2018-19 Summary of Recommendations

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2019-20

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For additional information: MMWR Recomm Rep 2018;67(No. RR-3) Influenza ACIP Vaccine Recommendations

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2018-19 Summary of Flu Vaccine Recommendations [1.09 KB, 4 Pages]

Groups Recommended for Vaccination

  • Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications.
  • A licensed, age-appropriate influenza vaccine (IIV, RIV4, or LAIV4) should be used. Consult package information for age indications.
  • Emphasis should be placed on vaccination of high-risk groups and their contacts/caregivers. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to (no hierarchy implied by order listed):
    • Children aged 6–59 months;
    • Adults aged ≥50 years;
    • Persons with chronic pulmonary (including asthma), cardiovascular (excluding isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);
    • Persons who are immunocompromised due to any cause, (including medications or HIV infection);
    • Women who are or will be pregnant during the influenza season;
    • Children and adolescents (aged 6 months through 18 years) receiving aspirin- or salicylate-containing medications and who might be at risk for Reye syndrome;
    • Residents of nursing homes and other long-term care facilities;
    • American Indians/Alaska Natives;
    • Persons who are extremely obese (BMI ≥40); and
    • Caregivers and contacts of those at risk:
      • Health care personnel in inpatient and outpatient care settings, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients;
      • Household contacts and caregivers of children aged ≤59 months (i.e., <5 years), particularly contacts of children aged <6 months, and adults aged ≥50 years; and
      • Household contacts and caregivers of persons with medical conditions that put them at high risk of severe complications from influenza.
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  • 2018-19 influenza vaccines will contain hemagglutinin (HA) derived from influenza viruses antigenically similar to those recommended by FDA.
  • Trivalent vaccines will contain
    • an A/Michigan/45/2015 (H1N1)pdm09–like virus,
    • an A/Singapore/INFIMH-16-0019/2016 (H3N2)–like virus; and
    • a B/Colorado/06/2017–like virus (Victoria lineage).
  • Quadrivalent vaccines will contain the same three HA antigens as trivalent vaccines, plus a B/Phuket/3073/2013–like virus (Yamagata lineage).
  • Vaccination should be offered by end of October; however, vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available.
  • Children aged 6 months through 8 years who require 2 doses should receive their first dose as soon as possible after vaccine becomes available, and the second dose ≥4 weeks later.

Volume per Dose for Children and Adults

  • Children aged 6 through 35 months may receive:
    • 0.5mL Fluarix Quadrivalent (IIV4) intramuscularly, or
    • 0.5mL FluLaval Quadrivalent (IIV4) intramuscularly, or
    • 0.25mL Fluzone Quadrivalent (IIV4) intramuscularly.
    • Note that dose volume differs for these different brands. Care should be taken to administer the correct dose.
  • Children aged 3 through 17 years may receive 0.5mL of an age- appropriate intramuscular IIV formulation.
  • Adults aged 18 years and older may receive 0.5mL intramuscularly of an age-appropriate IIV or RIV4.
  • If a smaller intramuscular dose (e.g., 0.25mL) is administered to a person ≥36 months of age:
    • If the error is discovered immediately, an additional 0.25mL dose should be administered to provide a full 0.5mL dose.
    • If the error is discovered later (after the recipient has left the vaccination setting), a full 0.5mL dose should be administered as soon as the recipient can return.
  • Healthy non-pregnant persons (see LAIV4 Contraindications and Precautions) aged 2 through 49 years may alternatively receive 0.2mL of LAIV4 intranasally (0.1mL per nostril using supplied sprayer).

Number of Doses for Children Aged 6 Months through 8 Years

  • Determine the number of doses needed for this age group as follows:
    • Has the child received ≥2 doses of trivalent or quadrivalent influenza vaccine before July 1, 2018? (Doses need not have been given during same or consecutive seasons)
      • If Yes: 1 dose of 2018-19 influenza vaccine
      • If No/Don’t Know: 2 doses of 2018-19 influenza vaccine (administered ≥4 weeks apart)

Pregnant Women

  • All women who are pregnant or who might be pregnant during the influenza season should receive influenza vaccine.
    • An age-appropriate IIV or RIV4 may be used.
    • LAIV4 should not be used during pregnancy.
  • Influenza vaccine can be administered at any time during pregnancy.

Adults Aged ≥65 years

  • Persons aged ≥65 years may receive any age-appropriate IIV (standard- or high-dose, trivalent or quadrivalent, adjuvanted or unadjuvanted) or RIV4.
  • High-dose IIV3 exhibited superior efficacy over comparator standard-dose IIV3 in a large randomized trial, and may provide better protection than standard dose IIV3 for this age group.
  • However, vaccination should not be delayed to find a particular product if an appropriate one is available.

Immunocompromised Persons

  • Immunocompromised persons should receive an age-appropriate IIV or RIV4.
  • LAIV4 should not be used for immunocompromised persons.
  • Immune response to vaccines might be blunted in immunocompromised persons.
  • Timing of vaccination might be a consideration (e.g., in some period before or after an immunocompromising intervention).

Caregivers and Contacts of  High-Risk Persons

  • Caregivers and contacts (including those of immunosuppressed persons) may receive any age-appropriate IIV or RIV4.
  • LAIV4 may be given to caregivers and contacts of persons who are not severely immunocompromised (i.e., who do not require a protected environment).
  • Health care personnel or hospital visitors who receive LAIV4 should avoid providing care for severely immunosuppressed persons (those requiring a protected environment) for 7 days after vaccination.

Persons with Egg Allergy

  • Persons who are able to eat lightly cooked egg (e.g., scrambled egg) without reaction are unlikely to be egg-allergic.
  • Persons who have experienced only hives after exposure to egg should receive any licensed, recommended, age-appropriate influenza vaccine (i.e., IIV, RIV4, or LAIV4).
  • Persons reporting symptoms other than hives after exposure to egg (such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention) may also receive any licensed and recommended influenza vaccine that is otherwise appropriate.
    • Additionally, for these persons, vaccine should be administered in an inpatient or outpatient medical setting and supervised by a health care provider who is able to recognize and manage severe allergic reactions.
  • A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of causing the reaction, is a contraindication to future receipt of the vaccine.

Vaccination Issues for Travelers

  • Travelers who wish to reduce the risk for influenza infection should consider influenza vaccination, preferably ≥2 weeks before departure.
  • Persons at high risk for complications of influenza who were not vaccinated during the preceding fall or winter should consider receiving influenza vaccine before departure, if they plan to travel to the tropics, with organized tourist groups or on cruise ships, or to the Southern Hemisphere during April–September.
  • Influenza vaccine formulated for the Southern Hemisphere might differ in viral composition from Northern Hemisphere vaccine.
  • Vaccination with Southern Hemisphere influenza vaccine prior to travel to the Southern Hemisphere may be reasonable; however, only one Southern Hemisphere formulation is licensed by FDA (Fluzone Quadrivalent, Sanofi Pasteur), and it is generally not commercially available in the U.S.

Vaccination and Influenza Antiviral Medications

  • IIV and RIV4 may be administered to persons receiving influenza antiviral medications for treatment orchemoprophylaxis.
  • Influenza antivirals may reduce the effectiveness of LAIV4, if administered from 48 hours before until 2 weeks after vaccination.

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  • IIIVs and RIV4 may be administered concurrently or sequentially with other inactivated or live vaccines.
  • Vaccines administered simultaneously should be given at separate anatomic sites.
  • LAIV4 may be administered simultaneously with other live vaccines, however if not given simultaneously ≥4 weeks should pass between administration of LAIV4 and another live vaccine.
  • Immunogenicity and safety of simultaneous or sequential administration of two vaccines containing novel (non-aluminum) adjuvants has not yet been evaluated.
  • In all cases, manufacturer packaging information should be consulted for authoritative guidance regarding storage and handling of influenza vaccines.
  • For guidance on specific situations not addressed in packaging materials, contact the manufacturer directly.
  • In general:
    • Vaccines should be protected from light and stored at recommended temperatures.
    • Influenza vaccines are recommended to be stored refrigerated between 2° to 8°C (36° to 46°F).
    • Vaccine that has been frozen should be discarded.
    • Single-dose vials should not be accessed for more than one dose.
    • Multiple-dose vials should be returned to recommended storage conditions between uses, and once initially accessed should not be kept beyond the recommended period of time.
    • Vaccines should not be used after the expiration date on the label.

CDC Influenza Information

American Academy of Pediatrics (AAP) Guidance

Infectious Diseases Society of America (ISDA) Guidance

Manufacturer package inserts

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Inactivated Influenza Vaccines (IIVs) and Recombinant Influenza Vaccine (RIV4)
Trade Name [Manufacturer] Presentation Age Indication HA, µG/dose (each virus) Egg-grown virus, Cell culture-grown virus, or Recombinant HA Adjuvanted Yes/No Latex Yes/No Thimerosal Yes/No
If yes, Mercury,
μg/0.5mL
Quadrivalent IIVs (IIV4s)
Afluria Quadrivalent* Seqirus 0.25 mL prefilled syringe* 6 through 35 mos* 7.5/0.25 mL Egg No No No
0.5 mL prefilled syringe* ≥3 yrs* 15/0.5 mL Egg No No No
5.0 mL multi-dose vial* ≥6 mos*(needle/syringe)

18 through 64 yrs (jet injector)

See note for dosing*

Egg No No Yes (24.5)
Fluarix Quadrivalent GlaxoSmithKline 0.5 mL prefilled syringe ≥6 mos 15/0.5mL Egg No No No
FluLaval Quadrivalent GlaxoSmithKline 0.5 mL prefilled syringe ≥6 mos 15/0.5mL Egg No No No
5.0 mL multi-dose vial ≥6 mos  15/0.5mL Egg No No Yes (<25)
Flucelvax Quadrivalent Seqirus (ccIIV4) 0.5 mL prefilled syringe ≥4 yrs 15/0.5mL Cell No No No
5.0 mL multi-dose vial ≥4 yrs 15/0.5mL Cell No No Yes (25)
Fluzone Quadrivalent† Sanofi Pasteur 0.25 mL prefilled syringe† 6 through 35 mos† 7.5/0.25 mL Egg No No No
0.5 mL prefilled syringe† ≥6 mos† 15/0.5 mL  Egg No No No
0.5 mL single-dose vial† ≥6 mos† See note
for dosing†		  Egg  No No No
5.0 mL multi-dose vial† ≥6 mos† See note
for dosing†		  Egg  No No Yes (25)
Trivalent IIV (IIV3s)
Fluad
Seqirus (aIIV3)		 0.5 mL prefilled syringe ≥65 yrs 15/0.5mL Egg Yes No No
Fluzone High-Dose Sanofi Pasteur (HD-IIV3) 0.5 mL prefilled syringe ≥65 yrs 60/0.5mL Egg No No No
Quadrivalent RIV (RIV4)
Flublok Quadrivalent Sanofi Pasteur 0.5 mL prefilled syringe ≥18 yrs 45/0.5mL Recombinant No No No

Abbreviations: IIV=inactivated influenza vaccine; RIV=recombinant influenza vaccine; HA=hemagglutinin; mos=months; yrs=years.

* for Afluria Quadrivalent, children aged 6 through 35 months should receive 0.25mL per dose. Persons ≥36 months (≥3 years) should receive 0.5mL per dose.

† for Fluzone Quadrivalent, children aged 6 through 35 months may receive either 0.25mL or 0.5mL per dose. Persons ≥36 months (≥3 years) should receive 0.5mL per dose

Administration of IIV4 and RIV4

  • IIV4s and RIV4 are administered intramuscularly (IM). For adults and older children, the deltoid is the preferred site. For infants and younger children, the anterolateral thigh is the preferred site. Detailed guidance for administration sites and needle length is available in the General Best Practice Guidelines on Immunization.
  • RIV4 is licensed for persons aged ≥18 years and should not be used for children and adolescents aged <18 years.
  • HD-IIV4 and aIIV4 are licensed for persons aged ≥65 years and should not be used for persons aged <65 years.

Table 2: Live Attenuated Influenza Vaccine (LAIV4)

Table 2: Live Attenuated Influenza Vaccine (LAIV4)
Trade Name 

Manufacturer

Available presentations Approved age indication Volume per dose
Quadrivalent LAIV (LAIV4) – Egg-based (contains 106.5-7.5 fluorescent focus units/0.2 mL)
FluMist Quadrivalent

AstraZeneca

0.2 mL prefilled single-use
intranasal sprayer		 2 through 49 yrs 0.1 mL each nostril (0.2 mLtotal)

Table 3: Influenza Vaccine Contraindications and Precautions

Table 3: Influenza Vaccine Contraindications and Precautions
Egg-based IIV4s Contraindications: 
  • History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine (other than egg), or to a previous dose of any influenza vaccine (any egg-based IIV, ccIIV, RIV, or LAIV of any valency).

Precautions:

  • Moderate or severe acute illness with or without fever.
  • History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine.
ccIIV4 Contraindications:
  • History of severe allergic reaction (e.g., anaphylaxis) to ccIIV of any valency, or to any component of ccIIV4.

Precautions:

  • Moderate or severe acute illness with or without fever.
  • History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine.
  • History of severe allergic reaction to a previous dose of any other influenza vaccine (any egg-based IIV, RIV, or LAIV of any valency).
RIV4 Contraindications:
  • History of severe allergic reaction (e.g., anaphylaxis) to RIV of any valency, or to any component of RIV4

Precautions:

  • Moderate or severe acute illness with or without fever
  • History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
  • History of severe allergic reaction to a previous dose of any other influenza vaccine (any egg-based IIV, ccIIV, or LAIV of any valency).
LAIV4 Contraindications:
  • History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine (other than egg) or to a previous dose of any influenza vaccine (i.e, any egg-based IIV, ccIIV, RIV, or LAIV of any valency).
  • Concomitant aspirin or salicylate-containing therapy in children and adolescents
  • Children aged 2 through 4 years who have received a diagnosis of asthma or whose parents or caregivers report that a health care provider 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 but not limited to medications, congenital or acquired immunodeficiency states, HIV infection, anatomic asplenia, or functional asplenia (e.g., due to sickle-cell anemia)
  • Close contacts and caregivers of severely immunosuppressed persons who require a protected environment
  • Pregnancy
  • Persons with active communication between the CSF and the oropharynx, nasopharynx, nose, or ear or any other cranial CSF leak
  • Persons with cochlear implants (due to potential for CSF leak, which might exist for some period of time after implantation.  Providers might consider consultation with a specialist concerning risk of persistent CSF leak if an age-appropriate inactivated or recombinant vaccine cannot be used).
  • Receipt of influenza antiviral medication within the previous 48 hours for oseltamivir and zanamivir, 5 days for peramivir, and 17 days for baloxavir (see Vaccination and influenza antiviral medications for additional guidance).

Precautions:

  • Moderate or severe acute illness with or without fever
  • History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
  • Asthma in persons aged ≥5 years
  • Other underlying medical conditions that might predispose to complications from influenza (e.g., chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus])
Vaccine Abbreviations
  • Main influenza vaccine types:
    • IIV= Inactivated Influenza Vaccine
    • RIV= Recombinant Influenza Vaccine
    • LAIV= Live Attenuated Influenza Vaccine
  • Numerals after letters indicate valency (the number of influenza viruses represented):
    • 4 for quadrivalent vaccines
    • 3 for trivalent vaccines
  • Prefixes are sometimes used to refer to specific IIVs:
    • a for adjuvanted IIV (e.g., aIIV4)
    • cc for cell culture-based IIV (e.g., ccIIV4)
    • HD for high-dose IIV (e.g., HD-IIV4)
    • SD for standard-dose IIV (e.g., SD-IIV4)
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