Can influenza, pneumococcal (Pneumococcal Conjugate Vaccine) and Tdap (Tetanus, Diphtheria, and Pertussis) vaccines be taken together in adults with asthma?

Can Influenza, Pneumococcal, and Tdap Vaccines Be Administered Together in Adults with Asthma?

Yes, influenza, pneumococcal conjugate vaccine (PCV), and Tdap vaccines can and should be administered simultaneously in adults with asthma during the same visit, using separate syringes at different anatomic sites. 1

Evidence for Simultaneous Administration

The ACIP explicitly recommends that if two or more vaccines are indicated, they should be administered during the same visit (simultaneous vaccination), with each vaccine given using a separate syringe at a different anatomic site. 1 This approach increases the likelihood that adults will receive all recommended vaccinations. 1

Specific Vaccine Combinations Supported by Guidelines

• Tdap can be co-administered with influenza vaccine and pneumococcal vaccines according to recent international guidelines. 1
• Studies demonstrate that Tdap administered simultaneously with trivalent inactivated influenza vaccine is safe, though pain at the Tdap injection site occurred slightly more frequently with simultaneous administration (67%) versus separate administration (61%). 1
• Simultaneous administration of influenza and pneumococcal vaccines has proven to be safe in adults over 55 years of age, with no statistically significant differences in local or systemic reactions compared to influenza vaccine alone. 2

Special Considerations for Asthma Patients

Why These Vaccines Are Particularly Important

Adults with asthma are at increased risk for severe complications from influenza and have been specifically identified as a priority population for annual influenza vaccination. 1 Before universal influenza vaccination recommendations, ACIP specifically recommended that adults with chronic pulmonary disease (including asthma) receive annual influenza vaccine due to their higher risk for influenza-related complications. 1

Safety Profile in Asthma

• Inactivated influenza vaccine does not cause clinically important increases in asthma exacerbations in the two weeks following vaccination. 3
• A Cochrane review of randomized trials involving 1,526 adults and 712 children with asthma found no significant increase in asthma exacerbations following inactivated split-virus influenza vaccination (risk difference 0.014; 95% CI -0.010 to 0.037). 3
• While one older study suggested pulmonary function abnormalities may occur as a complication of influenza vaccination, the risk was deemed very small and outweighed by the benefits of vaccination. 4

Practical Administration Algorithm

Step 1: Verify Vaccination History

• Confirm the patient has not received Tdap previously (if they have, use Td instead for routine boosters). 1
• Check timing of last tetanus-containing vaccine (routine interval is 10 years). 5, 6
• Verify pneumococcal and influenza vaccination status.

Step 2: Administer All Indicated Vaccines Simultaneously

• Use separate syringes for each vaccine. 1
• Administer at different anatomic sites (e.g., deltoid muscles of different arms). 1
• Experts recommend administering no more than two injections per muscle, separated by at least 1 inch. 1
• Tdap dose is 0.5 mL administered intramuscularly, preferably into the deltoid muscle. 1

Step 3: Patient Counseling

• Inform patients that pain at the Tdap injection site is common (reported in 75% of recipients). 7
• Explain that simultaneous administration may result in slightly more injection site pain but does not increase systemic reactions. 1
• Reassure asthma patients that these vaccines do not trigger asthma exacerbations. 3

Important Caveats and Pitfalls to Avoid

Contraindications

• Do not administer Tdap to patients with a history of serious allergic reaction (anaphylaxis) to any vaccine component or encephalopathy within 7 days of a previous pertussis-containing vaccine. 1, 7
• Moderate or severe acute illness with or without fever is a precaution; defer vaccination until the acute illness resolves. 1

Timing Considerations

• A single dose of Tdap can be given at intervals shorter than 10 years (as short as 2 years) when protecting against pertussis is a priority, though the standard interval is 10 years. 1
• Do not give tetanus boosters more frequently than every 10 years for routine immunization to avoid Arthus reactions (severe local hypersensitivity). 5

Potential Immunologic Interference

• One study found that Tdap given 3-4 weeks before PCV13 significantly reduced antibody response to six of 13 pneumococcal serotypes. 8
• To avoid this interference, administer Tdap and PCV simultaneously or give PCV before Tdap, rather than Tdap 3-4 weeks before PCV. 8

Common Mistake

• Do not use pediatric DTaP formulations in adults; use Tdap or Td instead. 1, 5

Coverage Gaps to Address

Despite long-standing recommendations, influenza vaccination coverage among adults with asthma and other high-risk conditions remains low (46.2% for those with lung disease in 2012-2013). 1 Approximately 90% of unvaccinated adults with high-risk conditions may have missed at least one opportunity to receive influenza vaccine through their healthcare provider. 1 Simultaneous administration of all indicated vaccines maximizes the opportunity to protect these vulnerable patients.