Seasonal influenza vaccine (Pocket Guide)

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Organization:
Public Health Agency of Canada

Type: Pocket Guide

Published: 2017-10-20

Recommendations from the National Advisory Committee on Immunization (NACI) 2017-2018

Correction

Please note that there was an error in a previous version of this document. The FLUZONE® High-Dose vaccine is only authorized in Canada for those aged 65 and older. If you accessed this document before October 18, 2017, please disregard and refer to the present version.

Who should receive the vaccine?

All individuals 6 months of age and older, who do not have contraindications to the vaccine, with a particular focus on:

People at high risk of influenza-related complications or hospitalization

  • All pregnant womenFootnote *.
  • Adults and children with the following chronic health conditions:
    • cardiac or pulmonary disorders (including bronchopulmonary dysplasia, cystic fibrosis and asthma);
    • diabetes mellitus and other metabolic diseases;
    • cancer, immune compromising conditions (due to underlying disease, therapy or both);
    • renal disease;
    • anemia or hemoglobinopathy;
    • neurologic or neurodevelopment conditionsFootnote **;
    • morbid obesity (body mass index [BMI] ≥40);
    • children and adolescents (age 6 months to 18 years) undergoing treatment for long periods with acetylsalicylic acid, because of the potential increase of Reye's syndrome associated with influenza.
  • People of any age who are residents of nursing homes and other chronic care facilities.
  • People ≥65 years of age.
  • All children 6 to 59 months of age.
  • Indigenous peoples.

People capable of transmitting influenza to those at high risk

  • Health care and other care providers in facilities and community settings who, through their activities, are capable of transmitting influenza to those at high risk of influenza complications.
  • Household contacts (adults and children) of individuals at high risk of influenza-related complications (whether or not the individual at high risk has been immunized):
    • household contacts of individuals at high risk, as listed in the section above;
    • household contacts of infants <6 months of age as these infants are at high risk of complications from influenza but cannot receive influenza vaccine;
    • members of a household expecting a newborn during the influenza season.
  • Those providing regular child care to children ≤59 months of age, whether in or out of the home.
  • Those who provide services within closed or relatively closed settings to persons at high risk (e.g., crew on a ship).

Others

  • People who provide essential community services.
  • People in direct contact during culling operations with poultry infected with avian influenza.

Who should not receive the vaccine?

  • People who have had an anaphylactic reaction to a previous dose of influenza vaccine; or
  • People who have had an anaphylactic reaction to any of the vaccine components, with the exception of egg (refer to the Canadian Immunization Guide Chapter on Influenza and Statement on Influenza Vaccine for 2017-2018 Section II - Contraindications and precautions).

Live attenuated influenza vaccine (LAIV) is also contraindicated for:

  • Children less than 24 months of age, due to increased risk of wheezing.
  • Individuals with severe asthma, as defined as currently on oral or high dose inhaled glucocorticosteroids or active wheezing, or those with medically attended wheezing in the 7 days prior to immunization.
  • Children and adolescents 2 to 17 years of age currently receiving aspirin or aspirin-containing therapy because of the association of Reye's syndrome with aspirin and wild-type influenza infection. It is recommended that aspirin-containing products in children less than 18 years of age be delayed for four weeks after receipt of LAIV.
  • Pregnant women, because it is a live attenuated vaccine and there is a lack of safety data at this time. However, it is not contraindicated in breastfeeding mothers.
  • Persons with immune compromising conditions, due to underlying disease, therapy, or both, as the vaccine contains live attenuated virus.

Co-administration

All intramuscular influenza vaccines may be given together with or at any time before or after administration of other live attenuated or inactivated vaccines.

Given the lack of data for immune interference, based on expert opinion, NACI recommends that LAIV can also be given together with or at any time before or after the administration of any other live attenuated or inactivated vaccine. NACI recognizes that some vaccine providers may choose to give LAIV and other live vaccines simultaneously or separated by at least 4 weeks to avoid any possibility of immune interference. Alternatively, trivalent inactivated influenza vaccine (TIV) or quadrivalent inactivated influenza vaccine (QIV) may be given.

Choice of influenza vaccine
Recipient by age group Vaccine types available for useFootnote Comments
Children 6-23 months of age TIV
QIV
ATIV

TIV, QIV and ATIV are authorized for this age group.

NACI recommends that, given the burden of influenza B disease, QIV should be used. If QIV is not available, either unadjuvanted or adjuvanted TIV should be used.

Children 2-17 years of age TIV
QIV
Quadrivalent LAIV

In children without contraindications to the vaccine, any of the following vaccines can be used: LAIV, QIV or TIV.

The current evidence does not support a recommendation for the preferential use of LAIV in children and adolescents 2-17 years of age.

Given the burden of influenza B disease in children and the potential for lineage mismatch between the predominant circulating strain of influenza B and the strain in a TIV, NACI continues to recommend that a quadrivalent formulation of influenza vaccine be used in children and adolescents 2-17 years of age. If quadrivalent is not available, TIV should be used.

LAIV is not recommended for children with immune compromising conditions.

LAIV, TIV or QIV can be used in children with chronic health conditions and without contraindications (See the Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018, sections on Contraindications and Precautions (Section II) and Choice of vaccine product for children 2 to 17 years of age (Section V) for more details).

Adults 18-59 years of age TIV
QIV
Quadrivalent LAIV

TIV and QIV are the recommended products for adults with chronic health conditions.

TIV and QIV, instead of LAIV, are recommended for health care workers.

LAIV is not recommended for adults with immune compromising conditions.

Adults 60-64 years of age TIV
QIV
TIV and QIV are authorized for use in this age group.
Adults 65+ years of age TIV
QIV
ATIV
High dose TIV
Given the burden of influenza A(H3N2) disease and evidence of better efficacy in this age group, it is expected that high dose TIV should provide superior protection compared with the standard dose intramuscular vaccine for older adults.
Pregnant women TIV
QIV
LAIV is not recommended because of the theoretical risk to the fetus from administering a live virus vaccine.
Footnote 1

TIV: Trivalent inactivated vaccine, QIV: Quadrivalent inactivated vaccine, LAIV: Live attenuated influenza vaccine, ATIV: Adjuvanted trivalent inactivated vaccine

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Recommended dosage & route, by age, for 2017-2018 season
Age group TIV or QIV without adjuvantFootnote * Intramuscular TIV without adjuvant, high-dose (FLUZONE® High-Dose) Intramuscular MF59-adjuvanted TIV (Fluad Pediatric® or Fluad®) Intramuscular LAIV (FluMist® Quadrivalent) Intranasal Number of doses required
6-23 months 0.5 mLFootnote ** - 0.25 mL - 1 or 2Footnote ***
2-8 years 0.5 mL - - 0.2 mL
(0.1 mL per nostril)
1 or 2Footnote ***
9-17 years 0.5 mL - - 0.2 mL
(0.1 mL per nostril)
1
18-59 years 0.5 mL - - 0.2 mL
(0.1 mL per nostril)
1
60-64 years 0.5 mL - - - 1
≥65 years 0.5 mL 0.5 mL 0.5 mL - 1
Footnote 1

Influvac® ≥3 years, Fluviral® ≥6 months, Agriflu® ≥6 months, Vaxigrip® ≥6 months, Fluzone® ≥6 months, Flulaval® Tetra ≥6 months and Fluzone® Quadrivalent ≥6 months.

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Footnote 2

This information differs from the product monograph. Published and unpublished evidence suggest moderate improvement in antibody response in infants, without an increase in reactogenicity, with the use of full vaccine doses (0.5 mL) for unadjuvanted inactivated influenza vaccines. This moderate improvement in antibody response without an increase in reactogenicity is the basis for the full dose recommendation for unadjuvanted vaccine for all ages. (For more information refer to Statement on Seasonal Influenza Vaccine for 2011-2012).

Return to footnote ** referrer

Footnote 3

Children 6 months to less than 9 years of age who have never received the seasonal influenza vaccine require two doses of influenza vaccine, with a minimum interval of four weeks between doses. Eligible children <9 years of age who have properly received one or more doses of seasonal influenza vaccine in the past should receive one dose per influenza vaccination season thereafter.

Return to footnote *** referrer

SOURCE: 2017 Public Health Agency of Canada. An Advisory Committee Statement, National Advisory Committee on Immunization (NACI), Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018 (See under Influenza for full document as well as related addenda available at www.phac-aspc.gc.ca/naci-ccni).

Footnotes

Footnote 1

The risk of influenza-related hospitalization increases with length of gestation, i.e., it is higher in the third than in the second trimester.

Return to footnote * referrer

Footnote 2

These include neuromuscular, neurovascular, neurodegenerative, neurodevelopmental conditions and seizure disorders (and, for children, febrile seizures), but exclude migraines and neuropsychiatric conditions without neurological conditions.

Return to footnote ** referrer

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