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Influenza Vaccine

By William D. Surkis, MD, Clinical Associate Professor of Medicine; Director, Internal Medicine Residency Program, Jefferson Medical College; Lankenau Medical Center
Jerome Santoro, MD, Clinical Professor of Medicine; Chief, Department of Medicine, Jefferson Medical College; Lankenau Medical Center

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Based on recommendations by the WHO and US Centers for Disease Control and Prevention (CDC), vaccines for influenza are modified annually to include the most prevalent strains (usually 2 strains of influenza A and 1 or 2 strains of influenza B). Sometimes slightly different vaccines are used in the northern and southern hemispheres.

Preparations

There are 2 basic types of vaccine:

  • Inactivated influenza vaccine (IIV)

  • Live-attenuated influenza vaccine (LAIV)

However, LAIV is not recommended for use in any population in the 2017-2018 flu season.

Trivalent vaccines are gradually being superseded by quadrivalent vaccines that cover an additional B virus strain. A trivalent recombinant influenza vaccine (RIV3) and a cell culture–based vaccine (ccIIV3) that do not contain egg protein are available. A high-dose trivalent vaccine is available for patients ≥ 65 yr.

Indications

Annual vaccination against influenza is recommended for

  • All people ≥ 6 mo

IIV can be given to all people ≥ 6 mo, including pregnant women.

An age-appropriate formulation should be used.

Adults ≥ 65 yr should be given high-dose IIV. The high dose is recommended only for those ≥ 65 yr.

RIV3 can be used in people aged 18 to 49 yr.

(For informational purposes only: The CDC does not recommend LAIV for any population in the 2017-2018 flu season.) LAIV can be given to healthy people aged 2 to 49 yr who are not pregnant and who do not have immunocompromising conditions. Safety of LAIV has not been established in people with disorders that predispose them to complications from influenza, including advanced lung disease or asthma.

Health care workers who care for immunocompromised people (ie, those who require care in a protected environment) should be given IIV or RIV3 rather than LAIV (or they should avoid contact with the immunocompromised people for 7 days after getting the vaccine).

Contraindications and Precautions

The main contraindication for IIV is

  • A severe allergic reaction (eg, anaphylaxis) after previous dose of IIV

Precautions with IIV include

  • Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves)

  • Guillain-Barré syndrome (GBS) within 6 wk after a previous dose of an influenza vaccine

(NOTE: For the 2017-2018 flu season, the CDC does not recommend LAIV for any population.)Contraindications for LAIV include

  • A severe allergic reaction (eg, anaphylaxis) after previous dose of LAIV

  • Immunocompromise (eg, due to disorders, including HIV infection, or use of immunosuppressants)

  • Certain chronic disorders (eg, asthma; reactive airway disease; diabetes; hemoglobinopathy; lung, heart, or kidney disorders)

  • For children and adolescents, long-term treatment with aspirin or other salicylates

  • Pregnancy

  • Age < 2 yr or ≥ 50 yr

  • Age < 5 yr if reactive airway disease (eg, known asthma, recurrent or recent wheezing episodes) is present

Precautions for LAIV include

  • Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves)

  • Guillain-Barré syndrome within 6 wk after a previous dose of an influenza vaccine

  • Use of specific antiviral drugs: ie, amantadine, rimantadine, zanamivir, oseltamivir (these drugs are stopped 48 h before vaccination and are not resumed for 14 days after vaccination)

The main contraindication for RIV3 is

  • A severe allergic reaction (eg, anaphylaxis) after a previous dose of RIV3

Precautions for RIV3 include:

  • Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves)

  • Guillain-Barré syndrome within 6 wk after a previous dose of an influenza vaccine

Precautions for patients with suspected egg allergy: Patients with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Any influenza vaccine that is otherwise recommended based on the recipient’s age and health status can be used.

Patients who report reactions to egg involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who required epinephrine or another emergency medical intervention, may similarly receive any influenza vaccine that is otherwise recommended based on the recipient’s age and health status. The vaccine should be given in an inpatient or outpatient medical setting and supervised by a health care practitioner capable of recognizing and managing severe allergic conditions.

Dose and Administration

The influenza vaccine is given yearly.

For IIV, the dose is

  • 0.25 mL IM for children aged 6 to 35 mo

  • 0.5 mL IM for people ≥ 3 yr

  • 0.1 mL for people aged 18 to 64 yr, given intradermally

The smaller, intradermal dose can be used to conserve vaccine in times of shortage.

For LAIV, the dose is 0.1 mL, sprayed into each nostril (total dose is 0.2 mL). (NOTE: For the 2017-2018 flu season, the CDC does not recommend LAIV for any population.)

For RIV3, the dose is 0.5 mL, given IM.

Adverse Effects

For IIV, adverse effects are usually limited to mild pain at the injection site. Fever, myalgia, and other systemic effects are relatively uncommon; however, people who have been vaccinated may mistakenly think that the vaccine is causing influenza. Such reactions do not contraindicate future vaccination, which should be encouraged.

Multidose vials contain thimerosal, a mercury-based preservative. Public concerns about a possible link between thimerosal and autism have proved unfounded (see Anti-Vaccination Movement : Thimerosal and autism); however single-dose vials, which are thimerosal-free, are available.

For LAIV, adverse effects are mild; rhinorrhea is the most common, and mild wheezing may occur. (NOTE: For the 2017-2018 flu season, the CDC does not recommend LAIV for any population.)

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • FLUMADINE
  • No US brand name
  • TAMIFLU
  • ADRENALIN
  • RELENZA