Influenza Virus Vaccine Inactivated

Class: Vaccines
VA Class: IM100
Brands: Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone

Introduction

Inactivated virus vaccine.103 104 106 107 160 161 186 187 188 189 190 Seasonal influenza virus vaccine inactivated contains noninfectious, suitably inactivated influenza virus types A and B subunits representing influenza strains likely to circulate in the US during the upcoming influenza season and is used to stimulate active immunity to influenza strains contained in the vaccine.100 103 104 106 107 160 161 186 187 188 189 190 557 558

Uses for Influenza Virus Vaccine Inactivated

Prevention of Seasonal Influenza A and B Virus Infections

Prevention of seasonal influenza virus infection in infants and children ≥6 months of age,103 104 558 adolescents,103 104 106 107 186 187 558 and adults.103 104 106 107 160 161 186 187 188 189 190 558

Influenza is an acute viral infection; influenza viruses spread from person to person mainly through large-particle respiratory droplet transmission.100 105 488 In the US, annual epidemics of seasonal influenza occur, usually during the fall or winter.100 Influenza viruses can cause illness in any age group; children have highest rate of infection.100 105 488 Influenza can exacerbate underlying medical conditions or lead to pneumonia in certain individuals.100 105 488 Adults ≥65 years of age, children <2 years of age, and individuals with chronic medical conditions have highest risk of influenza-related complications and death.100 105 488

Annual vaccination is the primary means of preventing seasonal influenza and its complications.100

US Public Health Service Advisory Committee on Immunization Practices (ACIP), AAP, and others recommend routine influenza vaccination for all adults, adolescents, and infants and children 6 months of age or older using an age-appropriate seasonal influenza vaccine, unless contraindicated.112 199 200 336 558 Vaccination against seasonal influenza recommended for otherwise healthy individuals as well as those who have medical conditions that put them at increased risk for influenza-related complications.100 112 Seasonal influenza vaccination is particularly important for individuals at increased risk for severe influenza or influenza-related complications and those who live with or care for such individuals (e.g., health-care personnel, household or other close contacts).100 Vaccination effort should continue to focus on these individuals, especially when supplies of seasonal influenza vaccine are limited.100 (See Table 1.)

Table 1. ACIP and AAP Recommend Targeted Seasonal Influenza Vaccination Efforts in the Following Individuals Using an Appropriate Vaccine:100112

Infants and children 6 through 59 months of age

Adults ≥50 years of age

Adults, adolescents, and children ≥6 months of age with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus)

Adults, adolescents, and children ≥6 months of age who are immunosuppressed, including those receiving immunosuppressive drugs and those with HIV infection

Women who are or will be pregnant during the influenza season

Children and adolescents 6 months through 18 years of age receiving long-term aspirin therapy who might therefore be at risk for Reye's syndrome after influenza infection

Adults, adolescents, and children ≥6 months of age who are residents of nursing homes and other chronic-care facilities

American Indians and Alaska Natives

Morbidly obese individuals (body mass index ≥40)

Health-care personnel

Household contacts (including children ≥6 months of age) and caregivers of children <5 years of age (especially contacts of infants <6 months of age)

Household contacts (including children ≥6 months of age) and caregivers of adults ≥50 years of age

Household contacts (including children ≥6 months of age) and caregivers of individuals with medical conditions that put them at high risk for severe influenza complications

For the 2014–2015 influenza season, 3 different types of influenza vaccines are commercially available in the US for prevention of seasonal influenza: parenteral inactivated influenza vaccine (IIV),103 104 106 107 186 187 188 189 190 558 intranasal live attenuated influenza vaccine (LAIV),157 558 and parenteral recombinant influenza vaccine (RIV).158 558 Some of these are available as trivalent formulations containing 2 influenza A antigens and a single influenza B antigen103 158 160 161 186 187 188 189 190 558 and some are available as quadrivalent formulations containing 2 influenza A antigens and 2 influenza B antigens.104 106 107 157 558 Although most inactivated vaccines for the 2014–2015 influenza season are egg-based,103 104 106 107 160 161 186 187 188 189 558 a cell culture-based inactivated vaccine also is available (ccIIV).190 558

Select specific seasonal influenza vaccine based on individual's age and whether they have certain underlying medical conditions that put them at increased risk of influenza complications (e.g., pregnancy, immunocompromising disease or therapy), are in close contact with severely immunocompromised individuals, or have a personal history that contraindicates use of certain vaccines (e.g., egg allergy).100 112 558 For many individuals, more than one vaccine type may be appropriate.100 112 558

For healthy children 2 through 8 years of age, ACIP states that intranasal live attenuated influenza vaccine should be used if it is immediately available and there are no contraindications or precautions;558 if the intranasal live vaccine is not immediately available, use parenteral inactivated influenza vaccine in these children.558 For other children and all adults, ACIP and AAP state there are no preferential recommendations for any specific vaccine type or trade name, provided an age-appropriate vaccine is chosen based on FDA-labeled indications and contraindications.112 558 In addition, ACIP and AAP do not state a preference for a trivalent or quadrivalent formulation for the 2014–2015 influenza season.112 558 If an age-appropriate vaccine is available and there are no contraindications, do not delay influenza vaccination to obtain a specific product.112 558

Inactivated influenza vaccine has several advantages over other available vaccine types because it can be used in the broadest range of patients, including those who cannot receive the recombinant vaccine (e.g., infants and children 6 months through 17 years of age, adults ≥50 years of age) and those who cannot receive intranasal live influenza vaccine (e.g., infants and children 6 months through 23 months of age, adults ≥50 years of age, pregnant women, children and adolescents receiving long-term aspirin therapy, individuals with underlying medical conditions that predispose them to severe disease following influenza infection, individuals who have close contact with severely immunocompromised individuals, individuals who have received other live virus vaccines within the past 4 weeks or are receiving antivirals for treatment or prevention of influenza).100 112 134

Although Flucelvax inactivated influenza vaccine is cell culture-based (not egg-based),112 190 558 seed viruses for the vaccine are created using reference virus strains that have been prepared by passage in eggs.100 112 The manufacturer does not include egg allergy as a precaution or contraindication to use of Flucelvax.190 ACIP and AAP state that use of Flucelvax can be considered for adults with egg allergy;112 558 however, because the possibility exists that this vaccine may contain trace amounts of ovalbumin, use in egg-allergic individuals should follow the same guidelines recommended for egg-based inactivated influenza vaccines.112 558 (See Egg Allergy under Cautions.)

Health-care personnel and individuals training for health-care professions should receive annual vaccination against seasonal influenza.100 336 ACIP and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend routine annual vaccination for all such individuals, unless contraindicated.100 336 This includes physicians, nurses, and other personnel in both inpatient and outpatient care settings, medical emergency response workers (e.g., paramedics, emergency medical technicians), employees of nursing homes and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.100 336

Travelers (especially those at high risk for influenza complications) should receive seasonal influenza vaccine ≥2 weeks before departure.117 551 Risk for exposure to seasonal influenza during travel depends on the time of year and destination.100 117 In the Northern Hemisphere, influenza season may begin as early as October and extend until May;117 in the Southern Hemisphere, influenza season may begin in April and last through September.117 In tropical and subtropical areas, influenza may occur throughout the year, but most countries will have defined seasonal peaks.117 Travelers may be exposed to influenza at any time of the year if they are traveling on a cruise or as part of a large tourist group that includes individuals from areas of the world where influenza is circulating.117 551

HIV-infected individuals may be at high risk for influenza-related complications and should receive annual vaccination against seasonal influenza.100 105 155 156 However, antibody response may be reduced in HIV-infected individuals and is inversely correlated with severity of the disease.100 105 116 232 233 310 376 Inactivated influenza vaccine (not intranasal live influenza vaccine) is recommended in HIV-infected individuals.155 (See Individuals with Altered Immunocompetence under Cautions.)

HSCT candidates should receive seasonal influenza virus vaccine inactivated during the influenza season prior to HSCT and then annually thereafter, beginning ≥6 months after HSCT.134 409 The vaccine may not be effective if given <6 months after HSCT.409

Seasonal influenza vaccines not effective against all strains of influenza, but may be effective against those strains (and possibly closely related strains) represented in the vaccine.100 488

Seasonal influenza vaccines for the 2014–2015 influenza season are expected to provide protection against the influenza A (H1N1)pdm09 virus and influenza A (H3N2) and influenza B viruses represented in the vaccines.112 557 558

Current information regarding influenza surveillance and updated recommendations for prevention and treatment of seasonal influenza is available from CDC at .

Influenza Virus Vaccine Inactivated Dosage and Administration

Administration

Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone, Fluzone High-Dose: Administer by IM injection.103 104 106 107 160 186 187 188 189 190 Do not administer IV,103 106 160 187 188 sub-Q,103 106 160 187 188 or intradermally;106 187 188 do not administer using a jet injector.543

Fluzone Intradermal: Administer intradermally.161

Do not mix with any other vaccine or solution.103 104 134 160 161 186 187 188 189 190

Discard vaccine if it contains particulates, appears discolored, or cannot be resuspended with thorough agitation.103 104 106 107 160 161 186 187 188 189 190

Administer seasonal influenza vaccine every year before exposure to seasonal influenza.558 Begin annual vaccination efforts by October (or as soon as influenza vaccine for current season is available);100 112 558 continue vaccination efforts throughout influenza season (even in December or later),100 112 558 whether or not influenza is circulating in the community.112 In the US, localized influenza outbreaks indicating start of annual influenza season can occur as early as October;100 112 peak influenza activity often occurs in January through March,100 112 but has occurred as late as April or May.488

May be given simultaneously with other age-appropriate vaccines during same health-care visit.100 134 (See Interactions.) When multiple vaccines are administered during a single health-care visit, each parenteral vaccine should be given with a different syringe and at different injection sites.134 Separate injection sites by at least 1 inch (if anatomically feasible) to allow appropriate attribution of any local adverse effects that may occur.134

Syncope (vasovagal or vasodepressor reaction; fainting) may occur following vaccination; such reactions occur most frequently in adolescents and young adults.134 Syncope and secondary injuries may be averted if vaccinees sit or lie down during and for 15 minutes after vaccination.134 If syncope occurs, observe patient until symptoms resolve.134

IM Administration

Shake vaccine vial before withdrawing a dose.103 104 107 186 188 189 Shake prefilled syringe before administering a dose.103 104 106 107 160 186 187 188 189 190

To ensure delivery into muscle, make IM injections at a 90° angle to the skin using a needle length appropriate for individual's age and body mass.134

In infants and children 6 months to 2 years of age, make IM injections into the anterolateral thigh;100 103 104 134 558 alternatively, deltoid muscle can be used in those 1–2 years of age if muscle mass is adequate.103 134 In adults, adolescents, and children ≥3 years of age, make IM injections into the deltoid muscle.103 104 106 107 134 160 186 187 188 189 190 558

Do not administer into gluteal region103 104 106 107 134 160 186 187 188 190 or any area where there may be a major nerve trunk.103 104 106 107 160 186 187 188 190 If the gluteal muscle is chosen for infants <12 months of age because of special circumstance (e.g., physical obstruction of other sites), it is essential to identify anatomical landmarks prior to injection.134

Intradermal Administration

Fluzone Intradermal is the only commercially available influenza vaccine for intradermal use.161

Gently shake the prefilled microinjection system prior to administration.161

Administer intradermal injections into the region of deltoid muscle with the needle at a 90° angle to the skin.161 Consult manufacturer's labeling for more detailed administration instructions.161

Dosage

Dose and dosing schedule for prevention of seasonal influenza depend on individual’s age, vaccination history, and specific product administered.103 104 106 107 112 160 161 186 187 188 189 190 558

Dosage of standard-dose preparations of inactivated influenza vaccine is identical regardless of whether a trivalent or quadrivalent vaccine is used.100 103 104 106 107 187 188

A single-dose regimen of seasonal influenza vaccine is used in adults, adolescents, and children ≥9 years of age.103 104 106 107 112 160 161 186 187 188 189 190 558

A 2-dose regimen of seasonal influenza vaccine is necessary in infants and children 6 months through 8 years of age who have not previously received any doses of any type of seasonal influenza vaccine, did not receive at least 1 dose of any seasonal influenza vaccine for the 2013–2014 season, have received <2 doses of any type of seasonal influenza vaccine since July 1, 2010, or have an uncertain history regarding prior influenza vaccination.103 104 106 107 112 186 187 188 189 558 (See Pediatric Dosage under Dosage and Administration.)

Fluzone (trivalent or quadrivalent) is used in adults, adolescents, and infants and children ≥6 months of age.103 104 558

Fluvirin (trivalent) is used in adults, adolescents, and children ≥4 years of age.186 558

Fluarix (trivalent or quadrivalent) and Flulaval (trivalent or quadrivalent) is used in adults, adolescents, and children ≥3 years of age.106 187 558

Although Afluria (trivalent) is labeled by FDA for use in adults, adolescents, and children ≥5 years of age,189 ACIP and AAP recommend that this vaccine be used only in adults, adolescents, and children ≥9 years of age.112 534 558 (See Pediatric Use under Cautions.)

Flucelvax (trivalent) is used only in adults ≥18 years of age.190 558

Fluzone Intradermal (trivalent) is used only in adults 18 through 64 years of age.161 558

Fluzone High-Dose (trivalent) is used only in adults ≥65 years of age.160 558 (See Geriatric Use under Cautions.)

Pediatric Patients

Prevention of Seasonal Influenza A and B Virus Infections
Infants and Children 6 through 35 Months of Age (Fluzone)
IM

Has not previously received any doses of any seasonal influenza vaccine or has an uncertain history regarding influenza vaccination: Two 0.25-mL doses administered at least 1 month (4 weeks) apart.103 104 112 558

Did not receive ≥1 dose of any seasonal influenza vaccine for the 2013–2014 season or received <2 doses of any seasonal influenza vaccine since July 1, 2010: ACIP and AAP recommend two 0.25-mL doses administered at least 4 weeks apart.112 558

Received ≥1 dose of any seasonal influenza vaccine for the 2013–2014 influenza season or received ≥2 doses of any seasonal influenza vaccine since July 1, 2010: ACIP and AAP recommend a single 0.25-mL dose.112 558

Children 3 through 8 Years of Age (Fluarix, Flulaval, Fluzone) or Children 4 through 8 Years of Age (Fluvirin)
IM

Has not previously received any doses of any seasonal influenza vaccine or has an uncertain history regarding influenza vaccination: Two 0.5-mL doses administered at least 1 month (4 weeks) apart.103 104 106 107 112 186 187 188 558

Did not receive ≥1 dose of any seasonal influenza vaccine for the 2013–2014 season or received <2 doses of any seasonal influenza vaccine since July 1, 2010: ACIP and AAP recommend two 0.5-mL doses administered at least 4 weeks apart.112 558

Received ≥1 dose of any seasonal influenza vaccine for the 2013–2014 influenza season or received ≥2 doses of any seasonal influenza vaccine since July 1, 2010: ACIP and AAP recommend a single 0.5-mL dose.112 558

Children 5 through 8 Years of Age (Afluria)
IM

Has not previously received any doses of any seasonal influenza vaccine or has an uncertain history of influenza vaccination: Two 0.5-mL doses administered approximately 1 month (4 weeks apart).189 558

Did not receive ≥1 dose of any seasonal influenza vaccine for the 2013–2014 season or received <2 doses of any seasonal influenza vaccine since July 1, 2010: Two 0.5-mL doses administered at least 4 weeks apart.112 558

Received ≥1 dose of any seasonal influenza vaccine for the 2013–2014 influenza season or received ≥2 doses of any seasonal influenza vaccine since July 1, 2010: Single 0.5-mL dose.112 558

Not recommended by ACIP and AAP for use in children <9 years of age.112 558 (See Pediatric Use under Cautions.)

Children and Adolescents 9 through 17 Years of Age (Afluria, Fluarix, Flulaval, Fluvirin, Fluzone)
IM

Single 0.5-mL dose.103 112 186 187 188 189 558

Adults

Prevention of Seasonal Influenza A and B Virus Infections
Adults ≥18 Years of Age (Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone)
IM

Single 0.5-mL dose.103 104 106 107 186 187 188 189 558 (See Geriatric Use under Cautions.)

Adults 18 through 64 Years of Age (Fluzone Intradermal)
Intradermal

Single 0.1-mL dose.161

Special Populations

Hepatic Impairment

No specific dosage recommendations.103 104 106 107 186 187 188 189 190

Renal Impairment

No specific dosage recommendations.103 104 106 107 186 187 188 189 190

Geriatric Patients

A standard-dose IM preparation or IM Fluzone High-Dose may be used.558 (See Geriatric Use under Cautions.)

Standard-dose Preparations (Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone)

No special dosage recommendations.103 186 187 188 189 190

Fluzone High-Dose

Geriatric adults ≥65 years of age: Single 0.5-mL IM dose.160 558

Cautions for Influenza Virus Vaccine Inactivated

Contraindications

  • History of severe hypersensitivity (e.g., anaphylaxis) to any component of the vaccine, including egg protein.103 104 106 107 112 160 161 186 187 188 189 190 (See Sensitivity Reactions under Cautions.)

  • History of severe hypersensitivity (e.g., anaphylaxis) to previous dose of any influenza vaccine.103 104 106 107 160 161 186 187 188 189

Warnings/Precautions

Sensitivity Reactions

Immediate, presumably allergic reactions (e.g., urticaria, angioedema, anaphylaxis, anaphylactic shock, allergic asthma) reported rarely.103 104 106 107 186 187 188 189 558 Reactions may result from sensitivity to certain vaccine components, such as residual egg protein that might be present in minute amounts.100 187 189

Prior to administration, review patient’s history with respect to possible sensitivity reactions to the vaccine or vaccine components, including egg protein, and prior vaccination-related adverse effects and assess benefits versus risks.100 106 107 112 186 187 188

Administer in a setting where appropriate medical treatment and supervision are available to manage possible anaphylactic reactions if they occur.103 104 106 107 112 134 160 161 186 187 188 189 190 Epinephrine187 188 and other appropriate agents should be readily available.103 186 187 188 189

Do not administer additional vaccine doses to any individual who experienced severe or life-threatening reactions to a previous dose.103 186 187 188 189 (See Contraindications under Cautions.)

Egg Allergy

Most currently available seasonal parenteral inactivated influenza vaccines (trivalent or quadrivalent) are produced using embryonated chicken eggs (Afluria, Fluarix, Flulaval, Fluvirin, Fluzone);103 104 106 107 112 160 161 186 187 188 189 558 these vaccines can contain residual egg protein (ovalbumin)106 107 186 187 188 189 558 that may induce immediate hypersensitivity reactions (e.g., anaphylaxis) in individuals with severe egg allergy.100 186 187 189

Although Flucelvax inactivated influenza vaccine (trivalent) is cell culture-based and prepared using virus propagated in Madin Darby Canine Kidney (MDCK) cells (not embryonated chicken eggs),100 112 190 seed viruses for the vaccine are created using reference virus strains that have been prepared by passage in eggs.100 112 ACIP and AAP state that use of Flucelvax in egg-allergic individuals should follow the same guidelines recommended for egg-based inactivated influenza vaccines.100 112

When considering use of influenza vaccine in patients who report a history of egg allergy, determine whether the presumed egg allergy is based on a mild reaction (i.e., urticaria alone) or severe reaction (i.e., anaphylaxis involving cardiovascular changes, respiratory symptoms, and/or GI symptoms; reactions requiring use of epinephrine).112 558

ACIP and AAP state that individuals with a history of egg allergy who have experienced only urticaria after eating eggs or egg-containing foods may receive influenza vaccine; however, age-appropriate parenteral inactivated influenza vaccine (egg-based or cell culture-based) or influenza vaccine recombinant is preferred over intranasal live influenza vaccine since relatively limited data available regarding use of the live vaccine in individuals with egg allergy.112 558 Recombinant influenza vaccine is egg-free and may be used in adults 18 through 49 years of age with any degree of egg allergy who have no other contraindications.112 558 If inactivated influenza vaccine (egg-based or cell culture-based) is used in an individual with a history of only urticaria after exposure to eggs, the vaccine should be administered by a health-care provider familiar with potential manifestations of egg allergy and the vaccine recipient should be observed for ≥30 minutes following vaccination.112 558

Individuals with a history of severe reaction after eating eggs or egg-containing products, including anaphylaxis, angioedema, respiratory distress (e.g., wheezing, throat swelling), lightheadedness, cardiovascular changes (e.g., hypotension), GI symptoms (e.g., nausea, vomiting), or any reaction requiring epinephrine or other emergency intervention (particularly reactions that occurred within minutes to hours following egg exposure), are more likely to have a serious systemic or anaphylactic reaction following reexposure to egg protein.112 558 Such individuals may receive the recombinant influenza vaccine if they are 18 through 49 years of age and there are no other contraindications.558 If the recombinant vaccine is not available or recipient is not within the indicated age range for the recombinant vaccine, age-appropriate inactivated influenza vaccine should be administered by a clinician with expertise in the recognition and management of severe allergic conditions and the vaccine recipient should be observed for ≥30 minutes following administration.112 558

Individuals who are able to eat lightly cooked eggs (e.g., scrambled eggs) without reaction are unlikely to be allergic and may receive influenza vaccination per usual protocols.558 However, tolerance to egg-containing foods does not exclude the possibility of egg allergy since some egg-allergic individuals may tolerate egg in baked products (e.g., bread, cake).558 Egg allergy can be confirmed by a consistent history of adverse reactions to eggs and egg-containing foods in addition to skin and/or blood testing for immunoglobulin E antibodies to egg proteins.558

Consultation with a clinician experienced in management of allergic conditions is recommended prior to administration of inactivated influenza vaccine in individuals with no known history of egg exposure, but who are suspected of being egg-allergic on the basis of prior allergy testing.558 Alternatively, recombinant influenza vaccine may be used if recipient is 18 through 49 years of age.558

Neomycin and/or Polymyxin B Allergy

Afluria: Each 0.5-mL dose may contain trace amounts of neomycin sulfate (≤0.2 picograms) and polymyxin B (≤0.03 picograms).189

Fluvirin: Each 0.5-mL dose may contain neomycin (≤2.5 mcg) and polymyxin B (≤3.75 mcg).186

Neomycin allergy usually results in delayed-type (cell-mediated) hypersensitivity reactions manifested as contact dermatitis.134 ACIP and AAP state that vaccines containing trace amounts of neomycin should not be used in individuals with a history of anaphylactic reaction to neomycin, but may be considered in those with a history of delayed-type neomycin hypersensitivity if benefits of vaccination outweigh risks.105 134

Thimerosal Allergy

All multiple-dose vials of inactivated influenza virus vaccine (Afluria, Flulaval, Fluvirin, Fluzone) contain thimerosal as a preservative;103 104 107 186 188 189 some preparations of the vaccine in prefilled syringes are preservative-free but contain trace amounts of thimerosal from the manufacturing process (Fluvirin).186 (See Thimerosal Precautions under Cautions.)

Hypersensitivity reactions to thimerosal contained in vaccines have been reported in some individuals.100 140 427 498 500 These reactions usually manifest as local, delayed-type hypersensitivity reactions (e.g., erythema, swelling),100 134 140 427 but a generalized reaction manifested as pruritus and an erythematous, maculopapular rash on all 4 extremities has been reported rarely.500

Even when patch or intradermal tests for thimerosal sensitivity are positive, most individuals do not develop hypersensitivity reactions to thimerosal administered as a component of vaccines.100 134 140

ACIP states that a history of delayed-type hypersensitivity to thimerosal is not a contraindication to use of vaccines that contain thimerosal.134

Latex Sensitivity

Flucelvax, Fluvirin: Some components (i.e., tip caps) of the single-dose prefilled syringes contain natural rubber latex.106 186 190

Some individuals may be hypersensitive to natural latex proteins.186 190 356 357 Take appropriate precautions if these preparation are administered to individuals with a history of latex sensitivity.356 357

ACIP and others state that a history of nonsevere allergy to latex is not a contraindication to these preparations of inactivated influenza vaccine.134

Guillain-Barré Syndrome (GBS)

If GBS occurred within 6 weeks after previous influenza vaccination, manufacturers state base decision to administer influenza vaccine on careful consideration of potential benefits and risks.103 104 106 107 160 161 186 187 188 189 190

Unclear whether influenza vaccination increases risk of recurrence of GBS.100 Temporal association was noted between administration of 1976 swine influenza vaccine and GBS.100 103 186 190 278 279 364 365 Investigations to date suggest no large increase in GBS associated with influenza vaccine (other than 1976 swine influenza vaccine) and if influenza vaccine does pose a risk it probably is quite small (i.e., approximately 1 additional case of GBS per 1 million vaccinees).100 364 365

ACIP states that, as a precaution, individuals who are not at high risk for severe influenza complications and who developed GBS within 6 weeks of a previous dose of influenza vaccine generally should not receive influenza vaccination;100 clinicians might consider use of antiviral prophylaxis for such individuals.100 However, ACIP states that the benefits of influenza vaccine may outweigh the risks for certain individuals with a history of GBS who are at high risk for severe complications from influenza.100

Individuals with Altered Immunocompetence

May be administered to individuals immunosuppressed as the result of disease or immunosuppressive therapy.100 Consider possibility that immune response to the vaccine and efficacy may be reduced in these individuals.100 103 160 161 186 187 188 189 190

CDC, NIH, IDSA, AAP, and other experts state that HIV-infected children, adolescents, and adults should receive annual vaccination against seasonal influenza; use parenteral inactivated influenza vaccine (not intranasal live vaccine) for prevention of seasonal influenza in HIV-infected individuals.100 112 155 156 Data are limited regarding safety of parenteral inactivated influenza vaccine in HIV-infected individuals, but there is no evidence of any clinically important effect on HIV infection or immunocompetence.100 Adequate antibody responses to parenteral inactivated influenza vaccine generally are attained in HIV-infected individuals with minimal AIDS-related symptoms and normal or near-normal CD4+ T-cell counts.100 Antibody response may be inversely correlated with severity of the disease.100 105 116 232 233 260 310 375 376 In one study, inactivated influenza vaccine was most effective in preventing influenza in HIV-infected individuals with CD4+ T-cell counts ≥100/mm3 and HIV-1 RNA levels <30,000 copies/mL.100 A second dose of influenza vaccine does not appear to improve immune response in HIV-infected individuals.100

May not be effective if given <6 months after HSCT.409

Limited data indicate influenza vaccine does not adversely affect allograft function or cause rejection episodes in kidney, heart, or liver transplant recipients.100 However, the vaccine may be less immunogenic in some solid organ transplant recipients, especially those vaccinated within 4 months after liver transplant.100

Fever and Febrile Seizures

Postmarketing reports of increased rates of fever and febrile seizures in infants and children 6 months through 4 years of age and increased incidence of fever in children 5–8 years of age who received a 2010 Southern Hemisphere parenteral inactivated influenza vaccine189 534 that is antigenically equivalent to and produced by the same manufacturer as one of the 2010–2011 seasonal parenteral inactivated influenza vaccines marketed in the US (i.e., Afluria; CSL).534

In a study evaluating safety and efficacy of the 2009–2010 formulation of Afluria, incidence of fever within 7 days after first dose was 37% in infants and children 6 months to <3 years of age, 32% in those 3 to <5 years of age, and 16% in those 5 to <9 years of age compared with 14, 11, and 8%, respectively, in children in these age groups who received a comparator vaccine.189

Based on available data, ACIP and AAP state Afluria should not be used in infants and children 6 months through 8 years of age.100 112 534 (See Pediatric Use under Cautions.)

Thimerosal Precautions

Although there is no convincing evidence that the low concentrations of thimerosal (a mercury-containing preservative) contained in some vaccines is harmful to vaccine recipients,100 493 494 499 501 502 503 504 505 506 efforts to eliminate or reduce the thimerosal content in vaccines is recommended as a prudent measure to reduce mercury exposure in infants and children and part of an overall strategy to reduce mercury exposures from all sources, including food and drugs.100 134 401 402 403 492

As a result of efforts initiated in 1999 to remove or reduce thimerosal in vaccines and expedite development and approval of preservative-free formulations of vaccines, inactivated influenza vaccine now is commercially available in prefilled syringes as preservative-free formulations that do not contain thimerosal103 187 189 427 and in prefilled syringes as preservative-free formulations that contain only trace amounts of thimerosal from the manufacturing process (≤1 mcg of mercury per 0.5-mL dose),186 427 FDA states that trace amounts of thimerosal from the manufacturing process are not considered clinically important.492 Only multiple-dose vials of inactivated influenza virus still contain thimerosal as a preservative (≤ 25 mcg of mercury per 0.5-mL dose).103 186 427 188 189 Intranasal live influenza vaccine does not contain thimerosal.100 157

Although it was suggested that thimerosal in vaccines theoretically could have adverse effects in vaccine recipients, there is no conclusive evidence that the low levels of thimerosal contained in vaccines cause harm in vaccine recipients.100 134 492 493 494 499 501 502 503 504 505 506 A link between thimerosal in vaccines and neurodevelopmental disorders in children (autism, attention deficit/hyperactivity disorder [ADHD], speech or language delay) possibly related to mercury neurotoxicity has been theorized; however, considerable evidence has accumulated that supports the absence of substantial risk for neurodevelopmental disorders or other harm resulting from exposure to thimerosal-containing vaccines.493 494 499 501 502 503 504 505 506 In 2004, the Immunization Safety Review Committee of the IOM examined the hypothesis that thimerosal-containing vaccines are causally associated with autism and concluded that the body of epidemiologic evidence favors rejection of a causal relationship between these vaccines and autism.506

Analysis of adverse effects reported to the Vaccine Adverse Event Reporting System (VAERS) indicates that there is no difference in the incidence of injection site reactions, rash, or infections in infants 6–23 months of age who received preservative-containing (thimerosal-containing) inactivated influenza vaccine compared with those who received preservative-free preparations of the vaccine.497 To date, the only adverse effects known to be caused by thimerosal contained in vaccines are local hypersensitivity reactions.134 140 427 493 (See Thimerosal Allergy under Cautions.)

USPHS, ACIP, AAP, AAFP, and other experts state that use of vaccines that contain thimerosal is preferable to withholding vaccination since failure to provide protection against vaccine-preventable diseases may represent an immediate threat, especially in infants.401 402 403 AAP states that the benefits of protecting children outweigh the hypothetical risks associated with the minute amounts of thimerosal contained in some currently available influenza vaccine preparations.403

Afluria (trivalent): Commercially available in 0.5-mL prefilled syringes as a preservative-free formulation (thimerosal not used in manufacturing process).189 Also available in multiple-dose vials containing thimerosal as a preservative (24.5 mcg of mercury per 0.5-mL dose).189

Fluarix (trivalent or quadrivalent): Commercially available in 0.5-mL prefilled syringes as a preservative-free formulation that does not contain thimerosal.106 187

Flucelvax (trivalent): Commercially available in 0.5-mL prefilled syringes as a preservative-free formulation that does not contain thimerosal.190

Flulaval (trivalent or quadrivalent): Commercially available in 0.5-mL prefilled syringes as a preservative-free formulation (thimerosal not used in manufacturing process) and in multiple-dose vials containing thimerosal as a preservative (<25 mcg of mercury per 0.5 mL).107 188

Fluvirin (trivalent): Commercially available in prefilled syringes in a preservative-free formulation containing only trace amounts of thimerosal from the manufacturing process (≤1 mcg of mercury per 0.5 mL).186 Also available in multiple-dose vials containing thimerosal as a preservative (25 mcg of mercury per 0.5-mL dose).186

Fluzone (trivalent): Commercially available in 0.25- and 0.5-mL prefilled syringes and single-dose 0.5-mL vials as a preservative-free formulation (thimerosal not used in manufacturing process).103 Also available in multiple-dose vials containing thimerosal as a preservative (25 mcg of mercury per 0.5-mL dose).103

Fluzone (quadrivalent): Commercially available in 0.25- and 0.5-mL prefilled syringes as a preservative-free formulation (thimerosal not used in manufacturing process).104

Fluzone Intradermal (trivalent): Commercially available in 0.1-mL prefilled microinjection systems as a preservative-free formulation.161

Fluzone High-Dose (trivalent): Commercially available in 0.5-mL prefilled syringes as a preservative-free formulation.160

Limitations of Vaccine Effectiveness

Following seasonal influenza vaccination, up to 2 weeks may be required to develop antibody protection against infection.100 477

May not protect all vaccine recipients against influenza.103 104 106 107 160 161 186 187 188 189 190

Seasonal influenza vaccines are formulated annually to contain influenza A and B antigens predicted to represent strains of influenza virus likely to circulate in the US during the upcoming influenza season.557 558 (See Actions.) Efficacy of seasonal vaccine during any given year depends on how closely viral strains represented in the vaccine match viral strains circulating during the season.100 488

Inactivated influenza vaccines for the 2014–2015 influenza season expected to provide protection against the influenza A (H1N1)pdm09 virus and influenza A (H3N2) and influenza B viruses represented in the vaccines.112 557 558

Duration of Immunity

Immunity declines during the year after seasonal influenza vaccination.100 188 189 488 In addition, circulating strains of seasonal influenza virus change from year to year.100 103 186 414 188 189 Annual vaccination is needed for prevention of seasonal influenza.100 103 104 106 107 186 187 188 189

Do not administer influenza vaccine from a previous influenza season in an attempt to provide protection during a subsequent influenza season.100 187

Concomitant Illness

Delay administration in individuals with moderate to severe acute illness (with or without fever) until symptoms have subsided.100 134

ACIP state that mild diarrhea or mild upper respiratory tract illness or other acute illness (with or without fever) does not preclude vaccination.134

Individuals with Bleeding Disorders

Because bleeding may occur following IM injection in individuals with thrombocytopenia or a bleeding disorder (e.g., hemophilia) or in those receiving anticoagulant therapy, some manufacturers recommend that IM influenza vaccine be used with caution in such individuals.187 188

ACIP states that vaccines may be given IM to such individuals if a clinician familiar with the patient's bleeding risk determines that the preparation can be administered with reasonable safety.134 In these cases, use a fine needle (23 gauge or smaller) to administer the vaccine and apply firm pressure to the injection site (without rubbing) for ≥2 minutes.134 If patient is receiving antihemophilia or similar therapy, administer the IM vaccine shortly after a scheduled dose of such therapy.134

Advise individuals and/or their family about the risk of hematoma from IM injections.134

Improper Storage and Handling

Improper storage or handling of vaccines may reduce vaccine potency resulting in reduced or inadequate immune responses in vaccinees.134

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.134 (See Storage under Stability.)

Do not administer vaccine that has been mishandled or has not been stored at the recommended temperature.134 If there are concerns about mishandling, contact the manufacturer or state or local immunization or health departments for guidance on whether the vaccine is usable.134

Specific Populations

Pregnancy

Afluria, Fluarix, Flucelvax, Flulaval, Fluzone Intradermal: Category B.106 161 187 188 189 190

Fluvirin, Fluzone, Fluzone High-Dose: Category C.103 104 160 186

Manufacturers state use in pregnant women only when clearly needed.103 104 106 160 161 186 187 188 189 190

Because pregnant women are at risk for influenza complications, ACIP, ACOG, and other experts recommend that all women who are pregnant or will be pregnant during influenza season receive inactivated influenza vaccine for prevention of seasonal influenza, including those without underlying influenza risk factors.100 155 ACIP states that recent studies concluded that there is no evidence that use of inactivated influenza vaccine in a pregnant woman harms the fetus.100

ACIP, ACOG, American College of Physicians (ACP), NIH, IDSA, and other experts state that parenteral inactivated influenza vaccine (not intranasal live influenza vaccine) should be used for prevention of seasonal influenza in pregnant women.100 155 200 The inactivated vaccine can be administered at any time during pregnancy.100

To monitor pregnancy outcomes and newborn health status following influenza vaccination of pregnant women, some manufacturers have established pregnancy registries.103 104 106 107 187 188 Women who receive the vaccine during pregnancy or their healthcare providers may contact the manufacturer at 888-452-9622 (Fluarix, Flulaval) or 800-822-2463 (Fluzone).104 106 107 161 187 188

Lactation

Not known whether parenteral inactivated influenza vaccine is distributed into milk.103 104 106 107 161 186 187 188 189 190 Manufacturers recommend caution.103 104 106 107 161 186 187 188 189 190

Although specific data not available, ACIP and AAP state breast-feeding is not a contraindication to influenza vaccination.112 134

Pediatric Use

Flucelvax, Fluzone Intradermal: Safety and efficacy not established in infants and children <18 years of age.161 190

Fluarix, Flulaval: Safety and efficacy not established in children <3 years of age.106 107 187 188

Fluvirin: Safety and efficacy not established in children <4 years of age.186

Fluzone: Safety and efficacy not established in infants <6 months of age.103 104

Fluzone High-Dose: Safety and efficacy not established in children or adolescents.160

Afluria: Although labeled by FDA for use in infants and children ≥5 years of age,189 ACIP and AAP state that Afluria should not be used in infants and children 6 months through 8 years of age.100 112 534 558 Based on available data suggesting Afluria may be associated with increased incidence of fever and febrile seizures in infants and children 6 months through 4 years of age and increased incidence of fever in children 5 through 8 years of age (see Fever and Febrile Seizures under Cautions), ACIP states that other age-appropriate seasonal influenza vaccines (not Afluria) should be used in infants and children 6 months through 8 years of age.534 558 If no other age-appropriate seasonal influenza vaccine is available, ACIP states that Afluria can be used in a child 5 through 8 years of age who has a medical condition that increases the risk for influenza complications; however, parents or caregivers should be advised of the benefits and risks of vaccination with Afluria before the vaccine is given.534 558

Because seasonal inactivated influenza vaccine is not indicated in infants <6 months of age, all household and other close contacts (e.g., day-care providers) of infants <6 months of age should be vaccinated against seasonal influenza using vaccine appropriate for their age and target group since this may provide some protection against seasonal influenza for these young infants.100

Geriatric Use

Fluzone Intradermal: Safety and efficacy not established in adults ≥65 years of age.161

Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone: No substantial differences in safety relative to younger adults;103 104 106 107 186 187 188 189 190 may be less immunogenic in geriatric individuals.100 103 186 188 189

Fluzone High-Dose: Use only in adults ≥65 years of age.100 160 Each 0.5 mL of Fluzone High-Dose contains 4 times the amount of antigen contained in Fluzone (see Preparations).100 160 Higher incidence of injection site reactions (pain, erythema, swelling) and systemic adverse effects (myalgia, malaise, headache, fever) reported with Fluzone High-Dose compared with Fluzone.160 There is some evidence that the high-dose formulation elicits higher antibody titers than the standard-dose formulation in adults ≥65 years of age,100 160 but additional study needed to determine whether this results in greater protection against influenza illness in this age group.100 160

ACIP states that all adults ≥65 years of age should be vaccinated against influenza using an IM inactivated influenza vaccine.100 ACIP does not express a preference for Fluzone High-Dose or any other IM influenza vaccine in this age group, and states that adults ≥65 years may receive a standard-dose preparation (Afluria, Fluarix, Flucelvax, Flulaval, Fluvirin, Fluzone) or Fluzone High-Dose.100

Common Adverse Effects

Injection site reactions (i.e., tenderness, pain, redness, induration, swelling), headache, fatigue, myalgia, fever, malaise.103 104 106 107 186 187 188 189 190

Injection site reactions (i.e., ecchymosis, erythema, induration, swelling, pruritus) occur more frequently with intradermal than IM administration.161

Interactions for Influenza Virus Vaccine Inactivated

Other Vaccines

Although specific studies may not be available evaluating concurrent administration with each antigen, simultaneous administration with other age-appropriate vaccines, including live virus vaccines, toxoids, or inactivated or recombinant vaccines, during the same health-care visit is not expected to affect immunologic response or adverse reactions to any of the preparations.100 105 134 Immunization with parenteral inactivated influenza vaccine can be integrated with immunization against diphtheria, tetanus, pertussis, Haemophilus influenzae type b (HIB), hepatitis A, hepatitis B, human papillomavirus (HPV), poliovirus, measles, mumps, rubella, rotavirus, meningococcal disease, pneumococcal disease, and varicella.100 105 134 However, each parenteral vaccine should be administered using a different syringe and different injection site.103 134 186 188 189

Specific Drugs

Drug

Interaction

Comments

Aldesleukin

Possible increased antibody response to influenza vaccine in geriatric adults173

Anticoagulants (e.g., warfarin)

Increased PT, GI bleeding, hematuria, muscle hematoma, epistaxis reported rarely423

Potential to inhibit warfarin clearance187 188

Consider possible interaction in individuals receiving warfarin;187 188 some clinicians suggest closely monitor for enhanced anticoagulant effects423 (See Individuals with Bleeding Disorders under Cautions)

Antiviral agents active against influenza (amantadine, rimantadine, oseltamivir, zanamivir)

Amantadine, rimantadine, zanamivir: No interference with antibody response to parenteral inactivated influenza vaccine120 122 134 408

Oseltamivir: No specific studies, but interference with antibody response to parenteral inactivated influenza vaccine not expected;407 oseltamivir does not interfere with humoral antibody response to influenza infection407

Amantadine, rimantadine, oseltamivir, zanamivir: May be used concomitantly with parenteral inactivated influenza vaccine if indicated100 120 122 123 407

Oseltamivir: May be administered simultaneously with or at any interval before or after parenteral inactivated influenza vaccine407

Aspirin

Possible increased antibody response to influenza vaccine in geriatric adults174

Immune globulin (immune globulin IM [IGIM], immune globulin IV [IGIV]) or specific hyperimmune globulin (hepatitis B immune globulin [HBIG], rabies immune globulin [RIG], tetanus immune globulin [TIG], varicella zoster immune globulin [VZIG])

No evidence that immune globulin preparations interfere with immune response to inactivated vaccines134

Parenteral inactivated influenza vaccine may be given simultaneously with or at any interval before or after immune globulin or specific hyperimmune globulin134

Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation)

Potential for decreased antibody response103 186 187 188 189 190

Corticosteroid therapy (prednisone or equivalent) in a dosage ≥2 mg/kg daily or ≥20 mg daily given for ≥2 weeks is considered immunosuppressive105 134

Children with malignant neoplasms: Administer influenza vaccine ≥3 weeks after chemotherapy is completed and peripheral granulocytes and lymphocyte counts are >1000/mL105

Consider deferring vaccination during short-term, high-dose corticosteroid therapy105

Parenteral inactivated influenza vaccine may be administered to those receiving long-term immunosuppressive therapy134 146 281

Phenytoin

Possible pharmacokinetic interaction (both increased and decreased serum concentrations of phenytoin reported);185 197 198 potential inhibition of phenytoin clearance187 188

Consider possible interaction in individuals receiving phenytoin187 188

Pneumococcal vaccine

PPSV23 (Pneumovax 23): Simultaneous administration with parenteral inactivated influenza vaccine does not interfere with the immune response or increase adverse effects of either vaccine100 105 134 354

PPSV23 (Pneumovax 23): May be administered simultaneously with parenteral inactivated influenza vaccine using different syringes and different injection sites100 134 352 353

PCV13 (Prevnar 13): May be administered simultaneously with parenteral inactivated influenza vaccine using different syringes and different injection sites105 112

Rotavirus vaccine (RV)

Concomitant use not studied167

May be administered simultaneously with or at any interval before or after parenteral inactivated influenza vaccine167

Theophylline

Potential interaction (clearance of theophylline inhibited)187 188

Clinical importance unknown; 178 211 212 consider possible interaction in individuals receiving theophylline187 188

Zoster vaccine (ZOS)

Concurrent administration of parenteral inactivated influenza vaccine and zoster vaccine live in adults ≥50 years of age results in antibody responses and adverse effects similar to those reported when the vaccines are administered 4 weeks apart490

May be given concurrently (using different syringes and different injection sites) or at any interval before or after zoster vaccine481

Stability

Storage

Parenteral

Injectable Suspension, for IM Use

2–8°C; do not freeze.103 104 106 107 160 161 186 187 188 189 190 If freezing occurs, discard vaccine.104 106 107 160 161 186 187 188 189

Return multiple-dose vials to 2–8ºC between uses.103 186 188 189 Manufacturers of Afluria and Flulaval state that multiple-dose vials should be discarded if not used within 28 days after they have been entered.107 188 189

Protect from light.186 187 188 189 190

Depending on the manufacturer, single-dose syringes and vials are preservative-free103 104 106 107 160 187 188 189 190 or contain only trace amounts of thimerosal from the manufacturing process.186 Multiple-dose vials contain thimerosal as a preservative.103 107 186 188 189 (See Thimerosal Precautions under Cautions.)

Injectable Suspension, for Intradermal Use

2–8°C; do not freeze.161 If freezing occurs, discard vaccine.161

Actions

  • Inactivated influenza virus vaccines are noninfectious, sterile suspensions of suitably inactivated influenza virus types A and B subunits.103 104 106 107 186 187 188 189 190

  • Most seasonal inactivated influenza vaccines commercially available in the US are split-virus preparations (i.e., contain purified subvirion or purified surface antigen) prepared from formaldehyde- or propiolactone-inactivated influenza viruses harvested from allantoic fluids of chick embryos (egg-based inactivated vaccines).100 103 104 106 107 186 187 188 189 A seasonal inactivated influenza vaccine prepared from propiolactone-inactivated influenza virus propagated in Madin Darby Canine Kidney (MDCK) cells (cell culture-based inactivated vaccine) also available in the US.190 558

  • Seasonal influenza vaccines are formulated annually to contain antigens representative of the strains of influenza A (H1N1), influenza A (H3N2), and influenza B viruses likely to circulate during the upcoming influenza season.557 558 559 For the 2014–2015 season, the antigenic components recommended by FDA for US formulations of seasonal influenza vaccines are the same as those recommended by WHO (Northern Hemisphere),557 559 and are the same as those that were used in vaccines for the 2013–2014 influenza season.557 558

  • For the 2014–2015 influenza season, trivalent inactivated influenza vaccines (egg- or cell culture-based) are available containing 2 influenza type A antigens (H1N1 and H3N2) and a single influenza type B antigen (B/Yamagata lineage).103 160 161 186 187 188 189 190 557 In addition, quadrivalent inactivated influenza vaccines (egg-based) are available containing 2 influenza type A antigens (H1N1 and H3N2) and 2 influenza type B antigens (B/Yamagata and B/Victoria lineages).104 106 107 557

  • The 2014–2015 trivalent seasonal influenza vaccines for the US contain A/California/7/2009 (H1N1)pdm09-like, A/Texas/50/2012-like (H3N2), and B/Massachusetts/2/2012-like (B/Yamagata lineage) virus antigens and the 2014–2015 quadrivalent seasonal influenza vaccines for the US contain these 3 antigens plus a B/Brisbane/60/2008-like (B/Victoria lineage) antigen.557 The quadrivalent formulations available for the 2014–2015 influenza season may offer improved protection against circulating influenza B since they contain antigens representing both the B/Yamagata and B/Victoria lineages and it has been difficult during some recent influenza seasons to predict which lineage would predominate.100 112 557 558

  • Influenza vaccines stimulate active immunity to influenza virus strains represented in the vaccines.103 186 187 188 189

  • Efficacy of influenza vaccines in preventing seasonal influenza virus infection depends on whether the virus strains represented in the vaccines are antigenically similar to influenza virus strains circulating during the influenza season.100 488 When there is a good match between the vaccine formulation and circulating strains, a protective effect generally is achieved in 70–90% of healthy adults <65 years of age following IM administration of inactivated vaccine.100 165 336 480

  • Immune response to IM seasonal influenza vaccine may be lower in geriatric individuals,100 103 336 188 189 very young children,295 302 326 or individuals who are immunocompromised or have certain chronic medical conditions.100 105 224 248 261 290 310 336 336 375 377 188 189

  • In adults 18 through 64 years of age, antibody responses following a dose of Fluzone Intradermal have been noninferior to those following an IM dose of Fluzone.161

  • Seasonal influenza vaccines for the 2014–2015 influenza season are expected to provide protection against the influenza A (H1N1)pdm09 virus and influenza A (H3N2) and influenza B strains represented in the vaccines.112 557 558 (See Limitations of Vaccine Effectiveness under Cautions.)

Advice to Patients

  • Prior to administration of seasonal parenteral inactivated influenza vaccine, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient's legal representative (VISs are available at ).103 104 106 107 160 161 186 187 189 190 477

  • Advise patients that parenteral inactivated influenza vaccine contains noninfectious killed viruses and cannot cause influenza.100 103 104 106 107 160 161 186 187 188 189 190

  • Advise patients that parenteral inactivated influenza vaccine provides protection against illness due to influenza viruses represented in the vaccine and cannot provide protection against all respiratory illness.103 104 106 107 160 161 186 186 187 188 189 190

  • Advise patient and/or patient's parent or guardian of the risks and benefits of vaccine administration.103 104 106 107 160 161 186 186 188 189 190

  • Advise patient and/or patient's parent or guardian that annual vaccination against seasonal influenza is necessary.103 104 106 107 160 161 186 186 187 188 189 190

  • Importance of receiving a 2014–2015 seasonal influenza vaccine, even if the individual received a 2013–2014 seasonal influenza vaccine.100 112

  • Advise patient and/or patient's parent or guardian that a single dose of seasonal influenza vaccine is necessary each year in adults, adolescents, and children ≥9 years of age, but that 2 doses of seasonal influenza vaccine may be necessary in some infants and children 6 months through 8 years of age.112 558 (See Pediatric Patients under Dosage and Administration.)

  • Importance of informing clinicians of any severe or life-threatening allergies, including severe allergy to eggs, or any history of severe reaction after prior influenza vaccination.477

  • Importance of informing clinicians of severe or unusual adverse effects.103 104 106 107 160 161 186 187 188 189 190 Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .103 104 106 107 160 161 186 187 188 189 190

  • Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as concomitant illnesses (e.g., GBS).103 104 106 107 160 161 186 187 188 189 190

  • Importance of women informing clinician if they are or plan to become pregnant or plan to breast-feed.103 104 106 107 160 161 186 187 188 189 190

  • Importance of informing patients of other important precautionary information.103 104 106 107 160 161 186 187 188 189 190 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Influenza Virus Vaccine Inactivated (2014–2015)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injectable suspension, for IM use

15 mcg hemagglutinin each of A/Brisbane/10/2010 (H1N1), A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 per 0.5 mL

Flucelvax

Novartis Vaccines

15 mcg hemagglutinin each of A/California/7/2009 (H1N1), A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 per 0.5 mL

Afluria

bioCSL

Flulaval

GlaxoSmithKline

Fluzone

Sanofi Pasteur

15 mcg hemagglutinin each of A/Christchurch/16/2010 (H1N1), A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 per 0.5 mL

Fluarix

GlaxoSmithKline

Fluvirin

Novartis Vaccines

60 mcg hemagglutinin each of A/California/7/2009 (H1N1), A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 per 0.5 mL

Fluzone High-Dose

Sanofi Pasteur

Injectable suspension, for intradermal use

9 mcg hemagglutinin each of A/California/7/2009 (H1N1), A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 per 0.1 mL

Fluzone Intradermal

Sanofi Pasteur

Influenza Virus Vaccine Inactivated Quadrivalent (2014–2015)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injectable suspension, for IM use

15 mcg hemagglutinin each of A/California/7/2009 (H1N1), A/Texas/50/2012 (H3N2), B/Massachusetts/2/2012, and B/Brisbane/60/2008 per 0.5 mL

Flulaval Quadrivalent

GlaxoSmithKline

Fluzone Quadrivalent

Sanofi Pasteur

15 mcg hemagglutinin each of A/Christchurch/16/2010 (H1N1), A/Texas/50/2012 (H3N2), B/Massachusetts/2/2012, and B/Brisbane/60/2008 per 0.5 mL

Fluarix Quadrivalent

GlaxoSmithKline

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions October 30, 2014. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

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