Table 1.

Trade name (manufacturer)	Presentations	Age indication	μg HA (IIV4s and RIV4) or virus count (LAIV4) for each vaccine virus (per dose)	Route	Mercury (from thimerosal, if present), μg/0.5 mL
IIV4 (standard-dose, egg-based vaccines^†)
Afluria Quadrivalent (Seqirus)	0.5-mL PFS^§	≥3 yrs^§	15 μg/0.5 mL	IM^¶	—**
	5.0-mL MDV^§	≥6 mos^§ (needle and syringe) 18 through 64 yrs (jet injector)	7.5 μg/0.25 mL 15 μg/0.5 mL	IM^¶	24.5
Fluarix Quadrivalent (GlaxoSmithKline)	0.5-mL PFS	≥6 mos	15 μg/0.5 mL	IM^¶	—
FluLaval Quadrivalent (GlaxoSmithKline)	0.5-mL PFS	≥6 mos	15 μg/0.5 mL	IM^¶	—
Fluzone Quadrivalent (Sanofi Pasteur)	0.5-mL PFS^††	≥6 mos^††	15 μg/0.5 mL	IM^¶	—
	0.5-mL SDV^††	≥6 mos^††	15 μg/0.5 mL	IM^¶	—
	5.0-mL MDV^††	≥6 mos^††	7.5 μg/0.25 mL 15 μg/0.5 mL	IM^¶	25
ccIIV4 (standard-dose, cell culture–based vaccine)
Flucelvax Quadrivalent (Seqirus)	0.5-mL PFS	≥6 mos	15 μg/0.5 mL	IM^¶	—
5.0-mL MDV	≥6 mos	15 μg/0.5 mL	IM^¶	25
HD-IIV4 (high-dose, egg-based vaccine^†)
Fluzone High-Dose Quadrivalent (Sanofi Pasteur)	0.7-mL PFS	≥65 yrs	60 μg/0.7 mL	IM^¶	—
aIIV4 (standard-dose, egg-based vaccine^† with MF59 adjuvant)
Fluad Quadrivalent (Seqirus)	0.5-mL PFS	≥65 yrs	15 μg/0.5 mL	IM^¶	—
RIV4 (recombinant HA vaccine)
Flublok Quadrivalent (Sanofi Pasteur)	0.5-mL PFS	≥18 yrs	45 μg/0.5 mL	IM^¶	—
LAIV4 (egg-based vaccine^†)
FluMist Quadrivalent (AstraZeneca)	0.2-mL prefilled single-use intranasal sprayer	2 through 49 yrs	10^6.5–7.5 fluorescent focus units/0.2 mL	NAS	—

Influenza vaccines — United States, 2022–23 influenza season*

Abbreviations: ACIP = Advisory Committee on Immunization Practices; FDA = Food and Drug Administration; HA = hemagglutinin; IIV4 = inactivated influenza vaccine, quadrivalent; IM = intramuscular; LAIV4 = live attenuated influenza vaccine, quadrivalent; MDV = multidose vial; NAS = intranasal; PFS = prefilled syringe; RIV4 = recombinant influenza vaccine, quadrivalent; SDV = single-dose vial.
*Vaccination providers should consult FDA-approved prescribing information for 2022–23 influenza vaccines for the most complete and updated information, including but not limited to indications, contraindications, warnings, and precautions. Package inserts for U.S.-licensed vaccines are available at https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states. Availability and characteristics of specific products and presentations might change or differ from what is described in this table and in the text of this report.
^†Although a history of severe allergic reaction (e.g., anaphylaxis) to egg is a labeled contraindication to the use of egg-based IIV4s and LAIV4, ACIP recommends that persons with a history of egg allergy may receive any licensed, recommended influenza vaccine that is otherwise appropriate for their age and health status. Those who report having had reactions to egg involving symptoms other than urticaria (e.g., angioedema or swelling, respiratory distress, lightheadedness, or recurrent emesis) or who required epinephrine or another emergency medical intervention should be vaccinated in an inpatient or outpatient medical setting (including but not necessarily limited to hospitals, clinics, health departments, and physician offices) supervised by a health care provider who is able to recognize and manage severe allergic reactions, if a vaccine other than ccIIV4 or RIV4 is used.
^§The approved dose volume for Afluria Quadrivalent is 0.25 mL for children aged 6 through 35 months and 0.5 mL for persons aged ≥3 years. However, 0.25-mL prefilled syringes are not expected to be available for the 2022–23 season. For children aged 6 through 35 months, a 0.25-mL dose must be obtained from a multidose vial.
^¶IM-administered influenza vaccines should be given by needle and syringe only, with the exception of the MDV presentation of Afluria Quadrivalent, which may alternatively be given by the PharmaJet Stratis jet injector for persons aged 18 through 64 years only. For adults and older children, the recommended site for intramuscular influenza vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh. Additional specific guidance regarding site selection and needle length for intramuscular administration is available in the ACIP General Best Practice Guidelines for Immunization, available at https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html.
**Not applicable.
^††Fluzone Quadrivalent is currently approved for ages 6 through 35 months at either 0.25 mL or 0.5 mL per dose; however, 0.25-mL prefilled syringes are not expected to be available for the 2022–23 influenza season. If a prefilled syringe of Fluzone Quadrivalent is used for a child in this age group, the dose volume will be 0.5 mL per dose.

Table 2.

Vaccine type	Contraindications	Precautions
Egg-based IIV4s	• History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine^† or to a previous dose of any influenza vaccine (i.e., any egg-based IIV, ccIIV, RIV, or LAIV)^§	• Moderate or severe acute illness with or without fever • History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
ccIIV4	• History of severe allergic reaction (e.g., anaphylaxis) to a previous dose of any ccIIV or any component of ccIIV4^§	• 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 (i.e., any egg-based IIV, RIV, or LAIV)^¶
RIV4	• History of severe allergic reaction (e.g., anaphylaxis) to a previous dose of any RIV or any component of RIV4^§	• 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 (i.e., any egg-based IIV, ccIIV, or LAIV)^¶
LAIV4	• History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine^† or to a previous dose of any influenza vaccine (i.e., any egg-based IIV, ccIIV, RIV, or LAIV)^§ • 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 immunosuppression caused by 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** • Receipt of influenza antiviral medication within the previous 48 hours for oseltamivir and zanamivir, previous 5 days for peramivir, and previous 17 days for baloxavir^††	• 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 after wild-type influenza infection (e.g., chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus])

Contraindications and precautions for the use of influenza vaccines — United States, 2022–23 influenza season*

Abbreviations: ACIP = Advisory Committee on Immunization Practices; ccIIV = cell culture–based inactivated influenza vaccine (any valency); ccIIV4 = cell culture–based inactivated influenza vaccine, quadrivalent; CSF = cerebrospinal fluid; FDA = Food and Drug Administration; IIV = inactivated influenza vaccine (any valency); IIV4 = inactivated influenza vaccine, quadrivalent; LAIV = live attenuated influenza vaccine (any valency); LAIV4 = live attenuated influenza vaccine, quadrivalent; RIV = recombinant influenza vaccine (any valency); RIV4 = recombinant influenza vaccine, quadrivalent.
*When a contraindication is present, a vaccine should not be administered. When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction (see ACIP General Best Practice Guidelines for Immunization, available at https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html). Vaccination providers should check FDA-approved prescribing information for 2022–23 influenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications, warnings, and precautions. Package inserts for U.S.-licensed vaccines are available at https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states.
^†Although a history of severe allergic reaction (e.g., anaphylaxis) to egg is a labeled contraindication to the use of egg-based IIV4s and LAIV4, ACIP recommends that persons with a history of egg allergy may receive any licensed, recommended influenza vaccine that is otherwise appropriate for their age and health status. Those who report having had reactions to egg involving symptoms other than urticaria (e.g., angioedema or swelling, respiratory distress, lightheadedness, or recurrent emesis) or who required epinephrine or another emergency medical intervention should be vaccinated in an inpatient or outpatient medical setting, including but not necessarily limited to hospitals, clinics, health departments, and physician offices, if a vaccine other than ccIIV4 or RIV4 is used. Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic reactions.
^§Labeled contraindication noted in package insert.
^¶If administered, vaccination should occur in a medical setting and should be supervised by a health care provider who can recognize and manage severe allergic reactions. Providers can consider consultation with an allergist in such cases, to assist in identification of the component responsible for the allergic reaction.
**Age-appropriate injectable vaccines are recommended for persons with cochlear implant due to the potential for CSF leak, which might exist for a period after implantation. Providers might consider consultation with a specialist concerning risk for persistent CSF leak if an age-appropriate inactivated or recombinant vaccine cannot be used.
^††Use of LAIV4 in context of influenza antivirals has not been studied; however, interference with activity of LAIV4 is biologically plausible, and this possibility is noted in the package insert for LAIV4. In the absence of data supporting an adequate minimum interval between influenza antiviral use and LAIV4 administration, the intervals provided are based on the half-life of each antiviral. The interval between influenza antiviral receipt and LAIV4 for which interference might potentially occur might be further prolonged in the presence of medical conditions that delay medication clearance (e.g., renal insufficiency). Influenza antivirals might also interfere with LAIV4 if initiated within 2 weeks after vaccination. Persons who receive antivirals during the period starting with the specified time before receipt of LAIV4 through 2 weeks after receipt of LAIV4 should be revaccinated with an age-appropriate IIV or RIV4.

Table 3.

Vaccine (of any valency) associated with previous severe allergic reaction (e.g., anaphylaxis)	Available 2022–23 influenza vaccines
	Egg-based IIV4s and LAIV4	ccIIV4	RIV4
Any egg-based IIV or LAIV	Contraindication^†	Precaution^§	Precaution^§
Any ccIIV	Contraindication^†	Contraindication^†	Precaution^§
Any RIV	Contraindication^†	Precaution^§	Contraindication^†
Unknown influenza vaccine	Allergist consultation recommended

Influenza vaccine contraindications and precautions for persons with a history of severe allergic reaction to a previous dose of an influenza vaccine* — United States, 2022–23 influenza season

Abbreviations: ACIP = Advisory Committee on Immunization Practices; ccIIV = cell culture–based inactivated influenza vaccine (any valency); ccIIV4 = cell culture–based inactivated influenza vaccine, quadrivalent; FDA = Food and Drug Administration; IIV = inactivated influenza vaccine (any valency); IIV4 = inactivated influenza vaccine, quadrivalent; LAIV = live attenuated influenza vaccine (any valency); LAIV4 = live attenuated influenza vaccine, quadrivalent; RIV = recombinant influenza vaccine (any valency); RIV4 = recombinant influenza vaccine, quadrivalent.
*Vaccination providers should check FDA-approved prescribing information for 2022–23 influenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications, warnings, and precautions. Package inserts for U.S.-licensed vaccines are available at https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states.
^†When a contraindication is present, a vaccine should not be administered, consistent with ACIP General Best Practice Guidelines for Immunization (Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices [ACIP]. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html). In addition to the contraindications based on history of severe allergic reaction to influenza vaccines that are noted in the table, each individual influenza vaccine is contraindicated for persons who have had a severe allergic reaction (e.g., anaphylaxis) to any component of that vaccine. Vaccine components can be found in package inserts. Although a history of severe allergic reaction (e.g., anaphylaxis) to egg is a labeled contraindication to the use of egg-based IIV4s and LAIV4, ACIP recommends that persons with a history of egg allergy may receive any licensed, recommended influenza vaccine that is otherwise appropriate for their age and health status. Those who report having had reactions to egg involving symptoms other than urticaria (e.g., angioedema or swelling, respiratory distress, lightheadedness, or recurrent emesis) or who required epinephrine or another emergency medical intervention should be vaccinated in an inpatient or outpatient medical setting (including but not necessarily limited to hospitals, clinics, health departments, and physician offices), if a vaccine other than ccIIV4 or RIV4 is used. Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic reactions.
^§When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction, consistent with ACIP General Best Practice Guidelines for Immunization (Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices [ACIP]. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html). Providers can consider using the following vaccines in these instances; however, vaccination should occur in an inpatient or outpatient medical setting with supervision by a health care provider who is able to recognize and manage severe allergic reactions: 1) for persons with a history of severe allergic reaction (e.g., anaphylaxis) to any egg-based IIV or LAIV of any valency, the provider can consider administering ccIIV4 or RIV4; 2) for persons with a history of severe allergic reaction (e.g., anaphylaxis) to any ccIIV of any valency, the provider can consider administering RIV4; and 3) for persons with a history of severe allergic reaction (e.g., anaphylaxis) to any RIV of any valency, the provider can consider administering ccIIV4. Providers can also consider consulting with an allergist to help determine which vaccine component is responsible for the allergic reaction.

Table 4.

Trade name (Manufacturer)	Dose volume for children aged 6 through 35 mos (μg HA per vaccine virus)
Afluria Quadrivalent (Seqirus)	0.25 mL (7.5 μg)^†
Fluarix Quadrivalent (GlaxoSmithKline)	0.5 mL (15 μg)
Flucelvax Quadrivalent (Seqirus)	0.5 mL (15 μg)
FluLaval Quadrivalent (GlaxoSmithKline)	0.5 mL (15 μg)
Fluzone Quadrivalent (Sanofi Pasteur)	0.5 mL (15 μg)^§

Dose volumes for inactivated influenza vaccines approved for children aged 6 through 35 months* — United States, 2022–23 influenza season

Abbreviation: HA = hemagglutinin.
*For persons aged ≥36 months (≥3 years), the dose volume is 0.5 mL per dose for all inactivated influenza vaccines with the exception of Fluzone High-Dose Quadrivalent (HD-IIV4), which is licensed for persons aged ≥65 years and for which the dose volume is 0.7 mL per dose.
^†The approved dose volume for Afluria Quadrivalent is 0.25 mL for children aged 6 through 35 months and 0.5 mL for persons aged ≥3 years. However, 0.25-mL prefilled syringes are not expected to be available for the 2022–23 season. For children aged 6 through 35 months, a 0.25-mL dose must be obtained from a multidose vial.
^§Per the package insert, Fluzone Quadrivalent is currently approved for children aged 6 through 35 months at either 0.25 mL or 0.5 mL per dose; however, 0.25-mL prefilled syringes are no longer available. If a prefilled syringe of Fluzone Quadrivalent is used for a child in this age group, the dose volume will be 0.5 mL per dose. The 0.5-mL single-dose vials should be accessed for only 1 dose and multidose vials for only 10 doses, regardless of the volume of the doses obtained or any remaining volume in the vial. Any vaccine remaining in a vial after the maximum number of doses has been removed should be discarded.

Box.

• Main influenza vaccine types: • IIV = inactivated influenza vaccine • RIV = recombinant influenza vaccine • LAIV = live attenuated influenza vaccine • Numerals following letter abbreviations indicate valency (the number of influenza virus hemagglutinin [HA] antigens represented in the vaccine): • 4 for quadrivalent vaccines: one A(H1N1), one A(H3N2), and two B viruses (one from each lineage) • 3 for trivalent vaccines: one A(H1N1), one A(H3N2), and one B virus (from one lineage) • All influenza vaccines expected to be available in the United States for the 2022–23 season are quadrivalent vaccines. However, abbreviations for trivalent vaccines (e.g., IIV3) might be used in this report when discussing information specific to trivalent vaccines. • Abbreviations for general vaccine categories (e.g., IIV) might be used when discussing information that is not specific to either trivalent or quadrivalent vaccines. • Prefixes are used when necessary to refer to certain specific IIVs: • a for MF59-adjuvanted inactivated influenza vaccine (e.g., aIIV3 and aIIV4) • cc for cell culture–based inactivated influenza vaccine (e.g., ccIIV3 and ccIIV4) • HD for high-dose inactivated influenza vaccine (e.g., HD-IIV3 and HD-IIV4) • SD for standard-dose inactivated influenza vaccine (e.g. SD-IIV3 and SD-IIV4)

• Main influenza vaccine types:
   • IIV = inactivated influenza vaccine
   • RIV = recombinant influenza vaccine
   • LAIV = live attenuated influenza vaccine
• Numerals following letter abbreviations indicate valency (the number of influenza virus hemagglutinin [HA] antigens represented in the vaccine):
   • 4 for quadrivalent vaccines: one A(H1N1), one A(H3N2), and two B viruses (one from each lineage)
   • 3 for trivalent vaccines: one A(H1N1), one A(H3N2), and one B virus (from one lineage)
• All influenza vaccines expected to be available in the United States for the 2022–23 season are quadrivalent vaccines. However, abbreviations for trivalent vaccines (e.g., IIV3) might be used in this report when discussing information specific to trivalent vaccines.
• Abbreviations for general vaccine categories (e.g., IIV) might be used when discussing information that is not specific to either trivalent or quadrivalent vaccines.
• Prefixes are used when necessary to refer to certain specific IIVs:
   • a for MF59-adjuvanted inactivated influenza vaccine (e.g., aIIV3 and aIIV4)
   • cc for cell culture–based inactivated influenza vaccine (e.g., ccIIV3 and ccIIV4)
   • HD for high-dose inactivated influenza vaccine (e.g., HD-IIV3 and HD-IIV4)
   • SD for standard-dose inactivated influenza vaccine (e.g. SD-IIV3 and SD-IIV4)

Abbreviation conventions for influenza vaccines discussed in this report

Barker WH. Excess pneumonia and influenza associated hospitalization during influenza epidemics in the United States, 1970–78. Am J Public Health 1986;76:761–5. PMID:3717461 https://doi.org/10.2105/AJPH.76.7.761
Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult population. Am J Epidemiol 1980;112:798–811. PMID:7457471 https://doi.org/10.1093/oxfordjournals.aje.a113052
Coleman BL, Fadel SA, Fitzpatrick T, Thomas SM. Risk factors for serious outcomes associated with influenza illness in high- versus low-and middle-income countries: systematic literature review and meta-analysis. Influenza Other Respir Viruses 2018;12:22–9. PMID:29197154 https://doi.org/10.1111/irv.12504
Mullooly JP, Bridges CB, Thompson WW, et al.; Vaccine Safety Datalink Adult Working Group. Influenza- and RSV-associated hospitalizations among adults. Vaccine 2007;25:846–55. PMID:17074423 https://doi.org/10.1016/j.vaccine.2006.09.041
Poehling KA, Edwards KM, Griffin MR, et al. The burden of influenza in young children, 2004–2009. Pediatrics 2013;131:207–16. PMID:23296444 https://doi.org/10.1542/peds.2012-1255
Poehling KA, Edwards KM, Weinberg GA, et al.; New Vaccine Surveillance Network. The underrecognized burden of influenza in young children. N Engl J Med 2006;355:31–40. PMID:16822994 https://doi.org/10.1056/NEJMoa054869
Siston AM, Rasmussen SA, Honein MA, et al.; Pandemic H1N1 Influenza in Pregnancy Working Group. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA 2010;303:1517–25. PMID:20407061 https://doi.org/10.1001/jama.2010.479
Fragaszy EB, Warren-Gash C, White PJ, et al.; Flu Watch Group. Effects of seasonal and pandemic influenza on health-related quality of life, work and school absence in England: results from the Flu Watch cohort study. Influenza Other Respir Viruses 2018;12:171–82. PMID:28991409 https://doi.org/10.1111/irv.12506
Van Wormer JJ, King JP, Gajewski A, McLean HQ, Belongia EA. Influenza and workplace productivity loss in working adults. J Occup Environ Med 2017;59:1135–9. PMID:28759481 https://doi.org/10.1097/JOM.0000000000001120
Willis GA, Preen DB, Richmond PC, et al.; WAIVE Study Team. The impact of influenza infection on young children, their family and the health care system. Influenza Other Respir Viruses 2019;13:18–27. PMID:30137663 https://doi.org/10.1111/irv.12604
Fiore AE, Uyeki TM, Broder K, et al.; CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep 2010;59(No. RR-8):1–62. PMID:20689501
CDC. How flu vaccine effectiveness and efficacy are measured: questions and answers. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/flu/vaccines-work/effectivenessqa.htm
Rolfes MA, Foppa IM, Garg S, et al. Annual estimates of the burden of seasonal influenza in the United States: a tool for strengthening influenza surveillance and preparedness. Influenza Other Respir Viruses 2018;12:132–7. PMID:29446233 https://doi.org/10.1111/irv.12486
Rolfes MA, Flannery B, Chung JR, et al.; US Influenza Vaccine Effectiveness (Flu VE) Network; Influenza Hospitalization Surveillance Network; Assessment Branch, Immunization Services Division, CDC. Effects of influenza vaccination in the United States during the 2017– 2018 influenza season. Clin Infect Dis 2019;69:1845–53. PMID:30715278 https://doi.org/10.1093/cid/ciz075
CDC. 2020–21 flu season summary FAQ. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm
CDC. Fluview. Weekly influenza surveillance report. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/flu/weekly/index.htm
Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2021–22 influenza season. MMWR Recomm Rep 2021;70(No. RR-5):1–28. PMID:34448800 https://doi.org/10.15585/mmwr.rr7005a1
Ahmed F. ACIP handbook for developing evidence-based recommendations, Version 1.2. Atlanta, GA: US Department of Health and Human Services, CDC; 2013.
Belongia EA, Sundaram ME, McClure DL, Meece JK, Ferdinands J, VanWormer JJ. Waning vaccine protection against influenza A (H3N2) illness in children and older adults during a single season. Vaccine 2015;33:246–51. PMID:24962752 https://doi.org/10.1016/j.vaccine.2014.06.052
Radin JM, Hawksworth AW, Myers CA, Ricketts MN, Hansen EA, Brice GT. Influenza vaccine effectiveness: maintained protection throughout the duration of influenza seasons 2010–2011 through 2013–2014. Vaccine 2016;34:3907–12. PMID:27265447 https://doi.org/10.1016/j.vaccine.2016.05.034
Ray GT, Lewis N, Klein NP, et al. Intraseason waning of influenza vaccine effectiveness. Clin Infect Dis 2019;68:1623–30. PMID:30204855 https://doi.org/10.1093/cid/ciy770
Powell LN, Bégué RE. Influenza vaccine effectiveness among children for the 2017–2018 season. J Pediatric Infect Dis Soc 2020;9:468–73. PMID:31774120 https://doi.org/10.1093/jpids/piz077
Castilla J, Martínez-Baz I, Martínez-Artola V, et al.; Primary Health Care Sentinel Network; Network for Influenza Surveillance in Hospitals of Navarre. Decline in influenza vaccine effectiveness with time after vaccination, Navarre, Spain, season 2011/12. Euro Surveill 2013;18:20388. PMID:23399423 https://doi.org/10.2807/ese.18.05.20388-en
Kissling E, Valenciano M, Larrauri A, et al. Low and decreasing vaccine effectiveness against influenza A(H3) in 2011/12 among vaccination target groups in Europe: results from the I-MOVE multicentre case-control study. Euro Surveill 2013;18:20390. PMID:23399425 https://doi.org/10.2807/ese.18.05.20390-en
Ferdinands JM, Fry AM, Reynolds S, et al. Intraseason waning of influenza vaccine protection: evidence from the US Influenza Vaccine Effectiveness Network, 2011–12 through 2014–15. Clin Infect Dis 2017;64:544–50. PMID:28039340
Puig-Barberà J, Mira-Iglesias A, Tortajada-Girbés M, et al.; Valencia Hospital Network for the Study of Influenza and other Respiratory Viruses (VAHNSI, Spain). Waning protection of influenza vaccination during four influenza seasons, 2011/2012 to 2014/2015. Vaccine 2017;35:5799–807. PMID:28941618 https://doi.org/10.1016/j.vaccine.2017.09.035
Kissling E, Nunes B, Robertson C, et al.; I-MOVE case–control study team. I-MOVE multicentre case-control study 2010/11 to 2014/15: is there within-season waning of influenza type/subtype vaccine effectiveness with increasing time since vaccination? Euro Surveill 2016;21. PMID:27124420 https://doi.org/10.2807/1560-7917.ES.2016.21.16.30201
Pebody R, Andrews N, McMenamin J, et al. Vaccine effectiveness of 2011/12 trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: evidence of waning intra-seasonal protection. Euro Surveill 2013;18:20389. PMID:23399424 https://doi.org/10.2807/ese.18.05.20389-en
Ng Y, Nandar K, Chua LAV, et al. Evaluating the effectiveness of the influenza vaccine during respiratory outbreaks in Singapore's long term care facilities, 2017. Vaccine 2019;37:3925–31. PMID:31160102 https://doi.org/10.1016/j.vaccine.2019.03.054
Young BE, Mak TM, Ang LW, et al. Influenza vaccine failure in the tropics: a retrospective cohort study of waning effectiveness. Epidemiol Infect 2020;148:e299. PMID:33261680 https://doi.org/10.1017/S0950268820002952
Mira-Iglesias A, López-Labrador FX, García-Rubio J, et al. Influenza vaccine effectiveness and waning effect in hospitalized older adults. Valencia Region, Spain, 2018/2019 season. Int J Environ Res Public Health 2021;18:1129. PMID:33514058 https://doi.org/10.3390/ijerph18031129
Ferdinands JM, Gaglani M, Martin ET, et al. Waning vaccine effectiveness against influenza-associated hospitalizations among adults, 2015–2016 to 2018–2019, United States Hospitalized Adult Influenza Vaccine Effectiveness Network. Clin Infect Dis 2021;73:726–9. PMID:33462610 https://doi.org/10.1093/cid/ciab045
Madhi SA, Cutland CL, Kuwanda L, et al.; Maternal Flu Trial (Matflu) Team. Influenza vaccination of pregnant women and protection of their infants. N Engl J Med 2014;371:918–31. PMID:25184864 https://doi.org/10.1056/NEJMoa1401480
Tapia MD, Sow SO, Tamboura B, et al. Maternal immunisation with trivalent inactivated influenza vaccine for prevention of influenza in infants in Mali: a prospective, active-controlled, observer-blind, randomised phase 4 trial. Lancet Infect Dis 2016;16:1026–35. PMID:27261067 https://doi.org/10.1016/S1473-3099(16)30054-8
Steinhoff MC, Katz J, Englund JA, et al. Year-round influenza immunisation during pregnancy in Nepal: a phase 4, randomised, placebo-controlled trial. Lancet Infect Dis 2017;17:981–9. PMID:28522338 https://doi.org/10.1016/S1473-3099(17)30252-9
Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med 2008;359:1555–64. PMID:18799552 https://doi.org/10.1056/NEJMoa0708630
CDC. The flu season. Atlanta, GA: US Department of Health and Human Services, CDC; 2015. https://www.cdc.gov/flu/about/season/flu-season.htm
Young B, Sadarangani S, Jiang L, Wilder-Smith A, Chen MI. Duration of influenza vaccine effectiveness: a systematic review, meta-analysis, and meta-regression of test-negative design case-control studies. J Infect Dis 2018;217:731–41. PMID:29220496 https://doi.org/10.1093/infdis/jix632
Ferdinands JM, Alyanak E, Reed C, Fry AM. Waning of influenza vaccine protection: exploring the trade-offs of changes in vaccination timing among older adults. Clin Infect Dis 2020;70:1550–9. PMID:31257422 https://doi.org/10.1093/cid/ciz452
Advisory Committee on Immunization Practices; CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60(No. RR-7):1–45. PMID:22108587
Pearson ML, Bridges CB, Harper SA; Healthcare Infection Control Practices Advisory Committee (HICPAC); Advisory Committee on Immunization Practices (ACIP). Influenza vaccination of healthcare personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(No. RR-2):1–16. PMID:16498385
Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html
Afluria Quadrivalent [Package Insert]. Parkville, Victoria, Australia: Seqirus; 2022.
Fluzone Quadrivalent [Package Insert]. Swiftwater, PA: Sanofi Pasteur; 2022.
Neuzil KM, Jackson LA, Nelson J, et al. Immunogenicity and reactogenicity of 1 versus 2 doses of trivalent inactivated influenza vaccine in vaccine-naive 5–8-year-old children. J Infect Dis 2006;194:1032–9. PMID:16991077 https://doi.org/10.1086/507309
Allison MA, Daley MF, Crane LA, et al. Influenza vaccine effectiveness in healthy 6- to 21-month-old children during the 2003–2004 season. J Pediatr 2006;149:755–62. PMID:17137887 https://doi.org/10.1016/j.jpeds.2006.06.036
Ritzwoller DP, Bridges CB, Shetterly S, Yamasaki K, Kolczak M, France EK. Effectiveness of the 2003–2004 influenza vaccine among children 6 months to 8 years of age, with 1 vs 2 doses. Pediatrics 2005;116:153–9. PMID:15995046 https://doi.org/10.1542/peds.2005-0049
Eisenberg KW, Szilagyi PG, Fairbrother G, et al.; New Vaccine Surveillance Network. Vaccine effectiveness against laboratory-confirmed influenza in children 6 to 59 months of age during the 2003–2004 and 2004–2005 influenza seasons. Pediatrics 2008;122:911–9. PMID:18977968 https://doi.org/10.1542/peds.2007-3304
Eick AA, Uyeki TM, Klimov A, et al. Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med 2011;165:104–11. PMID:20921345 https://doi.org/10.1001/archpediatrics.2010.192
ACOG Committee on Obstetric Practice. ACOG Committee opinion no. 732: influenza vaccination during pregnancy. Obstet Gynecol 2018;131:e109–14. PMID:29578985 https://doi.org/10.1097/AOG.0000000000002588
Heikkinen T, Young J, van Beek E, et al. Safety of MF59-adjuvanted A/H1N1 influenza vaccine in pregnancy: a comparative cohort study. Am J Obstet Gynecol 2012;207:177.e1–8. PMID:22939717 https://doi.org/10.1016/j.ajog.2012.07.007
Oppermann M, Fritzsche J, Weber-Schoendorfer C, et al. A(H1N1) v2009: a controlled observational prospective cohort study on vaccine safety in pregnancy. Vaccine 2012;30:4445–52. PMID:22564554 https://doi.org/10.1016/j.vaccine.2012.04.081
Pasternak B, Svanström H, Mølgaard-Nielsen D, et al. Vaccination against pandemic A/H1N1 2009 influenza in pregnancy and risk of fetal death: cohort study in Denmark. BMJ 2012;344:e2794. PMID:22551713 https://doi.org/10.1136/bmj.e2794
Sammon CJ, Snowball J, McGrogan A, de Vries CS. Evaluating the hazard of foetal death following H1N1 influenza vaccination; a population based cohort study in the UK GPRD. PLoS One 2012;7:e51734. PMID:23341865 https://doi.org/10.1371/journal.pone.0051734
Chambers CD, Johnson D, Xu R, et al.; OTIS Collaborative Research Group. Risks and safety of pandemic H1N1 influenza vaccine in pregnancy: birth defects, spontaneous abortion, preterm delivery, and small for gestational age infants. Vaccine 2013;31:5026–32. PMID:24016809 https://doi.org/10.1016/j.vaccine.2013.08.097
Huang WT, Tang FW, Yang SE, Chih YC, Chuang JH. Safety of inactivated monovalent pandemic (H1N1) 2009 vaccination during pregnancy: a population-based study in Taiwan. Vaccine 2014;32:6463–8. PMID:25285884 https://doi.org/10.1016/j.vaccine.2014.09.054
Ma F, Zhang L, Jiang R, et al. Prospective cohort study of the safety of an influenza A(H1N1) vaccine in pregnant Chinese women. Clin Vaccine Immunol 2014;21:1282–7. PMID:24990911 https://doi.org/10.1128/CVI.00375-14
Chambers CD, Johnson DL, Xu R, et al.; OTIS Collaborative Research Group. Safety of the 2010–11, 2011–12, 2012–13, and 2013–14 seasonal influenza vaccines in pregnancy: birth defects, spontaneous abortion, preterm delivery, and small for gestational age infants, a study from the cohort arm of VAMPSS. Vaccine 2016;34:4443–9. PMID:27449682 https://doi.org/10.1016/j.vaccine.2016.06.054
McMillan M, Porritt K, Kralik D, Costi L, Marshall H. Influenza vaccination during pregnancy: a systematic review of fetal death, spontaneous abortion, and congenital malformation safety outcomes. Vaccine 2015;33:2108–17. PMID:25758932 https://doi.org/10.1016/j.vaccine.2015.02.068
Bratton KN, Wardle MT, Orenstein WA, Omer SB. Maternal influenza immunization and birth outcomes of stillbirth and spontaneous abortion: a systematic review and meta-analysis. Clin Infect Dis 2015;60:e11–9. PMID:25409473 https://doi.org/10.1093/cid/ciu915
Irving SA, Kieke BA, Donahue JG, et al.; Vaccine Safety Datalink. Trivalent inactivated influenza vaccine and spontaneous abortion. Obstet Gynecol 2013;121:159–65. PMID:23262941 https://doi.org/10.1097/AOG.0b013e318279f56f
Donahue JG, Kieke BA, King JP, et al. Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12. Vaccine 2017;35:5314–22. PMID:28917295 https://doi.org/10.1016/j.vaccine.2017.06.069
Donahue JG, Kieke BA, King JP, et al. Inactivated influenza vaccine and spontaneous abortion in the Vaccine Safety Datalink in 2012–13, 2013–14, and 2014–15. Vaccine 2019;37:6673–81. PMID:31540812 https://doi.org/10.1016/j.vaccine.2019.09.035
Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179–86. PMID:12517228 https://doi.org/10.1001/jama.289.2.179
CDC. Past seasons vaccine effectiveness estimates. Atlanta, GA: US Department of Health and Human Services, CDC. https://www.cdc.gov/flu/vaccines-work/past-seasons-estimates.html#2021
DiazGranados CA, Dunning AJ, Kimmel M, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med 2014;371:635–45. PMID:25119609 https://doi.org/10.1056/NEJMoa1315727
Keitel WA, Treanor JJ, El Sahly HM, et al. Comparative immunogenicity of recombinant influenza hemagglutinin (rHA) and trivalent inactivated vaccine (TIV) among persons > or =65 years old. Vaccine 2009;28:379–85. PMID:19879222 https://doi.org/10.1016/j.vaccine.2009.10.037
Dunkle LM, Izikson R, Patriarca P, et al.; PSC12 Study Team. Efficacy of recombinant influenza vaccine in adults 50 years of age or older. N Engl J Med 2017;376:2427–36. PMID:28636855 https://doi.org/10.1056/NEJMoa1608862
Shay DK, Chillarige Y, Kelman J, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccines among US Medicare beneficiaries in preventing postinfluenza deaths during 2012–2013 and 2013–2014. J Infect Dis 2017;215:510–7. PMID:28329311 https://doi.org/10.1093/infdis/jiw641
Izurieta HS, Chillarige Y, Kelman J, et al. Relative effectiveness of cell-cultured and egg-based influenza vaccines among elderly persons in the United States, 2017–2018. J Infect Dis 2019;220:1255–64. PMID:30561688 https://doi.org/10.1093/infdis/jiy716
Izurieta HS, Chillarige Y, Kelman J, et al. Relative effectiveness of influenza vaccines among the United States elderly, 2018–2019. J Infect Dis 2020;222:278–87. PMID:32100009 https://doi.org/10.1093/infdis/jiaa080
Izurieta HS, Lu M, Kelman J, et al. Comparative effectiveness of influenza vaccines among U.S. Medicare beneficiaries ages 65 years and older during the 2019–20 season. Clin Infect Dis 2021;73:e4251–9. https://doi.org/10.1093/cid/ciaa1727
Lu Y, Chillarige Y, Izurieta HS, et al. Effect of age on relative effectiveness of high-dose versus standard-dose influenza vaccines among US Medicare beneficiaries aged ≥65 years. J Infect Dis 2019;220:1511–20. PMID:31290553 https://doi.org/10.1093/infdis/jiz360
Izurieta HS, Thadani N, Shay DK, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccines in US residents aged 65 years and older from 2012 to 2013 using Medicare data: a retrospective cohort analysis. Lancet Infect Dis 2015;15:293–300. PMID:25672568 https://doi.org/10.1016/S1473-3099(14)71087-4
Richardson DM, Medvedeva EL, Roberts CB, Linkin DR; CDC Epicenter Program. Comparative effectiveness of high-dose versus standard-dose influenza vaccination in community-dwelling veterans. Clin Infect Dis 2015;61:171–6. PMID:25829001 https://doi.org/10.1093/cid/civ261
Young-Xu Y, Van Aalst R, Mahmud SM, et al. Relative vaccine effectiveness of high-dose versus standard-dose influenza vaccines among Veterans Health Administration patients. J Infect Dis 2018;217:1718–27. PMID:29452380 https://doi.org/10.1093/infdis/jiy088
Young-Xu Y, Snider JT, van Aalst R, et al. Analysis of relative effectiveness of high-dose versus standard-dose influenza vaccines using an instrumental variable method. Vaccine 2019;37:1484–90. PMID:30745146 https://doi.org/10.1016/j.vaccine.2019.01.063
Young-Xu Y, Thornton Snider J, Mahmud SM, et al. High-dose influenza vaccination and mortality among predominantly male, white, senior veterans, United States, 2012/13 to 2014/15. Euro Surveill 2020;25. PMID:32431290 https://doi.org/10.2807/1560-7917.ES.2020.25.19.1900401
Pelton SI, Divino V, Shah D, et al. Evaluating the relative vaccine effectiveness of adjuvanted trivalent influenza vaccine compared to high-dose trivalent and other egg-based influenza vaccines among older adults in the US during the 2017–2018 influenza season. Vaccines (Basel) 2020;8:446. PMID:32784684 https://doi.org/10.3390/vaccines8030446
van Aalst R, Gravenstein S, Mor V, et al. Comparative effectiveness of high dose versus adjuvanted influenza vaccine: a retrospective cohort study. Vaccine 2020;38:372–9. PMID:31606249 https://doi.org/10.1016/j.vaccine.2019.09.105
Pelton SI, Divino V, Postma MJ, et al. A retrospective cohort study assessing relative effectiveness of adjuvanted versus high-dose trivalent influenza vaccines among older adults in the United States during the 2018–19 influenza season. Vaccine 2021;39:2396–407. PMID:33810903 https://doi.org/10.1016/j.vaccine.2021.03.054
DiazGranados CA, Robertson CA, Talbot HK, Landolfi V, Dunning AJ, Greenberg DP. Prevention of serious events in adults 65 years of age or older: a comparison between high-dose and standard-dose inactivated influenza vaccines. Vaccine 2015;33:4988–93. PMID:26212007 https://doi.org/10.1016/j.vaccine.2015.07.006
Vardeny O, Kim K, Udell JA, et al.; INVESTED Committees and Investigators. Effect of high-dose trivalent vs standard-dose quadrivalent influenza vaccine on mortality or cardiopulmonary hospitalization in patients with high-risk cardiovascular disease: a randomized clinical trial. JAMA 2021;325:39–49. PMID:33275134 https://doi.org/10.1001/jama.2020.23649
Gravenstein S, Davidson HE, Taljaard M, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial. Lancet Respir Med 2017;5:738–46. PMID:28736045 https://doi.org/10.1016/S2213-2600(17)30235-7
McConeghy KW, Davidson HE, Canaday DH, et al. Cluster-randomized trial of adjuvanted versus nonadjuvanted trivalent influenza vaccine in 823 US nursing homes. Clin Infect Dis 2021;73:e4237–43. PMID:32882710 https://doi.org/10.1093/cid/ciaa1233
Falsey AR, Treanor JJ, Tornieporth N, Capellan J, Gorse GJ. Randomized, double-blind controlled phase 3 trial comparing the immunogenicity of high-dose and standard-dose influenza vaccine in adults 65 years of age and older. J Infect Dis 2009;200:172–80. PMID:19508159 https://doi.org/10.1086/599790
Frey SE, Reyes MR, Reynales H, et al. Comparison of the safety and immunogenicity of an MF59®-adjuvanted with a non-adjuvanted seasonal influenza vaccine in elderly subjects. Vaccine 2014;32:5027–34. PMID:25045825 https://doi.org/10.1016/j.vaccine.2014.07.013
Schmader KE, Liu CK, Harrington T, et al. Safety, reactogenicity, and health-related quality of life after trivalent adjuvanted vs trivalent high-dose inactivated influenza vaccines in older adults: a randomized clinical trial. JAMA Netw Open 2021;4:e2031266. PMID:33443580 https://doi.org/10.1001/jamanetworkopen.2020.31266
Bosaeed M, Kumar D. Seasonal influenza vaccine in immunocompromised persons. Hum Vaccin Immunother 2018;14:1311–22. PMID:29485353 https://doi.org/10.1080/21645515.2018.1445446
Rubin LG, Levin MJ, Ljungman P, et al.; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014;58:e44–100. PMID:24311479 https://doi.org/10.1093/cid/cit684
CDC. Influenza antiviral medications: summary for clinicians. Atlanta, GA: US Department of Health and Human Services, CDC. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.
Woo EJ. Allergic reactions after egg-free recombinant influenza vaccine: reports to the US Vaccine Adverse Event Reporting System. Clin Infect Dis 2015;60:777–80. PMID:25428412 https://doi.org/10.1093/cid/ciu948
Woo EJ, Moro PL, Cano M, Jankosky C. Postmarketing safety surveillance of trivalent recombinant influenza vaccine: reports to the Vaccine Adverse Event Reporting System. Vaccine 2017;35:5618–21. PMID:28886946 https://doi.org/10.1016/j.vaccine.2017.08.047
Woo EJ, Moro PL. Postmarketing safety surveillance of quadrivalent recombinant influenza vaccine: Reports to the Vaccine Adverse Event Reporting System. Vaccine 2021;39:1812–7. PMID:33678452 https://doi.org/10.1016/j.vaccine.2021.02.052
Uyeki TM, Zane SB, Bodnar UR, et al.; Alaska/Yukon Territory Respiratory Outbreak Investigation Team. Large summertime influenza A outbreak among tourists in Alaska and the Yukon Territory. Clin Infect Dis 2003;36:1095–102. PMID:12715302 https://doi.org/10.1086/374053
Mutsch M, Tavernini M, Marx A, et al. Influenza virus infection in travelers to tropical and subtropical countries. Clin Infect Dis 2005;40:1282–7. PMID:15825030 https://doi.org/10.1086/429243
Ratnam I, Black J, Leder K, et al. Incidence and risk factors for acute respiratory illnesses and influenza virus infections in Australian travellers to Asia. J Clin Virol 2013;57:54–8. PMID:23380660 https://doi.org/10.1016/j.jcv.2013.01.008
Millman AJ, Kornylo Duong K, Lafond K, Green NM, Lippold SA, Jhung MA. Influenza outbreaks among passengers and crew on two cruise ships: a recent account of preparedness and response to an ever-present challenge. J Travel Med 2015;22:306–11. PMID:26031322 https://doi.org/10.1111/jtm.12215
Flumist Quadrivalent [Package Insert]. Gaithersburg, MD: MedImmune; 2021.
Rapivab (peramivir for injection) [Package Insert]. Durham, NC: BioCryst; 2017.
Xofluza (baloxavir marboxil) [Package Insert]. San Francisco, CA: Genentech; 2018. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210854s000lbl.pdf
Food and Drug Administration. Guidance for industry: bioavailability and bioequivalence studies for orally administered drug products: general considerations. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2003.
Izikson R, Brune D, Bolduc JS, et al. Safety and immunogenicity of a high-dose quadrivalent influenza vaccine administered concomitantly with a third dose of the mRNA-1273 SARS-CoV-2 vaccine in adults aged ≥65 years: a phase 2, randomised, open-label study. Lancet Respir Med 2022;10:392–402. Epub Feb. 21, 2022. PMID:35114141 https://doi.org/10.1016/S2213-2600(21)00557-9
Kerzner B, Murray AV, Cheng E, et al. Safety and immunogenicity profile of the concomitant administration of ZOSTAVAX and inactivated influenza vaccine in adults aged 50 and older. J Am Geriatr Soc 2007;55:1499–507. PMID:17908055 https://doi.org/10.1111/j.1532-5415.2007.01397.x
Levin MJ, Buchwald UK, Gardner J, et al. Immunogenicity and safety of zoster vaccine live administered with quadrivalent influenza virus vaccine. Vaccine 2018;36:179–85. PMID:28830693 https://doi.org/10.1016/j.vaccine.2017.08.029
Frenck RW Jr, Gurtman A, Rubino J, et al. Randomized, controlled trial of a 13-valent pneumococcal conjugate vaccine administered concomitantly with an influenza vaccine in healthy adults. Clin Vaccine Immunol 2012;19:1296–303. PMID:22739693 https://doi.org/10.1128/CVI.00176-12
Schwarz TF, Flamaing J, Rümke HC, et al. A randomized, double-blind trial to evaluate immunogenicity and safety of 13-valent pneumococcal conjugate vaccine given concomitantly with trivalent influenza vaccine in adults aged ≥65 years. Vaccine 2011;29:5195–202. PMID:21619909 https://doi.org/10.1016/j.vaccine.2011.05.031
McNeil SA, Noya F, Dionne M, et al. Comparison of the safety and immunogenicity of concomitant and sequential administration of an adult formulation tetanus and diphtheria toxoids adsorbed combined with acellular pertussis (Tdap) vaccine and trivalent inactivated influenza vaccine in adults. Vaccine 2007;25:3464–74. PMID:17270320 https://doi.org/10.1016/j.vaccine.2006.12.047
Nakashima K, Aoshima M, Ohfuji S, et al. Immunogenicity of simultaneous versus sequential administration of a 23-valent pneumococcal polysaccharide vaccine and a quadrivalent influenza vaccine in older individuals: A randomized, open-label, non-inferiority trial. Hum Vaccin Immunother 2018;14:1923–30. PMID:29561248 https://doi.org/10.1080/21645515.2018.1455476
Song JY, Cheong HJ, Tsai TF, et al. Immunogenicity and safety of concomitant MF59-adjuvanted influenza vaccine and 23-valent pneumococcal polysaccharide vaccine administration in older adults. Vaccine 2015;33:4647–52. PMID:25980426 https://doi.org/10.1016/j.vaccine.2015.05.003
Sukumaran L, McCarthy NL, Kharbanda EO, et al. Safety of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis and influenza vaccinations in pregnancy. Obstet Gynecol 2015;126:1069–74. PMID:26444109 https://doi.org/10.1097/AOG.0000000000001066
Stockwell MS, Broder K, LaRussa P, et al. Risk of fever after pediatric trivalent inactivated influenza vaccine and 13-valent pneumococcal conjugate vaccine. JAMA Pediatr 2014;168:211–9. PMID:24395025 https://doi.org/10.1001/jamapediatrics.2013.4469
Walter EB, Klein NP, Wodi AP, et al. Fever after influenza, diphtheria-tetanus-acellular pertussis, and pneumococcal vaccinations. Pediatrics 2020;145:e20191909. PMID:32029684 https://doi.org/10.1542/peds.2019-1909
Duffy J, Weintraub E, Hambidge SJ, et al.; Vaccine Safety Datalink. Febrile seizure risk after vaccination in children 6 to 23 months. Pediatrics 2016;138:e20160320. PMID:27273711 https://doi.org/10.1542/peds.2016-0320
Li R, Stewart B, McNeil MM, et al. Post licensure surveillance of influenza vaccines in the Vaccine Safety Datalink in the 2013–2014 and 2014–2015 seasons. Pharmacoepidemiol Drug Saf 2016;25:928–34. PMID:27037540 https://doi.org/10.1002/pds.3996
Patterson JL, Carapetian SA, Hageman JR, Kelley KR. Febrile seizures. Pediatr Ann 2013;42:249–54. PMID:24295158 https://doi.org/10.3928/00904481-20131122-09
Nolan T, Bernstein DI, Block SL, et al.; LAIV Study Group. Safety and immunogenicity of concurrent administration of live attenuated influenza vaccine with measles-mumps-rubella and varicella vaccines to infants 12 to 15 months of age. Pediatrics 2008;121:508–16. PMID:18310199 https://doi.org/10.1542/peds.2007-1064
Lum LC, Borja-Tabora CF, Breiman RF, et al. Influenza vaccine concurrently administered with a combination measles, mumps, and rubella vaccine to young children. Vaccine 2010;28:1566–74. PMID:20003918 https://doi.org/10.1016/j.vaccine.2009.11.054
Shingrix [Package Insert]. Research Triangle Park, NC: GlaxoSmithKline; 2017.
Fluad Quadrivalent [Package Insert]. Holly Springs, NC: Seqirus; 2022.
Heplisav-B [Package Insert]. Emeryville, CA: Dynavax; 2017.
Schwarz TF, Aggarwal N, Moeckesch B, et al. Immunogenicity and safety of an adjuvanted herpes zoster subunit vaccine coadministered with seasonal influenza vaccine in adults aged 50 years or older. J Infect Dis 2017;216:1352–61. PMID:29029224 https://doi.org/10.1093/infdis/jix481
Fluarix Quadrivalent [Package Insert]. Dresden, Germany: GlaxoSmithKline; 2022.
FluLaval Quadrivalent [Package Insert]. Quebec City, QC, Canada: ID Biomedical Corporation of Quebec; 2022.
Flucelvax Quadrivalent [Package Insert]. Holly Springs, NC: Seqirus; 2022.
Fluzone High-Dose Quadrivalent [Package Insert]. Swiftwater, PA: Sanofi Pasteur; 2022.
Flublok Quadrivalent [Package Insert]. Meriden, CT: Protein Sciences; 2022.
Food and Drug Administration. Clinical review: Flucelvax Quadrivalent. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2016.
Food and Drug Administration. Clinical review: Flucelvax Quadrivalent. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; March 2021.
Food and Drug Administration. Clinical review: Flucelvax Quadrivalent. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; October 2021.

CME / ABIM MOC / CE

Prevention and Control of Seasonal Influenza With Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season

Authors: Lisa A. Grohskopf, MD; Lenee H. Blanton, MPH; Jill M. Ferdinands, PhD; Jessie R. Chung, MPH; Karen R. Broder, MD; H. Keipp Talbot, MD; Rebecca L. Morgan, PhD; Alicia M. Fry, MD
CME / ABIM MOC / CE Released: 12/5/2022
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 12/5/2023, 11:59 PM EST

Start Activity

Target Audience and Goal Statement

This activity is intended for public health officials, internists, family medicine clinicians, pediatricians, infectious disease clinicians, pulmonologists, nurses, pharmacists, and other clinicians caring for patients in whom seasonal influenza vaccination may be indicated.

The goal of this activity is for learners to be better able to describe the recommendations of the Advisory Committee on Immunization Practices, updated from the 2021 to 2022 recommendations, regarding use of seasonal influenza vaccines in the United States during the 2022 to 2023 season, based on a report published in the Morbidity and Mortality Weekly Report.

Upon completion of this activity, participants will:

Assess changes in the Advisory Committee on Immunization Practices (ACIP) recommendations for 2022-23, updated from the 2021-22 recommendations, regarding the use of seasonal influenza vaccines in the United States during the 2022-23 season, based on a Morbidity and Mortality Weekly Report
Evaluate overall ACIP recommendations regarding use of seasonal influenza vaccines in the United States, based on a Morbidity and Mortality Weekly Report
Describe other ACIP recommendations regarding use of seasonal influenza vaccines in the United States in special populations, and other clinical considerations, based on a Morbidity and Mortality Weekly Report

Faculty

Lisa A. Grohskopf, MD

Influenza Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Lisa A. Grohskopf, MD, has no relevant financial relationships.

Lenee H. Blanton, MPH

Influenza Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Lenee H. Blanton, MPH, has no relevant financial relationships.

Jill M. Ferdinands, PhD

Influenza Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Jill M. Ferdinands, PhD, has no relevant financial relationships.

Jessie R. Chung, MPH

Influenza Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Jessie R. Chung, MPH, has no relevant financial relationships.

Karen R. Broder, MD

Immunization Safety Office
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Karen R. Broder, MD, has no relevant financial relationships.

H. Keipp Talbot, MD

Division of Infectious Diseases
Vanderbilt University Medical Center
Nashville, Tennessee

Disclosures

H. Keipp Talbot, MD, has no relevant financial relationships.

Rebecca L. Morgan, PhD

Department of Health Research Methods, Evidence, and Impact
McMaster University
Hamilton, Ontario, Canada

Disclosures

Rebecca L. Morgan, PhD, has no relevant financial relationships.

Alicia M. Fry, MD

Influenza Division
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia

Disclosures

Alicia M. Fry, MD, has no relevant financial relationships.

CME Author

Laurie Barclay, MD

Freelance writer and reviewer
Medscape, LLC

Disclosures

Laurie Barclay, MD, has the following relevant financial relationships:
Formerly owned stocks in: AbbVie

Compliance Reviewer/Nurse Planner

Leigh Schmidt, MSN, RN, CNE, CHCP

Associate Director, Accreditation and Compliance, Medscape, LLC

Disclosures

Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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From Morbidity & Mortality Weekly Report

CME / ABIM MOC / CE

Prevention and Control of Seasonal Influenza With Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season

Authors: Lisa A. Grohskopf, MD; Lenee H. Blanton, MPH; Jill M. Ferdinands, PhD; Jessie R. Chung, MPH; Karen R. Broder, MD; H. Keipp Talbot, MD; Rebecca L. Morgan, PhD; Alicia M. Fry, MDFaculty and Disclosures

THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 12/5/2022

Valid for credit through: 12/5/2023, 11:59 PM EST

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Abstract and Introduction

Abstract

This report updates the 2021–22 recommendations of the Advisory Committee on Immunization Practices (ACIP) concerning the use of seasonal influenza vaccines in the United States (MMWR Recomm Rep 2021;70[No. RR-5]:1–24). Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. For each recipient, a licensed and age-appropriate vaccine should be used.With the exception of vaccination for adults aged ≥65 years, ACIP makes no preferential recommendation for a specific vaccine when more than one licensed, recommended, and age-appropriate vaccine is available. All seasonal influenza vaccines expected to be available in the United States for the 2022–23 season are quadrivalent, containing hemagglutinin (HA) derived from one influenza A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus. Inactivated influenza vaccines (IIV4s), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4) are expected to be available. Trivalent influenza vaccines are no longer available, but data that involve these vaccines are included for reference.

Influenza vaccines might be available as early as July or August, but for most persons who need only 1 dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the season as long as influenza viruses are circulating and unexpired vaccine is available. For most adults (particularly adults aged ≥65 years) and for pregnant persons in the first or second trimester, vaccination during July and August should be avoided unless there is concern that vaccination later in the season might not be possible. Certain children aged 6 months through 8 years need 2 doses; these children should receive the first dose as soon as possible after vaccine is available, including during July and August. Vaccination during July and August can be considered for children of any age who need only 1 dose for the season and for pregnant persons who are in the third trimester if vaccine is available during those months.

Updates described in this report reflect discussions during public meetings of ACIP that were held on October 20, 2021; January 12, 2022; February 23, 2022; and June 22, 2022. Primary updates to this report include the following three topics: 1) the composition of 2022–23 U.S. seasonal influenza vaccines; 2) updates to the description of influenza vaccines expected to be available for the 2022–23 season, including one influenza vaccine labeling change that occurred after the publication of the 2021–22 ACIP influenza recommendations; and 3) updates to the recommendations concerning vaccination of adults aged ≥65 years. First, the composition of 2022–23 U.S. influenza vaccines includes updates to the influenza A(H3N2) and influenza B/Victoria lineage components. U.S.-licensed influenza vaccines will contain HA derived from an influenza A/Victoria/2570/2019 (H1N1)pdm09-like virus (for egg-based vaccines) or an influenza A/Wisconsin/588/2019 (H1N1)pdm09-like virus (for cell culture–based or recombinant vaccines); an influenza A/Darwin/9/2021 (H3N2)-like virus (for egg-based vaccines) or an influenza A/Darwin/6/2021 (H3N2)-like virus (for cell culture–based or recombinant vaccines); an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus; and an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus. Second, the approved age indication for the cell culture–based inactivated influenza vaccine, Flucelvax Quadrivalent (ccIIV4), was changed in October 2021 from ≥2 years to ≥6 months. Third, recommendations for vaccination of adults aged ≥65 years have been modified. ACIP recommends that adults aged ≥65 years preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines is available at an opportunity for vaccine administration, then any other age-appropriate influenza vaccine should be used.

This report focuses on recommendations for the use of vaccines for the prevention and control of seasonal influenza during the 2022–23 influenza season in the United States. A brief summary of the recommendations and a link to the most recent Background Document containing additional information are available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html. These recommendations apply to U.S.-licensed influenza vaccines used according to Food and Drug Administration–licensed indications. Updates and other information are available from CDC's influenza website (https://www.cdc.gov/flu). Vaccination and health care providers should check this site periodically for additional information.

Introduction

Influenza viruses typically circulate annually in the United States, most commonly from the late fall through the early spring. Most persons who become ill after influenza virus infection recover without serious complications or sequelae. However, influenza can be associated with serious illnesses, hospitalizations, and deaths, particularly among older adults, very young children, pregnant persons, and persons of all ages with certain chronic medical conditions.^[1–7] Influenza also is an important cause of missed work and school.^[8–10] Routine annual influenza vaccination for all persons aged ≥6 months who do not have contraindications has been recommended by CDC and the Advisory Committee on Immunization Practices (ACIP) since 2010.^[11]

Vaccination provides important protection from influenza illness and its potential complications. The effectiveness of influenza vaccination varies depending on several factors, such as the age and health of the recipient; the type of vaccine administered; the types, subtypes (for influenza A), and lineages (for influenza B) of circulating influenza viruses; and the degree of similarity between circulating viruses and those included in the vaccine.^[12] During each of the six influenza seasons from 2010–11 through 2015–16, influenza vaccination prevented an estimated 1.6–6.7 million illnesses, 790,000–3.1 million outpatient medical visits, 39,000–87,000 hospitalizations, and 3,000–10,000 respiratory and circulatory deaths each season in the United States.^[13] During the severe 2017–18 season, notable for an unusually long duration of widespread high influenza activity throughout the United States and higher rates of outpatient visits and hospitalizations compared with recent seasons, vaccination prevented an estimated 7.1 million illnesses, 3.7 million medical visits, 109,000 hospitalizations, and 8,000 deaths,^[14] despite an overall estimated vaccine effectiveness of 38% (62% against influenza A^H1N1pdm09 viruses, 22% against influenza A^H3N2 viruses, and 50% against influenza B viruses).^[14]

Influenza circulated at historically low levels in the United States and globally during the 2020–21 influenza season.^[15] This was coincident with widespread implementation of nonpharmaceutical interventions (e.g., masking, social distancing, and suspension of in-person work and school) intended to prevent transmission of SARS-CoV-2 (the virus that causes COVID-19). Influenza activity increased during the 2021–22 season, although severity indicators (e.g., influenza-associated hospitalizations and deaths) were overall lower than in recent previous seasons.^[16] Timing, intensity, and severity of the 2022–23 influenza season cannot be predicted. Influenza vaccination remains an important tool for the prevention of potentially severe respiratory illness, which might decrease stress on the U.S. health care system during ongoing circulation of SARS-CoV-2. Guidance for vaccine planning during the COVID-19 pandemic is available at https://www.cdc.gov/vaccines/pandemic-guidance/index.html.

This report updates the 2021–22 ACIP recommendations regarding the use of seasonal influenza vaccines^[17] and provides recommendations and guidance for vaccination providers regarding the use of influenza vaccines in the United States for the 2022–23 season. Various formulations of influenza vaccines are available (Table 1). Contraindications and precautions for the use of influenza vaccines are summarized (Table 2 and Table 3). Abbreviations are used in this report to denote the various types of vaccines (Box).

This report focuses on recommendations and guidance for the use of seasonal influenza vaccines for the prevention and control of influenza during the 2022–23 season in the United States. A summary of these recommendations and a Background Document containing additional information on influenza, influenza-associated illness, and influenza vaccines are available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html.

Page 1 of 7

Methods

CME / ABIM MOC / CE Information

References

Table 1.

Table 2.

Table 3.

Table 4.

Box.

References

Faculty and Disclosures

Faculty

Lisa A. Grohskopf, MD

Lenee H. Blanton, MPH

Jill M. Ferdinands, PhD

Jessie R. Chung, MPH

Karen R. Broder, MD

H. Keipp Talbot, MD

Rebecca L. Morgan, PhD

Alicia M. Fry, MD

CME Author

Laurie Barclay, MD

Compliance Reviewer/Nurse Planner

Leigh Schmidt, MSN, RN, CNE, CHCP

CME / ABIM MOC / CE

Prevention and Control of Seasonal Influenza With Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season

Target Audience and Goal Statement

Faculty

Lisa A. Grohskopf, MD

Lenee H. Blanton, MPH

Jill M. Ferdinands, PhD

Jessie R. Chung, MPH

Karen R. Broder, MD

H. Keipp Talbot, MD

Rebecca L. Morgan, PhD

Alicia M. Fry, MD

CME Author

Laurie Barclay, MD

Compliance Reviewer/Nurse Planner

Leigh Schmidt, MSN, RN, CNE, CHCP

Accreditation Statements

For Physicians

For Nurses

For Pharmacists

Instructions for Participation and Credit

Prevention and Control of Seasonal Influenza With Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season

Abstract and Introduction

Abstract

Introduction

Table of Contents