Flu Vaccines for 2018-2019

CDC has released recommendations for influenza vaccines for the 2018-19 influenza season. These recommendations can be found at: https://www.cdc.gov/mmwr/volumes/67/rr/rr6703a1.htm?s_cid=rr6703a1_w. Items that are addressed include the following:

  • Influenza vaccination is recommended for everyone ages six months and older who do not have contraindications, using any age-appropriate vaccine.1 Encourage patients to try to complete vaccination by the end of October. Though delayed vaccination may lead to increased immunity later in the season, it could also lead to missed opportunities to vaccinate, and is not recommended.1
    • LAIV4 (intranasal vaccine; FluMist) is an available option endorsed by the Advisory Committee on Immunization Practices (ACIP) for the 2018-19 flu season.1 This is a change from the 2016-17 and 2017-18 recommendations and might improve vaccination rates, especially in children.13 Early evidence suggests this year’s intranasal vaccine should work better than previous years.13
    • The inactivated vaccines are recommended over the LAIV4 by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) due to efficacy rates of the LAIV4 against the H1N1 influenza A strains in recent years. The AAP and AAFP recommend reserving the LAIV4 for age appropriate healthy patients (e.g., 2 to 49 years of age) who refuse an injection.9,14 See ACIP recommendations for LAIV4 at https://www.cdc.gov/mmwr/volumes/67/wr/ pdfs/mm6722a5-H.pdf.
  • Live-attenuated and inactivated influenza vaccines can be given at the same time as other vaccines, using separate administration sites.1 (See Fluad row below concerning co-administration of two adjuvanted vaccines.)
  • After giving a live vaccine (including LAIV4) other live vaccines should not be administered for at least four weeks.1
  • Trivalent flu vaccines protect against two influenza A-like viruses and one influenza B-like virus.1
  • Quadrivalent flu vaccines protect against two influenza A-like viruses and two influenza B-like viruses.1

Continue to the last page of this document for information about when two doses of influenza vaccine are needed; vaccination with an acute illness; vaccinating immunocompromised, pregnant, or breastfeeding patients; and managing patients with an egg allergy. The chart below provides information about approved influenza vaccines for the 2018-19 season including FDA-approved ages for use, route of administration, dose, and cost.

Abbreviations: IIV4 = influenza inactivated vaccine, quadrivalent; IIV3 = influenza inactivated vaccine, trivalent; IM = intramuscular; LAIV4 = live attenuated influenza vaccine, quadrivalent; MDV = multidose vial; PFS = pre-filled syringe; RIV4 = recombinant inactivated vaccine, quadrivalent; SDV = single-dose vial.

Brand Name
Manufacturer
a

Routea

Approved Ages for Usea

Availabilitya
(Cost/doseb)

Contains Thimerosal?a

Dosea

Commentsa

Quadrivalent inactivated (IIV4)

Afluria Quadrivalent

Seqirus

IM

≥5 years

0.5 mL PFS
($17.97)

5 mL MDV
($15.95 to $16.62)

Yes
(MDV only)

0.5 mL

No latex

Once entered, the MDV should be discarded after 28 days.

PharmaJet Stratis needle-free injector approved for ages 18-64 years.


Fluarix Quadrivalent

GSK


IM

≥6 months

0.5 mL PFS
($16.82)

No

0.5 mL

No latex

Flucelvax Quadrivalent

Seqirus

IM

≥4 years

0.5 mL PFS
($21.22)

5 mL MDV
($20.12)

Yes
(MDV only)

0.5 mL

This cell-cultured vaccine may be abbreviated ccIIV4.1

No latex

Flucelvax may contain egg protein, but a relatively small amount compared to other inactivated vaccines.1


FluLaval Quadrivalent

GSK

IM

≥6 months

0.5 mL PFS
($16.82)

5 mL MDV
($15.77)


Yes
(MDV only)

0.5 mL

No latex

Once entered, the MDV should be discarded after 28 days.

Fluzone Quadrivalent

Sanofi Pasteur

IM

≥6 months

0.25 mL PFS
($19.26)

0.5 mL PFS and SDV ($17.97)

5 mL MDV
($16.62)


Yes
(MDV only)

6-35 months:
0.25 mL

≥36 months:
0.5 mL

No latex

A max of ten doses can be withdrawn from the MDV vial.

Trivalent inactivated (IIV3)

Afluria

Seqirus

IM

≥5 years

0.5 mL PFS
($20.81)

5 mL MDV
($19.20)

Yes
(MDV only)

0.5 mL

No latex

Once entered the MDV vial should be discarded after 28 days.

PharmaJet Stratis needle-free injector approved for ages 18-64 years.


Fluad

Seqirus

IM

≥65 years

0.5 mL PFS
($48.08)

No1

0.5 mL

No latex.

This adjuvanted vaccine may be abbreviated aIIV3.1

May provide modestly greater reduction in flu risk vs non-adjuvanted trivalent vaccine in patients ≥65 years of age (n=227, unable to calculate NNT), [Evidence level B-2].1,5

Higher risk of adverse effects (injection site reactions, fatigue, myalgias, headache) than IIV3.1

Coadministration with other adjuvanted vaccines (e.g., Shingrix) has not been studied. There are theoretical concerns about more side effects. Don’t delay flu vaccination if Fluad is the only flu vaccine available.1


Fluzone High-Dose

Sanofi Pasteur

Contains 60 mcg of each virus strain compared to 15 mcg in standard-dose IM vaccines.1

IM

≥65 years

0.5 mL PFS
($46.94)

No1

0.5 mL

No latex

Provides modestly greater reduction in flu risk vs standard-dose trivalent vaccine in patients ≥65 years of age (n=31,989; NNT=200), [Evidence level A-1].1,3

Higher risk of nonserious adverse effects (injection site reactions, fever, myalgias) than standard dose.


Quadrivalent recombinant (RIV4)

Flublok Quadrivalent

Protein Sciences

Contains 45 mcg of each virus strain compared to 15 mcg in standard-dose IM vaccines.1


IM

≥18 years

0.5 ml PFS
($46.94)


No1

0.5 mL

No latex

Egg-free

May be slightly more effective than IIV4 vaccines in patients ≥50 years of age (n=8,604; NNT=100),
[Evidence level A-1].1,2

Quadrivalent live-attenuated (LAIV4)

FluMist Quadrivalent

MedImmune

Intranasal

2 to 49 years

0.2 mL prefilled intranasal sprayer
($22.95)

No1

0.1 mL per nostril

No latex

For use in healthy, non-pregnant patients.1

Avoid in patients with contraindications to live vaccines (e.g., chronic diseases, immunosuppression, severely immunosuppressed close contacts).

Avoid in children between the ages of 2 and 4 years with asthma or a history of wheezing in the last 12 months.1

Avoid in patients who have received influenza antivirals in the past 48 hours.1


  1. Information is from the following U.S. product labeling unless otherwise specified: Afluria Quadrivalent (April 2018); Fluarix Quadrivalent (June 2018); Flucelvax Quadrivalent (July 2018); FluLaval Quadrivalent (June 2018); Fluzone Quadrivalent (June 2018); Afluria (April 2018); Fluad (June 2018) Fluzone High-Dose (June 2018); Flublok Quadrivalent (June 2018); FluMist Quadrivalent (August 2018).
  2. Medication pricing by Elsevier, accessed August 2018. Cost provided is based on Wholesale Acquisition Cost (WAC).

Information and Clinical Pearls about Influenza Vaccine Administration

  • To provide optimal protection, children between the ages of 6 months and two years should receive two doses of influenza vaccine (separated by at least four weeks) if they have not received at least two doses of influenza vaccine (separated by at least four weeks) prior to July 1, 2018.1
  • Immunocompromised patients may receive any licensed, recommended, age-appropriate injectable flu vaccine.4
  • Vaccinate pregnant women (any trimester) with any licensed, recommended, age-appropriate injectable flu vaccine, regardless of thimerosal content.1,6
    • Risk of influenza and potential complications in pregnant woman and/or the fetus exceeds possible risks associated with influenza vaccination.7,8
    • Influenza vaccination is safe during breastfeeding. Vaccinate post-partum women who did not receive an influenza vaccine while pregnant.9,10
  • Patients with a history of severe egg allergy (symptoms more severe than hives [e.g., angioedema, respiratory distress, requiring epinephrine]) can usually tolerate any flu vaccine. But, they should receive the vaccine in a medical setting under the supervision of a healthcare professional who can identify and treat severe allergic reactions, if necessary. Flublok Quadrivalent is the only influenza vaccine considered egg-free.1 See our chart, Flu Vaccination and Egg Allergy, for answers to common questions about vaccinating egg-allergic patients.
  • Avoid missed opportunities to vaccinate by giving the influenza vaccine to patients who cannot remember if they received this season’s influenza vaccine, even if this means giving a second dose to some patients.11
  • Continue to give the flu vaccine to patients with mild acute illnesses in order to avoid missed opportunities to vaccinate. Mild acute illness with or without fever (e.g., diarrhea, upper respiratory infection) is not a contraindication to receiving the vaccine.12 Consider delaying vaccination in patients with moderate to severe illness as vaccination side effects (e.g., fever, malaise) may make it difficult to assess management of acute illness.12

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]

Project Leader in preparation of this clinical resource (341001): Beth Bryant, Pharm.D., BCPS, Assistant Editor

References

  1. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices – United States, 2018-19 influenza season. Updated August 24, 2018. https://www.cdc.gov/mmwr/volumes/67/rr/rr6703a1.htm?s_cid=rr6703a1_w. (Accessed August 31, 2018).
  2. Dunkle LM, Izikson R, Patriarca P, et al. Efficacy of recombinant influenza vaccine in adults 50 years of age or older. N Engl J Med 2017;376:2427-36.
  3. 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;371:635-45.
  4. CDC. General recommendations on immunization recommendations of the Advisory Committee on Immunization Practices (ACIP): altered immunocompetence. Last updated February 21, 2018. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.pdf. (Accessed August 31, 2018).
  5. Domnich A, Arata L, Amicizia D, et al. Effectiveness of MF59-adjuvanted seasonal influenza vaccine in the elderly: a systematic review and meta-analysis. Vaccine 2017;35:513-20.
  6. CDC. Flu vaccine safety and pregnancy. Updated October 3, 2018. https://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm. (Accessed August 31, 2018).
  7. Zerbo O, Modaressi S, Chan B, et al. No association between influenza vaccination during pregnancy and adverse birth outcomes. Vaccine 2017;35:3186-90.
  8. CDC. Flu vaccination & possible safety signal. Updated September 13, 2017. https://www.cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html. (Accessed August 31, 2018).
  9. Committee on Infectious Diseases. Recommendations for prevention and control of influenza in children, 2018-2019. Pediatrics 2018;doi: 10.1542/peds.2018-2367.
  10. The American College of Obstetricians and Gynecologists. All pregnant women should get flu vaccine, says ACOG. August 2014. https://www.acog.org/About-ACOG/News-Room/News-Releases/2014/All-Pregnant-Women-Should-Get-Flu-Vaccine-Says-ACOG. (Accessed September 4, 2018).
  11. Immunization Action Coalition. Ask the experts: influenza. Updated July 30, 2018. http://www.immunize.org/askexperts/experts_inf.asp. (Accessed September 6, 2018).
  12. Immunize Action Coalition. Ask the experts: precautions and contraindications. Updated February 1, 2018. http://www.immunize.org/askexperts/precautions-contraindications.asp. (Accessed September 6, 2018).
  13. CDC. Update: ACIP recommendations for the use of quadrivalent live attenuated influenza vaccine (LAIV4) – United States, 2018-19 influenza season. https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6722a5-H.pdf. (Accessed September 10, 2018).
  14. American Academy of Family Physicians. CDC releases guidance for the 2018-19 influenza season. AAFP gives preferential recommendation for IIV. September 6, 2018. https://www.aafp.org/news/health-of-the-public/20180906seasonalflurecs.html. (Accessed September 17, 2018).

Cite this document as follows: Clinical Resource, Flu Vaccines for 2018-2019. Pharmacist’s Letter/Prescriber’s Letter. October 2018.

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