brand logo

Am Fam Physician. 2017;96(8):545-546

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• All persons older than six months without a contraindication should receive annual influenza vaccination. There is no recommendation for a specific vaccine in persons for whom more than one licensed product is available.

• Pregnant women may receive any licensed, age-appropriate vaccine that is not live.

• Again this season, live attenuated influenza vaccine is not recommended because of its previous low effectiveness against influenza A(H1N1)pdm09.

From the AFP Editors

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) has released its recommendations on influenza vaccination for the 2017–2018 season. In this update, ACIP announces the currently available vaccine products (eTable A), reviews license and labeling changes, and issues recommendations for specific populations. A summary of ACIP's seasonal influenza vaccine recommendations is available at https://www.cdc.gov/flu/professionals/acip/index.htm.

Trade nameDispensing methodAge indicationsRoute of administration
Inactivated influenza vaccine, quadrivalent, standard-dose*
Afluria Quadrivalent0.5-mL prefilled syringe≥ 18 yearsIntramuscular
5.0-mL multidose vial≥ 18 years (needle and syringe)Intramuscular
18 through 64 years (jet injector)
Fluarix Quadrivalent0.5-mL prefilled syringe≥ 3 yearsIntramuscular
Flulaval Quadrivalent0.5-mL prefilled syringe≥ 6 monthsIntramuscular
5.0-mL multidose vial≥ 6 monthsIntramuscular
Fluzone Quadrivalent0.25-mL prefilled syringe6 through 35 monthsIntramuscular
0.5-mL prefilled syringe≥ 3 yearsIntramuscular
0.5-mL single-dose vial≥ 3 yearsIntramuscular
5.0-mL multidose vial≥ 6 monthsIntramuscular
Inactivated influenza vaccine, quadrivalent, standard-dose,* cell culture–based
Flucelvax Quadrivalent0.5-mL prefilled syringe≥ 4 yearsIntramuscular
5.0-mL multidose vial≥ 4 yearsIntramuscular
Inactivated influenza vaccine, quadrivalent, standard-dose, intradermal
Fluzone Intradermal Quadrivalent0.1-mL single-dose prefilled microinjection system18 through 64 yearsIntradermal§
Inactivated influenza vaccine, trivalent, standard-dose*
Afluria0.5-mL prefilled syringe≥ 5 yearsIntramuscular
5.0-mL multidose vial≥ 5 years (needle or syringe)Intramuscular
18 through 64 years (jet injector)
Fluvirin0.5-mL prefilled syringe≥ 4 yearsIntramuscular
5.0-mL multidose vial≥ 4 yearsIntramuscular
Adjuvanted inactivated influenza vaccine, trivalent, standard-dose*
Fluad0.5-mL prefilled syringe≥ 65 yearsIntramuscular
Inactivated influenza vaccine, trivalent, high-dose||
Fluzone High-Dose0.5-mL prefilled syringe≥ 65 yearsIntramuscular
Recombinant influenza vaccine, quadrivalent
Flublok Quadrivalent0.5-mL prefilled syringe≥ 18 yearsIntramuscular
Recombinant influenza vaccine, trivalent
Flublok0.5-mL single-dose vial≥ 18 yearsIntramuscular
Live attenuated influenza vaccine, quadrivalent (not recommended for use during the 2017–2018 season)**
Flumist Quadrivalent0.2-mL single-dose prefilled intranasal sprayer2 through 49 yearsIntranasal

ACIP recommends that all persons older than six months without a contraindication receive annual influenza vaccination. There is no recommendation for a specific vaccine in persons for whom more than one licensed product is available. The updated recommendations state that pregnant women may receive any licensed, age-appropriate vaccine that is not live. Contraindications and precautions to the influenza vaccines are listed in eTable B.

Vaccine typeContraindicationsPrecautions
Inactivated influenza vaccine
  • History of severe allergic reaction to any component of the vaccine* or after previous dose of any influenza vaccine

  • Moderate-to-severe acute illness with or without fever

  • History of Guillain-Barré syndrome within six weeks of receipt of influenza vaccine

Recombinant influenza vaccine
  • History of severe allergic reaction to any component of the vaccine

  • Moderate-to-severe acute illness with or without fever

  • History of Guillain-Barré syndrome within six weeks of receipt of influenza vaccine

For the 2017–2018 season, the Advisory Committee on Immunization Practices recommends that live attenuated influenza vaccine not be used. Content is provided for information only.
Live attenuated influenza vaccine
  • History of severe allergic reaction to any component of the vaccine* or after a previous dose of any influenza vaccine

  • Concomitant aspirin or salicylate-containing therapy in children and adolescents

  • Children two through four years of age who have received a diagnosis of asthma or whose parents or caregivers report that a health care professional has told them during the preceding 12 months that their child had wheezing or asthma or whose medical record indicates a wheezing episode has occurred during the preceding 12 months

  • Children and adults who are immunocompromised due to any cause (including immunosuppression caused by medications or by human immunodeficiency virus infection)

  • Close contacts and caregivers of severely immunosuppressed persons who require a protected environment

  • Pregnancy

  • Receipt of influenza antiviral medication within the previous 48 hours

  • Moderate-to-severe acute illness with or without fever

  • History of Guillain-Barré syndrome within six weeks of receipt of influenza vaccine

  • Asthma in persons five years or older

  • Other underlying medical conditions that might predispose to complications after wild-type influenza infection (e.g., chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus])

This season's available vaccine products include inactivated influenza vaccines in trivalent and quadrivalent formulations, and recombinant influenza vaccine in trivalent and quadrivalent formulations. The three viruses in this season's trivalent influenza vaccines include an A/Michigan/45/2015 (H1N1)pdm09–like virus, an A/Hong Kong/4801/2014 (H3N2)–like virus, and a B/Brisbane/60/2008–like virus (Victoria lineage). The quadrivalent vaccines include these three viruses plus a B/Phuket/3072/2013–like virus (Yamagata lineage). Afluria, a trivalent inactivated influenza vaccine, is now approved in persons five years or older, consistent with the U.S. Food and Drug Administration's labeling.

As in the 2016–2017 season, live attenuated influenza vaccine (LAIV4; Flumist Quadrivalent) is not recommended because of its low effectiveness against influenza A(H1N1) pdm09 in the United States. The 2017–2018 ACIP report mentions LAIV for informational purposes only.

Recommendations for Specific Populations

PERSONS AT HIGH RISK OF MEDICAL COMPLICATIONS AND THEIR CAREGIVERS

Vaccination is especially important in persons at increased risk of medical complications from influenza and of influenza-related outpatient, emergency department, or hospital visits. In cases of a limited vaccine supply, priority should be given to the following groups:

  • Children six through 59 months of age

  • Adults 50 years and older

  • Adults and children with chronic pulmonary (e.g., asthma) or cardiovascular (not including isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (e.g., diabetes mellitus)

  • Persons who are immunocompromised (e.g., from medications or human immunodeficiency virus infection)

  • Women who are pregnant or will be pregnant during the influenza season

  • Children and adolescents (six months through 18 years of age) who are receiving aspirin- or salicylate-containing medications and who may be at risk of Reye syndrome after influenza virus infection

  • Residents of nursing homes or long-term care facilities

  • American Indians and Alaska Natives

  • Persons with a body mass index of 40 kg per m2 or greater.

Although LAIV4 is not recommended during the 2017–2018 season, health care professionals who choose to use it should follow guidance for the use of LAIV4 for high-risk persons (eTable B). LAIV4 should not be used in persons with most forms of altered immunocompetence because of the possible risk of disease attributable to the vaccine virus. Additionally, it should not be used in pregnant women because it is a live virus.

Persons who live with or care for persons at higher risk of influenza-related complications should also be prioritized for vaccination. These include health care personnel in inpatient and outpatient care settings; employees of nursing homes or long-term care facilities who have contact with patients or residents; students who have contact with patients; household contacts (including children) and caregivers of children younger than five years or adults 50 years or older; and household contacts and caregivers of persons with medical conditions that put them at high risk of complications from influenza.

PERSONS WITH A HISTORY OF GUILLAIN-BARRÉ SYNDROME

A history of Guillain-Barré syndrome within six weeks after receiving any influenza vaccine is a precaution to vaccination. If not at high-risk of complications, these individuals generally should not be vaccinated. Influenza antiviral chemoprophylaxis may be considered. If persons with a history of Guillain-Barré are at high risk of complications from influenza, the benefits of vaccination may outweigh the risks.

PERSONS WITH A HISTORY OF EGG ALLERGY

Persons who have experienced only hives after exposure to egg should receive the influenza vaccine. Any licensed and recommended influenza vaccine (i.e., any inactivated influenza vaccine or recombinant influenza vaccine) that is otherwise appropriate for the individual may be used. Persons who have experienced more severe reactions (e.g., angioedema, respiratory distress, lightheadedness, recurrent emesis) or who required epinephrine or emergency medical intervention after exposure to egg may also receive any licensed and recommended influenza vaccine. These individuals should receive vaccination in an inpatient or outpatient setting under supervision of a clinician able to recognize and manage severe allergic reaction.

Persons who have previously experienced a severe allergic reaction to the influenza vaccine, regardless of the suspected component, should not receive the vaccine. Although a period of observation following vaccination is not recommended for persons with egg allergy, ACIP recommends that clinicians observe patients for 15 minutes after administration of any vaccine to decrease the risk of injury in case of syncope.

Guideline source: Advisory Committee on Immunization Practices

Evidence rating system used? No

Literature search described? No

Guideline developed by participants without relevant financial ties to industry? Not reported

Published source:MMWR Morb Mortal Wkly Rep. August 25, 2017;66(2):1–24

MARA LAMBERT, AFP Senior Associate Editor

Continue Reading


More in AFP

Copyright © 2017 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See https://www.aafp.org/about/this-site/permissions.html for copyright questions and/or permission requests.