INFLUENZA VACCINE CONSIDERATIONS SEASON Alicia Vanden Bosch, PharmD Creighton University SPAHP September,

Who Should Get Influenza Vaccine? Beginning with the 2010–11 vaccination season, ACIP recommends annual vaccination for all people ages 6 months and older who do not have a contraindication to the vaccine. Patient-specific factors influence vaccine selection 2

Persons at Risk for Medical Complications of Influenza Children aged <5 years, especially <2 years old Adults aged ≥65 years Pregnant women or will be pregnant during the influenza season American Indians/Alaska Natives Chronic Diseases - Adults and children with chronic pulmonary (including asthma), cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus) Immunosuppressed - Persons with immunosuppression (including caused by medications or by HIV infection) Aspirin Therapy - Children and adolescents (6 months--18 years) receiving long-term aspirin therapy who might be at risk for experiencing Reye’s syndrome after influenza virus infection Residents of nursing homes and other long-term care facilities Morbidly obese (BMI ≥40) Source: 3

Influenza Vaccine Content Trivalent Vaccines A/California/7/2009 (H1N1)-like virus, A/Texas/50/2012 (H3N2)-like virus, and a B/Massachusetts/2/2012-like virus Quadrivalent vaccines Include an additional vaccine virus, a B/Brisbane/60/2008-like virus Type B influenza strains more problematic in pediatric population Cause approximately same number of deaths as Type A Recommend quadrivalent vaccine for pediatric patients Source: 4

Influenza Abbreviations IIV (Inactivated Influenza Vaccine) Replaces TIV (Trivalent Inactivated Influenza Vaccine) IIV3: egg-based and cell culture-based trivalent inactivated influenza vaccine IIV4: egg-based quadrivalent inactivated influenza vaccine ccIIV3: When necessary to specifically denote a cell culture-based vaccine, the prefix “cc” is used RIV (Recombinant Hemagglutinin Influenza Vaccine) Available as trivalent formulation (RIV3) LAIV (Live Attenuated Influenza Vaccine) Available as a quadrivalent formulation (LAIV4) *IIV, LAIV & RIV denote vaccine categories *Numeric suffix indicates number of antigens in the vaccine Source: 5

Quadrivalent Live Attenuated Influenza Vaccine (LAIV4) Source: 6

Quadrivalent Inactivated Influenza Vaccine (IIV4) Injection Source: 7

ACIP: Vaccinating Persons with a History of Egg Allergy Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Avoid LAIV (little data available) Use IIV or RIV RIV is egg-free and may be used for persons aged years who have no other contraindications. IIV (egg- or cell-culture based) may also be used, with the following additional safety measures Healthcare provider familiar with the potential manifestations of egg allergy should administer vaccine Observe patients for at least 30 minutes for signs of a reaction after every vaccine dose Source: 8

Trivalent Cell Culture-Based Inactivated Influenza Vaccine (ccIIV3) Source: 9

Trivalent Recombinant Hemagglutinin Influenza Vaccine (RIV3) Source: 10

Adults ≥ 65 Years of Age Source: 11

Vaccinating Pregnant Women Pregnant women or women who will be pregnant during influenza season should receive IIV Live attenuated influenza vaccine (LAIV) is not recommended for use during pregnancy Postpartum women can receive either LAIV or IIV Pregnant and postpartum women do not need to avoid contact with persons recently vaccinated with LAIV Source: 12

Preservative Free/Latex Free Vaccines Preservative FreeLatex Free?Route Afluria (IIV3) 0.5 mL single-dose prefilled syringeYesIM Fluarix (IIV3) 0.5 mL single-dose prefilled syringeNoIM Flucelvax (IIV3) 0.5 mL single-dose prefilled syringeNoIM Fluzone (IIV3) 0.25 & 0.5 mL single-dose prefilled syringe YesIM Fluzone ID (IIV3) 0.1 mL prefilled microinjection systemYesID Fluzone HD (IIV3) 0.5 mL single-dose prefilled syringeYesIM Fluarix Quadrivalent (IIV4) 0.5 mL single-dose prefilled syringe NoIM Fluzone Quadrivalent (IIV4) 0.25 & 0.5 mL single-dose prefilled syringe YesIM FluMist Quadrivalent (LAIV4) 0.2 mL prefilled intranasal sprayer YesIN Table of Approved Influenza Vaccines for the U.S Season. Centers for Disease Control and Prevention Website. And product package inserts. 13

Influenza Vaccines – U.S Trade NamePresentationAgeRoute Inactivated influenza vaccine, quadrivalent (IIV4), standard dose Fluarix 0.5 ml single-dose prefilled syringe≥ 3 yrsIM FluLaval 0.5 ml single-dose prefilled syringe 5.0 ml multidose vial 0.25 ml single-dose prefilled syringe ≥ 3 yrs 6-35 mos IM Fluzone 0.5 ml single-dose prefilled syringe 0.5 ml single-dose vial 5.0 ml multidose vial ≥ 36 mos ≥ 6 mos IM Inactivated influenza vaccine, trivalent (IIV3), standard dose Afluria 0.5 ml single-dose prefilled syringe 5.0 ml multidose vial ≥ 9 yrs IM Fluarix 0.5 ml single-dose prefilled syringe≥ 3 yrsIM FluLaval 0.5 ml single-dose prefilled syringe 5.0 ml multidose vial ≥ 3 yrs IM Fluvirin 0.5 ml single-dose prefilled syringe 5.0 ml multidose vial ≥ 4 yrs IM Fluzone 0.5 ml single-dose prefilled syringe 5.0 ml multidose vial ≥ 36 mos ≥ 6 mos IM Fluzone Intradermal 0.1 ml prefilled microinjection system yrsID

Influenza Vaccines – U.S Trade NamePresentationAgeRoute Inactivated influenza vaccine, trivalent, standard dose, cell culture-based (ccIIV3) Flucelvax 0.5 ml single-dose prefilled syringe≥ 18 yrsIM Inactivated influenza vaccine, trivalent (IIV3), High dose Fluzone High Dose 0.5 ml single-dose prefilled syringe≥ 65 yrsIM Ricombinant influenza vaccine, trivalent (RIV3) FluBlok 0.5 ml single-dose vial yrsIM Live attenuated influenza vaccine, quadrivalent (LAIV4) FluMist 0.2 ml single-dose prefilled intranasal sprayer yrsIN Source:

Influenza Suspension vs. Solution FluBlok (RIV) available as solution (0.5 mL single dose vial) Shake vial gently prior to use (per manufacturer) All other influenza vaccine is suspension IIV3, ccIIV3, IIV4 or LAIV Multi-dose vials Single dose prefilled syringes IM, ID Check manufacturer package insert for specific instructions (shake vigorously, well or gently) prior to use (each use in the case of multi-dose vials) IN LAIV Suspension, but manufacturer does not indicate to shake prior to use 16