//fpnotebook.com/
Influenza Vaccine
Aka: Influenza Vaccine, Trivalent Influenza Vaccine, Quadrivalent Influenza Vaccine, Fluzone, Inactivated Influenza Vaccine, TIV Vaccine, Fluarix, FluLaval, Flublok, Flucelvax, Fluad
- See Also
- Influenza
- Live Attenuated Influenza Vaccine (Flumist, LAIV)
- Background: Vaccine Production
- Trivalent Vaccine and quadrivalent Vaccine
- Trivalent Vaccines cover 2 Influenza A Viruses (H1N1, H3N2) and 1 Influenza B virus
- Quadrivalent Vaccines cover one additional Influenza B virus (preferred Vaccine if available)
- Flumist is available as quadrivalent Vaccine as of 2013
- Fluarix, FluLaval and Fluzone are available in trivalent and quadrivalent as of 2013
- Other injectable Influenza Vaccines are available as trivalent Vaccines only
- High dose and augmented Vaccines
- Indicated for older patients (age >65 years old), to improve immune response to Vaccine
- Increased risk of injection site reactions
- Preparations
- Fluzone high dose (4 fold more Antigen than standard dose)
- Fluad augmented with adjuvant component
- H1N1 Coverage
- H1N1 is included in Influenza Vaccine as of 2011 in U.S.
- Live and inactivated Vaccines
- FlumistVaccine is live, attenuated Influenza Vaccine
- All other Vaccines (injectable) are inactivated
- Egg-grown Vaccine versus non-Egg grown Vaccine
- Egg-grown Vaccines (hens egg-grown Vaccines, requires >1 year of growth)
- Preparations: Fluzone, Fluarix, FluLaval
- Available as trivalent or quadrivalent Vaccines
- Avoid in egg allergy (Allergic Reaction to lightly cooked egg)
- Cell culture Vaccine: Flucelvax
- Approved only for adults
- May contain trace amounts of egg protein (avoid in severe egg allergy)
- Available as trivalent Vaccine
- More rapid production of flu Vaccine
- Recombinant Vaccine: Flublok (RIV3)
- Trivalent Recombinant Hemagglutinin Influenza Vaccine
- Approved for ages 18 to 49 years old
- Contains only virus protein related to Immunity with no egg protein
- Safe even in severe egg allergy
- Available as trivalent Vaccine
- More rapid production of flu Vaccine
- Virus strains chosen based on:
- Virulence
- Lack of Immunity in community
- Technical limitations on virus culture
- Vaccine developed and potency tested over 6-7 months
- Inject sheep and testing Antigenicity
- Measure effective hemagglutinin concentration
- Develop reference strains
- Efficacy
- Onset of Immunity at approximately 2 weeks from the time of Vaccination
- General
- Prevents illness in 70% healthy people age <65 years
- Prevents 30-70% Pneumonia hospitalizations in elderly
- Populations who benefit greatest from Vaccine (highest efficacy, best outcome data)
- Children (see NNT below)
- COPD
- Significantly reduced rate of hospitalization, Pneumonia, serious respiratory illness
- Poole (2006) Cochrane Database Syst Rev (1): CD002733 [PubMed]
- Number Needed to Treat (NNT)
- Vaccine NNT is highest in Children: 8
- However limited data in age under 2 years (the most seriously affected population)
- Best years (in which Vaccine matched predominant strains) Vaccine NNT: 33
- Worst years (in which Vaccines poorly matched active strains) Vaccine NNT: 100
- References
- Newman in Herbert (2013) EM:Rap 13(12): 15-6
- Jefferson (2010) Cochrane Database Syst Rev (7): CD001269 [PubMed]
- Jefferson (2012) Cochrane Database Syst Rev (8):CD004879 [PubMed]
- Indications: High risk groups (but recommended for all patients 6 months and over as of 2012)
- Age 65 years and older
- All children ages 6 months to 18 years
- Nursing Home and Chronic care residents
- Chronic pulmonary disease
- Asthma
- COPD
- Chronic disease (especially those requiring frequent hospitalization)
- Chronic Kidney Disease
- Chronic Liver Disease
- Heart disease
- Diabetes Mellitus
- Sickle Cell Anemia
- Long term Aspirin use under age 18 years
- Prevents Reye's Syndrome
- Vectors
- Health care workers
- Nursing Home personnel
- Family members of high risk patients
- Families and child care workers caring for children under age 5 years
- Essential service providers
- Students in Institutional settings
- Human Immunodeficiency Virus or other immunosuppresion
- Travel to tropics any time of year
- Travel to Southern Hemisphere April to September
- Pregnancy (second and third trimester)
- Administer injectable Influenza Vaccine in any trimester (do not use Flumist)
- Breast Feeding
- Contraindications
- Age under 6 months
- Anaphylaxis or severe allergy to eggs or other Vaccine components
- Exception: Flublok (Recombinant Vaccine) contains no egg protein
- See egg allergy under protocol below
- Acute febrile illness
- History of Guillain Barre Syndrome
- Protocol
- Site
- Adults and older children: Deltoid
- Infants and young children: Anterolateral thigh
- Timing
- Clinic Visits starting in September (typically recommended by end of October)
- Nursing Homes in October-November (not too early!)
- Dosing Frequency
- Annual Vaccination is recommended
- Waning Immunity even when the prior year's Vaccine constituents were identical (e.g. 2013 to 2014)
- Typically one or more Influenza Vaccine Antigens are different from the year prior
- Children (Age 6 months to 8 years)
- First Immunization year: 2 doses, 1 month apart before December
- Subsequent Immunization years: 1 dose before December
- Adults and children over age 9 years
- Dosing: 1 dose per year before December
- Consider a second dose if first dose given early
- Dose
- Age 6 to 35 months: 0.25 ml
- Age 3 years or older: 0.50 ml (contains 45 mcg hemagglutinin Antigen per dose)
- Age 65 years of older
- Standard dose as above (45 mcg hemagglutinin) or
- High dose Fluzone (180 mcg hemagglutinin)
- No evidence as of 2012 that high-dose significantly improves Immunity
- NNT 218 to prevent one additional case of Influenza in age over 65 years
- High dose Vaccine is associated with more local reactions and flu-like symptoms
- Egg Allergy precautions
- Observe for at least 30 minutes for reaction after Influenza dose
- Patient tolerates scrambled egg without reaction
- Standard Vaccine may be used
- Hives after egg exposure
- Trivalent Recombinant Influenza Vaccine (Flublok, RIV3) if age 18-49 years or
- Standard Inactivated Influenza Vaccine
- Systemic reaction to egg exposure (Anaphylaxis)
- Trivalent Recombinant Influenza Vaccine (Flublok, RIV3) if age 18-49 years
- Administer standard Inactivated Influenza Vaccine ONLY if prepared to treat for Anaphylaxis
- References
- Grohskopf (2014) MMWR Morb Mortal Wkly Rep 63(32): 691-7 [PubMed]
- Other Vaccinations on same day
- Influenza Vaccine may be given on the same day as others (e.g. Shingles Vaccine, penumococcal Vaccine)
- Use a different extremity for each Vaccine or choose entry sites at least 1 inch apart
- If Shingrix (Shingles Vaccine that contains adjuvant) given, avoid Fluad (contains adjuvant) on same day
- Preparations
- Standard preparations (available as trivalent and the preferred, quadrivalent)
- Fluzone IM (standard preparation)
- Fluzone Intradermal
- Introduced in 2012, as potentially a less uncomfortable injection
- Similar efficacy to the intramuscular Fluzone
- Associated with more local skin reactions than the Intramuscular Injection
- High dose and augmented Vaccines (age over 65 years old)
- High risk of injection site reactions
- Fluzone high dose
- Fluad (augmented with adjuvant component)
- Other Vaccines
- Intranasal Influenza Vaccine (Flumist)
- Offered in 2019 for ages 2-49 years old, non-pregnant, who refuse injectable Influenza Vaccine
- Was not recommended in 2016 due to questionable efficacy, but considered equivalent in 2019
- Adverse Effects
- No longer contains thimerosal
- Gastrointestinal adverse effects
- Febrile Seizure
- Low Grade Fever (<101)
- Occurs in 12% of children aged 1-5 years old
- Oculorespiratory Syndrome
- Conjunctival injection, cough, Wheezing and Difficult Swallowing
- Develops 2-3 after Influenza Vaccine, and resolves within 24 hours
- No longer significantly associated with Guillain-Barre
- Swine Influenza vacine (1976) was associated with increased risk (RR 4-8)
- Gullain-Barre occur in up to 1 per million doses (but likely much higher risk with Influenza infection)
- Kwong (2013) Lancet Infect Dis 13(9): 769-76 [PubMed]
- Influenza Vaccine is safe in infants and children
- France (2004) Arch Pediatr Adolesc Med 158:1031-6 [PubMed]
- Resources
- CDC Immunization Schedules (last accessed 10/28/2020)
- https://www.cdc.gov/vaccines/schedules/
- References
- (2016) Presc Lett 23(10)
- (2015) Presc Lett 22(9):49-50
- (2014) Presc Lett 21(9): 50
- (2013) Presc Lett 20(10): 55
- (1999) Preparing for the Next Pandemic telecast, CDC
- (1997) Am Fam Physician 56(1):279-282 [PubMed]
- Ackerman (2015) Am Fam Physician 92(6): 460-8 [PubMed]