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COVID-19 and Seasonal Flu 2020-2021
What Healthcare Professionals Need to Know

Online Continuing Education Course

Course Description

COVID-19 and seasonal flu (influenza) symptoms can be similar. Learn to distinguish the symptoms, prevent transmission in the healthcare setting, and educate yourself about the 2020-2021 flu shot/vaccines. Deepen your knowledge about virus transmission, patient education, and infection control during the coronavirus pandemic.

Course Price: $15.00

Contact Hours: 1

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Accreditation / Approval Information

COVID-19 and Seasonal Flu 2020–2021
What Healthcare Professionals Need to Know

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course you will be prepared to differentiate between seasonal flu and COVID-19 and discuss both treatment and vaccines. Specific learning objectives include:

  • Differentiate between the clinical presentation of COVID-19 and seasonal flu.
  • Explain the incubation, period of contagion, and transmission for SARS-CoV-2 and influenza viruses.
  • Discuss infection prevention measures.
  • Describe patient education considerations for influenza and COVID-19.
  • Explain concerns surrounding seasonal flu vaccine and routine immunizations during the COVID-19 pandemic.


Countries throughout the world are grappling with the effects of COVID-19, which is the worst pandemic since the Spanish Flu Pandemic in 1918–1919. While there is still a great deal not known about COVID-19 and the virus that causes it, some valuable information is available to guide healthcare professionals.

Concerns about COVID-19 in the context of the annual influenza (flu) season also raise new questions for healthcare professionals, such as:

  • How is the flu related to COVID-19?
  • How can I tell the difference between the flu and COVID-19?
  • What are the symptoms of COVID-19, and how long does it take for them to appear?
  • How long is someone contagious after developing COVID-19 or flu?
  • How are COVID-19 and flu transmitted?
  • What steps can be taken to prevent infection?
  • What do I need to teach patients and families about COVID-19 and flu?
  • Should people get a flu shot during the pandemic?
  • How can vaccines be safely administered during the pandemic?

Signs and Symptoms

Some symptoms overlap between COVID-19 and influenza. It is important to know the clinical manifestations of each condition and how to differentiate between them.

Both the flu and COVID-19 are contagious respiratory illnesses, but they are caused by different viruses. COVID-19 is caused by a new coronavirus (SARS-CoV-2), and the flu is caused by infection with a variety of influenza viruses.

Since influenza and COVID-19 share a number of symptoms, differentiation between the two can be problematic. Both the flu and COVID-19 can cause mild to severe illness, including these common signs/symptoms:

  • Fever
  • Chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Sore throat
  • Runny or stuffy nose
  • Muscle pain
  • Body aches
  • Headache
  • Vomiting and diarrhea (more common in children than adults)

According to the CDC, COVID-19 seems to cause more serious illnesses in some people. A significant difference between the flu and COVID-19 is that COVID-19 may cause a change in or loss of taste or smell (CDC, 2021a).


Symptoms of COVID-19 can be mild at the beginning but become more intense over five to seven days, with cough and shortness of breath becoming worse if pneumonia develops. The severity of illness can vary significantly from person to person. A person may have a cough or other symptoms but no fever (or a low-grade fever), particularly in the first few days of illness. It is also possible for a person infected by the SARS-CoV-2 virus to have minor or even no symptoms at all. Children generally have a milder form of the illness and seldom require hospitalization. However, there have been reported cases of very young babies becoming seriously ill with pneumonia. Children are also at risk for a rare complication known as multisystem inflammatory syndrome in children (MIS-C) (Maragakis, 2020).

Incubation Period

One or more days can pass between becoming infected and when symptoms start to appear in both flu and COVID-19. With flu, patients typically develop symptoms within one to four days. The typical time frame for symptom development with COVID-19 is five days after becoming infected. The incubation time range can vary, however, with symptoms of COVID-19 appearing as early as two days after infection or as late as 14 days after infection (CDC, 2021a).

Severe symptoms of flu may develop and end quite swiftly, usually within 5 days. COVID-19 symptoms may develop more gradually, and severe symptoms may not appear for several days after exposure. During the recovery process, people with COVID-19 might have recurring symptoms alternating with periods of feeling better that persists for days or even weeks (Maragakis, 2021).

Degree of Communicability

It is possible to spread flu and COVID-19 for at least one day prior to experiencing any symptoms.

With influenza, the majority of people are contagious for about one day prior to showing symptoms. It appears that older children and adults are most contagious during the initial three to four days of their illness, but many remain contagious for about seven days. Infants and people with weakened immune systems may be contagious for an even longer period of time (CDC, 2021a).

It is possible for people to spread the SARS-CoV-2 virus for approximately two days before experiencing signs or symptoms and remain contagious for at least 10 days after signs or symptoms first appear. If someone is asymptomatic or their symptoms abate, it is possible to remain contagious for at least 10 days after testing positive for COVID-19 (CDC, 2021a).

Modes of Transmission

The ease of transmission from person to person can vary. COVID-19 appears to spread more efficiently than influenza but not as efficiently as measles, which is among the most contagious viruses known to affect people.

Both influenza viruses and SARS-CoV-2 can spread from person to person between people who are in close contact with each other (within about six feet). Both are spread primarily by droplets made when people who are infected cough, sneeze, or talk. It may also be possible to acquire infection by physical contact with infected people (e.g., shaking hands) or by touching contaminated surfaces and then touching the mouth, nose, or, possibly, the eyes (CDC, 2021a).

Even though SARS-CoV-2 and flu viruses are believed to spread in similar ways, SARS-CoV-2 is more contagious among certain populations and age groups than the flu virus. Also, COVID-19 has been observed to have more superspreading events than flu. This means the virus that causes COVID-19 can quickly and easily spread to many people, resulting in continuous spread as time progresses (CDC, 2021a).


Based on limited current information, the risk of animals spreading COVID-19 to humans is considered low. Infected pets might get sick or they might not have any symptoms. A small number of pets, including cats and dogs, worldwide have been reported to be infected with SARS-CoV-2, mostly after close contact with infected people. Of those pets who have been sick with COVID-19, most had only mild illness and fully recovered.

To protect pets, the CDC recommends:

  • Limiting pet interactions with people outside of the household
  • Keeping cats indoors when possible and not allowing them to roam outside
  • Avoiding public places where a large number of people gather
  • Avoiding putting masks on pets (since this could harm the pet)

There is no evidence that the virus can spread to people from the skin, fur, or hair of pets. Pets should not be wiped or bathed with chemical disinfectants, alcohol, hydrogen peroxide, or any other product not approved for animal use. If someone in the household has COVID-19, that person should avoid contact with the pet (CDC, 2021b).


Although most people with COVID-19 have mild to moderate symptoms, the disease can cause the following complications:

  • Pneumonia
  • Respiratory distress
  • Organ failure
  • Cardiac problems and heart failure
  • Acute respiratory distress syndrome
  • Blood clots
  • Acute kidney injury
  • Additional viral and bacterial infections
    (Mayo Clinic, 2020a)

Most people who get the flu recover in a few days to less than two weeks. However, some people develop severe complications, such as:

  • Pneumonia
  • Bronchitis
  • Asthma exacerbations
  • Sinus and ear infections
  • Acute respiratory distress syndrome
  • Myocarditis
  • Encephalitis
  • Muscle inflammation
  • Multi-organ failure
  • Extreme bodily inflammatory response
  • Sepsis
  • Worsening chronic heart disease
    (CDC, 2020a)


Influenza viruses and SARS-CoV-2 can both cause serious illness leading to hospitalization or death.

The World Health Organization (2021) estimates that 290,000 to 650,000 people die of flu-related causes every year worldwide. The COVID-19 pandemic is evolving rapidly, and doctors and scientists are working to estimate the mortality rate of the virus. Mortality is believed to be substantially higher—possibly 10 times more—than that of most strains of flu (Maragakis, 2021).

High-Risk Populations


Among adults, the risk for severe illness from COVID-19 increases with age. The greatest risk for severe illness from COVID-19 is among those aged 85 and older, who have a 13 times higher risk for hospitalization and a 630 times higher risk for death due to COVID-19. When compared to 18- to 29-year-olds, those between 30 and 39 years have two times higher risk for hospitalization and four times higher risk for death (CDC, 2020b).

It has been recognized for many years that people 65 years and older are at high risk of developing serious complications from flu when compared to young, healthy adults. In recent years, an estimated 70%–85% of seasonal flu-related deaths have occurred in people 65 years and older, and 50%–70% of seasonal flu-related hospitalizations have occurred among people in this age group (CDC, 2021c).

Each year thousands of children are hospitalized and some children die from influenza. Although all children younger than 5 years old are considered at high risk for serious flu complications, the highest risk is for those younger than 2 years old, with the highest hospitalization and death rates among infants younger than 6 months old (CDC, 2020c).


According to the CDC, many health conditions are known to increase a person’s risk of serious complications from both flu and COVID-19 (see table below).

(CDC, 2021d, 2021e)
Increased risk:
  • Cancer
  • Chronic renal disease
  • COPD
  • Down syndrome
  • Serious heart conditions (e.g., heart failure, coronary artery disease, cardiomyopathies)
  • Immunocompromised state due to solid organ transplant
  • Obesity (BMI 30 or higher)
  • Pregnancy
  • Sickle cell disease
  • Type 2 diabetes
Possible increased risk:
  • Asthma (moderate to severe)
  • Cerebrovascular disease
  • Cystic fibrosis
  • Hypertension
  • Immunocompromised state due to blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune-weakening medicines
  • Neurologic conditions (e.g., dementia)
  • Liver disease
  • Overweight (BMI >25 but <30)
  • Pregnancy
  • Pulmonary fibrosis
  • Thalassemia
  • Type 1 diabetes
Increased risk:
  • Asthma
  • Neurologic and neurodevelopment conditions
  • Blood disorders (e.g., sickle cell disease)
  • Chronic lung disease (e.g., COPD, cystic fibrosis)
  • Endocrine disorders (e.g., diabetes mellitus)
  • Heart disease (e.g., congenital heart disease, congestive heart failure, coronary artery disease)
  • Kidney disease
  • Liver disorders
  • Metabolic disorders (e.g., inherited metabolic disorders, mitochondrial disorders)
  • Obesity (BMI 40 or higher)
  • People under 19 years on long-term aspirin- or salicylate-containing medications
  • Immunocompromised state due to disease (e.g., HIV/AIDS, some cancers such as leukemia) or medications (e.g., chemotherapy/radiation treatment for cancer, chronic corticosteroids, other drugs that suppress the immune system)
  • Stroke
Others at high risk:
  • Pregnant women and women up to 2 weeks after end of pregnancy
  • Nursing home and other long-term care facility residents
  • Non-Hispanic Black persons, Hispanics or Latino persons, American Indian or Alaska Native persons


Both the annual influenza season and the COVID-19 pandemic create additional challenges in preventing infection, how healthcare is delivered, and the operations of healthcare facilities. The way both diseases spread (droplets, close contact, etc.) may put healthcare professionals at higher risk since they work not only with patients who are known to be infected but with patients who may be asymptomatic as well.

Prevention Strategies for Seasonal Influenza in Healthcare Settings

A summary of CDC recommendations for prevention of flu transmission in healthcare settings is provided below, and more details can be found on the CDC website:

  • Provide opportunities for all employees to receive the flu vaccine at work.
  • Before patients and visitors arrive at a healthcare setting, instruct them to inform healthcare personnel if they have symptoms of any respiratory infection and to take appropriate prevention actions (e.g., wear a mask).
  • During periods of influenza activity, limit elective visits by patients with suspected or confirmed influenza.
  • Take steps to ensure all persons with symptoms of a respiratory infection adhere to respiratory hygiene, cough etiquette, hand hygiene, and triage procedures throughout the visit.
  • Post visual alerts about the previous steps in strategic locations throughout the healthcare facility.
  • Provide facemasks.
  • Provide supplies to perform hand hygiene.
  • Provide social distancing in common areas (e.g., waiting rooms).
  • Instruct staff members not to report to work, or if at work, to stop patient-care activities, don a facemask, and notify their supervisor and infection control personnel before leaving work. (Staff members should not return to work until at least 24 hours after they no longer have a fever without the use of fever-reducing medicines.)
  • Develop sick-leave policies for staff members that are nonpunitive.
  • Develop employee procedures for tracking absences.
  • Adhere to Standard Precautions.
  • Adhere to Droplet Precautions.
  • Use caution when performing aerosol-generating procedures.
  • Manage visitor access and movement within the facility.
  • Train and educate healthcare personnel on the prevention of infectious agents, including influenza.
    (CDC, 2018)

Adjusting Healthcare Service Delivery During the COVID-19 Pandemic

To avoid the spread of SARS-CoV-2 in the healthcare setting, the CDC recommends that facilities adjust their standard approaches to service delivery to minimize risk to patients and healthcare professionals:

  • Implement telehealth services.
  • Use nurse-directed triage protocols to determine if an appointment is necessary or if the patient can be managed from home.
  • Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility.
  • Limit and monitor points of entry to the facility.
  • Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control.
  • Properly manage anyone with suspected or confirmed SARS-CoV-2 infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection.
  • Isolate such patients in an examination room with the door closed. If an examination room is not immediately available, such patients should not wait among other patients seeking care.
  • Re-evaluate admitted patients for signs and symptoms of COVID-19.
  • Implement universal source control measures such as cloth masks or facemasks.
  • Instruct healthcare personnel to wear a facemask at all times when in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.
  • Educate patients, visitors, and healthcare personnel about the importance of hand hygiene immediately before and after any contact with their facemask.
  • Encourage physical distancing.
  • Implement universal use of personal protective equipment.
  • Consider performing targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19.
  • Consider if elective procedures, surgeries, and nonurgent outpatients should be postponed in certain circumstances.
  • Optimize use of engineering controls and indoor air quality.
  • Create a process to respond to SARS-CoV-2 exposures among health providers and others.
    (CDC, 2021f)

Recommended Practices When Caring for a Patient with Suspected or Confirmed SARS-Cov-2 Infection

In addition to routine Standard Precautions, the CDC identifies the following additional practices as necessary to protect healthcare professionals, patients, and visitors when caring for patients with suspected or confirmed SARS-CoV-2 infection.

  • Establish reporting within and between healthcare facilities and to public health authorities.
  • Place infected patients in a single-person room, with the door closed, and with a dedicated bathroom. Reserve airborne infection isolation rooms (AIIRs) for patients who will be undergoing aerosol-generating procedures.
  • When necessary, house only patients with the same respiratory pathogen in the same room.
  • Limit transport and movement of patients outside of the room to medically essential purposes.
  • Ensure patients wear well-fitting source control to contain secretions during transport.
  • Following a patient’s discharge or transfer, refrain from entering the vacated room until sufficient time has elapsed for sufficient air exchange to occur.
  • Practice hand hygiene (with soap and water or alcohol-based hand sanitizer with 60%–95% alcohol).
  • Adhere to Standard Precautions and use a NIOSH-approved N-95 or equivalent or higher-level respirator, gown, gloves, and eye protection.
  • Follow CDC strategies for optimizing personal protective equipment supplies when PPE are in short supply or unavailable.
  • Instruct all staff (and others as appropriate) on how to don, use, doff, dispose of, disinfect, and maintain PPE, and the limitations of PPE.
  • Use recommended PPE for caring for a patient with suspected or confirmed COVID-19, including:
    • N-95 respirator, filtering facepiece respirator, powered air purifying respirator, or elastomeric respirators
    • Eye protection applied upon entry to patient room or care area
    • Gloves
    • Gowns
  • Manage visitor access and movement within the facility.
  • Follow recommended methods of environmental infection control.
    (CDC, 2021e)


It is important that patients receive accurate education regarding prevention, testing, and treatment of flu and COVID-19. The application of knowledge should help to reduce the number of infections, increase testing, and implement treatment initiatives.

Influenza Education

There are steps that individuals can take to prevent contracting the flu. The most important step is to receive an annual flu vaccine (see also “2020–2021 Influenza Vaccine” later in this course). Children younger than 6 months are at risk but too young to be vaccinated. People who care for infants should be vaccinated instead.

Additional actions include:

  • Avoid close contact with people who are sick.
  • Stay at home when ill.
  • Cover mouth and nose when sneezing or coughing.
  • Avoid touching eyes, nose, or mouth.
  • Perform frequent hand hygiene.
  • Clean and disinfect surfaces and objects that may be contaminated.
  • Stay at home for at least 24 hours after fever is gone except to get medical care or other necessities. (Fever should be gone without the need to use a fever-reducing medicine.)
  • Take flu antiviral drugs if prescribed.
    (CDC, 2021g)

The most common tests to detect influenza viruses are rapid influenza diagnostic tests (RIDTs), which detect the virus antigens that cause an immune response. Results are available within about 10–15 minutes. RIDTs are not considered as accurate as other flu tests. Rapid molecular assays are more accurate than RIDTs and provide results in 15–20 minutes. Other more accurate and sensitive tests must be performed in specialized laboratories. These tests require a nose or back-of-throat swab, and obtaining results takes several hours (CDC, 2021h).

In a patient infected with influenza, antiviral drugs may be a treatment option. Antiviral drugs can lessen symptoms and shorten the time of illness by one or two days. Such drugs can also prevent serious flu complications such as pneumonia. Antiviral drugs work best when taken within 48 hours of the onset of symptoms, but they may still have some benefit even if taken later. FDA-approved antiviral drugs include:

  • Tamiflu (oseltamivir phosphate)
  • Relenza (zanamivir)
  • Rapivab (peramivir)
  • Xofluza (baloxavir marboxil)

Other treatment measures are largely supportive in nature. These include taking acetaminophen for fever, staying hydrated, and getting plenty of rest (CDC, 2021i).

COVID-19 Education

There are a number prevention measures that individuals can take to avoid contracting COVID-19. These include:

  • Wash hands frequently for at least 20 seconds with soap and water. If soap and water are not available, a hand sanitizer that contains at least 60% alcohol should be used.
  • Avoid close contact with people who are sick in the same household.
  • Avoid crowds.
  • Avoid poorly ventilated spaces. If indoors, bring in fresh air by opening windows and doors if possible.
  • Outside the home, maintain at least six feet between oneself and others who do not live in the same household.
  • Wear a mask in public settings and when around others who do not live in the same household.
  • Cover the mouth and nose with a tissue when sneezing or coughing, and throw used tissues in the trash. Wash hands immediately.
  • Avoid touching eyes, nose, and mouth with unwashed hands.
  • Clean and disinfect frequently touched surfaces daily. Use a household disinfectant from the EPA’s List N: Disinfectants for Coronavirus (COVID-19) (see “Resources” at the end of this course).
  • Be alert for symptoms of COVID-19.
    (CDC, 2021j)

Two kinds of tests are available: viral and antibody. The viral nucleic acid amplification test (NAAT) is used to detect current infection and requires an anterior nasal swab or a deep nasal self-swab. Antibody tests detect viral proteins and are generally not as sensitive as NAATs. Antibody test results may need to be confirmed with an NAAT. Patients may consult with their state or local health department’s websites to find testing locations. If symptoms are present, healthcare providers should be consulted prior to going for a test (CDC, 2021k).

Most people with the infection have mild illness and can recover without medical care. If someone is infected with SARS-CoV-2 but does not show signs of serious illness, then no immediate treatment measures are recommended. Supportive care such as acetaminophen, staying hydrated, and resting may mitigate symptoms until recovery.

To prevent further disease spread, patients with COVID-19 are advised to stay home and avoid public places. They should separate themselves from other people, including those in the same household. They should stay in a separate room and, if possible, use a separate bathroom. Household items should not be shared, and all high-touch surfaces should be cleaned and disinfected frequently. If the patient must be around others or around pets, a mask should be worn.

Symptoms should be monitored and medical help immediately obtained if the patient develops trouble breathing, pain or pressure in the chest, new confusion, inability to wake or stay awake, and/or develops bluish lips or face (CDC, 2020d).


The FDA has given the CDC an emergency use authorization for a specialized test that can detect both flu and COVID-19. The use of this test is focused on public health surveillance efforts and does not currently replace any COVID-19 tests used in commercial laboratories, hospitals, clinics, and other healthcare settings (CDC, 2021l).

Characteristics INFLUENZA (FLU) COVID-19
(CTCA, 2020)
Signs and Symptoms
  • Fever
  • Chills
  • Cough
  • Fatigue
  • Sore throat
  • Runny or stuffy nose
  • Muscle pain
  • Body aches
  • Headache
  • Vomiting and diarrhea (more common in children than adults)
  • Fever
  • Chills
  • Cough
  • Fatigue
  • Sore throat
  • Runny or stuffy nose
  • Muscle pain
  • Body aches
  • Headache
  • Vomiting and diarrhea (more common in children than adults)
  • Change in or loss of taste or smell
Incubation Period Symptoms typically develop within 1 to 4 days. Symptoms typically develop 5 days after being infected, but symptoms may appear as early as 2 days or as late as 14 days after infection.
  • Droplet transmission
  • Droplet transmission
Note: transmission is still under investigation.
  • Pneumonia
  • Bronchitis
  • Asthma exacerbations
  • Ear infections
  • Acute respiratory distress syndrome
  • Myocarditis
  • Encephalitis
  • Muscle inflammation
  • Multi-organ failure
  • Pneumonia
  • Respiratory distress
  • Multi-organ failure
  • Acute respiratory distress syndrome
  • Blood clots
  • Acute kidney injury
  • Additional viral and bacterial infections
  • Handwashing
  • Distancing
  • Flu vaccine
  • Mask wearing
  • Social distancing
  • Handwashing
  • Antiviral drugs
  • Supportive measures
  • Supportive measures

The World Health Organization has identified a number of myths regarding COVID-19. Therefore, it has released the following facts aimed at countering any misinformation:

  • Vitamin and mineral supplements cannot cure COVID-19.
  • Studies show that hydroxychloroquine does not have clinical benefits in treating COVID-19.
  • People should not wear masks while exercising when it reduces the ability to breathe comfortably.
  • The likelihood of shoes spreading COVID-19 is very low.
  • Water or swimming does not transmit the SARS-CoV-2 virus.
  • COVID-19 is caused by a virus, not bacteria. Since antibiotics do not combat viruses, antibiotics cannot prevent or treat COVID-19.
  • The prolonged use of properly worn masks does not cause CO2 intoxication or oxygen deficiency.
  • Most people who get COVID-19 recover from it.
  • Drinking alcohol does not protect against COVID-19.
  • Thermal scanners cannot detect COVID-19.
  • Adding pepper to food does not prevent or cure COVID-19.
  • COVID-19 is not transmitted through houseflies and cannot be spread through mosquito bites.
  • Spraying and introducing bleach or other disinfectants into the body will not protect against COVID-19 and is dangerous.
  • Drinking methanol, ethanol, or bleach does not prevent or cure COVID-19 and is dangerous.
  • 5G mobile networks do not spread COVID-19.
  • Exposure to the sun or high temperatures does not protect against COVID-19.
  • Contracting COVID-19 does not mean you will have it for life.
  • Being able to hold one’s breath for 10 seconds or more without coughing or having discomfort does not mean that a person does not have COVID-19.
  • COVID-19 can spread in hot and humid climates. Cold weather and snow cannot kill COVID-19.
  • Taking a hot bath does not prevent COVID-19.
  • Hand dryers are not effective in killing the COVID-19 virus.
  • Ultraviolet lamps should not be used to disinfect the skin.
  • Antibiotics cannot prevent or treat COVID-19.
  • Pneumonia vaccines do not protect against COVID-19.
  • Rinsing the nose with saline does not prevent COVID-19.
  • Eating garlic does not prevent COVID-19.
    (WHO, 2020)


2020–2021 Influenza Vaccine

The CDC recommends that everyone 6 months of age and older get a flu vaccine for the 2020–2021 season, with rare exceptions. Children younger than 6 months of age and people with severe, life-threatening allergies to flu vaccine (or its ingredients) should not receive the flu vaccine. Flu shots are also recommended for use in pregnant women (CDC, 2021m, 2021n).


Vaccine options for the 2020–2021 season include:

  • Standard-dose flu shots
  • High-dose shots for people 65 years of age and older
  • Shots made with adjuvant for people 65 years of age and older to promote a better immune response
  • Shots made with virus grown in cell culture (i.e., no eggs are involved in its production)
  • Shots made using a vaccine production testing technology (recombinant vaccine) that do not require having a candidate vaccine virus (CVV) sample to produce
  • Live attenuated influenza vaccine (LAIV), which is made with attenuated (weakened) live virus and that is given by nasal spray
    (CDC, (2021o)

There are also two new vaccines licensed for use during the 2020–2021 flu season. These are:

  • A quadrivalent high-dose vaccine licensed for use in adults 65 years of age and older and that replaces the previously licensed trivalent high-dose vaccine
  • A quadrivalent adjuvanted vaccine for use in adults 65 years and older that is similar to the previously licensed trivalent vaccine containing MF59 adjuvant, but with one additional influenza B component
    (CDC, 2021o)

The nasal spray flu vaccine is approved for use in nonpregnant persons ages 2 through 49. Those who should not receive the nasal spray vaccine include:

  • People with severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine
  • Children 2 through 17 years who are receiving aspirin- or salicylate-containing medications
  • People who are, care for, or are close contacts of severely immunocompromised individuals (or avoid contact for 7 days after getting the nasal spray vaccine)
  • Children 2 through 4 years who have asthma or who have a history of wheezing in the past 12 months
  • People without a spleen or with a nonfunctioning spleen
  • People with an active leak between the CSF and the mouth, nose, ear, or other place within the skull
  • People with cochlear implants
  • People who have taken flu antiviral drugs within a specific time frame dependent upon the drug taken
    (CDC, 2021n)

Because of the limited use of a new nasal spray vaccine with new virus ingredients recommended for the 2018–2019 influenza season, there are no effectiveness estimates in the United States as yet (CDC, 2021p).


The CDC has not made changes to its recommendation on timing of vaccination during the 2020–2021 season. Getting vaccinated in July or August is too early, especially for older adults because of the likelihood of reduced protection against flu infection later in the flu season. September and October are generally recommended as the best time frame for getting the vaccine. However, as long as flu viruses are circulating, vaccination should continue, even in January or later (CDC, 2021o).


Healthcare providers should identify children and adolescents 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.

The CDC (2020e) recommends that pregnant women who have not received recommended maternal vaccines (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap]) be scheduled for follow-up and receive vaccination during their next in-person appointment. Healthcare providers should take steps to ensure that their adult patients receive vaccines according to the Standards for Adult Immunization practice (see “Resources” at the end of this course).

Vaccination of Persons with Suspected or Confirmed COVID-19

Routine influenza 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 with COVID-19 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 (CDC, 2020e).

Safe Administration of Vaccines during a Pandemic

The potential for asymptomatic transmission of the SARS-CoV-2 virus that causes COVID-19 requires meticulous attention to infection prevention practices during all patient encounters, including physical distancing, respiratory and hand hygiene, surface decontamination, and source control while in a healthcare facility (CDC, 2020e).


To help ensure the safe delivery of care during influenza vaccination visits, providers should minimize chances for exposures, including:

  • Screen for symptoms of COVID-19 in persons with possible COVID-19 prior to and upon arrival at the facility.
  • 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.
    (CDC, 2020e)


All healthcare facility staff should adhere to recommended infection prevention and control procedures, including:

  • 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.


When administering all types of vaccines:

  • 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 post-vaccination 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).

When administering intranasal or oral vaccines:

  • Wear gloves when administering intranasal or oral vaccines.
  • Change gloves between patients in addition to performing hand hygiene.
  • Administration of vaccines is not considered an aerosol-generating procedure, and the use of an N95 or higher-level respirator is not recommended.

For intramuscular or subcutaneous vaccines:

  • If gloves are worn during vaccine administration, change gloves between patients in addition to performing hand hygiene.

(CDC, 2020e)


There are four types of COVID-19 vaccines:

  • Whole virus vaccines use a weakened or deactivated version of the virus.
  • Viral vector-based vaccines use a harmless virus to “smuggle” instructions for making antigens from the disease-causing virus into the cells.
  • Protein subunit vaccines use fragments of protein from the disease-causing virus.
  • Nucleic acid vaccines use genetic material from a disease-causing virus.

A number of vaccines have been authorized and recommended to prevent COVID-19, and other vaccines remain in the trial phase. Examples of COVID-19 vaccines include those developed by:

  • Pfizer-BioNTech
  • Moderna
  • AstraZeneca
  • Johnson & Johnson’s Janssen
  • Novavax

Studies show that COVID-19 vaccines are effective, and experts think that receiving a COVID-19 vaccine may help prevent a person from becoming seriously ill with COVID.

Although COVID-19 vaccines are effective, it is still unknown how well vaccines prevent transmitting the virus to others, even if the person is not sick (asymptomatic). If exposed to the virus after being vaccinated, it is possible for an individual to be infected or “carry” the virus, but not have any symptoms.

The CDC has developed a new smartphone-based tool, v-safe, for individuals to report vaccine side effects and to identify any safety issues with new vaccines. The government is also working toward making vaccines widely available for everyone at no cost. Some vaccination providers, however, may bill the patient’s insurance company, Medicaid, or Medicare for an administration fee.

The CDC is continually updating vaccine information during the pandemic, and healthcare professionals should visit the CDC COVID-19 vaccination webpage often for the latest information (see “Resources” below) (CDC, 2021r).


NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.

Cancer Treatment Centers of America (CTCA). (2020). COVID-19, the flu, a cold, or allergies: what’s the difference in symptoms? Retrieved from

Centers for Disease Control and Prevention (CDC). (2021a). Similarities and differences between flu and COVID-19? Retrieved from

Centers for Disease Control and Prevention (CDC). (2021b). Coronavirus disease 2019: if you have pets. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021c). Flu & people 65 years and older. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021d). People with certain medical conditions. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021e). People at high risk for flu complications. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021f). Infection control guidance. Retrieved from

Centers for Disease Control and Development (CDC). (2021g). Prevent seasonal flu. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021h). Influenza (flu) diagnosis questions and answers. Retrieved from

Centers for Disease Control and Prevention. (CDC). (2021i). What are flu antiviral drugs? Retrieved from

Centers for Disease Control and Prevention (CDC). (2021j). Coronavirus disease 2019: how to protect yourself and others. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021k). Coronavirus disease 2019: older adults. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021l). Influenza (flu) diagnosis questions and answers. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021m). Who should and who should not get a flu vaccine? Retrieved from

Centers for Disease Control and Prevention (CDC). (2021n). Who needs a flu vaccine and when? Retrieved from

Centers for Disease Control and Prevention (CDC). (2021o). Frequently asked influenza (flu) questions 2020–2021 season. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021p). Live attenuated influenza vaccine (LAIV)/nasal spray vaccine. Retrieved

Centers for Disease Control and Prevention (CDC). (2020q). Vaccination guidance during a pandemic. Retrieved from

Centers for Disease Control and Prevention (CDC). (2021r). Key things to know. Retrieved from

Centers for Disease Control and Prevention (CDC). (2020a). Flu symptoms & complications. Retrieved from

Centers for Disease Control and Prevention (CDC). (2020b). Coronavirus disease 2019: older adults. Retrieved from

Centers for Disease Control and Prevention (CDC). (2020c). Flu and children. Retrieved from

Centers for Disease Control and Prevention (CDC). (2020d). Coronavirus disease 2019: what to do if you are sick. Retrieved from

Centers for Disease Control and Prevention (CDC). (2018). Prevention strategies for seasonal influenza in healthcare settings. Retrieved from

Maragakis LL. (2021). Coronavirus disease 2019 vs. the flu. Retrieved from

Maragakis LL. (2020). Coronavirus symptoms: frequently asked questions. Retrieved from

Mayo Clinic. (2020a). Coronavirus disease 2019 (COVID-19). Retrieved from

World Health Organization (WHO). (2021). Burden of disease. Retrieved from

World Health Organization (WHO). (2020). Coronavirus disease (COVID-19) advice for the public: myth busters. Retrieved from

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