A flu season with a difference

sign that says: 'flu jab next exit'

What impact is the COVID-19 vaccine rollout having on the uptake of the flu shot and how can pharmacists promote the importance of the influenza vaccine?

According to the Australian Technical Advisory Group on Immunisation (ATAGI), the annual influenza vaccination continues to be the most important measure to prevent influenza and its complications, and is recommended for all people older than six months of age.

Nonetheless, we began the year under a cloud of uncertainty over whether the 2021 influenza vaccine and the COVID-19 vaccine could be administered concurrently. There was even rumoured talk about suspending, or at least slowing, the coronavirus vaccine rollout to allow for the administration of flu vaccines ahead of peak season (which has since been recanted!).

We now know that the COVID-19 and influenza vaccine cannot be administered together; people must wait 14 days between the two. Furthermore, the ATAGI advises:

  • There is no particular requirement regarding the order of receiving a dose of influenza vaccine and either the first or second dose of a COVID-19 vaccine.
  • People in high priority groups for COVID-19 vaccination should ensure they receive the COVID-19 vaccine as soon as it is available to them, and then receive their influenza vaccine. People in later COVID-19 vaccine priority groups not yet scheduled to receive a COVID-19 vaccine should receive their influenza vaccine first, so they are ready to have their COVID-19 vaccine when it becomes available to them.
  • There may be circumstances where co-administration or near administration (within days) of an influenza vaccine with a COVID-19 vaccine may be considered.
  • If an influenza vaccine has been inadvertently co-administered or given within a shorter interval than 14 days with a COVID-19 vaccine, revaccination with either vaccine is not considered necessary.

Yet, despite the latest advice on the administration of the influenza and COVID-19 vaccines, many pharmacists are claiming fewer people are requesting the flu jab this year.

A different kind of flu season

Last year there were 21,354 laboratory confirmed cases of influenza in Australia. In comparison to the 313,465 flu cases in 2019, this shows a 93% decrease in 2020.

Indeed, if we look at the latest surveillance data, it appears 2021 is likely to see even fewer cases of the flu. In January we recorded 55 cases, which compares with 6,978 in January 2020; there were 53 cases in February, in contrast to 7,170 cases in February last year; and 62 cases in March, versus 307 cases in March 2020.

Similarly, the northern hemisphere experienced an atypical flu season in 2020 with global surveillance data revealing much lower rates of influenza transmission than in previous years. In fact, data shows as much as a 99% drop in flu cases. This unusual pattern of influenza has been attributed to multiple factors including social distancing, improved hygiene practices, mask wearing, as well as increased flu vaccination.

Elise Wheadon, proprietor and pharmacist at Wizard Pharmacy in Kalgoorlie, WA, tells the AJP, “It’s been a really slow season so far, but this is especially evident as last year was crazy; people were asking for flu shots, or at least enquiring when they would be available, as early as February.

“The problem is stock. Every year we have more people who want to be immunised and we find that each year we run out of stock, so we continually increase the amount we order annually. Of course, because of last year’s high demand we ordered a lot more but the uptake is 50% of what it would normally be.

“I’m sure there are many pharmacies across Australia who have over ordered in anticipation of a surge like last year, which we’re just not seeing.”

Health Minister Greg Hunt receives his 2021 flu vaccine

Numbers are down

Lisa Barnes, pharmacy manager, Terry White Chemmart Coorparoo, Queensland, says their flu vaccine numbers are doing okay, but remain down compared to last year’s numbers. However, she attributes this to an early spike in demand in 2020.

“This year we are expecting a more delayed and prolonged approach to people receiving their flu vaccination, more alike the usual cold and flu season. Over the coming months as the weather cools down and winter approaches, we expect to see an increase in people requesting their flu vaccination, as shown in previous years.”

Ms Wheadon says there are many different reasons why people are delaying or deciding against getting the flu vaccine.

“Social distancing is one reason, but there is also the confusion around the COVID-19 vaccination. The communication has been really poor. Some people have told me they thought the COVID vaccine had the flu vaccine within it.

“Other people have explained they thought they had to prioritise the COVID vaccine; they weren’t aware you could have both as long as they’re administered 14 days apart.

“Additionally, the majority of communication coming from the government has been centred around the coronavirus vaccine, there’s been very little advertising or promotion for the flu vaccination.

“There are also the safety concerns with the AstraZeneca vaccine and the link to blood clots, which I believe has made the anti-vax movement swell. Last year I heard very few negative sentiments regarding the flu vaccine. However, this year I feel people are clutching to the negative aspects of AstraZeneca and associating it with all vaccinations—not just that one for COVID-19.”

Addressing concerns and encouraging uptake 

“I believe that originally people were holding off getting their flu vaccine early, as they were waiting to get the COVID vaccine first. With the prominence that coronavirus is playing in everyone’s lives, the focus this year for many individuals is on this vaccine alone.

TerryWhite Chemmart and many other organisations have put a lot of work and effort into ensuring people realise it is still vitally important for people to receive their flu vaccine as well this year,” says Ms Barnes.

“With the roll out of the COVID-19 vaccine being slightly slower than expected, people have since started coming in to get their flu vaccine first, which will still allow plenty of time for the required 14 days to pass before getting their COVID vaccination. Certainly, I think there was some confusion initially as to what the best timing was to receive the flu and COVID-19 vaccinations and this may have resulted in a slower uptake.

“We are now seeing people who were in the earlier COVID-19 vaccination groups and have already had their first dose of the vaccine (or both if they received the Pfizer vaccine), coming in at least 14 days later to have their flu vaccine.

“However, some people have commented that as the flu numbers were so low last year, they don’t feel as though they need the flu vaccination this year. Our pharmacy team use this opportunity to remind them of the importance of the flu vaccination and highlight that both social distancing and the high uptake of flu vaccinations were critical factors in keeping case numbers so low last year.”

Ms Wheadon says, “In March 2020 alone we would have done as many flu vaccines as we have done this year in March, April and May combined. However, despite the numbers being lower, there are always flu conversations happening in store.

“We are utilising in-store marketing in the form of banners and posters, as well as social media marketing to encourage more conversations about flu prevention. We are also working closer this year with our business partners.

“Wizard Pharmacy stores have teamed up with the Chamber of Commerce to advertise our flu vaccinations to local businesses. We know that if an employee contracts the flu, the business can suffer as a result of lost productivity.

We’re encouraging local businesses to get their staff immunised, so that it’s one less stress for them to worry about during this year’s flu season.”

Ms Barnes adds, “TerryWhite Chemmart is utilising multiple channels to promote this year’s flu vaccine including TV and radio advertising, social media, catalogues and in-store flyers. The team have also engaged in significant PR this year using consumer research insights to both highlight the importance of ongoing vaccinations as well as help combat some of the myths floating around this year about flu vaccinations.

“At a store level, we are using every opportunity to discuss and encourage on-the-spot flu vaccinations for our customers. We are fortunate to be able to offer ‘walk in’ flu vaccinations across our business hours, as well as having many booking times available online.

“Our pharmacists recommend the flu vaccine to all patients above the age of six months, as per ATAGI 2021 recommendations. We particularly reinforce the benefits of the flu vaccination for vulnerable customers, such as those with chronic illnesses, pregnancy, those with lowered immunity themselves or their family members and anyone over the age of 65 years.

We refer all patients to their doctor if eligible for their vaccine under the National Immunisation Program and vaccinate where appropriate in the pharmacy those over 10 years of age.

“While the flu vaccination will do nothing to stop COVID-19, an annual flu vaccination is the best defence against the flu and by reducing the flu cases, we also play a part in reducing the impact on the healthcare system of other respiratory diseases.”

Managing flu presentations

“As pharmacists we are at the forefront of customer requests for the management of cold and flu symptoms. Where appropriate, we can recommend over-the-counter pharmacological treatment, such as oral and nasal decongestants, cough suppressants or expectorants, antihistamines and paracetamol or ibuprofen for associated pain and fever.

“Benefits have also been shown for adjunctive treatments such as saline nasal sprays and rinses to improve efficacy of nasal sprays, or as a mono-therapy if medications or medical conditions limit other pharmacological options.

“We also advise patients on non-pharmacological management, such as rest, hydration, steam inhalation and abstaining from work. Given the coronavirus pandemic, all patients with overlapping symptoms are also advised to get a COVID test and isolate while awaiting results,” says Ms Barnes.

Ms Wheadon tells the AJP, “Nowadays, if someone is experiencing what they believe to be flu-like symptoms they tend to call the coronavirus helpline. Even if they do present to the pharmacy or their GP, they would be referred to the nearest COVID clinic or hospital to be tested to ensure it’s just the flu and not coronavirus.”

Ms Barnes adds, “As the overlap between COVID-19 and cold and flu symptoms is very high, it is important that we treat any customer with any of these symptoms as a potential COVID case.

“We have signs on the doors asking any customers with cold and flu symptoms to please wait outside and call the pharmacy for further assistance. We offer a delivery service, which is very helpful for any customers with symptoms, in isolation, or in a high risk group who don’t feel comfortable visiting the pharmacy in person.

“We also have screens between our staff and customers at all registers, frequently clean down benches and surfaces, sanitise our hands regularly between customers and maintain a 1.5 m distance wherever possible. We wear a mask while providing any health service where a 1.5 m distance isn’t possible, such as when delivering a flu vaccination.”

For those people that do, in fact, have the flu, pharmacists can take several steps to help optimise treatment outcome. This includes:

  • advising on correct dose and administration
  • managing expectations around symptom relief
  • advising on when they can expect improvement
  • advising on adjunct non-pharmacological treatment
  • discussing what to do if there is no improvement in symptoms or when follow-up is necessary
  • discussing red flag symptoms to look out for
  • reinforcing appropriate infection control measures, such as hand hygiene, staying home.

While people may be giving less thought to the flu this year, pharmacy plays an import role in reminding people that the influenza virus can cause severe illness. The single most effective way to prevent the flu is to get vaccinated annually.


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  1. Rebecca Bragg

    Updated clinical guidance from ATAGI on 2nd June states the recommended minimum interval between COVID-19 vaccine and other vaccines (including influenza vaccine) is 7 days but can be shortened (including same day administration) in special circumstances.

    • Jarrod McMaugh

      it’s also worth noting for consideration of “special circumstances” that the reason this time gap exists, is so that any adverse event that occurs can be attributed to the vaccination that caused it.

      We should expect over time that – if booster doses are needed for covid – these will likely be co-administered with influenza vaccination, or even co-formulated

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