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Pulmonary Disease - Guideline Summaries

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) — United States, 2017-18

Here’s a quick glance at what has changed year-over-year.

Neeta O’Mara, PharmD, BCPS

Clinical Advisor: Allan Goldstein, MD


I. Introduction


Influenza infection typically occurs in the United States from late fall through the spring. Although most patients with influenza will recover from a bout of flu, in some patients it can lead to serious illness and death, especially in older adults, very young children, pregnant women, and those who are immunocompromised. However, every year, previously healthy individuals develop serious complications and die from influenza infection.

II. Changes From 2016-2017 Guidance


Every year, the Advisory Committee of Immunization Practices updates its recommendations for influenza vaccination in the United States to reflect updates in the literature, changes in the viral antigen composition of the vaccine for the current season, and it also makes minor changes on guidance for use of influenza viruses.

Changes in the recommendations from last year include:

  • In the trivalent and quadrivalent vaccines, only 1 new strain (A/Michigan/45/2015 (H1N1) pdm09-like virus) will be included. It replaces A/California/7/2009 (H1N1)-like virus. As with last year’s vaccine, the 2017-2018 trivalent vaccine will contain A/Hong Kong/4801/2014 (H3N2)-like virus and a B/Brisbane/60/2008-like virus. The 2017-2018 quadrivalent influenza vaccine will also contain an addition B strain (B/Phuket/3073/2013-like virus), which is the same additional B strain contained in last year’s quadrivalent vaccine product.
  • New vaccine products including Afluria® Quadrivalent and Flublok® Quadrivalent have been included in the updated recommendations.
  • The age indications for Afluria Trivalent vaccine have been updated to age ≥5 years (previously age ≥9 years) and FluLaval® Quadrivalent to age ≥6 months (previously age ≥3 years) have been included.
  • As with last year’s recommendations, FluMist® Quadrivalent (live, intranasal vaccine) is not recommended in any patients, as there are concerns about its effectiveness against influenza A (H1N1)pdm09 viruses in the United States.


Below, additional details are provided for a number of specific situations.

III. General Recommendation


As in the last few years, the ACIP recommends routine influenza vaccination with a licensed and age-appropriate influenza vaccine for all persons aged ≥6 months who do not have contraindications.

 Comments: The table below summarizes the available vaccines in the United States and the age indications for each. In general, there is no preference for one vaccine over another among the recommended, approved injectable influenza vaccines. Also included are the mercury and latex contents of each vaccine, to determine which vaccines are acceptable for those patients who wish to receive a mercury-free vaccination or for those who are latex-allergic.

Brand name/manufacturer Use in those ages Mercury (µg/0.5 mL) Latex
Afluria® (trivalent)
Seqirus
≥5 years (by needle/syringe)
18 through 64 years (by jet injector)
none (syringe)
24.5 (multidose vial)
none
Afluria® (trivalent)
Seqirus
≥18 years (by needle/syringe)
18 through 64 years (by jet injector)
none (syringe)
24.5 (multidose vial)
none
Fluad® (trivalent)
Seqirus
≥65 years none yes (syringe tip cap)
Fluarix® Quadrivalent
GlaxoSmithKline
≥3 years none none
Flublok® (trivalent)
Protein Sciences
≥18 years none none
Flublok® Quadrivalent
Protein Sciences
≥18 years none none
Flucelvax Quadrivalent®Seqirus ≥4 years none (syringe)
25 (multidose vial)
none
FluLaval® Quadrivalent
ID Biomedical Corp. of Quebec (distributed by GlaxoSmithKline)
≥6 months none (syringe)
<25 (multidose vial)
none
FluMist® Quadrivalent
MedImmune
Not recommended for use
2 through 49 years none none
Fluvirin® (trivalent)
Seqirus
≥4 years ≤1 (syringe)
25 (multidose vial)
yes (syringe tip cap)
none (vial)
Fluzone® High-Dose (trivalent)
Sanofi Pasteur
≥65 years none none
Fluzone® Intradermal Quadrivalent
Sanofi Pasteur
18 through 64 years none none
Fluzone® Quadrivalent
Sanofi Pasteur
6 through 35 months (0.25 mL prefilled syringe)
≥3 years (0.5 mL prefilled syringe, single-dose vial)
≥6 months (multidose vial)
none (syringe)
25 (multidose vial
none

Source: ACIP

IV. Administration


Recommendation: Influenza vaccine should be administered before the onset of influenza activity in the community.

Details: In the United States, the start of influenza can occur as early as October, but in recent years, peak influenza activity has not occurred until January or later. As a general rule, influenza vaccine is not fully effective for approximately 2 weeks. Using this information, it would appear that vaccination should optimally be offered by the end of October, if possible. The only exception would be in children aged <8 years who require 2 doses (eg, those children who have not received ≥2 doses of influenza vaccine, not necessarily during the same or consecutive seasons, before July 1, 2017, or in whom the prior influenza vaccine administration history is not known). Because these children require 2 doses separated by at least 4 weeks, they should receive their first dose as soon as possible after vaccine becomes available, to allow the second dose to be administered by the end of October.

Although early vaccination (eg, in July and August) might be associated with less-than-optimal immunity by the end of the flu season, the impact of waning versus other determinants is unknown. The clinical implications of waning immunity versus the potential for a “missed opportunity” to administer the vaccine must be considered. Revaccination later in the same influenza season of patients who have already been fully vaccinated is not recommended. Vaccination should continue as long as influenza viruses are circulating and vaccine is available. In any given season, the optimal time to vaccinate cannot be predicted precisely because influenza seasons vary in timing and duration. Moreover, more than one outbreak might occur in a given community in a single year.

V. Vaccinating the Elderly


Recommendation: Adults aged ≥65 years may receive any age-appropriate inactivated influenza vaccine product.

Details: The ACIP does not recommend any specific inactivated influenza vaccine product over another. Patients aged ≥65 years can receive any influenza product (standard- or high-dose, trivalent or quadrivalent, adjuvanted or unadjuvanted), or recombinant influenza vaccines.

Although both high-dose inactivated trivalent influenza vaccine (Fluzone High-Dose) and recombinant quadrivalent influenza vaccine (Flublok Quadrivalent) have shown superior efficacy over comparator standard-dose trivalent inactivated influenza vaccine and egg-grown, quadrivalent inactivated influenza vaccine, respectively, vaccination should not be delayed to find a particular product if an appropriate one is available.

V. Vaccinating the Elderly


Recommendation: Adults aged ≥65 years may receive any age-appropriate inactivated influenza vaccine product.

Details: The ACIP does not recommend any specific inactivated influenza vaccine product over another. Patients aged ≥65 years can receive any influenza product (standard- or high-dose, trivalent or quadrivalent, adjuvanted or unadjuvanted), or recombinant influenza vaccines.

Although both high-dose inactivated trivalent influenza vaccine (Fluzone High-Dose) and recombinant quadrivalent influenza vaccine (Flublok Quadrivalent) have shown superior efficacy over comparator standard-dose trivalent inactivated influenza vaccine and egg-grown, quadrivalent inactivated influenza vaccine, respectively, vaccination should not be delayed to find a particular product if an appropriate one is available.

VI. Vaccinating the Immunocompromised


Recommendation: Most immunocompromised patients can receive inactivated influenza vaccine (trivalent or quadrivalent).

Details: Only limited data are available regarding the use of influenza vaccines in the majority of immunocompromised states. Although not recommended in any patients this influenza season, clinicians who are considering the use of the live, intranasal influenza vaccine (FluMist) should not use it in immunocompromised patients or in caregivers and contacts of immunocompromised patients. Although their efficacy may be blunted in those who are immunocompromised, all parenteral inactivated vaccines (trivalent and quadrivalent) are considered safe in patients who are immunocompromised.

The Infectious Diseases Society of America has guidance regarding the selection and timing of vaccines for persons with specific immunocompromising conditions, such as congenital immune disorders, stem cell and solid organ transplant, anatomic and functional asplenia, and therapeutic drug-induced immunosuppression, as well as for persons with cochlear implants or other conditions leading to persistent cerebrospinal fluid-oropharyngeal communication.

VII. Vaccinating Those With Egg Allergies


Recommendation: Influenza vaccine can be given in most patients who report an egg allergy.

Details: In patients who report an egg allergy, the ACIP recommends the following:

  • Persons with a history of egg allergy who have experienced only urticaria (hives) after exposure to egg can receive influenza vaccine. Any licensed and recommended influenza otherwise appropriate for the recipient’s age and health status may be used.
  • Persons who report having had reactions to egg involving symptoms other than urticaria (hives), such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, can also receive any licensed and recommended influenza vaccine that is otherwise appropriate for the recipient’s age and health status. The influenza vaccine should be administered in an inpatient or outpatient medical setting and should be supervised by a health care provider who is able to recognize and manage severe allergic conditions.
  • Although there is no suggested period of observation following vaccination in an egg-allergic patient, general recommendations suggest that all patients be observed for 15 minutes to reduce the risk of injury should syncope occur.

VIII. CDC Links


For additional information, the Centers for Disease Control and Prevention has the following Webpages:

References


About the Authors

Dr. O’Mara is a clinical pharmacist/study coordinator at Dialysis Clinic, Inc, based in Nashville, TN. Dr. Goldstein is a pulmonologist with Pulmonary Associates Southeast, Birmingham, AL.

References

DiazGranados CA, Dunning AJ, Kimmel M, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med 2014; 371 (August 14): 635-645.

Dunkle LM, Izikson R, Patriarca P, et al. Recombinant influenza vaccine in adults 50 years of age or older. N Engl J Med 2017; 376 (June 22): 2427-2436.

Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 influenza season. MMWR 2017; 66 (August 25): 1-20.

Rubin LG, Levin MJ, Ljungman P, et al.; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58 (July 1): 309-318.

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