In an adult aged 50 years or older without severe allergies or acute illness, can the seasonal influenza vaccine and the shingles (zoster) vaccine be administered on the same day?

Can Flu and Shingles Vaccines Be Given the Same Day?

Yes, influenza and shingles vaccines can and should be administered on the same day at separate anatomic sites. This applies to both the recombinant zoster vaccine (RZV/Shingrix) and the live attenuated zoster vaccine (ZVL/Zostavax) when given with inactivated influenza vaccines. 1

Evidence-Based Rationale

For Recombinant Zoster Vaccine (RZV/Shingrix)

• RZV can be given concomitantly with seasonal influenza vaccine according to current guidelines, with a weak recommendation based on moderate quality evidence. 1

• Inactivated vaccines, including RZV and inactivated influenza vaccines, may be administered concomitantly with or at any time before or after other inactivated vaccines without interference in immune responses. 1

• FDA-approved drug labeling confirms no evidence of interference in immune response when SHINGRIX and quadrivalent influenza vaccine (FLUARIX QUADRIVALENT) were administered concomitantly in clinical trials involving adults aged 50 years and older. 2

For Live Attenuated Zoster Vaccine (ZVL/Zostavax)

• ZVL can be given concomitantly with seasonal influenza vaccine with the same weak recommendation based on moderate quality evidence. 1

• Live vaccines given by parenteral route, including ZVL, may be administered concomitantly with other injected live vaccines. If not given simultaneously, a minimum 4-week interval should be maintained between two live parenteral vaccines. 1

• Clinical trial data demonstrates comparable antibody responses whether ZVL and inactivated influenza vaccine were given concomitantly or 4 weeks apart in adults aged ≥50 years. 1, 3, 4

Practical Administration Guidelines

Injection Site Management

• Administer vaccines at separate anatomic sites (different injection locations, preferably different arms if feasible) to minimize confusion about local reactions. 1

• Do not mix vaccines in the same syringe. Each vaccine must be administered separately. 1

Type of Influenza Vaccine Matters

• Inactivated influenza vaccines (IIV) and recombinant influenza vaccines (RIV4) may be administered concomitantly or sequentially with zoster vaccines without timing restrictions. 1

• Live attenuated influenza vaccine (LAIV4) may be administered simultaneously with other live or inactivated vaccines, but if not given simultaneously with another live vaccine, at least 4 weeks should pass before administering another live vaccine. 1

Important Clinical Considerations

Expected Adverse Reactions

• Adverse reactions are more frequently reported when vaccines are co-administered, though these symptoms are generally mild or moderate. 1

• Patients should be counseled that they may experience more pronounced local and systemic reactions when receiving both vaccines simultaneously, particularly with RZV which has higher reactogenicity. 1

• Reassuring safety profiles have been noted for simultaneous administration of influenza vaccines with both live attenuated zoster vaccine and RZV in multiple clinical trials. 1, 3, 4

Impact on Future Vaccination Behavior

• One cohort study found that patients who received concurrent influenza and zoster vaccines were significantly less likely to receive influenza vaccine the following year (87.3% vs 91.3%; adjusted OR 0.74,95% CI 0.71-0.78). 5

• The reduced willingness may be due to misattribution of systemic side effects caused by the zoster vaccine (particularly RZV) to the influenza vaccine. 1, 5

• Enhanced patient counseling about expected vaccine side effects is critical when administering vaccines concomitantly, especially with RZV which causes systemic side effects in a large proportion of patients. 5

Common Pitfalls to Avoid

• Do not delay either vaccine to administer them separately unless there is a specific clinical contraindication—this creates missed opportunities for protection and the benefits of timely vaccination outweigh concerns about simultaneous administration. 1

• Do not confuse RZV (recombinant, inactivated) with ZVL (live attenuated)—RZV is now the preferred vaccine for most adults ≥50 years and is the only option for immunocompromised patients. 1

• Do not assume that increased local reactions indicate vaccine failure or contraindicate future vaccination—these are expected and generally mild to moderate in severity. 1

• Do not forget to counsel patients extensively about expected side effects before concurrent administration, particularly emphasizing that RZV commonly causes systemic symptoms (fatigue, myalgia, headache) that should not be attributed to the influenza vaccine. 5

Special Populations

• Immunocompromised patients should receive RZV (not ZVL) and can receive it concomitantly with inactivated influenza vaccine. 1

• Patients with autoimmune inflammatory rheumatic diseases can receive RZV concomitantly with influenza vaccine, with RZV being the recommended herpes zoster vaccine for this population. 1

• No serologic testing or history of varicella is required before administering zoster vaccine with influenza vaccine. 6