesitancy: The Case for the Motivational Interviewing Approach by Amanda Gabarda, EdD, MPH, CHES and Susan W. Butterworth, PhD, MS, recommends incorporating the “Spirit of MI” in your conversations about vaccine acceptance through:

Partnership: Building trust and rapport and being together on equal ground.

Example: “Together, we will find a solution that you are comfortable with.”

Acceptance: Prizing the inherent worth and potential of every patient/resident, acknowledging their strengths and supporting autonomy.

Example: “The choice is yours, and you are the expert on what will work for you and your family.”

Compassion: Actively promoting another’s welfare and giving priority to their needs.

Example: “Your well-being is our top priority.”

Evocation: Drawing out the patient/resident’s strengths, resources, ideas, feelings and motivations.

Example: “What are some possible benefits you might get from being vaccinated?”

Another strategy is using OARS (Open-ended questions, Affirming, Reflective listening and Summarizing). You can learn more about OARS and why it’s effective here.

Open Questions: “Tell me more about your thoughts on the influenza vaccine.” “What are your concerns about the pneumococcal vaccine?”

Affirmation: “You’ve already done quite a bit of research and are well informed.” “You value your family and want to make sure they are safe.”

Reflection: “You’re feeling pressured and you need more time to determine if this is the best decision for you.” “You are eager to get the vaccine because it will provide a sense of security for you and your family.”

Summary: “We’ve discussed both the pros and the cons and you seem to be leaning in favor of getting vaccinated. You are reassured that the benefits outweigh the risks now that you’ve learned more about the clinical trial process. Would it be okay to talk about next steps for you and your family?”

Developed by Telligen, this toolkit offers trusted online sources for credible immunization information on influenza and pneumococcal vaccines for patients/residents and families to explore outside of the doctor’s office.

This one-page flyer provides strategies and key talking points that are supported with clinical evidence in order to address common staff concerns with the COVID-19 vaccines.

This on-demand continuing education module by Stanford Center for Continuing Medical Education, which is jointly accredited by AACME, ACPE and ANCC, covers how to approach several common vaccine hesitancy scenarios.

Immunize.org has resources that are available to help medical professionals discuss immunization with concerned patients/residents. Vaccine Confidence & Addressing Concerns from Immunize.org provides several different topics to diminish fears and provides information to patients/residents and families about the composition of vaccines and the way in which they work.

Ensure all immunizing staff are qualified and meet regulatory requirements for your state. Consider internal documentation of administration technique and make training resources readily available.

Encourage your staff to receive all recommended vaccines for healthcare providers.

Training resources for administration techniques:

• Intramuscular (IM): APhA IM video, CDC video, needle gauge and length recommendations. Download a flyer for vaccines that are administered IM.
• Subcutaneous (SQ): APhA SQ video, needle gauge and length recommendations.
• Intranasal: Live attenuated influenza vaccine video, APhA intranasal video.

Any staff administering vaccines must be offered the Hepatitis B vaccine at no cost.

• • Provide staff with this Hepatitis B fact sheet and Hepatitis B vaccine VIS.
  • Document whether the vaccine was provided, employee is already vaccinated or declines the vaccine. Staff that initially decline may change their mind and get the vaccine at any point during employment.
  • See Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogen and Needlestick Prevention Safey webpage for more information.

Ensure you have policies, procedures and training to address:

Exposure/needlestick event:

• • Follow OSHA standards and resources for evaluating and controlling exposure.
  • Needlestick event – consider including this video and CDC recommended needlestick prevention strategies in staff training.
  • Proper sharps disposal.

Mandatory reporting to the FDA’s Vaccine Adverse Event Reporting System (VAERS), Vaccine Injury Compensation Program (VICP) and Countermeasures Injury Compensation Program (CICP).

• • See a comparison of VICP & CICP.
  • VICP Injury Table can be found here.

• Standing orders:
  1. With standing orders, there is increased access to vaccination for community members. These programs can be instituted in inpatient and outpatient organizations, long-term care facilities, managed care assisted living, correctional facilities, pharmacies and workplaces. Immunize.org (formerly the Immunization Action Coalition) provides sample standing orders for influenza, pneumococcal and COVID-19 vaccines.
  2. Standing orders can allow nurses and pharmacists to administer vaccinations per a physician or agency-approved protocol.

Review the recommended areas to address in your policy.

Ensure your organization has a clear and concise policy for storing and handling vaccines from point of receipt from the manufacturer/wholesaler to point of administration to the patient/resident.

• • Refer to the CDC Vaccine Storage and Handling Toolkit for best practices.

Refer to this checklist while developing procedures and include:

• • Process for checking the transport temperature monitor from the manufacturer/wholesaler for potential excursions (and a process for what to do if out of range). In most cases, it is appropriate to label the vaccine “do not use” and then store appropriately (refrigerator or freezer depending on vaccine) as usual until further instructions can be provided by the manufacturer.
  • Procedures for temperature monitoring in your storage unit (section three of this CDC handbook) and what to do if there is an excursion.
  • Procedures for taking a vaccine off-site short-term (i.e., mobile clinic with refrigerated vaccine) as well as emergency transport (i.e., due to power outage). If there is a need to transport frozen vaccine, refer to section six of the Vaccine Storage and Handling Toolkit.
  • Temperature logs and other useful tools can be found here.

For more information, review the CDC At-A-Glance Resource Guide.

Vaccine preparation:

• • Ensure proper vaccine preparation and handling practices are included in your organization’s policy.
  • Staff should be comfortable working with vaccine diluents and trained in proper reconstitution techniques, when applicable.

• Review possible administration errors and incorporate best practices to avoid them.

• Curbside/Drive-Through Vaccination Clinics
• Mobile Clinic Checklist

Recognizing that preventing the spread of respiratory viruses in nursing homes requires a comprehensive approach, the CDC has developed a Viral Respiratory Pathogens Toolkit for Nursing Homes with recommended processes to implement.

• Develop a process to routinely screen and identify patient/resident need for vaccination.
  1. CDC immunization schedules can be found here.
  2. Guides for all Advisory Committee on Immunization Practices (ACIP) can be found here.
  3. Learn about common vaccine related questions patients may have.
  4. Post the Vaccines Work! document and utilize it as an educational tool.
  5. Use this printable screening checklist for adult vaccinations.
• Patient/resident monitoring: Determine an appropriate wait time accounting for the patient/resident’s medical history/status based on chart notes and/or responses to vaccination screening questions (will generally be 15-30 minutes).
  1. Post this resource for staff to aid in medical management of vaccine reactions.
  2. Ensure staff are prepared to recognize and treat anaphylaxis.
  3. Use the CDC Excipient Guide to identify potential allergies to vaccine components.
• Ensure your organization has an emergency protocol and supplies readily accessible.
  1. Ensure staff are trained in emergency protocol procedures. See Appendix D in this example from the Iowa Board of Pharmacy.
  2. Include a process to ensure supplies are not out of date (i.e., expiration dates of epinephrine or diphenhydramine).
  3. Ensure your patient/resident/caregiver/staff is offered a CDC VIS sheet as required. Document the date of the current VIS sheet on your vaccine record/consent.
• Document vaccine administration or refusal.
  • Document administered vaccines in the following places to maximize patient/resident healthcare:
    1. Electronic health record
    2. State Immunization Registry – Please refer to your state’s immunization program for additional information, resources and links.
       1. QIN-QIO states: Colorado, Illinois, Iowa, Oklahoma
       2. HQIC states: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Illinois, Missouri, Nebraska, Nevada, Oklahoma, Texas, Wisconsin, Wyoming
    3. For nursing homes – NHSN (visit our NHSN resources page for more information)
  • Document declined immunizations including a reason when possible.
    • For nursing homes, a declination form should be signed by the resident or representative. Documenting the reason helps knowing where to focus efforts in improving resident acceptance rates.

During an outbreak of a contagious respiratory illness (i.e., COVID-19, influenza or RSV), it is vital to continue offering vaccination for qualified patients/residents and staff who are not currently ill.

People with a known or potential COVID-19 exposure may receive the vaccine if they do not have symptoms consistent with COVID-19 while continuing to follow the CDC’s infection prevention and control guidance. For people recovering from a respiratory illness, it is recommended to defer vaccination until the acute illness has ended (if symptoms were present, symptoms are improving and there is no active fever) and criteria to discontinue isolation have been met. Those presenting with symptoms of long COVID can and should receive recommended vaccines for COVID-19 and other respiratory illnesses.

Note, it is not required to wait 90 days after a COVID-19 infection to get vaccinated if the resident/patient is due for a vaccination. The decision to vaccinate or wait 90 days should be based on shared clinical decision-making considering factors such as risk for severe illness and complications, age, comorbid conditions, immunocompromise and vaccine accessibility.

See guidance regarding vaccinating for influenza while taking antiviral medication for influenza.

Coadministration, or simultaneous administration, is the practice of administering more than one vaccine at an appointment. This does not mean that vaccine is to be combined into one syringe. Always follow manufacturer instructions for administration.

According to the CDC’s General Best Practice Guidelines for Immunization, it is recommended to administer all age-appropriate vaccines a patient is eligible for simultaneously. This includes coadministration for seasonal respiratory vaccines. See Table 3-4 for updated guidance and exceptions on coadministration. Most adult vaccines are not live vaccines. A list of vaccines by type can be found here.

Occasionally, there may be supply shortages. The CDC provides recommendations in times of shortages which can be found here.

Report all vaccination adverse events through the U.S. Food and Drug Administration (FDA) Vaccine Adverse Event Reporting System (VAERS). Instructions for reporting adverse reactions that patients/residents experience can be found on the VAERS website.

V-safe After Vaccination Health Checker is a smartphone app that reports side effects to the CDC and provides reminders if you need a second dose.

• Adult Immunization: Importance of Staying Up to Date with Vaccines | Immunize.org
• Communicating the Benefits of Influenza Vaccination | Immunize.org
• Adult Vaccination | CDC
• The Adult Vaccine Quiz | CDC

• Summary and complete ACIP RSV recommendations for adults 60 years of age and older
• Clinical considerations and shared clinical decision-making
• VIS sheet
• Products available in the United States

• Summary and complete ACIP recommendations
• One product – Shingrix – available in the United States
• VIS sheet

• Summary and complete ACIP Tetanus, Diphtheria, Pertussis Recommendations
• Guidance on Td vaccine shortage
• VIS sheets for Td and Tdap
• Products available in the United States
  • Note for adults 65 and older:
    • Either Td (Tenivac®) or Tdap is acceptable as a booster for those adults 65 and older
    • When Tdap is used, Boostrix® is preferred, but Adacel® (FDA approved 10-64 years) is deemed acceptable by the CDC if Boostrix® is not available