Influenza Vaccine Considerations 2013-2014 Season Karen K. O’Brien, PharmD Creighton University SPAHP September, 2013

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

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 long-term 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

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

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

Quadrivalent Live Attenuated Influenza Vaccine (LAIV4) FluMist Quadrivalent Indicated for healthy, nonpregnant persons aged 2 through 49 years Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1

Quadrivalent Inactivated Influenza Vaccine (IIV4) Injection Fluzone Quadrivalent Indicated for persons aged 6 months and older Fluarix Quadrivalent Indicated for persons aged 3 years and older FluLaval Quadrivalent Source: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm#table1

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

Trivalent Cell Culture-Based Inactivated Influenza Vaccine (ccIIV3) Flucelvax 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

Trivalent Recombinant Hemagglutinin Influenza Vaccine (RIV3) FluBlok 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

Adults ≥ 65 Years of Age Fluzone HD (High Dose) Rationale 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

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

Preservative Free/Latex Free Vaccines Route Afluria (IIV3) 0.5 mL single-dose prefilled syringe Yes IM Fluarix (IIV3) 0.5 mL single-dose prefilled syringe No Flucelvax (IIV3) 0.5 mL single-dose prefilled syringe Fluzone (IIV3) 0.25 & 0.5 mL single-dose prefilled syringe Fluzone ID (IIV3) 0.1 mL prefilled microinjection system ID Fluzone HD (IIV3) 0.5 mL single-dose prefilled syringe Fluarix Quadrivalent (IIV4) 0.5 mL single-dose prefilled syringe Fluzone Quadrivalent (IIV4) 0.25 & 0.5 mL single-dose prefilled syringe FluMist Quadrivalent (LAIV4) 0.2 mL prefilled intranasal 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.

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