Delaware Health & Social Services
Division of Public Health
IMMUNIZATION
STANDING
ORDERS
2015-2016
SEASONAL INFLUENZA
VACCINATION
Delaware Division of Public Health
2015-2016 Seasonal Influenza Standing Orders
2015-2016 Seasonal Influenza Vaccine Formulas:
Trivalent and Quadrivalent Vaccines will contain hemagglutinin derived from:
 A/California/7/2009 (H1N1)-like virus
 A/Switzerland/9715293/2013 (H3N2)-like virus
 B/Phuket/3073/2013-like virus (B/Yamagata lineage)
Quadrivalent Vaccines will also include:
 B/Brisbane/60/2008-like virus (B/Victoria/2/87 lineage)
Vaccine prepared for a previous influenza season should NOT be administered to provide
protection for the current season.
All persons aged > 6 months should be vaccinated annually. Influenza vaccination should not
be delayed to procure a specific vaccine preparation if an appropriate one is already available.
For healthy children aged 2 through 8 years who have no contraindications or precautions,
either LAIV or IIV is an appropriate option. No preference is expressed for LAIV or IIV for any
person aged 2 through 49 years for whom either vaccine is appropriate. An age-appropriate
formulation of vaccine should be used.
When vaccine supply is limited vaccination efforts should focus on delivering vaccination to
persons who:
 are aged 6 months through 4 years (59 months);
 are ≥ 50 years;
 have chronic pulmonary (including asthma), cardiovascular (except isolated
hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including
diabetes mellitus);
 are immunosuppressed (including immunosuppression caused by medications or by
human immunodeficiency virus);
 are or will be pregnant during the influenza season;
 are aged 6 months through 18 years and receiving long-term aspirin therapy and who
therefore might be at risk for experiencing Reye syndrome after influenza virus
infections (these individuals should get intramuscular or intradermal IIV preparations
only, NOT LAIV);
 are residents of nursing homes and others chronic-care facilities;
 are American Indians/Alaska Natives;
 are morbidly obese (body-mass index > 40);
 are health care personnel*;
 are household contacts and caregivers of children aged <5 years and adults aged > 50
years, with particular emphasis on vaccinating contacts of children aged <6 months; and
 are household contacts (including children) and caregivers of persons with medical
conditions that put them at higher risk for severe complications from influenza.
*Including public health workers, as well as persons who are members of volunteer ambulance
companies or volunteer fire companies acting as "first responders" in the State of Delaware;
employees of the Delaware Emergency Management Agency; and any other person(s) at the
discretion of the Director, Division of Public Health.
To permit time for production of protective antibody levels, vaccination optimally should occur before
onset of influenza activity in the community. Therefore, vaccination providers should offer
vaccination as soon as vaccine is available, and if possible, by October. Vaccination should be
offered through the influenza season (i.e., as long as influenza viruses are circulating in the
community).
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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Intramuscular Inactivated Influenza Vaccines (IIV IM) for Different Age Groups
VACCINE
Fluzone®Quad
Fluarix®Quad
Fluzone®Quad
Fluzone®Quad
Fluvirin®Trivalent
PRESENTATION THIMEROSAL ROUTE
0.25 mL syringe
Single dose
0.5 mL syringe
Single dose
0.5 mL vial or
0.5 mL syringe
Single dose
5.0 mL vial
Multi-dose
0.5 mL syringe**
Single dose
6-35
mos
3 yrs
4 yrs
5–7
yrs
8-17
yrs
≥ 18
yrs
PREGNANT
No
IM*
Yes
No
No
No
No
No
No
No
IM*
No
Yes
Yes
Yes
Yes
Yes
Yes
No
IM*
.25mL
Yes
Yes
Yes
Yes
Yes
Yes
Yes
IM*
No1
No1
No1
No1
Yes
Yes
No1
Yes
IM*
No1
No1
No1
No1
Yes
Yes
No1
*IM – Intramuscular **Tips of prefilled syringes may contain natural rubber latex.
1
Presentations of influenza vaccine that contains thimerosal are approved by the FDA for vaccination of persons in these categories;
however, Delaware Law, Title 16 Delaware Code Chapter 5 §510 prohibits the administration of these mercury (thimerosal) containing
vaccines for children under 8 years of age and pregnant women unless an exemption to the law has been granted by the Director of the
Division of Public Health (or designee).
When an exemption is in effect, prior to administration of a thimerosal containing vaccine:
1. the provider shall inform client or parent/legal guardian of client that the vaccine contains thimerosal and is believed to be
medically necessary, and the Public Health Director (or designee) has formally determined the vaccine may be given;
2. the client or parent/guardian of client shall acknowledge receiving required information from the provider and ask that the
vaccine be given by placing signature on "Exemption Declaration Due To Shortage Client Consent Form".
Intranasal Live, Attenuated Influenza Vaccine (LAIV IN) for Different Age Groups
VACCINE
FluMist®Quad
PRESENTATION THIMEROSAL ROUTE
0.2 mL spray
Single dose
No
IN*
6-23 mos
24 mos4 yrs
5–49 yrs
≥ 50 yrs
PREGNANT
No
Yes2
Yes2
No
No
Reference: Adapted from CDC as noted above.
*IN - Intranasal
2. Healthy individuals 2-49 years of age.
See LAIV Contraindications (CDC ACIP Recommendations 2015-2016, p822) including: individuals aged <2 years or > 49 years,
pregnant women, persons with a history of egg allergy, severe allergic reactions to the vaccine or any of its components or to a
previous dose of any influenza vaccine; immunosuppressed persons, children or adolescents receiving aspirin or aspirin
containing products, children 2-4 years who have asthma or from whom parents report that health care provider stated that they
had wheezing or asthma within the last 12 months; persons who have taken influenza antiviral medications within the previous 48
hours.
See LAIV Precautions (CDC ACIP Recommendations 2015-2016, p822-8223) including persons with asthma (greater or equal to 5
years) who might be at increased risk for wheezing after administration of LAIV; and those persons with underlying medical conditions that
might predispose them to complications after wild-type influenza infection: e.g. chronic pulmonary, cardiovascular, renal, hepatic,
neurologic/neuromuscular, hematologic or metabolic disorders in which safety of LAIV has not been established. Persons who
care for severely immunosuppressed person who require a protective environment should not receive LAIV or should avoid
contact with such person for 7 days after receipt, given theoretical risk for transmission of live attenuated vaccine virus.
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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Inactivated Influenza Vaccine (IIV)
IIV DOSE
Influenza vaccine dosage by age group - United States 2015-16 Season
AGE GROUP
DOSE
NUMBER of DOSES ROUTE
6 – 35 months
0.25 mL
1 or 2 *
IM
3 – 8 years
0.5 mL
1 or 2 *
IM
 9 years
0.5 mL
1
IM
*NUMBER OF DOSES AND INTERVALS FOR CHILDREN
For simplicity use chart below
FIGURE 1. Influenza vaccine dosing algorithm for children aged 6 months through 8
years — Advisory Committee on Immunization Practices, United States, 2015–16
influenza season
CDC MMWR Weekly Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States,
2015–16 Influenza Season 64(30); 818-825. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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IIV PREFERRED SITE
 The recommended site of vaccination is the deltoid muscle for adults and older children.
 The preferred site for infants and young children is the antero-lateral aspect of the thigh.
INDICATIONS
All persons aged ≥6 months should be vaccinated annually to protect from influenza infection and the
complications that may follow.
CONTRAINDICATIONS
Severe allergic reaction to any component of the vaccine, including egg protein, or after previous
dose of any influenza vaccine. Such individuals should be referred to their primary care physician for
further evaluation. See vaccine components in each vaccine preparation in Vaccine Excipient
and Media Summary table (pp10).
PRECAUTIONS
 Moderate or severe acute illness with or without fever. However, minor illnesses with or without
fever do not contraindicate use of influenza vaccine.
 Guillain-Barre Syndrome (GBS) within 6 weeks following a previous dose of IIV is considered to
be a precaution for use of IIV. Refer client to primary care provider.
POSSIBLE REACTIONS
 Soreness (in >50% of recipients), redness and/or swelling at the vaccination site are the most
frequent side effects of vaccination. Other mild problems include headache, lethargy, sore
throat, red itchy eyes, cough, fever and muscle aches. If these problems occur they usually
begin soon after the injection and last 1-2 days.
 Other possible infrequent, but severe problems include immediate responses such as hives,
angioedema, allergic asthma, or systemic anaphylaxis (severe allergic reaction is estimated at less
than 1 in a million doses.)
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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GUIDELINES FOR INACTIVATED INFLUENZA VACCINE (IIV) VACCINATION OF
CHILDREN AND ADULTS
CIRCUMSTANCE
ACTION
Well individual, eligible for vaccine
as indicated above.
Immunize
Moderate or severe acute illness.
Defer immunization until symptoms have abated.
History of anaphylactic reaction or
hypersensitivity to eggs
Do NOT immunize. Refer to primary care provider.
HIV infected persons.
Immunize with IIV preparation
Pregnant and Lactating Women
Immunize at any gestation with IIV.
Simultaneous administration.
Can receive influenza vaccine at the same time they
receive other vaccinations.
Infant/Child 6 months through 8
years of age who has received:
No (zero) or one dose trivalent or
quadrivalent
influenza
vaccine
before July 1, 2015.
Give 2 doses this season.
OR
Infant/Child 6 months through 8
years of age for whom vaccine
history before July 1, 2015 cannot be
determined.
Infant/Child 6 months through 8
years of age who has received:
Two or more doses of trivalent or
quadrivalent influenza vaccine prior
to July 1, 2015.
Well individual, eligible for vaccine,
who received a 2014-2015 seasonal
vaccine.
Give 1 dose this season.
Immunize
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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Live, Attenuated Influenza Vaccine (LAIV): FluMist®
CDC ACIP Recommendations re: Live Attenuated Influenza Vaccine (LAIV) for Children (2-8 yr.)
LAIV is an option for vaccination of healthy persons aged 2 - 49 years, including healthcare workers
and other persons in close contact with groups at high risk for influenza. During periods when
inactivated vaccine is in short supply, use of LAIV is encouraged for eligible persons because use of
LAIV by these persons might increase availability of inactivated vaccine for persons with
contraindications that preclude them from receiving LAIV.
DOSE
AGE GROUP
PRODUCT
DOSE
NUMBER of DOSES
ROUTE
2 - 49 years
LAIV
0.2 mL divided equally
in each nostril.
1 or 2 *
Intranasal
*NUMBER OF DOSES AND INTERVALS
For simplicity see Influenza vaccine dosing algorithm for children aged 6 months
through 8 years --- Advisory Committee on Immunization Practices (ACIP), 2015-2016
influenza season on p.4 above.
 Children 2 through 8 years of age who received 2 or more total doses of trivalent or quadrivalent
influenza vaccine prior to July 1, 2015 should receive 1 dose.
 Children 2 through 8 years of age who received one dose of trivalent or quadrivalent influenza vaccine
prior to July 1, 2015 should receive 2 doses, spaced ≥ 4 weeks apart.
 Children 2 through 8 years of age receiving a trivalent or quadrivalent influenza vaccine for the first time
should receive 2 doses, spaced ≥ 4 weeks apart.
 Children 2 through 8 years of age for whom seasonal influenza vaccine history prior to July 1, 2015
cannot be determined should receive 2 doses; spaced ≥ 4 weeks apart.
PREFERRED SITE
 For nasal use only.
 Approximately half of the total sprayer contents are sprayed into the first nostril while the
recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to
administer the second half of the dose into the other nostril. If the vaccine recipient sneezes
after administration, the dose should not be repeated.
INDICATIONS
Healthy individuals 2 through 49 years of age to protect from influenza infection and the
compromising sequelae that may follow.
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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CONTRAINDICATIONS
 Individuals aged <2 years or >50 years;
 Persons with contraindications listed in the package insert:
o Children or adolescents (aged 2 to 18 years) receiving aspirin or other salicylates
(because of the risk, in these individuals, of developing Reye’s syndrome after
receiving LAIV).
o Persons who have experienced severe allergic reactions to the vaccine or any of its
components (including egg protein or gentamicin), or to a previous dose of any
influenza vaccine. See complete vaccine components in each preparation in
Vaccine Excipient and Media Summary table (pp10).
 Pregnant Women;
 Immunocompromised Persons (including immunosuppression caused by medications or by
human immunodeficiency virus);
 Persons with history of egg allergy;
 Children aged 2 through 4 years who have asthma or who have had a wheezing episode noted
in the medical record within the past 12 months, or for whom parents report that a health care
provider state that they had wheezing or asthma within the last 12 months;
 Moderate or severe acute illness with or without fever.
 LAIV should not be administered until 48 hours after cessation of influenza antiviral therapy.
Influenza antiviral medications should not be administered for 2 weeks after receipt of LAIV.
 Persons who care for severely immunosuppressed persons who require a protective
environment should not receive LAIV, or should avoid contact with such persons for 7 days after
receipt, given the theoretical risk for transmission of live attenuated vaccine virus to close
contacts.
 Persons of any age with asthma might be at increased risk for wheezing after administration of
LAIV. Give IIV instead or refer to PCP if desires LAIV.
 Individuals with underlying medical conditions: chronic pulmonary, cardiovascular (except
isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including
diabetes mellitus). Give IIV instead or refer to PCP if desires LAIV.
 Guillain-Barre Syndrome (GBS) within 6 weeks following a previous dose of influenza vaccine is
considered to be a precaution for use of influenza vaccines. Refer client to primary care
provider.
POSSIBLE REACTIONS
Mild problems that have been reported following LAIV:
Children and adolescents (2-17 years of age):
 runny nose, nasal congestion or cough
 fever
 headache and muscle aches
 wheezing
 abdominal pain or occasional vomiting or diarrhea
Adults (18-49 years of age):
 runny nose or nasal congestion
 sore throat
 cough, chills
 tiredness/weakness
 headache
A severe allergic reaction could occur after any vaccine (estimated less than 1 in a million doses).
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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GUIDELINES FOR LIVE, ATTENUATED INFLUENZA VACCINE (LAIV) IMMUNIZATION
OF CHILDREN AND ADULTS:
CIRCUMSTANCE
ACTION
Well individuals 2 through 49 years
eligible for vaccine.
Immunize as indicated above.
Minor acute illness with or without fever.
Immunize
Persons with nasal congestion serious
enough to make breathing difficult, such
as a very stuffy nose.
Do NOT immunize with LAIV. Immunize with
inactivated flu vaccine.
Hypersensitivity to eggs.
Do NOT immunize. Refer to primary care
provider.
Pregnant Women
Do NOT immunize with LAIV. Immunize with
inactivated flu vaccine.
Individuals who are <2 or ≥ 50 years of
age.
Do NOT immunize with LAIV. Immunize with
inactivated flu vaccine.
Simultaneous administration with other
vaccines.
An inactivated vaccine can be administered
either simultaneously or at any time before or
after LAIV.
A live vaccine should either be administered on
the same day as LAIV or administered ≥4 weeks
before or after LAIV.
Well individual, eligible for vaccine, who
received 2014-2015 seasonal influenza
vaccine
Immunize with LAIV
Individuals with asthma, chronic
pulmonary, cardiovascular (except
isolated hypertension), renal, hepatic,
neurologic, hematologic, or metabolic
disorders (including diabetes mellitus).
Do not immunize with LAIV. Immunize with IIV.
Refer to primary care provider if desires LAIV.
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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Vaccine Excipient & Media Summary
Excipients Included in Influenza Vaccines Purchased by DPH, by Vaccine
This table includes not only vaccine ingredients (e.g., adjuvants and preservatives), but also
substances used during the manufacturing process, including vaccine-production media, that
are removed from the final product and present only in trace quantities. In addition to the
substances listed, most vaccines contain Sodium Chloride (table salt).
All reasonable efforts have been made to ensure the accuracy of this information. If in doubt,
check the manufacturer’s package insert. See links below.
Vaccine*
Influenza (Fluarix
Quadrivalent)
Influenza (FluMist
Quadrivalent)
Influenza (Fluzone:
Quadrivalent)
Fluvirin® (Trivalent)
Contains
octoxynol-10 (Triton X-100), α-tocopheryl hydrogen succinate,
polysorbate 80 (Tween 80), hydrocortisone, gentamicin sulfate,
ovalbumin (egg protein), sodium deoxycholate, and
formaldehyde
monosodium glutamate, hydrolyzed porcine gelatin, arginine,
sucrose, dibasic potassium phosphate, monobasic potassium
phosphate, ovalbumin (egg protein), gentamicin sulfate, and
ethylenediamine tetraacetic acid (EDTA)
ovalbumin(egg protein), sodium phosphate-buffered isotonic
sodium chloride solution, formaldehyde, octylphenol ethoxylate
and thimerosal/mercury (multi-dose vial only)
Thimerosal/mercury, ovalbumin (egg protein), polymyxin,
neomycin, betapropiolactone and nonylphenol ethoxylate
Source:
Manufacturer’s
P.I. Dated
Revised: 6/2015
Revised 7/2015
Revised:
June 2015
Revised:
Feb 2015
GlaxoSmithKline Fluarix® Quadrivalent Influenza Virus Vaccine Suspension for Intramuscular Injection.
Highlights of and Full Prescribing Information, 2015-2016 Formula, Revised: 6/2015, Accessed: 8/27/15.
https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Fluarix_Quad
rivalent/pdf/FLUARIX-QUADRIVALENT.PDF
MedImmune Flumist® Quadrivalent (Influenza Vaccine Live, Intranasal). Highlights of and Full Prescribing
Information, 2015-2016, Revised: 7/2015, Accessed: 8/27/15.
http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM123743.pdf
Novartis Influenza Virus Vaccine Fluvirin®. Highlights of and Full Prescribing Information, 2015-2016, Revised:
Feb 2015, Accessed: 9/2/15.
http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM123694.pdf
Sanofi pasteur 450/477 Fluzone® Quadrivalent, Highlights of and Full Prescribing Information, 2015-2016
Formula, Revised: June 2015, Accessed: 8/27/15.
https://www.vaccineshoppe.com/image.cfm?doc_id=12943&image_type=product_pdf
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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References and Resources:
Center for Disease Control and Prevention. MMWR Weekly. Prevention and Control of Influenza with
Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States,
2015–16 Influenza Season 64(30); 818-825.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
http://www.cdc.gov/mmwr/pdf/wk/mm6430.pdf
Centers for Disease Control and Prevention. Prevention and Control of Seasonal Influenza with
Vaccines: Recommendations of the Advisory Committee on Immunization Practices – (ACIP) – United
States, 2014-2015 Influenza Season http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
http://www.cdc.gov/mmwr/pdf/wk/mm6332.pdf
Centers for Disease Control and Prevention. Prevention and Control of Influenza with Vaccines:
Recommendations of the Advisory Committee on Immunization Practices – (ACIP) – United States,
2013-2014 http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm
Centers for Disease Control and Prevention. Vaccine Information Statement, Flu Vaccine, Inactivated
(8/7/15) 42 U.S.C. §300aa-26. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf
Centers for Disease Control and Prevention. Vaccine Information Statement Flu Vaccine, Live,
Intranasal (8/7/15) U.S.C. §300aa26 http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flulive.pdf
GlaxoSmithKline Fluarix® Quadrivalent Influenza Virus Vaccine Suspension for Intramuscular
Injection. Highlights of and Full Prescribing Information, 2015-2016 Formula, Revised: 6/2015,
Accessed: 8/27/15.
https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Flu
arix_Quadrivalent/pdf/FLUARIX-QUADRIVALENT.PDF
MedImmune Flumist® Quadrivalent (Influenza Vaccine Live, Intranasal). Highlights of and Full
Prescribing Information, 2015-2016, Revised: 7/2015, Accessed: 8/27/15.
http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM123743.pdf
Novartis Influenza Virus Vaccine Fluvirin®. Highlights of and Full Prescribing Information, 2015-2016,
Revised: Feb 2015, Accessed: 9/2/15.
http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM123694.pdf
Sanofi pasteur 450/477 Fluzone® Quadrivalent, Highlights of and Full Prescribing Information, 20152016 Formula, Revised: June 2015, Accessed: 8/27/15.
https://www.vaccineshoppe.com/image.cfm?doc_id=12943&image_type=product_pdf
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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THE PRECEDING PROCEDURES, GUIDELINES AND INFLUENZA
STANDING ORDERS ARE APPROVED FOR USE BY DIVISION OF
PUBLIC HEALTH REGISTERED NURSES AND REGISTERED
NURSES WORKING UNDER THE DIRECTION OF THE DIVISION OF
PUBLIC HEALTH.
____________________________________________
EFFECTIVE DATES:
Sept 4, 2015 – June 30, 2016
____________________________________________
Delaware Division of Public Health 2015–2016 Influenza Standing Orders
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