Flu Vaccines for 2017-2018

CDC has released recommendations for influenza vaccines for the 2017-18 influenza season. These recommendations can be found at: https://www.cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm. Items that are addressed include the following:

  • Influenza vaccination is recommended for everyone ages six months and older who do not have contraindications, using any age-appropriate injectable vaccine.1 Encourage patients to try to complete vaccination by the end of October. Though delayed vaccination may lead to increased immunity later in the season, it could also lead to missed opportunities to vaccinate, and is not recommended.1
    • LAIV4 (intranasal vaccine; FluMist) is not recommended for 2017-18.1 This recommendation is based on low effectiveness against the H1N1 strain during the 2013-14 and 2014-15 flu seasons in the United States.
  • Immunocompromised patients may receive any licensed, recommended, age-appropriate injectable flu vaccine.4
  • Vaccinate pregnant women (any trimester) with any licensed, recommended, age-appropriate injectable flu vaccine, regardless of thimerosal content.1,6
    • Risk of influenza and potential complications in pregnant woman and/or the fetus exceeds possible risks associated with influenza vaccination.7,8
  • Patients with a history of severe egg allergy (symptoms more severe than hives [e.g., angioedema, respiratory distress, requiring epinephrine]) can usually tolerate any flu vaccine. But, they should receive the vaccine in a medical setting under the supervision of a healthcare professional who can identify and treat severe allergic reactions, if necessary. Flublok and Flublok Quadrivalent are the only influenza vaccines that are considered egg-free.1 See our chart, Flu Vaccination and Egg Allergy, for answers to common questions about vaccinating egg-allergic patients.
  • The influenza vaccine can be given at the same time as other vaccines.1
  • Trivalent flu vaccines protect against two influenza A-like viruses and one influenza B-like virus.
  • Quadrivalent flu vaccines protect against two influenza A-like viruses and two influenza B-like viruses.

The chart below provides information about approved seasonal influenza vaccines for the 2017-18 season including FDA-approved ages for use, route of administration, dose, and cost.

Abbreviations: IIV4 = influenza inactivated vaccine, quadrivalent; IIV3 = influenza inactivated vaccine, trivalent; IM = intramuscular; LAIV4 = live attenuated influenza vaccine, quadrivalent; MDV = multidose vial; PFS = pre-filled syringe; RIV3 = recombinant inactivated vaccine, trivalent; RIV4 = recombinant inactivated vaccine, quadrivalent; SDV = single-dose vial.

Brand Name
Manufacturer
a

Routea

Approved Ages for Usea

Availabilitya (Cost/doseb)

Contains Thimerosal?a

Dosea

Commentsa

Quadrivalent inactivated (IIV4)

Afluria Quadrivalent

Seqirus

IM

≥18 years

0.5 mL PFS ($17.61)

5 mL MDV ($16.46)

Yes (MDV only)

0.5 mL

No latex

Once entered, the MDV should be discarded after 28 days.

PharmaJet Stratis needle-free injector approved for ages 18-64 years.

Fluarix Quadrivalent

GSK

IM

≥3 years

0.5 mL PFS ($16.82)

No

0.5 mL

No latex

Flucelvax Quadrivalent

Seqirus

IM

≥4 years

0.5 mL PFS ($21.22)

5 mL MDV ($20.12)

Yes (MDV only)

0.5 mL

This cell-cultured vaccine may be abbreviated ccIIV4.1

No latex

Flucelvax may contain egg protein, but a relatively small amount compared to other inactivated vaccines.1

FluLaval Quadrivalent

ID Biomedical

IM

≥6 months

0.5 mL PFS ($16.82)

5 mL MDV ($15.77)

Yes (MDV only)

0.5 mL

No latex

Once entered, the MDV should be discarded after 28 days.

Fluzone Quadrivalent

Sanofi Pasteur

IM

≥6 months

0.25 mL PFS ($18.72)

0.5 mL PFS ($17.97)

0.5 mL SDV ($17.97)

5 mL MDV

($16.22)

Yes (MDV only)

6-35 months:
0.25 mL

≥36 months:
0.5 mL

No latex

A max of ten doses can be withdrawn from the MDV vial.

Fluzone Intradermal Quadrivalent

Sanofi Pasteur

Intra-dermal

18-64 years

0.1 mL prefilled micro-injection system ($17.97)

No1

0.1 mL

No latex

Higher risk of injection site reactions compared to IM vaccine.

Trivalent inactivated (IIV3)

Afluria

Seqirus

IM

≥5 years


0.5 mL PFS, ($17.01)

5 mL MDV ($15.64)

Yes (MDV only)

0.5 mL

No latex

Once entered the MDV vial should be discarded after 28 days.

Recommendation to avoid in children <9 years old has been removed.1

PharmaJet Stratis needle-free injector approved for ages 18-64 years.

Fluad

Seqirus

IM

≥65 years

0.5 mL PFS ($44.18)

No1

0.5 mL

Tip caps of syringes contain latex.

This adjuvanted vaccine may be abbreviated aIIV3.1

May provide modestly greater reduction in flu risk vs nonadjuvanted trivalent vaccine in patients ≥65 years of age (n=227, unable to calculate NNT), [Evidence level B-2].1,5

Higher risk of adverse effects (injection site reactions, fatigue, myalgias, headache) than IIV3.1

Fluvirin

Seqirus

IM

≥4 years

0.5 mL PFS ($17.01)

5 mL MDV ($15.64)

Yes (MDV; trace amount in PFS)

0.5 mL

Tip caps of syringes may contain latex.

Fluzone High-Dose

Sanofi Pasteur

Contains 60 mcg of each virus strain compared to 15 mcg in standard-dose IM vaccines.1

IM

≥65 years

0.5 mL PFS ($43.13)

No1

0.5 mL

No latex

Provides modestly greater reduction in flu risk vs standard-dose trivalent vaccine in patients ≥65 years of age (n=31,989; NNT=200), [Evidence level A-1].1,3

Higher risk of nonserious adverse effects (injection site reactions, fever, gastrointestinal effects) than standard dose.

Trivalent recombinant (RIV3)

Flublok

Protein Sciences

IM

≥18 years

0.5 mL SDV ($42.75)

No1

0.5 mL

No latex

Egg-free

Quadrivalent recombinant (RIV4)

Flublok Quadrivalent

Protein Sciences

IM

≥18 years

0.5 ml PFS ($48.75)

No1

0.5 mL

No latex

Egg-free

May be slightly more effective than IIV4 vaccines in patients ≥50 years of age (n=8,604; NNT=100), [Evidence level A-1].1,2

Quadrivalent live-attenuated (LAIV4) **NOT RECOMMENDED FOR USE, due to concerns about effectiveness**

FluMist Quadrivalent

**NOT recommended for use**

Intranasal

2 to 49 years

0.2 mL prefilled intranasal sprayer (Price not available)

No1

0.1 mL per nostril

No latex

For use in healthy, non-pregnant patients.1

Avoid in patients with contraindications to live vaccines (e.g., chronic diseases, immunosuppression).

  1. Information is from the following U.S. product labeling unless otherwise specified: Afluria Quadrivalent (March 2017); Fluarix Quadrivalent (April 2017); Flucelvax Quadrivalent (April 2017); FluLaval Quadrivalent (April 2017); Fluzone Intradermal Quadrivalent (July 2017); Fluzone Quadrivalent (July 2017); Afluria (March 2017); Fluad (March 2017); Fluvirin (March 2017); Fluzone High-Dose (July 2017); Flublok (March 2017); Flublok Quadrivalent (March 2017); FluMist (July 2016, NOTE: 2017 product information not available at time of publication).
  2. Cost provided is based on Wholesale Acquisition Cost (WAC) when available. WAC pricing was not available for all products therefore Average Wholesale Price (AWP) is provided for Flublok and Flublok Quadrivalent.

Project Leader in preparation of this clinical resource (331001): Beth Bryant, Pharm.D., BCPS, Assistant Editor

References

  1. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices – United States, 2017-18 influenza season. Updated August 24, 2017. https://www.cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm. (Accessed August 25, 2017).
  2. Dunkle LM, Izikson R, Patriarca P, et al. Efficacy of recombinant influenza vaccine in adults 50 years of age or older. N Engl J Med 2017;376:2427-36.
  3. 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.
  4. CDC. General recommendations on immunization recommendations of the Advisory Committee on Immunization Practices (ACIP): altered immunocompetence. Last updated April 20, 2017. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.pdf. (Accessed September 8, 2017).
  5. Domnich A, Arata L, Amicizia D, et al. Effectiveness of MF59-adjuvanted seasonal influenza vaccine in the elderly: a systematic review and meta-analysis. Vaccine 2017;35:513-20.
  6. CDC. Flu vaccine safety and pregnancy. Updated August 30, 2017. https://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm. (Accessed September 13, 2017).
  7. Zerbo O, Modaressi S, Chan B, et al. No association between influenza vaccination during pregnancy and adverse birth outcomes. Vaccine 2017;35:3186-90.
  8. CDC. Flu vaccination & possible safety signal. Updated September 13, 2017. https://www.cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html. (Accessed September 13, 2017).

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]

Cite this document as follows: Clinical Resource, Flu Vaccines for 2017-18. Pharmacist’s Letter/Prescriber’s Letter. October 2017.

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