Vaccination Guidance During a Pandemic
The COVID-19 pandemic has caused healthcare providers to change how they operate to continue to provide essential services to patients. Ensuring immunization services are maintained or reinitiated is essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks and reducing the burden of respiratory illness during the upcoming influenza season.
The following are a collection of federal resources designed to guide vaccine planning during the COVID-19 pandemic:
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This interim guidance is intended to assist immunization providers 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. Healthcare providers who administer vaccines should also consult guidance from state, local, tribal, and territorial health officials.
Efforts to reduce transmission of COVID-19, 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 upcoming influenza season, influenza vaccination will be paramount to reduce the impact of respiratory illnesses 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 women) that should not be delayed because of the COVID-19 pandemic. In light of COVID-19-related reductions in people accessing vaccination services, it is important to assess the vaccination status of all patients at each 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 providers 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 women: 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 women should be scheduled for follow-up and receive vaccination during the next in-person appointment.
- Adults: Healthcare providers, 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. Older adults and adults with underlying medical conditions are particularly at increased risk for preventable disease and complications if vaccination is deferred.
Annual influenza vaccination is recommended for all persons age 6 months and older to decrease morbidity and mortality caused by influenza. Healthcare providers 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 providers should use every opportunity during the influenza vaccination season to administer influenza vaccines to all eligible persons, including:
- Essential workers: Healthcare personnel, including nursing home, long-term care facility, and pharmacy staff, and other critical infrastructure workforce
- Persons at increased risk for severe illness from COVID-19: Including adults age 65 years and older, residents in a nursing home or long-term care facility, persons of all ages with certain underlying medical conditions. Severe illness from COVID-19 has been observed to disproportionately affect members of certain racial/ethnic minority groups
- Persons at high risk for influenza complications: Including infants and young children, children with neurologic conditions, pregnant women, adults age 65 years and older, and other persons with certain underlying medical conditions
Routine vaccination should be deferred for persons with suspected or confirmed COVID-19, regardless of symptoms, until criteria have been met for them to discontinue isolation. While mild illness is not a contraindication to vaccination, vaccination visits for these individuals should be postponed to avoid exposing healthcare personnel and other patients to the virus that causes COVID-19. 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.
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 providers 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.
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 providers 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 providers 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 mass 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 mass vaccination 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.
- 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).
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. IIS 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, 13th ed
- Vaccine administration Resource Library
Stay-at-home and shelter-in-place orders have resulted in declines in outpatient pediatric visits and fewer vaccine doses being administered, leaving children at risk for vaccine-preventable diseases. As states develop plans for reopening, healthcare providers are encouraged to work with families to keep or bring children up to date with their vaccinations. Primary care practices in communities affected by COVID-19 should continue to use strategies to separate well visits from sick visitsexternal icon. Examples could include:
- Scheduling sick visits and well-child visits during different times of the day
- Reducing crowding in waiting rooms, by asking patients to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment, or setting up triage booths to screen patients safely
- Collaborating with healthcare providers in the community to identify separate locations for providing well visits for children
Healthcare providers should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in person appointments, starting with newborns, infants up to 24 months, young children and extending through adolescence. State-based immunization information systems and electronic health records may be able to support this work.
All newborns should be seen by a pediatric healthcare provider shortly after hospital discharge (3 to 5 days of age). Ideally, newborn visits should be done in person during the COVID-19 pandemic in order to evaluate for dehydration and jaundice, ensure all components of newborn screening were completed and appropriate confirmatory testing and follow-up is arranged, and evaluate mothers for postpartum depression. Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified.
More than 114 million children at risk of missing out on measles vaccines, as COVID-19 surges
ATLANTA/GENEVA/NEW YORK, 14 April 2020: As COVID-19 continues to spread globally, over 114 million children in 38 countries may miss out on receiving life-saving measles vaccine. Measles immunization campaigns in 23 countries have already been delayed; more will be postponed.
During this challenging period, the Measles & Rubella Initiative (M&RI) expresses solidarity with families, governments, emergency responders, partners, Gavi, the Vaccine Alliance, the Global Polio Eradication Initiative (GPEI) and other global immunization and health partners in the world’s focus and fight against the threat of COVID-19. The pandemic sweeping the globe requires a coordinated effort and commitment of resources to ensure our staff and frontline health workers around the world are protected, as they face and respond to this new threat. At the same time, we must also champion efforts to protect essential immunization services, now and for the future.
The World Health Organization (WHO) has issued new interim guidelines – endorsed by the Strategic Advisory Group of Experts on Immunization (SAGE) – to help countries to sustain immunization activities during the COVID-19 pandemic.pdf iconexternal icon The guidelines recommend that governments temporarily pause preventive immunization campaigns where there is no active outbreak of a vaccine-preventable disease. M&RI partners, which include the American Red Cross, the U.S. Centers for Disease Control and Prevention, UNICEF, the United Nations Foundation and WHO, strongly agree with these recommendations. We urge countries to continue routine immunization services, while ensuring the safety of communities and health workers. The recommendations also ask governments to undertake a careful risk-benefit analysis when deciding whether to delay vaccination campaigns in response to outbreaks, with the possibility of postponement where risks of COVID-19 transmission are deemed unacceptably high.
If the difficult choice to pause vaccination is made due to the spread of COVID-19, we urge leaders to intensify efforts to track unvaccinated children, so that the most vulnerable populations can be provided with measles vaccine as soon as it becomes possible to do so. While we know there will be many demands on health systems and frontline workers during and beyond the threat of COVID-19, delivering all immunization services, including measles vaccine, is essential to saving lives that would otherwise be lost to vaccine-preventable diseases.
The M&RI supports the need to protect communities and health workers from COVID-19 through a pause of mass campaigns, where risks of the disease are high. However, this should not mean that children permanently miss out. Urgent efforts must be taken now at local, national, regional and global levels to prepare to close the immunity gaps that the measles virus will exploit, by ensuing that vaccines are available, and that they reach children and vulnerable populations, as quickly as possible, to keep them safe.
Despite having a safe and effective vaccine for over 50 years, measles cases surged over recent years and claimed more than 140,000 lives in 2018, mostly of children and babies – all of which were preventable. Against this already dangerous backdrop, preventive measles vaccination campaigns have now been paused or postponed in 23 countries to help avert further spread of COVID-19. Campaigns expected to take place later in 2020 in an additional 15 countries may not be implemented. Together, more than 114 million children in 38 countries, many of whom live in regions with ongoing measles outbreaks, could be impacted by the suspension of scheduled immunization activities. This staggering number does not include the number of infants that may not be vaccinated because of the effect of COVID-19 on routine immunization services. Children younger than 12-months of age are more likely to die from measles complications, and if the circulation of measles virus is not stopped, their risk of exposure to measles will increase daily.
The M&RI salutes the heroism of health and emergency workers across the globe, and we recognize the vital role they play in delivering clear, trusted information, as well as preventive and supportive care within their communities. Health workers need to be invested in, protected from infection, and empowered as part of sustainable and functioning primary health systems. They are the first line of defense against global epidemics. We also recognize the role of parents and caregivers in ensuring their children are vaccinated and following physical distancing recommendations in line with national guidance. Finally, we call on countries and local leaders to implement effective communication strategies to engage communities, ensure supply and demand for vaccination remains strong, and help assure a healthy life for every child especially in this challenging time.
The Measles & Rubella Initiative is a global partnership, founded by the American Red Cross, the Centers for Disease Control and Protection, the United Nations Foundation, UNICEF and the World Health Organization, that is committed to achieving and maintaining a world without measles, rubella and congenital rubella syndrome. Founded in 2001, the Initiative has helped vaccinate over 2.9 billion children and save over 21 million lives by increasing vaccination coverage, improving disease response, monitoring and evaluation, and building public confidence and demand for immunization. The Initiative works closely with Gavi, the Vaccine Alliance to achieve these goals.
- Latest WHO measles surveillance dataexternal icon
- New interim recommendations for immunization programmesexternal icon
- The Measles & Rubella Initiativeexternal icon
For more details, please contact:
Priyanka Khanna, M&RI Communications Specialist, at firstname.lastname@example.org
Interim guidance to prevent mother-to-child transmission of hepatitis B virus during COVID-19-related disruptions in routine preventive services
This guidance is being provided to ensure that certain safety nets are in place to prevent mother-to-child hepatitis B virus (HBV) transmission in the event of significant COVID-19 pandemic-related disruptions in routine preventive services before, during, and after labor and delivery. The guidance is intended to be used by obstetric and pediatric care staff for consideration while prioritizing the Advisory Committee on Immunization Practices (ACIP) recommendations for prevention of mother-to-child transmission of HBV infection (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm).
Prenatal care of hepatitis B surface antigen (HBsAg)-positive women
Ensure that HBsAg-positive pregnant women are able to advocate for the proper care of their HBV-exposed infants in case labor and delivery occurs at an unplanned facility or is attended by staff that are not knowledgeable about managing HBV-exposed infants:
- Educate HBsAg-positive women on their HBsAg status and the importance of proper preventive care for their infant, including hepatitis B immune globulin (HBIG) and single antigen hepatitis B vaccine at birth, hepatitis B vaccine series completion at six months of age, and post-vaccination serologic testing.
- Supply HBsAg-positive women with documentation of HBsAg laboratory results and ask them to provide this documentation to labor and delivery staff at the time of delivery.
Labor and Delivery Care
- Identify HBsAg status of all women presenting for delivery.
- If a woman’s HBsAg status is positive, HBIG and single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth.
- If a woman’s HBsAg status is unknown, single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth. Administration of HBIG should be determined per ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Infants weighing <2,000 grams should receive HBIG if the mother’s HBsAg status cannot be determined within 12 hours of birth.
- Provide the birth dose of hepatitis B vaccine to all other newborns within 24 hours of birth to prevent horizontal hepatitis B virus transmission from household or other close contacts.
Pediatric care of HBV-exposed infants
- Every effort should be made to ensure HBV-exposed infants complete the hepatitis B vaccine series following the ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Providers using single-component vaccine who are experiencing immunization service disruption should administer hepatitis B vaccine as close to the recommended intervals as possible, including series completion at 6 months, and follow ACIP recommendations for post-vaccination serologic testing.
- If post-vaccination serologic testing is delayed beyond 6 months after the hepatitis B series is completed, the provider should consider administering a “booster” dose of single antigen hepatitis B vaccine and then ordering post-vaccination serologic testing (HBsAg & antibody to HBsAg [anti-HBs]) 1-2 months after the “booster” dose.
COVID-19 Operational Guidance
- Administration of vaccines is an essential medical service.
- Assess the vaccination status of all patients across the life span at every health care visit.
- Administer routinely recommended vaccines to children, adolescents, and adults (including pregnant women).
- Delay vaccination for persons with suspected or confirmed COVID-19.
- Follow guidance to prevent the spread of COVID-19 in health care settings.
- Encourage vaccination at the patient’s medical home.
- Implement effective strategies for catch-up vaccination.
- Communicate with patients/families about how they can be safely vaccinated during the pandemic.