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

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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
Valid for credit through: 12/5/2023

Start Activity

Credits Available

Physicians - maximum of 2.50 AMA PRA Category 1 Credit(s)™

ABIM Diplomates - maximum of 2.50 ABIM MOC points

Nurses - 2.50 ANCC Contact Hour(s) (2.5 contact hours are in the area of pharmacology)

Pharmacists - 2.50 Knowledge-based ACPE (0.250 CEUs)

You Are Eligible For
- Letter of Completion
- ABIM MOC points

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.

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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

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

Valid for credit through: 12/5/2023

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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

Earn Credit 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

Credits Available

You Are Eligible For

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