2021 to 2022 seasonal influenza vaccine: Mobile guide for health professionals

Last updated: December 2021

This content will not be updated for the 2022–2023 influenza season. For current guidance, refer to the Canadian Immunization Guide: Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2022–2023.

About this guide

This guidance was based on available scientific evidence and expert opinion during the 2021–2022 influenza season. The following is a summary of 2021–2022 recommendations from the National Advisory Committee on Immunization (NACI).

Who should receive the vaccine

Everyone 6 months of age and older should receive the vaccine unless they have contraindications to the vaccine.

It is especially important that the following people receive the vaccine:

People at high risk of severe COVID-19 related illness

For a comprehensive list, refer to:
- People who are at risk of more severe disease or outcomes from COVID-19
For more information on what is presently known about the clinical features of COVID-19, including presentation, co-morbidities and the spectrum of disease severity, refer to:
- COVID-19 signs, symptoms and severity of disease: A clinician guide

People at high risk of influenza-related complications or hospitalization

All children 6 to 59 months of age
Adults and children with the following chronic health conditions:
- cardiac or pulmonary disorders (includes bronchopulmonary dysplasia, cystic fibrosis and asthma)
- diabetes mellitus and other metabolic diseases
- cancer, immune compromising conditions due to underlying disease, therapy, or both, such as solid organ transplant or hematopoietic stem cell transplant recipients
- renal disease
- anemia or hemoglobinopathy
- neurologic or neurodevelopment conditions, including:
  - neuromuscular
  - neurovascular
  - neurodegenerative
  - neurodevelopmental conditions
  - seizure disorders (for children, this includes febrile seizures and isolated developmental delay)
- obesity (body mass index (BMI) of 40 and over)
- children 6 months to 18 years of age undergoing treatment for long periods with acetylsalicylic acid
  - this is because of the potential increase of Reye's syndrome associated with influenza
People who are pregnant
People of any age who are residents of nursing homes and other chronic care facilities
Adults 65 years of age and older
Indigenous people

People capable of transmitting influenza to those at high risk of influenza-related complications or hospitalization

Healthcare workers and other care providers in facilities and community settings
Household contacts, both adults and children, of individuals at high risk, whether or not the individual at high risk has been vaccinated, such as:
- household contacts and care providers of infants less than 6 months of age
- members of a household expecting a newborn during the influenza season
Those providing regular child care to children 0 to 59 months of age, whether in or out of the home
Those who provide services within closed or relatively closed settings with people at high risk (for example, crew on a ship)

Others

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

The influenza vaccine is a critical tool to protect against influenza-related disease and to reduce the influenza-associated burden on the Canadian healthcare system. This is even more important this influenza season:

given potential influenza and COVID-19 co-circulation
to enhance the capacity to respond to ongoing COVID-19 activity

Schedule

Adults and children 9 years of age and older should receive 1 dose of influenza vaccine each year.

Children 6 months to less than 9 years of age who have never received the influenza vaccine in a previous influenza season should:

be given 2 doses of influenza vaccine in the current season
have a minimum interval of 4 weeks between doses

If they have been vaccinated with 1 or more doses in the past, they should receive 1 dose of influenza vaccine per season thereafter.

Contraindications

Who should not receive the vaccine

People who have had an anaphylactic reaction to:
- a previous dose of influenza vaccine
- any of the vaccine components, with the exception of egg
People who have developed Guillain-Barré Syndrome (GBS) within 6 weeks of a previous influenza vaccination, unless another cause was found for the GBS

Who should not receive a live attenuated influenza vaccine

In addition to the above-mentioned contraindications, NACI also recommends that live attenuated influenza vaccine (LAIV) should not be given to:

people with immune compromising conditions due to underlying disease, therapy, or both
- the exception is children with stable HIV infection on highly active antiretroviral therapy (HAART) and with adequate immune function
people with:
- severe asthma (defined as currently on oral or high-dose inhaled glucocorticosteroids or active wheezing) or
- medically attended wheezing in the 7 days prior to the proposed date of vaccination due to increased risk of wheezing
  - LAIV is not contraindicated for people with a history of stable asthma or recurrent wheeze
children less than 24 months of age due to increased risk of wheezing
children 2 to 17 years of age currently receiving aspirin or aspirin-containing therapy
- this is because of the association of Reye's syndrome with aspirin and wild-type influenza infection
- aspirin-containing products in children less than 18 years of age should be delayed for 4 weeks after receipt of LAIV
people who are pregnant because it is a live attenuated vaccine and there is a lack of safety data at this time
- LAIV is not contraindicated in breastfeeding individuals; however, there is limited data for the use of LAIV in lactating individuals

LAIV should not be administered until 48 hours after antiviral agents active against influenza are stopped, for example:

oseltamivir
zanamivir

These antiviral agents should be avoided if possible for 2 weeks after receipt of LAIV. This is so that the antiviral agents do not inactivate the replicating vaccine virus.

If these anti-viral agents are administered within this time frame (from 48 hours pre-vaccination with LAIV to 2 weeks post-vaccination):

revaccination should take place at least 48 hours after the antivirals are stopped or
an inactivated influenza vaccine could be given at any time

Considerations for influenza vaccination during the COVID-19 pandemic

Individuals with symptoms of COVID-19 or an acute respiratory infection

During the COVID-19 pandemic, individuals should postpone influenza vaccination until they have recovered if they have:

acute symptoms of COVID-19
any symptoms of acute respiratory infection, including minor symptoms such as sore throat or runny nose

This is because they can pose an unnecessary risk to others and healthcare providers if they have COVID-19. Individuals with COVID-19 symptoms should visit a healthcare professional or contact their local public health authority for information on getting tested.

Individuals currently in quarantine (self-isolation) for SARS-CoV-2 infection (COVID-19)

Individuals should postpone vaccination until the individual is no longer required to quarantine or isolate according to criteria indicated by public health authorities in their province or territory

For additional advice, refer to the following guidance document developed in consultation with NACI:

Guidance on the use of seasonal influenza vaccine in the presence of COVID-19

Simultaneous administration with other vaccines

For people 12 years of age and older, seasonal influenza vaccines (including the LAIV) may be given:

at the same time as a COVID-19 vaccine
at any time before a COVID-19 vaccine
at any time after a COVID-19 vaccine

For children aged 5 to 11, it is not recommended that COVID-19 vaccines be routinely given simultaneously (i.e., same day) with non-COVID-19 vaccines (live or non-live). NACI recommends that a 14-day interval between a COVID-19 vaccine and the influenza vaccine should be considered. This is a precaution to assist with the monitoring of possible side effects from each vaccine.

Simultaneous administration or a shortened interval between a COVID-19 vaccine and a non-COVID-19 vaccine may be warranted on an individual basis in some circumstances at the clinical discretion of the healthcare provider.

Provinces and territories may decide on a specific interval for this age group as part of their vaccination programs.

If more than 1 type of vaccine is administered at a single visit, they should be administered at different injection sites using separate injection equipment.

Informed consent should include a discussion of the benefits and risks given the limited data available on administration of COVID-19 vaccines at the same time as, or shortly before or after, other vaccines.

NACI will continue to:

monitor the evidence base, including ongoing and anticipated trials investigating influenza vaccines administered at the same time as, or any time before or after, COVID-19 vaccines
update its recommendations as needed

Consult the COVID-19 vaccine chapter in the Canadian Immunization Guide for more information on the simultaneous administration of COVID-19 vaccines with other vaccines.

Choice of vaccine product

Abbreviations

HAART: highly active antiretroviral therapy
IIV: inactivated influenza vaccine
IIV3: trivalent inactivated influenza vaccine
IIV3-Adj: adjuvanted egg-based trivalent inactivated influenza vaccine
IIV3-HD: high-dose egg-based trivalent inactivated influenza vaccine
IIV3-SD: standard-dose egg-based trivalent inactivated influenza vaccine
IIV4: quadrivalent inactivated influenza vaccine
IIV4-cc: standard-dose cell culture-based quadrivalent inactivated influenza vaccine
IIV4-HD: high-dose egg-based quadrivalent inactivated influenza vaccine
IIV4-SD: standard-dose egg-based quadrivalent inactivated influenza vaccine
IM: intramuscular
LAIV: live attenuated influenza vaccine
LAIV4: egg-based quadrivalent live attenuated influenza vaccine

Children

For children 6 to 23 months of age:

any available and age appropriate IIV4 should be used
if IIV4 is not available, any available and age appropriate IIV3 should be used
LAIV is contraindicated

For healthy children (2 to 17 years of age):

IIV4 or LAIV should be used in children without contraindications, including those with non-immune compromising chronic health conditions
if IIV4 or LAIV are not available, any available IIV3 should be used
LAIV is contraindicated for those:
- who are currently receiving aspirin or aspirin-containing therapy
- with most immune compromising conditions (see exceptions under contraindications)
- with severe asthma or medically attended wheezing in previous 7 days
- who are pregnant (IIV4 should be used instead)

For children with immune compromising conditions (2 to 17 years of age):

IIV4 should be used
if IIV4 is not available, any available IIV3 should be used
LAIV is generally contraindicated but may be given to children with:
- stable HIV infection if the child is currently being treated with HAART and has adequate immune function or
- cystic fibrosis who are not treated with immunosuppressive drugs (for example, prolonged systemic corticosteroids)

For children with severe asthma or medically attended wheezing in previous 7 days (2 to 17 years of age):

IIV4 should be used
if IIV4 is not available, IIV3 should be used
LAIV is contraindicated but may be given to children with stable, non-severe asthma

Adults

For healthy adults (18 to 59 years of age):

IIV3, IIV4 or LAIV should be used

For adults with chronic health conditions (18 to 59 years of age):

IIV3 or IIV4 should be used
LAIV is contraindicated for adults with any of the high-risk chronic health conditions listed under contraindications

For adults 60 to 64 years of age:

IIV3 or IIV4 should be used

For adults 65 years of age or older:

IIV-HD should preferably be used instead of IIV-SD
IIV3-Adj and IIV4-cc may also be used

Specific populations

For people who are pregnant:

IIV3 or IIV4 should be used
LAIV is contraindicated

For healthcare workers:

IIV3 or IIV4 should be used
LAIV is not recommended as a precautionary measure to avoid the theoretical risk of transmitting a vaccine virus to people with severe immune compromising conditions

Recommended dose and route by age

Table 1. Influenza vaccine type (route of administration) by age group and number of doses
Age group	IIV3-SD^{Table 1 footnote a} or IIV4 –SD^{Table 1 footnote b} (IM)	IIV4-cc^{Table 1 footnote c} (IM)	IIV3-Adj (IM)^{Table 1 footnote d}	IIV3-HD^{Table 1 footnote e} (IM)	IIV4-HD^{Table 1 footnote f} (IM)	LAIV4^{Table 1 footnote g} (intranasal)	Number of doses required
6 to 23 months	0.5 mL^{Table 1 footnote h}	-	0.25 mL	-	-	-	1 or 2^{Table 1 footnote i}
2 to 8 years	0.5 mL	-	-	-	-	0.2 mL (0.1 mL per nostril)	1 or 2^{Table 1 footnote i}
9 to 17 years	0.5 mL	0.5 mL	-	-	-	0.2 mL (0.1 mL per nostril)	1
18 to 59 years	0.5 mL	0.5 mL	-	-	-	0.2 mL (0.1 mL per nostril)	1
60 to 64 years	0.5 mL	0.5 mL	-	-	-	-	1
65 years or older	0.5 mL	0.5 mL	0.5 mL	0.5 mL	0.7 mL	-	1
Table 1 footnotes Table 1 footnote a IIV3-SD formulations (Agriflu^® (6 months and older), Fluviral^® (6 months and older), and Influvac^® (3 years and older)) are authorized but will not be available for use in Canada during the 2021-2022 influenza season. Return to footnote a referrer Table 1 footnote b Afluria^® Tetra (5 years and older), Flulaval^® Tetra (6 months and older), Fluzone^® Quadrivalent (6 months and older), Influvac^® Tetra (3 years and older) Return to footnote b referrer Table 1 footnote c Flucelvax^® Quad (Seqirus) standard dose mammalian cell culture-based quadrivalent inactivated influenza vaccine (currently recommended by NACI for use in adults and children 9 years and older) is now authorized by Health Canada for use in persons ≥2 years of age. Refer to the product monograph for further details. This updated authorized age for use supersedes the information for Flucelvax Quad found within the NACI Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2021–2022. NACI will be reviewing the current recommendations and supporting evidence on the use of Flucelvax Quad. Return to footnote c referrer Table 1 footnote d IIV3-Adj formulations (Fluad Pediatric^® ((6–23 months) and Fluad^® (65 years and older)) are authorized in Canada, however only Fluad^® (65 years and older) is being supplied for the 2021-2022 influenza season. Return to footnote d referrer Table 1 footnote e Fluzone^® High-Dose (65 years and older) was previously authorized, but marketing of the vaccine has been discontinued as of February 2021. Return to footnote e referrer Table 1 footnote f Fluzone^® High-Dose Quadrivalent (65 years and older) Return to footnote f referrer Table 1 footnote g FluMist^® Quadrivalent (2–59 years) Return to footnote g referrer Table 1 footnote h Evidence suggests 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 inactivated vaccine for all ages. For more information, refer to Statement on Seasonal Influenza Vaccine for 2011–2012. Return to footnote h referrer Table 1 footnote i Children 6 months to less than 9 years of age receiving seasonal influenza vaccine for the first time in their life should be given 2 doses of influenza vaccine, with a minimum interval of 4 weeks between doses. Children 6 months to less than 9 years of age who have been properly vaccinated with one or more doses of seasonal influenza vaccine in the past should receive 1 dose of influenza vaccine per season thereafter. Return to footnote i referrer

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Date modified:: 2022-10-31

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