NYU Dysautonomia Center

Vaccination Recommendations 2022-2023

In accordance with recommendations by the

Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control (CDC)


Summary of Recommendations as of Sept 1st, 2022


  • COVID-19 vaccine: The NYU Dysautonomia Center recommends the COVID-19 vaccine for all FD patients over the age of 6 months and people in close contact with them, including all household members. The vaccine is FDA-approved and has been well-tolerated in the FD population. The vaccination is highly effective in preventing serious outcomes of COVID-19 including severe disease, hospitalization, and death.
  • COVID-19 booster: We recommend that FD patients aged 12 and up receive a booster dose of the bilvalent COVID—19 vaccine at least 3 months AFTER their last booster or COVID infection. FD patients aged 5 years and older should receive the monovalent booster, as well as the bivalent booster when it is available at least 3 months AFTER their last booster or COVID infection.
  • Influenza: The NYU Dysautonomia Center recommends the influenza vaccination for all FD patients older than 6 months and people in close contact with them, including all household members.
  • Timing for vaccines:
    • Flu and COVID-19 vaccines: We recommend to space the COVID-19 vaccine and influenza vaccine two weeks apart in FD patients to minimize risk of autonomic crisis associated with the vaccine.
    • COVID infection/booster in the last 3 months: If you have had COVID-19 infection, monoclonal antibodies, OR the COVID-19 monovalent mRNA COVID-19 booster in the last 3 months, wait until the 3 month mark to get the bivalent booster
  • Pneumococcus: Pneumococcal conjugate vaccine [PCV13] series is recommended for all children under the age of 2.  Pneumococcal polysaccharide vaccine [PPSV23] is recommended for individuals with FD at the age of 2 years, 19 years, and 65 years, with some variation depending on dose history.
  • All other childhood/adolescent and booster vaccinations should be administered according to the guidelines set forth by the AAP, ACIP, and CDC. 

Antiviral Treatments

  • RSV (Respiratory Syncytial Virus): Individuals with FD could benefit from the medication palivizumab in the first, and often the second, year of life. 
  • Influenza: Treatment for influenza with Oseltamivir is recommended to be started within 48 hours in patients with high suspicion of influenza infection.
  • COVID-19: Treatment with monoclonal antibodies, paxlovid, OR remdesivir is recommended to be started within 48 hours of COVID symptoms. Call NYU Dysautonomia Center at 212-263-7225 for more guidance.

NYU Dysautonomia Center

Vaccination Recommendations 2022-2023

In accordance with recommendations by the

Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control (CDC)

Recommendations as of September 1st, 2022


COVID -19 vaccine

  • The authorized bivalent COVID-19 vaccines, or updated booster, includes an mRNA component of the original strain to provide an immune response that is broadly protective against COVID-19 and an mRNA component in common between the omicron variant BA.4 and BA.5 lineages to provide better protection against COVID-19 caused by the omicron variant. 
  • FD patients are at high-risk of serious illness from COVID-19 and the Dysautonomia Center recommends for all FD patients receive the COVID-19 vaccine and booster.
  • If you have had COVID-19 infection, monoclonal antibodies, or the COVID-19 monovalent mRNA COVID-19 booster in the last 3 months, wait until the 3 month mark to get the bivalent booster
  • Ex. If you tested positive for COVID in March 2022, and had the booster in July 2022, get the Bivalent booster in Oct 2022.
  • If you had COVID in August 2022 and received monoclonal antibodies on August 15th, 2022, get the bivalent booster AFTER November 15th, 2022.

Vaccine Dosing Schedule

  • The CDC states no contraindication to receiving the COVID-19 booster and the flu shot at the same time.
  • If a patient is to receive both vaccines at the same time, each vaccine should be administered on a different limb (right and left arm) to avoid local site injection reactions.
  • To reduce the risk of autonomic crisis associated with the vaccine, we recommend scheduling the COVID-19 vaccine and influenza vaccine two weeks apart in FD patients


Special Precautions for the COVID-19 Vaccine (Booster) and FD Autonomic Crisis

  • FD patients have reported to similar responses to the booster as the first and second dose of the vaccine.
  • Anticipating “flu-like symptoms” from the vaccine is very normal and commonly occurs from any vaccine. Those symptoms, which sometimes include fever, malaise, chills, body aches, or local site pain at the injection site, are all signs of our own bodies mounting good immune responses. So while that’s a good sign, we understand it can be very uncomfortable to most, and in FD may trigger an autonomic crisis.
  • We recommend starting ibuprofen around the clock the evening after the vaccination (or acetaminophen if you have kidney disease or GI bleeds) and continuing for 2-3 days. To accomplish this, we recommend taking the weight-appropriate dose (check the label of whatever medication you are using) every 6 hours, including while sleeping. We recommend including periods of sleep, especially the first night after the dose, because some people with FD have    awakened with a fever and experienced an autonomic crisis as a result. Similarly, some people have only wanted to take ibuprofen or acetaminophen after measuring or feeling fever or otherwise feeling bad, and in these cases, autonomic crises may have already begun alongside those other symptoms. However, everyone who has followed this advice and taken their antipyretic (anti-fever) medication every 4-6 hours has felt fine and has not experienced increased autonomic crisis.


Influenza Vaccine


All flu vaccines for the 2022-2023 season are QUADRIvalent, instead of trivalent options in the past. This means all options contain the same 4 strains of virus that have been the most predicted to be present this year.

Of these quadrivalent vaccines there are options including inactivated influenza vaccine [IIV], recombinant influenza vaccine [RIV], or live attenuated influenza vaccine (LAIV).

  • The recommendation for our patients is to take the quadrivalent inactivated influenza vaccine [IIV] by regular injection. If they desire “jet injection” and it’s available to them that is OK, but the regular injection by a needle into the arm is the best. Also, jet injection is only for those over age 18.
  • The recombinant option is for people with egg allergies as it’s not grown in egg. It is also only for those over 18 years old.
  • Those with NEUROLOGICAL or NEURODEVELOPMENTAL disorders (including FD) should NOT receive a live attenuated virus (the nasal spray).
  • There is a “high dose” quadrivalent IIV that is only recommended for patients over 65 years old. It contains the same virus strains as the low dose, but is 4 times the amount of virus to help elicit a response from an older immune system. There is also a vaccine with an adjuvant ingredient added that helps boost an immune response which is also only for those older than 65 years of age. This option comes in both trivalent and quadrivalent options this year. People with FD under age 65 should get the same protection offered by the quadrivalent standard dose with no adjuvant.
  • It is safe to administer influenza vaccine with all other routine vaccinations.


Influenza (“the flu”) is a serious disease caused by a group of viruses that spread from person to person primarily through coughing and sneezing of infected persons. Epidemics of influenza typically occur in the winter months.  Rates of infection are highest among children and the rates of serious illness are highest among the elderly and those with medical conditions that place them at increased risk for complications. People with neurologic conditions may have trouble with muscle function, lung function or difficulty coughing, swallowing, or clearing fluids from their airways. These are problems that can make flu illness worse.


Risk for complications is increased if infected concurrently with both influenza virus and the COVID-19 virus, so it remains as important or more than ever to be vaccinated against influenza this year. We recommend receiving the influenza vaccine when it becomes available this year, and not to delay until peak flu season, to help provide protection against influenza while the COVID-19 virus still has community transmission throughout the U.S.


The viruses that cause influenza change often, and so the influenza vaccine is updated each year.  Protection is good but because the viruses change often, coverage may not be complete.  People who get influenza despite being vaccinated often have a milder case than those who did not get the vaccine.  Influenza vaccination is the primary method for preventing influenza and its severe complications. 


Who should get influenza vaccine?  Nearly everyone!


The NYU Dysautonomia Center recommends influenza vaccination for all people with FD older than 6 months and all household members older than 6 months.


  • The only absolute contraindication is a severe allergy to influenza vaccination such as anaphylaxis. Vaccination should be delayed during an acute febrile illness. Individuals with severe reaction to eggs (greater than hives) should receive vaccination in a monitored setting.


How many flu shots do I need? Adults- one. Children under 8- two.

  • Children under 6 months are too young to be immunized.
  • Individuals 8 years and older need only 1 dose regardless of whether they have received earlier doses of influenza vaccine.
  • Children between 6 months and 8 years of age –
    • Require 2 doses of the inactivated influenza vaccine during the same season (4 weeks apart) the first season they are being vaccinated against influenza
    • If a child has received two or more doses of trivalent or quadrivalent influenza vaccine before July 1, 2022, only one dose of 2021-2022 flu vaccine is recommended.


When should I get the annual influenza vaccine?  Now!

  • The CDC recommends the best time to get vaccinated for the flu is in September or October.
  • Flu season can begin as early as September and last as late as May. The vaccine takes about 2 weeks to build up immunity to the virus. Everyone aged 6 months or older should receive an influenza vaccine every year, by the end of October if possible. However, significant seasonal influenza virus activity can continue into May, so if not vaccinated early, vaccination later in the season can still be beneficial.
  • Children aged 6 months through 8 years who require 2 doses should receive their first dose as soon as possible after the vaccine becomes available to allow the second dose (which must be administered ≥4 weeks later) to be received by the end of October.


Can I get the flu from the flu shot? No.

  • The virus in the injected influenza vaccine is dead and cannot cause influenza. Vaccination is given at the beginning of cold and flu season, so it is possible that coincidental respiratory disease unrelated to influenza vaccination can occur after vaccination. Also, mild flu-like symptoms can present after vaccination, which is a sign the immune system is mounting a good response to the vaccine.
  • Side effects occur infrequently.  The most frequent side effect is soreness at the vaccination site.  Other side effects may include flu-like symptoms such as fever, muscle aches, and fatigue. This may occur as soon as 6-12 hours after vaccination; Tylenol is an effective treatment for these side effects. 


Should the flu vaccine be given to someone with suspected or confirmed COVID-19?

  • No, it should be delayed. Flu vaccination should be deferred for people with suspected or confirmed COVID-19, whether or not they have symptoms, until they have met the criteria to discontinue their isolation. While mild illness is not a contraindication to flu vaccination, vaccination visits for these people should be postponed to avoid exposing healthcare personnel and other patients to the virus that causes COVID-19. When scheduling or confirming appointments for flu vaccination, patients should be instructed to notify the health care professional’s office or clinic in advance if they currently have or develop any symptoms of COVID-19.


Where do I get the vaccination?

  • Vaccinations are provided by primary care providers, pediatricians, pulmonologists, as well as in walk-in clinics and many pharmacies. You can visit any of these places for vaccination. We recommend scheduling an appointment or visiting a walk-in site during non-peak hours to avoid large groups of people and to utilize social distancing, mask-wearing, and other hygienic measures to help reduce risk of getting any communicable infection.
  • The NYU Dysautonomia Center does not stock vaccines and is not able to provide influenza or COVID-19 vaccination.


Pneumococcal vaccine [PCV]

What is pneumococcal disease? Pneumococcus is a bacteria that can cause disease in many different areas of the body. Pneumococcus remains a leading cause of serious illness among young children and adults worldwide and is the most frequent cause of pneumonia, bacteremia (bacteria in the blood), sinusitis, and acute otitis media (ear infection).  These bacteria is also responsible for meningitis, urinary tract infections, skin infections (impetigo), and throat infections (strep throat).


The Dysautonomia Center recommends complete standard pneumococcal conjugate vaccine series for all children, typically completed by 18 months of age, although catch-up doses may be given after this period.


After completion of PCV13 series, pneumococcal polysaccharide vaccine [PPSV23] is recommended for individuals with FD after the age of 2 years


Pneumococcal vaccination is recommended again at 19 and 65 years of age for people with FD. Local providers should refer to CDC guidelines for patients with chronic lung disease.


RSV (Respiratory Syncytial Virus) Protection

RSV is a viral infection that produces “cold” symptoms in older children and adults.  It is the most common cause of serious respiratory infections- mostly bronchiolitis and pneumonia in infants and young children. Virtually all children have been infected with RSV by the age of 3.  The virus spreads from infected persons to the nose and throat of others.


RSV has been shown to be a particular problem in the FD population


Review of patient charts and data from the Dysautonomia Center shows that RSV infection in FD patients is poorly tolerated and frequently escalates to pneumonia requiring hospital admission. 


What is palivizumab (Synagis)?  It is a monthly injection given during the RSV season (November through April) that has been shown to be safe and effective in preventing severe RSV infection in children under 2 years of age. 


The Dysautonomia Center recommends monthly Synagis to all patients with FD during cold season in their first year of life. Coverage up until the age of 1 is currently endorsed by the AAP (American Academy of Pediatrics) for children with difficulty clearing secretions due to neurological impairment, as is the case in individuals with FD. It is recommended in the second year of life for children who have previously been hospitalized for respiratory infection. Because FD is not specifically discussed in major medical recommendations, we have encountered a great deal of resistance from insurance carriers and cannot ensure that all FD patients will be covered.



All Other Routine Vaccinations:

All other childhood/adolescent and booster vaccinations should be administered according to the guidelines set forth by the AAP, ACIP, and CDC.  FD poses no contraindication to routine vaccination and as such we recommend full, standard vaccination (including Gardasil and Menactra.)