| Influenza |
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| Disease Issues |
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How serious a problem is influenza in the
U.S.? |
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| Influenza is the
most frequent cause of death from a
vaccine-preventable disease in the United
States after COVID-19. Rates of infection from
seasonal
influenza are highest among children, but the
risks for complications, hospitalizations, and
deaths are higher among adults age 65 years
and older,
children younger than 5 years, pregnant women,
and people of any age who have medical
conditions that place them at increased risk
for complications
from influenza. |
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| From the 2010–11
through the 2019–20 seasons, the annual
influenza-related disease burden has varied
from approximately 9–45 million illnesses,
4–21
million medical visits, 140,000–810,000
hospitalizations and 12,000–61,000 deaths per
year.* The number of influenza laboratory
confirmed deaths in
children reported to CDC has averaged 133
deaths (range 37–199) per year. This is
considered an underestimate of actual
pediatric deaths as some
influenza-related deaths are likely not
reported or recognized. For more information
on the health burden of influenza, see
www.cdc.gov/flu/about/burden/index.html. |
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| * Estimates from
2017–20 are preliminary. These estimates
include median estimates for all years except
for 2019–20 season where the 95% confidence
interval is included as the median estimate is
not yet published. |
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| What medical
conditions increase the risk of severe illness
from influenza? |
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| While even
healthy children and adults can get severe
influenza or die from influenza and its
complications, the risk of severe influenza is
higher for
children younger than 5 years, adults 50 years
and older, pregnant women, Alaska Natives and
American Indians, and residents of nursing
homes or
other long-term care facilities. Medical conditions that increase a person's risk of
severe influenza include chronic pulmonary
(including asthma),
cardiovascular (excluding isolated
hypertension), renal, hepatic, neurologic,
hematologic, or metabolic disorders (including
diabetes mellitus);
immunocompromising conditions due to any cause
(including but not limited to immune
suppression caused by medications or HIV);
extreme obesity
(body mass index of >40 for adults); and the
chronic use of aspirin- or salicylate-containing
medications in children through age 18 (due to
the risk of
Reye syndrome after influenza infection). |
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| More information
about risk factors for severe influenza
infection can be found at:
www.cdc.gov/flu/highrisk/index.htm. |
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| How do risk
groups for severe illness from influenza and
SARS-CoV-2 compare to each other? |
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| People of all
ages are susceptible to illness from both
influenza and SARS-CoV-2, the virus that
causes COVID-19. High risk groups for severe
illness
from influenza and SARS-CoV-2 are very
similar. The most significant differences are
that people with isolated hypertension or any
degree of overweight
or obesity (not just extreme obesity) are at
increased risk of severe COVID-19 illness. CDC
identifies people at increased risk of severe COVID as older
adults, with risk increasing as age increases;
and people with cancer; chronic kidney
disease; chronic lung diseases; dementia and
other neurologic
conditions; Down syndrome; HIV infection; immunocompromised state (weakened immune
system, solid organ or blood stem cell
transplant); liver
disease; overweight and obesity (body mass
index [BMI] of 25 or higher); heart conditions
such as heart failure, coronary artery
disease,
cardiomyopathies, or hypertension; stroke or
cerebrovascular disease; sickle cell disease
or thalassemia; current or former smoker;
substance use
disorders; type 1 and type 2 diabetes, or
pregnancy and recently pregnant. |
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| More information
about risk factors for severe COVID-19 can be
found at:
www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html. |
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| Since
influenza virus circulation was very limited
during the 2020–21 influenza season, what
might be expected for 2021–22 influenza
season? |
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| The timing and
severity of influenza seasons are always
unpredictable. Influenza viruses circulated at
low levels in 2020–21 while measures to
prevent the
spread of COVID-19 were widely adopted,
including social distancing, mask wearing, and
reduction in travel. As the use of these
COVID-19 mitigation
measures has decreased, increases in the
circulation of other non-influenza respiratory
viruses have occurred. Thus, it is likely that
influenza virus
circulation will also increase during 2021–22.
Current information on non-influenza
respiratory viruses can be found at
www.cdc.gov/surveillance/nrevss/index.html.
Current information on influenza virus
circulation can be found at
www.cdc.gov/flu/weekly/index.htm. |
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| Can influenza
viruses circulate at the same time as
SARS-CoV-2, the virus that causes COVID-19? |
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| Yes. Both viruses
co-circulated at the start of the COVID-19
pandemic, although the number of influenza
viruses detected in the U.S. decreased
substantially beginning in the spring of 2020.
The extent to which SARS-CoV-2 and influenza
viruses will co-circulate during this upcoming
influenza is
unknown, however, providers should prepare for
increases in influenza as the use of
prevention measures like masks, and social
distancing decrease. |
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| Where can I
get information on influenza and its
surveillance? |
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| Information
regarding influenza surveillance is available
year-round from CDC at
www.cdc.gov/flu/weekly/fluactivitysurv.htm.
The full FluView surveillance
report is published each Friday afternoon from
October through mid-May and an abbreviated FluView report is published Mid-May through September. In
addition, periodic updates about influenza are
published in MMWR. |
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| State and local
health departments should be consulted
regarding availability of influenza vaccine,
access to vaccination programs, information
about state
or local influenza activity, and for reporting
influenza outbreaks and receiving advice
regarding their control. |
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| Please
summarize what's new in the 2021–22 influenza
vaccine recommendations? |
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| Yearly influenza
vaccination continues to be recommended for
everyone age 6 months and older. All available
influenza vaccines in the United States are
now quadrivalent (containing two influenza A
and two influenza B strains). The 2021–22
vaccines have been updated to include new
influenza A (H3N2) and influenza A (H1N1)
virus vaccine antigens. One vaccine product, Flucelvax Quadrivalent (ccIIV4, Seqirus) is
now FDA-approved for children age 2 years and
older (formerly approved for children age 4
years and older). |
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| In addition, the
2021–22 recommendations discuss considerations
for co-administration of influenza vaccine
with a COVID-19 vaccine. Influenza vaccines
and other vaccines may be administered at the
same time as a COVID-19 vaccine. Guidance on
COVID-19 vaccination, including coadministration with other vaccines, is
available here:
www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html.
If administered simultaneously, COVID-19
vaccines and influenza vaccines that might be
more likely to cause a local reaction [e.g.,
adjuvanted inactivated influenza vaccine
(aIIV4, Fluad Quadrivalent, Seqirus) or
high-dose inactivated vaccine (HD-IIV4 Fluzone
High-Dose Quadrivalent (Sanofi Pasteur)]
should be administered in different limbs, if
possible]. |
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| CDC also now
recommends that providers consider influenza
vaccination of pregnant people in their third
trimester as soon as vaccine is available. CDC
continues to recommend that children not
previously vaccinated who need two doses of
influenza receive their first dose as soon as
possible so that they can get their second
dose before the end of October. The two doses
should be separated by at least 4 weeks. For
non-pregnant adults, CDC continues to
recommend avoiding influenza vaccination in
July and August unless there is a concern that
later vaccination may not be possible. |
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| Lastly, CDC
revised guidance for the contraindications and
precautions for the use of Flucelvax
Quadrivalent (ccIIV4) and Flublok Quadrivalent
(RIV4, Sanofi Pasteur) among people with a
history of a severe allergic reaction to an
influenza vaccine. For ccIIV4, a history of a
severe allergic reaction to a prior dose of
any egg-based IIV, live attenuated vaccine
(LAIV), or RIV is a precaution. For RIV4, a
history of a severe allergic reaction to IIV,
LAIV, or ccIIV4 is a precaution. People with
precautions for receiving ccIIV4 and RIV4
should be vaccinated in a medical setting
under supervision of a provider who can
recognize and manage severe allergic
reactions. RIV4 continues to be
contraindicated for people with a prior
allergic reaction to any RIV vaccine
components. Similarly, ccIIV4 is
contraindicated for people with a prior
allergic reaction to any ccIIV components. |
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| Who is
recommended to be vaccinated against
influenza? |
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| ACIP recommends
annual vaccination for all people ages 6
months and older who do not have a
contraindication to influenza vaccination. |
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| Which
influenza vaccines will be available during
the 2021–22 influenza season? |
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| Multiple
manufacturers are producing influenza vaccine
for the U.S. market for the 2021–22 season.
Inactivated influenza vaccines (IIV4) will be
produced using egg-based, cell culture-based,
and recombinant technologies. Live attenuated
nasal spray vaccine (LAIV4, Flumist
Quadrivalent; AstraZeneca) will also be
available. All influenza vaccines are
quadrivalent (containing four strains of
influenza virus). |
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| Influenza
vaccines are not all licensed for the same age
groups. ACIP does not state a preference for
one influenza vaccine over another for people
for whom more than one vaccine is recommended
and appropriate. |
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| IAC has a handout
that summarizes each of the products available
for the current influenza vaccination season
at
www.immunize.org/catg.d/p4072.pdf. |
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| What are the
vaccine viruses for the 2021–22 influenza
season? |
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| Vaccine viruses
differ by the type of vaccine, but they are
designed to protect against the same strains
of circulating viruses. For the 2021–22
season, U.S. egg-based influenza vaccines
(i.e., vaccines other than ccIIV4 and RIV4)
will contain hemagglutinin (HA) derived from: |
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an influenza
A/Victoria/2570/2019 (H1N1)pdm09-like
virus [new]; |
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an influenza A/Cambodia/e0826360/2020
(H3N2)-like virus [new]; |
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an influenza B/Washington/02/2019
(Victoria lineage)-like virus; and |
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an influenza B/Phuket/3073/2013 (Yamagata
lineage)-like virus. |
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| For the 2021–22
season, U.S. cell culture–based inactivated
(ccIIV4) and recombinant (RIV4) influenza
vaccines will contain HA derived from: |
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an influenza A/Wisconsin/588/2019
(H1N1)pdm09-like virus [new]; |
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an influenza A/Cambodia/e0826360/2020
(H3N2)-like virus [new]; |
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an influenza B/Washington/02/2019
(Victoria lineage)-like virus; and |
| • |
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an influenza B/Phuket/3073/2013 (Yamagata
lineage)-like virus. |
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| What influenza
vaccines are available for children for the
2021–22 influenza season? |
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| Four egg-based
quadrivalent inactivated influenza vaccines
(IIV4s), all given as intramuscular
injections, are available for children age 6
months and older: |
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Afluria Quadrivalent (Seqirus): 0.25 mL/dose
for age 6 through 35 months; 0.5 mL/dose
for age 3 years and older |
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Fluarix Quadrivalent (GlaxoSmithKline):
0.5 mL/dose for age 6 months and older |
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FluLaval Quadrivalent (GlaxoSmithKline):
0.5 mL/dose for age 6 months and older |
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Fluzone Quadrivalent (Sanofi Pasteur):
0.25 mL or 0.5 mL per dose for age 6
through 35 months; 0.5 mL/dose age 3 years
and older |
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| Flucelvax
Quadrivalent (ccIIV4, Seqirus): 0.5 mL/dose
given intramuscularly, is available for
children age 2 years and older. |
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| Flumist
Quadrivalent (LAIV4, AstraZeneca): 0.2 mL
administered intranasally (0.1 mL in each
nostril), is available for healthy,
non-pregnant children age 2 years and older. |
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| What influenza
vaccines are available for adults? |
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| Four egg-based
quadrivalent standard dose IIV vaccines
(SD-IIV4s), all given as intramuscular
injections, are available for adults of all
ages: |
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Afluria Quadrivalent (Seqirus): 0.5 mL/dose |
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Fluarix Quadrivalent (GlaxoSmithKline):
0.5 mL/dose |
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FluLaval Quadrivalent (GlaxoSmithKline):
0.5 mL/dose |
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Fluzone Quadrivalent (Sanofi Pasteur): 0.5
mL/dose |
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| Flublok
Quadrivalent (RIV4, Sanofi Pasteur): 0.5 mL/dose
given intramuscularly is available for all
adults age 18 years and older. |
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| Flumist
Quadrivalent (LAIV4, AstraZeneca): 0.2 mL
administered intranasally (0.1 mL in each
nostril), is available for healthy,
non-pregnant adults through age 49 years. |
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| Fluzone High-Dose
Quadrivalent (egg-based HD-IIV4, Sanofi
Pasteur): 0.7 mL administered intramuscularly,
is available for adults age 65 years and
older. |
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| Fluad
Quadrivalent (egg-based aIIV4, Seqirus): 0.5
mL administered intramuscularly, is available
for adults age 65 years and older. |
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| Which children
younger than age 9 years will need 2 doses of
influenza vaccine in this influenza season? |
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| Children age 6
months through 8 years should receive a second
dose 4 weeks or more after the first dose 1)
if they are receiving influenza vaccine for
the first time, 2) if they have not received a
total of at least two doses of any seasonal
influenza vaccine before July 1 of the current
year, or 3) if their vaccination history is
unknown. The two previous doses need not have
been received during the same season or
consecutive seasons. |
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| Children who are
8 years old and are recommended to receive two
doses during the current season but who have a
9th birthday during the current season before
receiving dose 2 should still receive dose 2. |
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| IAC's handout
titled "Guide for Determining the Number of
Doses of Influenza Vaccine to Give to Children
Age 6 Months Through 8 Years" provides
additional guidance on this issue; it is
available at
www.immunize.org/catg.d/p3093.pdf. |
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| When does CDC
recommend starting influenza vaccination? |
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| For most people,
vaccination should begin in September and,
ideally, be done by the end of October. |
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| There are two
groups of people for whom CDC recommends
vaccination as soon as vaccine becomes
available: pregnant people in the third
trimester and children who need two doses of
vaccine this season. Vaccination during pregnancy has been shown to reduce
influenza-related hospitalizations during
early infancy as a result of maternal antibodies passed to the fetus. Pregnant
people in their third trimester are
recommended to be vaccinated as soon as
vaccine is available in order to allow time
for some vaccine-induced protection to be
passed to the fetus. Other pregnant people
should be vaccinated by the end of October. |
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| CDC continues to
recommend that children not previously
vaccinated who need two doses of influenza
receive their first dose as soon as vaccine is
available so that they can get their second
dose before the end of October. |
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| For nonpregnant
adults, influenza vaccination during July and
August should be avoided unless there is
concern that later vaccination might not be
possible. Early vaccination has been
associated with decreased vaccine
effectiveness before the end of the influenza
season, particularly among older adults. |
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| CDC recommends
that influenza vaccination be offered by the
end of October. This balances considerations regarding the unpredictability of timing of
onset of the influenza season and concerns
that vaccine-induced immunity might wane over
the course of a season, particularly for older
adults. |
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| For people not
vaccinated by the end of October, vaccination
efforts should continue throughout the season,
even after influenza activity has begun. |
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| Should our
practice consider revaccinating our high risk
and older patients a second time during the
year due to concerns with waning immunity? |
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| For people who
have already been fully vaccinated,
revaccination later in the season is not
recommended. |
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| How late in
the season can I vaccinate my patients with
influenza vaccine? |
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| Peak influenza
activity generally occurs in the Northern
Hemisphere in January or February. Providers
should continue vaccinating patients
throughout the influenza season, including
into the spring months (for example, through
May), as long as they have unexpired vaccine
in stock and unvaccinated patients in their
office. |
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| Because influenza
occurs in many areas of the world during April
through September, vaccine should be given to travelers who missed vaccination in the
preceding fall and winter. Another late season
use of vaccine is for children younger than
age 9 years who needed 2 doses of vaccine but
failed to get their second dose. For each of these situations, vaccine can be given through
the month of June since most injectable
influenza vaccine has a June 30 expiration
date. |
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| What types of
personal protective equipment do healthcare
personnel need for administering vaccines in light of COVID-19? |
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| CDC recommends
that healthcare personnel administering any
vaccines during COVID-19 wear surgical masks. N95 respirators are not recommended. Eye
protection is recommended in areas with
moderate or substantial community COVID-19
transmission; it is optional in communities
with minimal or no COVID-19 transmission. Gloves are recommended when giving intranasal
or oral vaccines because of the increased
likelihood of coming into contact with a
patient's mucous membranes and body fluids.
Gloves are optional for other vaccines. Importantly, hands should be washed and
gloves, when worn, should be changed between
each patient. For additional details, visit
the CDC web page "Interim Guidance for Routine
and Influenza Immunization Services During the
COVID-19 Pandemic" at
www.cdc.gov/vaccines/pandemic-guidance/index.html
or IAC's handout, "Protective Measures for
Vaccinating during the Pandemic," available at
https://immunize.org/catg.d/p2009.pdf. |
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| May influenza
vaccines be given at the same time as other
vaccines, including COVID-19 vaccines? |
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| Yes. CDC's
clinical guidance for the use of COVID-19
vaccines states that any vaccine may be given
on the same day or any day before or after
COVID-19 vaccination, at a different anatomic
site. According to the CDC's "General Best
Practice Guidelines for Immunization,"
simultaneously administering all vaccines for
which a person is eligible at the time of a
visit increases the probability that a person
will be fully vaccinated by the appropriate time. If administered at the same time,
COVID-19 vaccines and influenza vaccines that
might be more likely to cause a local reaction
(aIIV4 or HD-IIV4) should be administered in
separate limbs, if possible. |
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| Because CDC
guidance on COVID-19 vaccination is updated as
new information emerges, periodically check
the CDC website for updates to ACIP
recommendations on the use of COVID-19 vaccine
(www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html)
and updates to CDC's interim clinical guidance
for the use of COVID-19 vaccines (www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html). |
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| IIV and RIV can
be administered on the same day or any other
day before or after other live or inactivated
vaccines. Injectable vaccines should be
administered in separate anatomic sites when
given on the same day. |
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| LAIV may be given
on the same day as any other live or
inactivated vaccines. However, if two live
vaccines are not given on the same day, they
should be separated by at least 4 weeks. |
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| We are
considering co-locating our COVID-19
drive-through testing site and influenza
vaccination sites. Can we vaccinate someone
with suspected or confirmed COVID-19
infection? |
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| CDC recommends
deferring vaccination for people with
suspected or confirmed COVID-19 until they
have met criteria for no longer needing
quarantine or isolation to avoid exposing
healthcare personnel and others. When
scheduling or confirming appointments for
vaccination, patients should be screened for
COVID-19 symptoms and recent exposure. |
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| Which
travelers are recommended to get influenza
vaccine? |
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| Healthcare
providers should vaccinate any person who
failed to get vaccinated in the previous
vaccination season and who wants to reduce
their risk of getting influenza during their
upcoming travel, particularly if they are at high risk for influenza-related complications.
This includes people who are traveling to the
tropics, traveling with organized tourist
groups at any time of year, or traveling to
the Southern Hemisphere during
April–September. |
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| If a patient
received a dose of influenza vaccine in June
(for example, for international travel), how
long should the patient wait before getting
vaccinated with the next season's flu vaccine? |
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| There should be a
minimum of 4 weeks between the doses in such
situations. |
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| What are CDC
recommendations for influenza vaccination of
people who have already become ill with influenza during the season? |
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| Because more than
one type or subtype of influenza virus can
circulate in any given influenza season,
providers should offer influenza vaccination
to unvaccinated people throughout the
influenza season, including people who may
have had an influenza illness already in the
season. |
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| How long does
immunity from influenza vaccine last? |
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| Protection from
influenza vaccine is thought to persist for at
least 6 months. Protection declines over time
because of waning antibody levels and because
of changes in circulating influenza viruses
from year to year. For people who need only 1
dose of influenza vaccine for the season,
yearly vaccination (i.e., in July and August)
is likely to be associated with suboptimal
immunity before the end of the influenza
season, particularly among older adults. |
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| Some of my
patients refuse influenza vaccination because
they insist they "got the flu" after receiving
the injectable vaccine in the past. What can I
tell them? |
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| There are several
reasons why this misconception persists: |
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Less than 1%
of people who are vaccinated with the
injectable vaccine develop flu-like
symptoms, such as mild fever and muscle
aches, after vaccination. These side
effects are not the same as having
influenza, but people confuse the
symptoms. |
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Protective immunity doesn't develop until
1–2 weeks after vaccination. Some people
who get vaccinated later in the season
(December or later) may be infected with
influenza virus shortly afterward. These
late vaccinees develop influenza because
they were exposed to someone with the
virus before they became immune. It is not
the result of the vaccination. |
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For many people, "the flu" is any illness
with fever, cold symptoms or
gastrointestinal symptoms. If they get any
viral illness, they may blame it on flu
vaccine or think they got "the flu"
despite being vaccinated. Influenza
vaccine only protects against certain
influenza viruses, not all viruses. |
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Influenza vaccination is our best
protection against influenza disease;
however, some people who are vaccinated
will still get influenza illness despite
vaccination. |
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| While vaccine
effectiveness (VE) can vary, recent studies
show that flu vaccination reduces the risk of
flu illness by between 40% and 60% among the
overall population during seasons when most
circulating flu viruses are well-matched to
the flu vaccine. VE is generally lower for
adults age 65 years and older. Influenza
vaccination has also been shown to reduce
influenza disease severity even if someone
does get sick after vaccination, and reduces
the risk of influenza hospitalization, and
deaths in children and adults. Influenza
vaccination also reduces the risk of acute
cardiac events, like heart attack and heart
failure, among people with heart disease. |
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| For more
information on this topic, go to:
www.cdc.gov/flu/vaccines-work/index.html. |
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| When
administering influenza vaccine, is giving
patients a vaccine information statement (VIS)
mandatory or is it only "recommended"? |
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| Giving patients
an influenza Vaccine Information Statement
(VIS) is mandatory under the National
Childhood Vaccine Injury Act of 1986. The VIS
must be given to all adults as well as to
parents or guardians of children prior to
vaccination. Two VISs are available, one for
live attenuated influenza vaccine (LAIV) and
one for inactivated influenza vaccine (IIV)
and recombinant vaccine (RIV). Each can be
found at www.immunize.org/vis/ in multiple
languages. The current influenza vaccine VISs
are dated August 6, 2021. |
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| The latest VIS
for all vaccines plus translations in multiple
languages are located on the IAC website
www.immunize.org/vis/. |
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| Are there
recommendations for the prevention of
institutional outbreaks of influenza? |
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| The most
important factor in preventing outbreaks is
annual vaccination of all residents and staff
who work at facilities such as nursing homes,
assisted living facilities, and other group
living situations. Groups that should be targeted include physicians, nurses, and other
personnel in hospitals and outpatient settings
who have contact with high-risk patients in
all age groups, and providers of home care to
high-risk people (for example, visiting
nurses, therapists, and volunteers). |
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| We are trying
to provide influenza vaccination to all
eligible patients during their stay in our
hospital. If a patient does not remember if he
or she has already received the vaccine this
season, should we go ahead and vaccinate? |
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| If a patient or
family member cannot remember if the patient
received influenza vaccine this season and no
record is available, proceed with
administering influenza vaccine, even if it
might mean an extra dose is given. When a
patient reports that they HAVE received
influenza vaccine but does not have written
documentation, ACIP states that in the
specific case of influenza (and pneumococcal
polysaccharide) vaccination, patient
self-report of being vaccinated can be
accepted as evidence of vaccination. |
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| Live
Attenuated Influenza Vaccine (LAIV)
Issues |
Back to top |
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| For whom is
Flumist Quadrivalent approved? |
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| Flumist
Quadrivalent (LAIV4; AstraZeneca) is currently
approved by FDA only for healthy non-pregnant
people age 2 through 49 years. |
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| Is
administering Flumist an aerosol-generating
procedure requiring airborne precautions
during the COVID-19 pandemic? |
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| No. Giving
Flumist is not considered an
aerosol-generating procedure. See the CDC web
page Interim Guidance for Routine and
Influenza Immunization Services During the
COVID-19 Pandemic for additional details at:
https://www.cdc.gov/vaccines/pandemic-guidance/index.html. |
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| How is Flumist
administered? |
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| The vaccine dose
(0.2 mL) comes inside a special sprayer
device. A plastic clip on the plunger divides
the dose into two equal parts. The patient is
seated
in an upright position with head tilted back.
Half of the contents of the sprayer (0.1 mL)
is sprayed into each nostril. |
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| Can Flumist be
administered to people with minor acute
illnesses, such as a mild upper respiratory infection (URI) with or without fever? |
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| Yes, unless
clinical judgment suggests nasal congestion is
present that might keep the vaccine from
making good contact with the nasopharyngeal
mucosa. In that case, consider either
deferring its use until the congestion resolves or using an appropriate alternative
influenza vaccine, if available. |
|
| Can a woman
who is breastfeeding receive Flumist? |
|
| Yes.
Breastfeeding is not a contraindication for
any routine vaccination including Flumist. |
|
| Can Flumist be
given to contacts of immunosuppressed
patients? |
|
| With rare
exceptions, yes. Like other live vaccines,
Flumist should not be administered to
immunosuppressed people. ACIP has stated a
preference for
using inactivated influenza vaccine for all
close contacts of severely immunosuppressed
individuals (for example, patients with
hematopoietic stem cell
transplants) during those periods in which the
immunosuppressed person requires care in a
protective environment because of the theoretical risk that the
live attenuated vaccine virus could be
transmitted to the severely immunosuppressed individual and cause disease. Healthcare
personnel or other people
who have close contact with people with lesser
degrees of immunosuppression (for example,
people with diabetes, people with asthma
taking
corticosteroids, or people living with HIV)
who are otherwise eligible for Flumist may
receive it. No special precautions need to be
taken by the vaccinated
person. |
|
| How long after
someone is vaccinated with Flumist must they
stay away from a severely immunosuppressed
person (a person who is hospitalized in
protective [reverse] isolation)? |
|
| People should
avoid contact with any person who is severely
immunosuppressed for at least 7 days after
receiving Flumist. There are no restrictions
on
being in contact with any other patients. |
|
| Is Flumist
contraindicated for adults with asthma? |
|
| Asthma is a
precaution for Flumist in people 5 years of
age and older. |
|
| Can we give
Flumist to a person who is taking an influenza
antiviral medication? |
|
| An antiviral drug
active against influenza virus may reduce the
effectiveness of Flumist. ACIP has recommended different intervals between the last dose
of an antiviral medication and Flumist
administration, based upon the half-life of
the antiviral medication. The new
recommendations are as follows: |
|
| • |
|
Oseltamivir
or zanamivir: wait at least 48 hours after
last dose before administering Flumist |
| • |
|
Peramivir: wait at least 5 days before
administering Flumist |
| • |
|
Baloxavir: wait at least 17 days before
administering Flumist |
|
|
| If any influenza
antiviral medication must be given within 14
days after Flumist administration, the patient
should be revaccinated without delay with any
age-appropriate inactivated influenza vaccine.
All inactivated influenza vaccines and
recombinant influenza vaccine (Flublok
Quadrivalent) may be
administered at any time relative to antiviral
medication. |
|
| One of our
young patients made it impossible to
administer the second part of the Flumist
dose. What should we do? |
|
| A half dose of
Flumist (or any other vaccine) is a
non-standard dose and should not be counted.
If you were unable to give the second half of
the vaccine
at that same appointment, you will have to
provide another full dose of influenza vaccine
at another time. If you want to give Flumist
again, you should wait
four weeks, because it is a live vaccine.
Alternatively, you can give inactivated
influenza vaccine any time after this partial
dose. |
|
|
|
|
|
| Which children
should receive influenza vaccine? |
|
| ACIP recommends
annual influenza vaccination for all children
age 6 months and older who do not have a contraindication to the vaccine. |
|
| Please provide
details about the inactivated influenza
vaccine options for children younger than 3
years. |
|
| Four egg-based
quadrivalent inactivated influenza vaccines
(IIV4s), all given as intramuscular (IM)
injections, are available for children age 6
through 35
months: |
|
| • |
|
Afluria
Quadrivalent (Seqirus): 0.25 mL/dose |
| • |
|
Fluarix
Quadrivalent (GlaxoSmithKline): 0.5 mL/dose |
| • |
|
FluLaval
Quadrivalent (GlaxoSmithKline): 0.5 mL/dose |
| • |
|
Fluzone
Quadrivalent (Sanofi Pasteur): 0.25 mL or
0.5 mL per dose |
|
|
| Flucelvax
Quadrivalent (ccIIV4, Seqirus) is available to
children ages 24 months (2 years) and older:
administer 0.5 mL/dose IM |
|
| Which children
younger than age 9 years will need 2 doses of
influenza vaccine in this influenza season? |
|
| Children age 6
months through 8 years should receive a second
dose 4 weeks or more after the first dose 1)
if they are receiving influenza vaccine for
the first time, 2) if they have not received a
total of at least two doses of any seasonal
influenza vaccine before July 1 of the current
year, or 3) if their
vaccination history is unknown. The two previous doses need not have been received
during the same season or consecutive seasons. |
|
| Children who are
8 years old and are recommended to receive two
doses during the current season but who have a
9th birthday during the current
season before receiving dose 2 should still
receive dose 2. |
|
| IAC's handout
titled "Guide for Determining the Number of
Doses of Influenza Vaccine to Give to Children
Age 6 Months Through 8 Years" provides
additional guidance on this issue; it is
available at
www.immunize.org/catg.d/p3093.pdf. |
|
| When
determining whether a child age 2 through 8
years needs one or two doses of influenza
vaccine this season, can we count doses of Flumist
administered in past years? |
|
| Yes. CDC advises
that doses of Flumist administered in past
seasons can be counted. |
|
| If a child age
8 years or younger has had one dose of
trivalent and one dose of quadrivalent
influenza vaccine in the past, do they need
one or two doses
for the upcoming season? |
|
| They need just
one dose of any appropriate influenza vaccine
annually. |
|
| Can a child
age 6–35 months who needs 2 doses of influenza
vaccine this season receive a combination of Afluria, Fluzone, FluLaval, Fluarix, or
Flumist
vaccine? |
|
| Yes. The two
doses do not have to be the same brand.
Afluria Quadrivalent (0.25 mL per dose),
Fluzone Quadrivalent (0.25 mL or 0.5 mL per
dose),
FluLaval Quadrivalent (0.5 mL per dose), and
Fluarix Quadrivalent (0.5 mL per dose) are
approved by the FDA for use in children age
6–35 months. |
|
| Flucelvax
Quadrivalent (Seqirus) is an option beginning
at age 2 years at 0.5 mL dose. Flumist
Quadrivalent is another option for children
beginning at age
2 years. |
|
| Can a child 36
months through 8 years of age who needs 2
doses of influenza vaccine this season receive
a combination of Fluzone, FluLaval, Fluarix,
Flucelvax, Afluria, or Flumist vaccine? |
|
| Yes. The two
doses do not have to be the same brand.
Fluzone Quadrivalent (0.5 mL dose), FluLaval
Quadrivalent (0.5 mL dose), Fluarix
Quadrivalent (0.5
mL dose), Afluria Quadrivalent (0.5 mL dose),
Flucelvax (0.5 mL dose) and Flumist
Quadrivalent are all options for use in
children age 3 years and older. |
|
| If a child
receives Fluzone Quadrivalent vaccine (0.25 mL)
at age 34 or 35 months for the first time and then returns for the second dose at age 37
months, should we give another 0.25 mL dose of
Fluzone Quadrivalent or should we give the 0.5
mL dose that is indicated for age 3 years and
older? |
|
| The child should
always receive the dose appropriate for his or
her age at the time of the clinic visit; at
age 37 months that would be 0.5 mL. |
|
| Can a clinic
vaccinate children younger than age 3 years
with influenza vaccine taken from a multi-dose vial of influenza vaccine? The multi-dose
vials
contain thimerosal as a preservative. |
|
| Yes. Multi-dose
vials of inactivated influenza vaccine contain
a small amount of thimerosal to prevent
bacterial and fungal growth in the vial.
Thimerosal-containing vaccines are safe to use in
children. No scientific evidence indicates
that thimerosal in vaccines causes adverse
events unless the patient has
a severe allergy to thimerosal. However, a few
states have enacted legislation that restricts
the use of thimerosal-containing vaccines in
children. To find
out if your state has such restrictions, check
with your state immunization program (see
www.immunize.org/coordinators for contact
information). |
|
| Do any
children age 9 years need two total doses
during an influenza season? |
|
| Yes, but only
under one particular set of circumstances. A
9-year-old should receive a dose of influenza
vaccine if they turned 9 years old during the
current season and already received one dose
during the current season when they were 8
years old, AND they did not receive a total of
at least two prior
doses of influenza vaccine before July 1 of
the current year, or their vaccination history
before July 1 of the current year is unknown. |
|
| There is a
debate within my clinical department about not
allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state
these
should not be given concomitantly? |
|
| A CDC study has
shown a small increased risk for febrile
seizures during the 24 hours after a child
receives the inactivated influenza vaccine at
the same
time as the PCV13 vaccine or DTaP vaccine.
However, the risk of febrile seizure with any
combination of these vaccines is small and
ACIP recommends
giving these vaccines at the same visit if
indicated. See
www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html
for more information. |
|
|
|
|
|
| Is influenza
vaccine recommended for pregnant women? |
|
| Yes. It is
especially important to vaccinate pregnant
women because of their increased risk for
influenza-related complications and their
baby's increased
risk of influenza-related illness and
hospitalizations during the first 6 months of
life. |
|
| Influenza
vaccination during pregnancy reduces mothers'
risk of influenza illness, preterm labor, and
their infants' risk of influenza and
influenza-related
hospitalization in the first 6 months of life. |
|
| Most studies of
influenza vaccination in pregnant women have
administered vaccine in the second or third trimester using inactivated influenza vaccine. |
|
| Vaccination can
occur in any trimester, including the first.
Only inactivated or recombinant influenza
vaccines may be given to pregnant women. Flumist,
a live vaccine, should not be used in pregnant
women. |
|
| Why do we
vaccinate pregnant women against influenza
when it is not recommended to vaccinate
infants younger than age 6 months? |
|
| ACIP has
recommended vaccinating pregnant women with
inactivated influenza vaccine since 1997.
Pregnant women are at increased risk for
complications, hospitalization, and even death
from influenza because of the increased
physiologic strain of pregnancy on their
heart, lungs, and immune
system. Vaccination can occur in any trimester, including the first. |
|
| Influenza vaccine
is not recommended for children younger than
age 6 months because it is not approved for
this age group. However, vaccinating during
pregnancy provides maternal antibodies to the
fetus; this helps protect the young infant
against influenza during the first 6 months of
life. Vaccinating
pregnant women protects women, their unborn
babies, and their babies after birth. |
|
| Does ACIP
recommend one influenza product over another
for pregnant women? |
|
| Pregnant women
may receive any inactivated or recombinant
influenza vaccine. They should not be given
Flumist Quadrivalent because it is a
live-virus
vaccine. |
|
| Can
thimerosal-containing vaccine be given to
pregnant women? |
|
| Yes, unless you
live in a state that has enacted legislation
restricting use in pregnant women. There is no
scientific evidence that thimerosal in
vaccines is
a cause of adverse events unless the patient
has a systemic allergy to thimerosal. |
|
|
If a patient was vaccinated earlier in the
influenza season and later becomes pregnant
during the same season, should she be
revaccinated due to her
pregnancy? |
|
| No. The Advisory
Committee on Immunization Practices (ACIP)
does not recommend more than one dose of influenza vaccine per season, except for
certain children being vaccinated for the
first time. |
|
| I heard that a
study suggested an increase in miscarriage
among women who received inactivated influenza
vaccine. Please provide details. |
|
| A CDC-funded
study found that women who had been vaccinated
early in pregnancy with an influenza vaccine containing the pandemic H1N1
(H1N1pdm09) component and who also had been
vaccinated the prior season with an
H1N1pdm09-containing influenza vaccine had an
increased risk of
spontaneous abortion (miscarriage) in the 28
days after vaccination. This study did not
quantify the risk of miscarriage and did not
prove that influenza
vaccine was the cause of the miscarriage.
Earlier studies have not found a link between
influenza vaccination and miscarriage. A
larger follow-up study
also funded by CDC which included 3 more years
of data found no association between early
miscarriage and influenza vaccination
regardless of
previous influenza season vaccination. These
results are reassuring regarding the safety of
influenza vaccination of pregnant women. |
|
| CDC, ACIP, and
the American College of Obstetricians and
Gynecologists (ACOG) have not changed the recommendation for influenza vaccination of
pregnant women. It is recommended that
pregnant women receive influenza vaccine
during any trimester of their pregnancy
because influenza poses a
danger to pregnant women and the vaccine can
prevent influenza in pregnant women and their
infants. |
|
| A co-worker of
mine says we are supposed to give infants
preservative-free influenza vaccine. Is this
true? |
|
| No. CDC and ACIP
express no preference for preservative-free
vaccine for infants or any other group of
vaccine recipients. |
|
| No scientific
evidence exists that thimerosal in vaccines is
a cause of adverse events unless the patient
has a systemic allergy to thimerosal. However,
some states have enacted legislation that
restricts the use of thimerosal-containing
vaccines. Check with your state immunization
manager to see if your
state is one of them (www.immunize.org/coordinators). |
|
| Do people with
diabetes who control their disease with diet
need influenza vaccine? |
|
| People with a
metabolic disease, including diabetes, should
receive annual influenza vaccination with an inactivated or recombinant influenza vaccine. |
|
| Is influenza
vaccine safe to administer to patients with
multiple sclerosis? |
|
| Yes. Multiple
sclerosis is not a contraindication to any
vaccine, including influenza and pneumococcal
vaccines. |
|
| Does influenza
vaccine increase the HIV titer in the blood of
people with HIV infection? |
|
| Although some
studies have demonstrated a transient increase
in replication of HIV following inactivated
influenza vaccine, other studies have not
found
this. This temporary increase in HIV titer has
not been associated with deterioration in
either T-lymphocyte counts or clinical
condition. ACIP believes that
annual influenza vaccination with inactivated
vaccine will benefit many HIV-infected people. |
|
| Please tell me
about Fluad Quadrivalent, one of the influenza
vaccines for people age 65 years and older. |
|
| In November 2015,
FDA licensed Fluad (aIIV3, Seqirus), a
trivalent, MF59-adjuvanted inactivated
influenza vaccine, for people age 65 years and
older.
Fluad is now quadrivalent (aIIV4). Fluad was
the first adjuvanted influenza vaccine
marketed in the U.S. An adjuvant is a
substance added to a vaccine to
increase its immunogenicity. The MF59 adjuvant
is based on squalene, an oil that occurs
naturally in many plants and animals. Fluad
has been used in
Europe since 1997 and is approved in 38 other
countries. In contrast to Fluzone High-Dose Quadrivalent (Sanofi Pasteur), Fluad is a
standard-dose
vaccine, containing 15 mcg of hemagglutinin
per virus per dose. In a small observational
study among adults age 65 years and older Fluad (trivalent) was
associated with greater protection against
influenza illness compared to unadjuvanted
trivalent standard dose inactivated influenza
vaccine. ACIP has not
stated a preference for any specific licensed
influenza vaccine for people age 65 years and
older. |
|
| A study
published in 2014 found that the injectable
vaccine Fluzone High-Dose protected people 65
years and older better than standard-dose Fluzone.
Does ACIP preferentially recommend use of
Fluzone High-Dose for all people age 65 years
and older? |
|
|
Aging decreases the body's ability to develop
a good immune response after getting influenza
vaccine, which places older people at greater
risk of severe
illness from influenza. A higher dose of
antigen in the vaccine should give older
people a better immune response and therefore
provide better protection
against influenza. There is published evidence
of better protection from Fluzone High-Dose
when compared to standard-dose Fluzone (N Engl
J Med
2014; 371:635–45); however, ACIP has not
stated a preference for any specific licensed
influenza vaccine for people age 65 years and
older. |
|
| Should Fluzone
High-Dose Quadrivalent or Fluad Quadrivalent
be administered to patients younger than age
65 years? |
|
|
No. These vaccines are licensed only for
people age 65 years and older and are not
recommended for younger people. |
|
| Would giving
an older patient 2 doses of standard-dose
influenza vaccine be the same as administering the high-dose product? |
|
|
No, and this is not recommended. |
|
| If a patient
is undergoing treatment for cancer, is it safe
to vaccinate her or him against influenza? |
|
|
People with cancer need to be protected from
influenza, and they can and should receive
inactivated or recombinant influenza vaccine
(but not live nasal
spray vaccine [Flumist]) even if they are
immunosuppressed. Cancer patients and
survivors are at higher risk for complications
from influenza, including
hospitalization and death. Here is a helpful
CDC web page on cancer and influenza for
patients:
www.cdc.gov/cancer/flu. |
|
| How soon after
bone marrow transplant do we start to
vaccinate our patients against influenza? |
|
|
Inactivated influenza vaccine or recombinant
influenza vaccine should be administered
beginning at least 6 months after bone marrow
transplant and
annually thereafter for the life of the
patient. A dose of vaccine can be given as
early as 4 months after transplant, but a
second dose should be
considered in this situation. A second dose is
recommended routinely for all children younger
than 9 years receiving influenza vaccine for
the first time. |
|
|
|
|
|
| Why is
influenza vaccination important for HCP? |
|
| We already
encourage them to stay home from work when
they are sick. Unfortunately, by the time a
HCP has symptoms of influenza, they may have
already exposed many patients since the virus
is shed for 1–2 days before symptoms begin.
Further, many studies show that HCP often go
to work while
they are sick and may be infectious to others.
Start planning early to make sure all
employees in your work setting receive annual
influenza vaccination
before the influenza season begins. |
|
| What are the
ACIP recommendations for influenza vaccination
of HCP? |
|
| Because HCP
provide care to patients at high risk for
complications of influenza, they should be
considered a high-priority group for receiving
vaccination. Achieving high rates of
vaccination among HCP will protect staff and
their patients, and reduce disease burden and
healthcare costs.
Vaccination rates of HCP are still too low; overall only 81% of HCP report influenza
vaccination during the 2019–20 season. |
|
| Influenza
vaccination key points for HCP include: |
|
| • |
|
All HCP should be educated regarding the
benefits of influenza vaccination |
|
|
|
| • |
|
Influenza
vaccine should be administered annually to
all eligible HCP |
|
|
|
| • |
|
A signed
declination should be obtained from HCP
who decline influenza vaccination |
|
|
|
| • |
|
Healthcare facilities should monitor HCP
influenza vaccination coverage and
declination at regular intervals |
|
|
|
| • |
|
HCP vaccination coverage should be used as
one measure of a patient-safety quality
program |
|
|
| In 2011, ACIP
published "Immunization of Health-Care
Personnel," which includes information about
all recommended vaccines (see
www.cdc.gov/mmwr/pdf/rr/rr6007.pdf). |
|
| Which health
care personnel should be vaccinated against
influenza? |
|
| It is important
to vaccinate all healthcare personnel,
including paid and unpaid workers who may be
exposed to patients or infectious materials.
This
includes direct patient care staff (e.g.,
physicians, nurses, and therapists), and staff
and volunteers in pharmacy, radiology,
laboratory, human resources,
facilities management (housekeeping), food
services, and laundry. Vaccination should
include healthcare staff in all settings, such
as hospitals, outpatient
clinics, pharmacies, emergency response,
nursing homes and assisted living facilities,
and home care. |
|
| Which
employees of congregate living facilities,
such as assisted living facilities and nursing
homes, should be vaccinated against influenza? |
|
| All people
working in long-term care facilities who do
not have a valid contraindication should
receive annual influenza vaccination. |
|
| What is the
Joint Commission's recommendation on
vaccinating healthcare workers against
influenza? |
|
| Since January
2007 the Joint Commission has required
accredited organizations to offer annual
influenza vaccination to staff, volunteers,
and licensed
independent practitioners who have close
patient contact. |
|
| I would like
to help establish a policy of mandatory
influenza vaccination for HCP in our facility
and would like to learn from others. Can you
help? |
|
| Every year more
healthcare facilities are adopting mandatory
vaccination policies for their employees. IAC
has included more than 1,150 of these on its
Honor Roll for Patient Safety, which gives
special recognition to institutions that
enforce mandatory vaccination for all
personnel who are in the vicinity of
a patient (including volunteers and
housekeeping staff). To read about the
policies of the various facilities included in
the Honor Roll, go to
www.immunize.org/honor-roll/influenza-mandates/honorees.asp.
In addition, the National Adult and Influenza
Immunization Summit has developed tools to
assist post-acute and long-term care
facilities that plan to implement influenza
vaccination requirements for HCP at
www.izsummitpartners.org/naiis-workgroups/influenza-workgroup/tools-for-ltcf/.
We hope reviewing these policies and tools
will give you the information you need to assist in developing a
policy for your facility. |
|
| We have a
mandatory vaccination policy in our facility;
however, we allow employees to choose not to
be vaccinated after filling out and signing an
informed declination form. What can we do to
achieve assurances that patient safety is
still maintained? |
|
| Though
vaccination is the most effective means of
protecting your patients from influenza, there
may be instances where employees are not
vaccinated
for medical or personal reasons. In these
instances, you may want to consider reassigning unvaccinated workers to
non-patient areas or requiring that
they wear masks throughout the influenza season. |
|
| Does the
federal law that requires providing patients
with VISs apply when administering influenza vaccine to employees and volunteers in
hospitals or
other workplaces? |
|
| If a vaccine is
covered under the National Childhood Vaccine
Injury Act—and almost all vaccines routinely administered to adults are (with the exception
of PPSV and zoster)—it is mandatory under
federal law to give the VIS for that vaccine
to the vaccinee. Therefore, when you give
influenza vaccine to
employees and staff, you are required by law
to provide them with a VIS. |
|
| Why does CDC
recommend that we consider obtaining a signed
declination from HCP who refuse influenza
vaccination? |
|
| Some studies have
shown an increase in HCP influenza vaccine
acceptance when decliners are required to sign such a statement. In addition, such
statements can help a vaccination program
assess the reasons for declination and plan
future educational efforts. IAC has posted the
following suggested
declination form for healthcare workers at
www.immunize.org/catg.d/p4068.pdf. |
|
| Please tell me
which professional associations have endorsed
mandatory influenza vaccination for HCP and
have created policy statements. |
|
| There are many
professional associations that have issued
policy statements supporting mandatory
healthcare worker influenza vaccination. You
can find
information about these organizations as well
as a list of more than 1,150 healthcare
settings that have implemented mandatory
vaccination programs on
IAC's website at IAC's Influenza Vaccination
Honor Roll web section at
www.immunize.org/honor-roll/influenza-mandates/. |
|
|
|
|
|
| What are the
contraindications and precautions for people
with a history of a severe allergic reaction
to a previous influenza vaccination? |
|
| A severe allergic
reaction to any influenza vaccine is a
contraindication to receiving additional doses
of the same vaccine or receiving any egg-based
influenza vaccines. The following table
summarizes the contraindications and precautions for different types of influenza
vaccine and is adapted from
table 3 on page 5 of the 2021–22 influenza
ACIP recommendations at
www.cdc.gov/mmwr/volumes/70/rr/pdfs/rr7005a1-H.pdf: |
|
| Vaccine (of any valency)
associated
with previous serious or anaphylactic
reaction |
Available 2021–22 influenza vaccines |
| |
Egg-based IIV4s
and LAIV4 |
ccIIV4 |
RIV4 |
| Any egg-based IIV or LAIV |
Contraindication |
Precaution
† |
Precaution
† |
| Any ccIIV |
Contraindication |
Contraindication |
Precaution
†
|
| Any RIV |
Contraindication |
Precaution
† |
Contraindication |
| Unknown influenza vaccine |
Allergist consultation recommended |
|
|
|
† Note regarding
patients having either of the above
precautions for either ccIIV or IIV: Use of
ccIIV4 and RIV4 in such instances should occur
in an
inpatient or outpatient medical setting under
the supervision of a healthcare provider (HCP)
who can recognize and manage severe allergic
reaction;
HCPs can also consider consulting with an
allergist to help identify the vaccine
component responsible for the reaction. |
|
| What are the
contraindications and precautions for Flumist
Quadrivalent? |
|
|
Contraindications are: |
|
| • |
|
a history of severe allergic reaction to a
vaccine component (except egg—see next
question) or after a previous dose of any
influenza vaccine |
|
|
|
| • |
|
concomitant
aspirin or salicylate-containing therapy
in children and adolescents because of the
risk of Reye syndrome |
|
|
|
| • |
|
children age
2 through 4 years who have received a
diagnosis of asthma or whose parents or
caregivers report that a healthcare
provider has
told them during the preceding 12 months
that their child had wheezing or asthma or
whose medical record indicates a wheezing
episode during the
preceding 12 months |
|
|
|
| • |
|
immunosuppression due to any cause
including medications or HIV infection |
|
|
|
| • |
|
cerebral spinal fluid (CSF) leak, cochlear
implant, or anatomic asplenia or
functional asplenia (e.g., due to sickle
cell anemia) |
|
|
|
| • |
|
close contacts and caregivers of severely
immunosuppressed people who require a
protected environment (e.g., reverse
isolation in a hospital) |
|
|
|
| • |
|
pregnancy |
|
|
|
| • |
|
receipt of influenza antiviral medication
within the previous 48 hours for
oseltamivir and zanamivir, previous 5 days
for peramivir, and previous
17 days for baloxavir |
|
|
| Precautions are: |
|
| • |
|
moderate or severe acute illness with or
without fever |
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| • |
|
history of
Guillain-Barré syndrome within 6 weeks
after a dose of influenza vaccine |
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| • |
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asthma in a
person age 5 years or older |
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| • |
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underlying medical conditions that might
predispose to complications after
influenza virus infection, such as chronic
pulmonary, cardiovascular
(except isolated hypertension), renal,
hepatic, neurologic, hematologic, or metabolic disorders including diabetes
mellitus |
|
|
| What is the
latest ACIP guidance on influenza vaccination
and egg allergy? |
|
|
ACIP recommends that people with a history of
egg allergy who have experienced only hives
after exposure to egg should receive influenza
vaccine
without specific precautions (except the
standard 15-minute observation period for
syncope). Any age-appropriate vaccine may be
used. For people who
report having had an anaphylactic reaction to
egg (more severe than hives), if a vaccine
other than Flucelvax Quadrivalent (ccIIV,
Seqirus) or Flublok
Quadrivalent (RIV4, Sanofi Pasteur) is given,
the vaccine should be administered in an inpatient or outpatient medical setting
supervised by a healthcare
provider who is able to recognize and manage severe allergic conditions. Although not
specifically recommended by ACIP, providers
may prefer
administering an age-appropriate egg-free
vaccine (ccIIV4 or RIV4) for patients with
severe egg allergy. |
|
|
A previous severe allergic reaction to
influenza vaccine, regardless of the component
suspected to be responsible for the reaction,
is a contraindication to
future receipt of the vaccine. For a complete
list of vaccine components (i.e., excipients
and culture media) used in the production of
the vaccine, check
the package insert (available at
www.immunize.org/fda) or go to
www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. |
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|
For more details about giving influenza
vaccine to people with a history of egg
allergy, see the ACIP guidance at
www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6908a1-H.pdf.
You also may find the IAC handout "Influenza Vaccination of People with a History of Egg
Allergy"
helpful (see
www.immunize.org/catg.d/p3094.pdf). |
|
| Is allergy to
chicken or duck feathers a contraindication to
receipt of an egg-based influenza vaccine? |
|
| No. |
|
| The influenza
VIS states that giving pneumococcal conjugate
vaccine and inactivated influenza vaccine simultaneously to young children may increase
the risk of febrile seizures. Can we continue
to give these two vaccines at the same time? |
|
| Yes, you can.
Some, but not all, studies have reported
increased rates of febrile seizures among
children, especially those age 12 through 23
months,
who received simultaneous vaccination with IIV
and pneumococcal conjugate vaccine (PCV13,
Pfizer) or DTaP vaccine (Daptacel, Infanrix,
Pediarix,
Pentacel), when compared with children who
received these vaccines separately. However,
because of the risks associated with delaying
either of these
vaccines, ACIP does not recommend
administering them at separate visits or
deviating from the recommended vaccine
schedule in any way. |
|
| Febrile seizures,
occurring in 2% to 5%, of all children, are
not uncommon, and they are generally benign. Healthcare providers should be prepared to
answer parents' questions about febrile
seizures and fever when discussing
vaccinations. Here is a helpful CDC resource:
www.cdc.gov/vaccinesafety/Concerns/FebrileSeizures.html. |
|
| We usually
instruct our patients that they should
separate vaccinations and allergy shots by at
least 24 hours because if there were a
reaction to one or
the other, it wouldn't be possible to
determine which was the cause. This becomes
problematic during influenza vaccination
season. What should we do? |
|
| The probability
of a serious allergic reaction following any
vaccine is extremely low if the person is
properly screened. ACIP has not issued a
recommendation that desensitization injections
and vaccines be separated by any specific time
period; consequently, we feel that you should
take the
opportunity to vaccinate. |
|
| When I was 5
years old, I had Guillain-Barré syndrome (GBS)
unrelated to vaccination. I am now 35 with no
residual effects of the GBS. I am a nurse
and my facility requires employees to receive
influenza vaccine. Is it safe for me to be
vaccinated? |
|
| Yes. A history of
GBS unrelated to influenza vaccine is not a
contraindication or precaution to influenza
vaccination. GBS within 6 weeks following a
previous dose of influenza vaccine is
considered a precaution for use of influenza vaccines. |
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|
| What is the
most up-to-date Influenza Vaccine Information
Statement (VIS) for the 2021–22 influenza season? |
|
| Both the
inactivated and recombinant influenza vaccine
VIS and the live influenza vaccine VIS were
updated on August 6, 2021. These VISs and
translations in multiple languages are
available here:
www.immunize.org/vis/. |
|
| Which
formulations of influenza vaccines are
licensed for various age groups? |
|
| Influenza
vaccines differ with regard to age group
indications. IAC has a handout that summarizes
each of the products available for the current
influenza
vaccination season at
www.immunize.org/catg.d/p4072.pdf.
ACIP does not state a preference for one
influenza vaccine over another for people for
whom
more than one vaccine is recommended and is
age- and health condition-appropriate. |
|
| Where can I
find resources to help me plan mass
vaccination clinics for influenza or COVID-19
vaccines? |
|
| Multiple
resources are available on the CDC website at:
www.cdc.gov/vaccines/hcp/admin/mass-clinic-activities/index.html
and at IAC's "Mass Vaccination
Resources" website at:
www.mass-vaccination-resources.org. |
|
| We are
considering co-locating our COVID-19
drive-through testing site and influenza
vaccination sites. Can we vaccinate someone
with suspected or
confirmed COVID-19 infection? |
|
| CDC recommends
deferring vaccination for people with
suspected or confirmed COVID-19 until they
have met criteria for no longer needing
quarantine
or isolation to avoid exposing healthcare
personnel and other patients. When scheduling
or confirming appointments for vaccination,
patients should be
screened for COVID-19 symptoms and recent
exposure. |
|
| Is it
acceptable to draw up vaccine into syringes at
the beginning of the day? If it isn't, how
much in advance can this be done? |
|
| CDC discourages
the practice of prefilling vaccine into
syringes for several reasons, including: |
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| • |
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the increased possibility of
administration and dosing errors |
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| • |
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the increased
risk of inappropriate storage temperature |
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| • |
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the
probability of bacterial contamination |
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| • |
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the probability of reducing the vaccine's
potency over time |
|
|
| Prefilling
vaccine into syringes also violates basic
medication administration guidelines, which
state that an individual should administer
only those
medications he or she has prepared and drawn
up. |
|
| Although
pre-drawing vaccine is discouraged, a limited
amount of vaccine may be pre-drawn in a
mass-immunization clinic setting under the
following
conditions: |
|
| • |
|
Only a single type of vaccine (for
example, influenza) is administered at the
mass-immunization clinic setting |
|
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| • |
|
Vaccine is
not drawn up in advance of its arrival at
the mass-vaccination clinic site |
|
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| • |
|
These
pre-drawn syringes are stored at
temperatures appropriate for the vaccine
they hold |
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| • |
|
No more than 1 vial or 10 doses (whichever
is greater) is drawn into syringes |
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| • |
|
Clinic staff monitor patient flow
carefully and avoid drawing up unnecessary
doses or delaying administration of
pre-drawn doses |
|
|
| At the end of the
clinic day, all remaining vaccine in syringes
prefilled by staff should be discarded. |
|
| Can people who
are currently infected with COVID-19 be
vaccinated against influenza? |
|
| In general,
people who are in quarantine following
exposure to someone with COVID-19 or in
isolation due to infection with COVID-19
should not be
brought to a vaccination location to avoid
exposing others to COVID-19. For people with
moderate or severe COVID-19, vaccination
should generally be
deferred until they have recovered. For
patients with mild or asymptomatic infection
with SARS-CoV-2, influenza vaccination may
also be deferred to
avoid confusing COVID-19 symptoms with
potential influenza vaccination-related
reactions. Aside from these considerations,
there are no other reasons
to further defer influenza vaccination
following infection with COVID-19.
Periodically check CDC guidance on influenza
vaccination during the COVID-19
pandemic for updates at
www.cdc.gov/vaccines/pandemic-guidance/index.html. |
|
| Does ACIP
prefer that healthcare professionals
administer high-dose or adjuvanted influenza
vaccine to people age 65 years and older, or
is standard-dose influenza vaccine acceptable? |
|
| ACIP has
expressed no preference. |
|
| The
pneumococcal conjugate vaccine (PCV13) package
insert says that in adults, antibody responses
to PCV13 were diminished when given with
inactivated influenza vaccine. Does this mean
we should not give PCV13 and influenza vaccine
at the same visit? |
|
| The available
data have been interpreted that any changes in
antibody response to either of the vaccines' components were clinically insignificant. The
antibody response was only lowered for three
components, and ONLY in patients younger than
65 years of age. In this age group, if PCV13
is
recommended, it means there is a high-risk of
invasive pneumococcal disease for those
unvaccinated. If PCV13 and influenza vaccine
are both indicated
and recommended, they should be administered
at the same visit. See the PCV13 ACIP recommendations at
www.cdc.gov/mmwr/pdf/wk/mm6337.pdf,
page 824. |
|
| We have had
three employees who have tested positive for
influenza by nasal swab within 2 weeks of receiving Fluarix Quadrivalent
(GlaxoSmithKline)
vaccine. Is there a time period after
receiving influenza vaccine that a nasal swab
can give a false positive result? |
|
| Inactivated
influenza vaccines, including Fluarix, are not
known to cause false positive nasal swab
tests. However, false positive test results
are possible
with rapid tests, and these are more likely to
occur when influenza prevalence in the area is
low. For more information regarding
interpretation of rapid
influenza tests see
www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm. |
|
| What is the
preferred anatomic site for administration of
inactivated influenza vaccine (IIV) and recombinant influenza vaccine? |
|
| IIV should be
administered in the anterolateral thigh muscle
of an infant or young child. IIV and RIV
(approved for people age 18 years and older)
should
be administered in the deltoid muscle of an
older child, adolescent, or adult. The
anterolateral thigh muscle can also be used
for an older child,
adolescent, or adult if necessary. It is critical that intramuscular influenza vaccine
be injected into a muscle. Influenza
vaccination season is an opportune
time to review proper intramuscular injection
techniques with your staff. IAC has prepared a
handout on how to administer intramuscular
vaccine
injections (available at
www.immunize.org/catg.d/p2020.pdf)
that can be used as a staff training tool. |
|
| Some of our
patients believe that they have had reactions
to influenza vaccine in the past and request
the dose to be split into 2 doses administered
on
different days. Is this an acceptable
practice? |
|
| This is
definitely not an acceptable practice. Doses
of influenza vaccine (or any other vaccine)
should never be split into "half doses." If a
"half dose" is
administered, it should not be accepted as a
valid dose and should be repeated as soon as
possible with a full age-appropriate dose. |
|
| Should staff
at drive-through influenza vaccination clinics
encourage drivers to park and wait for 15 minutes after vaccination to make sure they
don't have
a syncopal (fainting) episode? |
|
| Yes. Syncope may
occur following any vaccination. It is prudent
for all people to be observed for syncope for
at least 15 minutes after any vaccination. |
|
| Sometimes I am
unable to get 10 doses of influenza vaccine
out of a 5.0 mL (10-dose) vial. Do you have
any suggestions? |
|
| Certain vaccine
syringes have small hubs where a volume of the
vaccine that is withdrawn from the vial
collects and is not available to be injected.
Syringes without a hub are available; their
use results in less vaccine wastage. |
|
| When removing
both pediatric (0.25 mL) and adult (0.5 mL)
doses from a multi-dose vial of Fluzone
Quadrivalent, we can get more than 10 doses
from
the 5.0 mL vial. Can we continue to remove
doses from the vial until it is empty? |
|
| No. Only the
number of doses indicated in the
manufacturer's package insert should be
withdrawn from the vial. For a 5.0 mL vial of
Fluzone Quadrivalent
this is 10 doses. For Afluria Quadrivalent 5.0
mL multi-dose vial, the package insert states
that the stopper can be punctured up to 20
times, allowing up to
20 doses of 0.25 mL dose for children age 6–35
months old. After the maximum number of doses
has been withdrawn or number of punctures of the
stopper has met the FDA-recommended limit, the
vial should be discarded, even if there is
vaccine remaining in the vial and the
expiration date has not
been reached. |
|
| We
inadvertently administered a 0.5 mL dose of
Flucelvax (Seqirus) to a 1-year-old child
before realizing that the vaccine is only
licensed for use in
people age 2 years and older. Do we need to
repeat the dose with an age-appropriate
product? |
|
|
No, the dose does not
need to be repeated. However, this is a
vaccine administration error as this
formulation is not licensed for children
younger than
age 2 years. Clinicians should carefully
select an influenza vaccine that is licensed
for the age group of the person being
vaccinated. Currently Fluzone
Quadrivalent 0.25 mL or 0.5 mL (Sanofi
Pasteur), FluLaval Quadrivalent 0.5 mL (GSK),
Fluarix Quadrivalent 0.5 mL (GSK), and Afluria
Quadrivalent 0.25
mL (Seqirus) are the only inactivated
influenza vaccines approved for use in
children age 6 months through 23 months. Flumist Quadrivalent
(AstraZeneca) is approved for healthy
non-pregnant people age 2 through 49 years. |
|
| If the child
needs a second dose of influenza vaccine, an
age-appropriate vaccine should be selected.
IAC's educational piece "Influenza Vaccine
Products for the 2021–22 Influenza Season"
(available at
www.immunize.org/catg.d/p4072.pdf)
provides helpful information on the wide
variety of influenza
vaccines in use this season. |
|
| If the
recombinant influenza vaccine (RIV4, Flublok
Quadrivalent) was given inadvertently to a
person younger than 18 years, can it be
counted? Would
there be any adverse side effects from this
error? |
|
| Flublok
Quadrivalent is not licensed for people
younger than 18 years of age, so there are no
data regarding safety and efficacy in this age
group.
However, no serious side effects would be
expected. The dose does not need to be
repeated. Even if no adverse reaction occurs,
we request that vaccine
administration errors like this be reported to
the Vaccine Adverse Events Reporting System at
www.vaers.hhs.gov. |
|
| A 3 year old
patient received 0.25mL of Fluzone. Does this
patient need to return for a repeat dose and when? |
|
| If the error is
discovered on the same clinic day you can
administer the other "half" of the Fluzone
Quadrivalent dose. If the error is discovered
the next
day or later, the dose should not be counted.
The child should be recalled to the office as
soon as possible and given a full
age-appropriate repeat dose of
influenza vaccine. |
|
| A 1-year-old
was inadvertently given a 0.25 mL dose of
FluLaval (or Fluarix) rather than the
recommended 0.5 mL dose. What should we do? |
|
| If the error is
discovered on the same clinic day you can
administer the other "half" of the FluLaval
Quadrivalent (or Fluarix Quadrivalent) dose.
If the error
is discovered the next day or later, the dose
should not be counted. The child should be
recalled to the office as soon as possible and
given a full age-appropriate repeat dose, either a 0.5 mL dose
of FluLaval Quadrivalent, a 0.5 mL dose of
Fluarix Quadrivalent, a 0.25 or 0.5 mL dose of
Fluzone
Quadrivalent, or a 0.25 mL dose of Afluria
Quadrivalent. |
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|
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|
| How should
influenza vaccines be stored? |
|
| All influenza
vaccines (inactivated, recombinant, and live
attenuated vaccines) should be stored at
refrigerator temperature of 2° through 8°C
(36° through
46°F). No influenza vaccine should be frozen.
Influenza vaccine exposed to freezing
temperature should not be used. |
|
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ACIP Recommendations
Vaccine Information Statements 
