• ACIP Releases 2023-2024 Influenza Vaccine Recommendations

    Additional Precautions for Patient Egg Allergies No Longer Necessary

    Sept 12, 2023, News Staff — Family physicians will be able to choose from up to nine different influenza vaccines for the 2023-2024 flu season now that the CDC has published a report and summary of recommendations for the prevention and control of seasonal influenza from the Advisory Committee on Immunization Practices.

    The AAFP approved the recommendations earlier in the year following review by the Commission on Health of the Public and Science, and the Academy has updated its Seasonal Influenza Prevention & Control webpage with the latest information.

    Vaccination against influenza continues to make a significant difference in reducing negative health outcomes. For the 2019-2020 season, the CDC estimates that influenza vaccines averted 7 million illnesses, 3.4 million medical visits, 100,000 hospitalizations and 7,100 deaths.

    Important Updates

    One notable update in the new recommendations says that anyone with any history of egg allergy, regardless of severity, may receive any influenza vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status. Additional safety measures beyond those recommended for any vaccine are no longer called for.

    Pamela Rockwell, D.O., of Ann Arbor, Mich., the Academy’s liaison to the ACIP, told AAFP News that the egg allergy recommendation is a “significant change” and noted that it may simplify the process of ordering and storing vaccines.

    “This change in recommendation will allow physicians to offer influenza vaccine to all of their egg-allergic patients without having to stock a separate supply of non-egg-based vaccines,” Rockwell said.

    A second notable update pertains to the composition of seasonal influenza vaccines. For the 2023-2024 season, U.S.-licensed influenza vaccines will contain hemagglutinin derived from

    1. an influenza A/Victoria/4897/2022 (H1N1)pdm09-like virus (for egg-based vaccines) or an influenza A/Wisconsin/67/2022 (H1N1)pdm09-like virus (for cell culture-based and recombinant vaccines);
    2. an influenza A/Darwin/9/2021 (H3N2)-like virus (for egg-based vaccines) or an influenza A/Darwin/6/2021 (H3N2)-like virus (for cell culture-based and recombinant vaccines);
    3. an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus; and
    4. an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus.

    Story Highlights

    Available Vaccines and Recommended Age Groups

    The ACIP recommends routine annual influenza vaccination for everyone ages 6 months and older who do not have contraindications to vaccination. If supplies become limited, vaccination efforts should focus on people at increased risk for complications from severe influenza who do not have contraindications.

    All influenza vaccines available in the United States for the 2023-2024 season are quadrivalent. The vaccines and approved age ranges are:

    • Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent and Flucelvax Quadrivalent for people ages 6 months and older;
    • Flublok Quadrivalent for ages 18 years and older;
    • FluMist Quadrivalent for people ages 2 through 49 years; and
    • Fluzone High-Dose Quadrivalent and Fluad Quadrivalent for people ages 65 years and older.

    Afluria Quadrivalent is to be administered in different doses and methods based on patient age.

    More Details for Clinicians

    Other noteworthy details of the recommendations include:

    Timing and dosing: Most people who need only one dose of influenza vaccine for the season should ideally receive it in September or October, and optimally before onset of influenza activity in the community.  However, the ACIP also recommends that vaccination efforts continue beyond October and throughout the season as long as influenza viruses are circulating.

    Children: Children ages 6 months through 8 years who have not previously received two or more doses of trivalent or quadrivalent influenza vaccine four or more weeks apart or whose vaccination status is unknown require two doses of influenza vaccine given at least 4 weeks apart, and are recommended to receive the first one as soon as it available. For children aged 8 years who require two doses, both should be administered even if the child turns 9 before the second dose.

    Pregnant patients: Patients who are pregnant or might become pregnant during the influenza season should receive influenza vaccine. Any licensed, recommended, age-appropriate inactivated or recombinant influenza vaccine may be administered at any time during pregnancy. Live attenuated influenza vaccines should not be used during pregnancy, but can be administered in the postpartum period.

    Patients with chronic medical conditions: Live attenuated vaccine is not recommended for people with some chronic medical conditions, including a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine; immunocompromise due to any cause; cranial cerebrospinal fluid leaks; cochlear implants; and recent receipt of certain influenza antiviral medications (within the previous 48 hours for oseltamivir and zanamivir, 5 days for peramivir and 17 days for baloxavir).

    The recommendations contain a table with an extensive list of contraindications and precautions. In addition, the Infections Diseases Society of America has published guidance on the timing of influenza vaccination in relation to interventions that may compromise a person’s immunity.

    Vaccination of patients with COVID-19: The ACIP recommends that clinicians may consider deferral of influenza vaccination for people with COVID-19 who are mildly ill or asymptomatic, and should defer it for those who are moderately or severely ill until they recover from the acute illness.

    Co-administration with other vaccines: Inactivated and recombinant influenza vaccines may be administered concurrently or sequentially with other live or inactivated vaccines.

    Live attenuated influenza vaccine may be administered simultaneously with other inactivated or live vaccines. However, if two live vaccines are not given simultaneously, then administration of a live attenuated influenza vaccine and another live vaccine should occur at least four weeks apart.

    Injectable vaccines given simultaneously should be administered at different places on the body.

    In May, the FDA approved the use of two vaccines (Abrysvo, manufactured by Pfizer, Inc., and Arexvy, manufactured by GSK plc) to prevent severe complications of RSV infection in adults 60 years and older. Regarding co-administration, the ACIP said, “For more recently introduced and new vaccines (e.g., respiratory syncytial virus [RSV] vaccine) data informing simultaneous administration with influenza vaccines might be limited or evolving. Providers should consult current CDC/ACIP recommendations and guidance for up-to-date information.”

    Family Physician perspective

    Rockwell, who also serves as a professor in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor, highlighted other details of the update for family physicians, including:

    The role of Abrysvo and Arexvy in reducing disease burden in older adults: “I believe the new RSV vaccines for adults will save many older adults from acquiring lower respiratory tract disease, reduce hospitalizations and reduce exacerbation of comorbidities, especially chronic lung and heart disease due to RSV infection. For decades, RSV disease in adults has been underreported and underestimated. We are learning now that the burden of RSV disease in adults rivals and perhaps surpasses that of influenza.”

    A possible tripledemic of influenza, COVID-19 and RSV in the coming season:
    “I have concern that adults presenting with respiratory viral symptoms this fall and winter will be difficult to diagnose without testing. People may be infected with more than one virus at a time, and there is a possibility that all three respiratory viruses (COVID-19, influenza and RSV) may be heavily circulating this winter, and all three illnesses can present with similar symptoms. We have COVID-19 and influenza tests that have become common and often used. We need to increase frequency of testing adults for RSV disease to better inform treatment plans. Point-of-care RSV antigen testing is useful to diagnose RSV in children, but not in adults. PCR testing with a nasopharyngeal swab is a better test for diagnosing RSV in adults, and not all physicians are aware of this.”

    Addressing vaccine hesitancy and explaining the importance of immunizations to parents: “I inform my patients who are hesitant to vaccinate themselves or their children that though some side effects to vaccination are possible, effects of the illness the vaccine prevents may be much more serious and devastating. I have confidence in our vaccine safety protocols and ongoing safety monitoring. Keeping our children and ourselves healthy through disease prevention is cost-effective and can be life-saving. A strong recommendation to vaccinate, using presumptive language, from a family physician has been proven effective to help reduce vaccine hesitancy.”