Flu Alert for Healthcare Providers

ACIP Recommendations for Influenza Vaccine for the 2018-19 Season

Posted Sept. 12, 2018. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Routine annual influenza vaccination of all persons 6 months of age and older without contraindications continues to be recommended; however, some changes to the recommendations from the Advisory Committee on Immunization Practices (ACIP) have occurred for the 2018-19 influenza season. Influenza vaccine is now readily available in the Spokane community.

Vaccine viruses included in the 2018-19 U.S. trivalent influenza vaccines will be 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 influenza vaccines will contain these three viruses and an additional influenza B vaccine virus, a B/Phuket/3073/2013-like virus (Yamagata lineage).

The use of LAIV4 (Live Attenuated Influenza Vaccine; FluMist®, or the “nasal spray”) is approved by ACIP as an option for those for whom it is appropriate.

Following two seasons (2016-17 and 2017-18) during which ACIP recommended that LAIV4 not be used, vaccination providers now may choose to administer any licensed, age-appropriate influenza vaccine (IIV [Inactivated Influenza Vaccine], RIV4 [Recombinant Influenza Vaccine], or LAIV4). The Centers for Disease Control and Prevention (CDC) and ACIP make no preferential recommendation between LAIV4 and the other injectable influenza vaccines available. However, the American Academy of Pediatrics (AAP) released its own recommendations for prevention and control of influenza in children, advising that LAIV4 be used in children who would not otherwise receive an influenza vaccine (e.g., refusal of injection) and for whom it’s appropriate due to age (2 years of age and older) and health status (healthy and no underlying health conditions).*

LAIV4 is contraindicated in

  • persons with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine;
  • children and adolescents receiving concomitant aspirin or salicylate-containing medications;
  • children aged 2 through 4 years who have received a diagnosis of asthma or whose parents or caregivers report that a healthcare 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;
  • persons who are immunocompromised due to any cause;
  • close contacts and caregivers of severely immunosuppressed persons who require a protected environment;
  • pregnant women; and
  • persons who have received influenza antiviral medications within the previous 48 hours.

Recent regulatory changes have occurred in two different influenza vaccine products.

  • Afluria Quadrivalent (IIV4), previously licensed for aged ≥18 years, is now licensed for aged ≥5 years.
  • Fluarix Quadrivalent (IIV4), previously licensed for persons aged ≥3 years, is now licensed for persons aged ≥6 months. Children aged 6 through 35 months may receive Fluarix Quadrivalent at the same 0.5 mL per dose (containing 15 µg of hemagglutinin [HA] per vaccine virus) as is used for older children and adults. This licensure creates a third option for inactivated influenza vaccines for children aged 6 through 35 months, in addition to the previously available 0.5 mL per dose (containing 15 µg of HA per vaccine virus) presentation of FluLaval Quadrivalent (IIV4) and 0.25 mL per dose presentation (containing 7.5 µg of HA per vaccine virus) of Fluzone Quadrivalent (IIV4).

The ACIP and CDC offer guidance on the timing of influenza vaccine.

Vaccination should be offered by the 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 two doses should receive their first dose as soon as possible after vaccine becomes available, and the second dose ≥4 weeks later.

Recommendations for influenza vaccination of persons with egg allergy remain the same as the previous two influenza seasons (all children with egg allergy can receive an influenza vaccine).

Most influenza vaccines are manufactured using egg-based technology. Because of this, they contain a small amount of egg proteins. However, studies that have examined the use of flu vaccine in egg-allergic and non-egg-allergic patients indicate that severe allergic reactions in people with egg allergies are unlikely (1.31 per one million vaccine doses given).

  • Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Any licensed, recommended and age-appropriate influenza vaccine (IIV, RIV4, LAIV4) that is otherwise appropriate for the recipient’s age and health status may be used.
  • Persons who report having had reactions to egg involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may similarly receive any licensed, recommended and age-appropriate influenza vaccine that is otherwise appropriate for the recipient’s health status. The selected vaccine should be administered in an inpatient or outpatient medical setting. Vaccine administration should be supervised by a healthcare provider who is able to recognize and manage severe allergic conditions.
  • A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine.
  • For more information, go to: http://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm.

Complete recommendations and information from the ACIP for the 2018-19 season can be found here, including groups recommended for vaccination, guidance for use in specific situations, administration/storage/handling, adverse event reporting, and a complete list of products available for this season:


*The full list of recommendations from the AAP for the 2018-19 season can be found here: http://pediatrics.aappublications.org/content/early/2018/08/30/peds.2018-2367.

Upcoming Educational Opportunities

Virtual Immunization Communication Network: 2018-19 Seasonal Flu Recommendations and Communications Messaging
Date: Monday, September 17, 2018 at 10 - 11 a.m.

CDC Clinician Outreach and Communication Activity (COCA) Call:
2018-2019 Recommendations for Influenza Prevention and Treatment in Children: An Update for Pediatric Providers  
Date: Thursday, September 27, 2018 at 11 am – 12 pm
Influenza remains a serious threat to children due to its potential to cause serious morbidity and mortality. More than 175 flu-associated deaths in children were reported to the CDC during the 2017–2018 influenza season. Clinicians play a critical role in taking action to immunize children, the children’s family members and caregivers, and themselves. The early use of antiviral drugs in children can reduce the duration of symptoms and prevent serious complications of influenza. However, immunization remains the most effective way to prevent influenza illness and its complications, including death.

During this COCA call, subject matter experts from the AAP and CDC will discuss strategies primary care providers and medical subspecialists can use to improve flu prevention and control in children for the 2018-2019 season. The presenters will share AAP and CDC recommendations about influenza vaccination and antiviral treatment, including updated recommendations for the use of intranasal live attenuated influenza vaccine (LAIV4) in children.