Tuesday, December 5, 2023
| Trade name (manufacturer) |
Presentation |
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 mL15 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 mL15 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 | 106.5–7.5 fluorescent focus units/0.2 mL | NAS | — |
Influenza vaccines — United States, 2023–24 influenza season*
Abbreviations: ACIP = Advisory Committee on Immunization Practices; HA = hemagglutinin; IIV4 = inactivated influenza vaccine, quadrivalent;
IM = intramuscular; LAIV4 = live attenuated influenza vaccine, quadrivalent; MDV = multidose vial; PFS = prefilled syringe;
RIV4 = recombinant influenza vaccine, quadrivalent; SDV = single-dose vial.
*Manufacturer package inserts and updated CDC and ACIP guidance should be consulted for additional information concerning,
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 all persons aged ≥6 months with egg allergy should receive influenza vaccine and that any influenza vaccine (egg based or nonegg based) that is otherwise appropriate for the recipient's age and health status can be used (see Persons with a History of Egg Allergy).
§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 no longer available. 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 administered 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 older children and adults, the recommended site for IM 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 IM administration is available in the 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 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.
| 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, 2023–24 influenza season*
| Vaccine (of any valency) associated with previous severe allergic reaction (e.g., anaphylaxis) |
Available 2023–24 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, 2023–24 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; 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.
*Manufacturer package inserts and updated CDC and ACIP guidance should be consulted for additional 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 the General Best Practice Guidelines for Immunization (Source: Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization; 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 all persons aged ≥6 months with egg allergy should receive influenza vaccine, and that any influenza vaccine (egg based or nonegg based) that is otherwise appropriate for the recipient's age and health status can be used (see Persons with a History of Egg Allergy).
§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 the General Best Practice Guidelines for Immunization
(Source: Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization; 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.
| 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, 2023–24 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 no longer available. 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 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.
| • 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 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 2023–24 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 valency or to a specific vaccine in that category. • 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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This report updates the 2022–23 recommendations of the Advisory Committee on Immunization Practices (ACIP) concerning the use of seasonal influenza vaccines in the United States (MMWR Recomm Rep 2022;71[No. RR-1]:1–28). Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. All seasonal influenza vaccines expected to be available in the United States for the 2023–24 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.
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. Influenza vaccines might be available as early as July or August, but 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 during these months if vaccine is available.
ACIP recommends that all persons aged ≥6 months who do not have contraindications receive a licensed and age-appropriate seasonal influenza vaccine. 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. 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.
Primary updates to this report include the following two topics: 1) the composition of 2023–24 U.S. seasonal influenza vaccines and 2) updated recommendations regarding influenza vaccination of persons with egg allergy. First, the composition of 2023–24 U.S. influenza vaccines includes an update to the influenza A(H1N1)pdm09 component. U.S.-licensed influenza vaccines will contain HA derived from 1) an influenza A/Victoria/4897/2022 (H1N1)pdm09-like virus (for egg-based vaccines) or an influenza A/Wisconsin/67/2022 (H1N1)pdm09-like virus (for cell culture-based and recombinant vaccines); 2) 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 and recombinant vaccines); 3) an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus; and 4) an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus. Second, ACIP recommends that all persons aged ≥6 months with egg allergy should receive influenza vaccine. Any influenza vaccine (egg based or nonegg based) that is otherwise appropriate for the recipient's age and health status can be used. It is no longer recommended that persons who have had an allergic reaction to egg involving symptoms other than urticaria should be vaccinated in an inpatient or outpatient medical setting supervised by a health care provider who is able to recognize and manage severe allergic reactions if an egg-based vaccine is used. Egg allergy alone necessitates no additional safety measures for influenza vaccination beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings in which personnel and equipment needed for rapid recognition and treatment of acute hypersensitivity reactions are available.
This report focuses on recommendations for the use of vaccines for the prevention and control of seasonal influenza during the 2023–24 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.
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 multiple 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[H1N1]pdm09 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, 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).[15] The 2021–22 influenza season saw increased activity compared with 2020–21, with influenza activity remaining elevated later into the spring than any previous season for which data are available.[16] The 2022–23 season was marked by early influenza activity peaking in late November to early December.[17] The timing, intensity, and severity of the 2023–24 influenza season cannot be predicted. Influenza vaccination remains an important tool for the prevention of potentially severe respiratory illness.
This report updates the 2022–23 ACIP recommendations regarding the use of seasonal influenza vaccines[18] and provides recommendations and guidance for vaccination providers regarding the use of influenza vaccines in the United States for the 2023–24 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). 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.
