1
INFLUENZA VACCINE
CONSIDERATIONS
2013-2014 SEASON
Karen K. O’Brien, PharmD
Creighton University SPAHP
September, 2013
2
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
3
Persons at Risk for Medical Complications
of Influenza
• All children aged 6 through 59 months
• All persons aged ≥50 years
• Adults and children with chronic pulmonary (including asthma),
•
•
•
•
•
•
cardiovascular (except isolated hypertension), renal, hepatic,
neurological, hematologic, or metabolic disorders (including diabetes
mellitus)
Persons who have immunosuppression (including
immunosuppression caused by medications or by HIV infection)
Women who are or will be pregnant during the influenza season
Children and adolescents (aged 6 months--18 years) receiving longterm aspirin therapy and who might be at risk for experiencing Reye’s
syndrome after influenza virus infection
Residents of nursing homes and other long-term care facilities
American Indians/Alaska Natives
Persons who are morbidly obese (BMI ≥40)
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
4
2013-2014 Influenza Vaccine Content
• Trivalent Vaccines
• A/California/7/2009 (H1N1)-like virus, A/Victoria/361/2011 (H3N2)
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
• Encourage quadrivalent vaccine for pediatric patients
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
5
Influenza Abbreviations 2013-2014
• 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) in 2013-2014
• LAIV (Live Attenuated Influenza Vaccine)
• Available as a quadrivalent formulation (LAIV4) in 2013-2014
*IIV, LAIV & RIV denote vaccine categories
*Numeric suffix indicates number of antigens in the vaccine
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
6
Quadrivalent Live Attenuated Influenza
Vaccine (LAIV4)
• Indicated for healthy, nonpregnant persons aged 2 through 49
years
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
7
Quadrivalent Inactivated Influenza
Vaccine (IIV4) Injection
• Indicated for persons aged 6 months and older
• Indicated for persons aged 3 years and older
• Indicated for persons aged 3 years and older
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
8
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 18-49 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: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
9
Trivalent Cell Culture-Based Inactivated
Influenza Vaccine (ccIIV3)
• Indicated for persons aged 18 years and older
• Influenza viruses grown in mammalian cultured cells,
rather than hens’ eggs
• Vaccine seed strain is passaged in eggs & could
contain tiny amounts of albumin
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
10
Trivalent Recombinant Hemagglutinin
Influenza Vaccine (RIV3)
• Indicated for persons aged 18 through 49 years
• Produced with insect virus and recombinant DNA
technology
• Hemagglutinin is sole virus component; created by
infecting insect cell cultures with a baculovirus
Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
11
Adults ≥ 65 Years of Age
(High Dose)
• Trivalent inactivated influenza vaccine (IIV3) for IM injection
• Contains 4x amount of antigen in standard dose
• Rationale
• Age-related weakened immune response puts older individuals at risk
for severe illness
• Ageing decreases immune response to vaccine
• Patient Outcomes
• Clinical trial data shows higher antibody levels post Fluzone HD vs.
Fluzone
• Study to compare ability of Fluzone HD vs. Fluzone to prevent
influenza due to be completed in 2014-2015
• Neither CDC nor ACIP express a preference for Fluzone HD
over another vaccine at this time
Source: http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm
12
Vaccinating Pregnant Women
• Women who are or 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: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1
13
Preservative Free/Latex Free Vaccines
Preservative Free
Latex Free?
Route
Afluria (IIV3) 0.5 mL single-dose prefilled syringe
Yes
IM
Fluarix (IIV3) 0.5 mL single-dose prefilled syringe
No
IM
Flucelvax (IIV3) 0.5 mL single-dose prefilled syringe
No
IM
Fluzone (IIV3) 0.25 & 0.5 mL single-dose prefilled
syringe
Yes
IM
Fluzone ID (IIV3) 0.1 mL prefilled microinjection system Yes
ID
Fluzone HD (IIV3) 0.5 mL single-dose prefilled syringe
Yes
IM
Fluarix Quadrivalent (IIV4) 0.5 mL single-dose prefilled
syringe
No
IM
Fluzone Quadrivalent (IIV4) 0.25 & 0.5 mL single-dose
prefilled syringe
Yes
IM
FluMist Quadrivalent (LAIV4) 0.2 mL prefilled intranasal Yes
sprayer
IN
Table of Approved Influenza Vaccines for the U.S. 201314 Season. Centers for Disease Control and Prevention Website.
http://www.cdc.gov/flu/protect/vaccine/vaccines.htm. And product package inserts.
14
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