Flu information for healthcare and public health professionals

Healthcare providers and local public health are instrumental in preventing and controlling the spread of influenza in Massachusetts.

Here are some important updates for this year:

2018–2019 Recommendation Highlights

  • During the 2017-2018 influenza season, the United States had record breaking levels of influenza illness.  Hospitalizations were of high severity in all age groups and geographically widespread for an extended period.  Last season, deaths in children (180) were the highest reported during a regular influenza season.
  • Influenza vaccines have been updated to better match circulating viruses (the B/Victoria component was changed and the influenza A/H3N2 component was updated).
  • Vaccine manufacturers have projected that they will supply as many as 163 to 168 million doses of influenza vaccine for the 2018-2019 season nationwide.  More than 80% of the doses will be quadrivalent.
  • For the upcoming 2018-2019 season, the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP), recommend routine annual influenza vaccination of all persons aged ≥6 months with any licensed, age-appropriate flu vaccine that is otherwise appropriate for the person’s health status. 
    • There will be many different vaccine choices, including inactivated influenza vaccines (IIV); recombinant influenza vaccine (RIV4) and live attenuated influenza vaccine quadrivalent (LAIV4) which is again an option this year (see section on ‘Recommendations for LAIV’ for more information).  No preferences are expressed for one influenza vaccine over another when more than one is appropriate.
    • High-dose inactivated influenza vaccine (HD-IIV3) and adjuvanted inactivated influenza vaccine (aIIV3) will be available in trivalent formulations for those 65 years and older.

For more information on this year’s flu recommendations:

2018-2019 Key Points

  • Vaccine viruses included in the 2018–19 U.S. influenza trivalent vaccines will be:
    • an A/Michigan/45/2015 (H1N1)pdm09–like virus
    • an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus, (NEW); and
    • a B/Colorado/06/2017–like virus (Victoria lineage) (NEW).
      Quadrivalent influenza vaccines will contain these three viruses and an additional influenza B vaccine virus:
    • a B/Phuket/3073/2013–like virus (Yamagata lineage).
  • New Formulations.
    • Fluarix. FDA lowered the minimum age for Fluarix from 3 years old to 6 months.  Fluarix is now approved as a 0.5 mL dose for everyone 6 months of age and older. 
      This licensure represents a 3rd option for children aged 6 through 35 months of age. 
      Remember, the dose volumes for these formulations are different.  Children in this age group may receive either:
    • Fluarix Quadrivalent: 0.5 mL; OR
    • FluLaval Quadrivalent: 0.5 mL; OR
    • Fluzone Quadrivalent:  0.25 mL dose.
      Care must be taken to administer the correct dose volume for each dose of the product used in this age group.  Dose volume is distinct from the number of doses neededA child aged 6 months through 8 years who needs 2 doses (for example a first time vaccinee) still needs a 2nd dose >4 weeks later, regardless of the dose volume (0.25 mL or 0.5 mL) of the first dose of vaccine.
  • Afluria. FDA lowered the minimum age for Afluria Quadrivalent (IIV4) from ≥18 years to ≥5 years.
  • Egg Allergy.
    Persons with a history of egg allergy of any severity may receive any licensed, recommended, and age-appropriate influenza vaccine (IIV, RIV4, or LAIV4).  IIV and RIV4 have been previously recommended.  Use of LAIV4 for persons with egg allergy was approved by ACIP in February 2016.
  • Recommendations for the use of LAIV4 have been updated.
    • In February 2018, the ACIP voted to recommend that for the 2018–19 season, vaccination providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, RIV4, or LAIV4). LAIV4 is an option for those for whom it is appropriate.
      The ACIP was presented data from the vaccine manufacturer about a new influenza A/H1N1 vaccine-strain virus for LAIV4, which has improved replication and shedding resulting in an improved immune response.  While there was not yet effectiveness data for LAIV containing the new A/H1N1, these other data are encouraging.  In addition, previous studies showed LAIV to have good effectiveness against influenza B viruses and generally did not differ from IIV against A/H3N2.
      Influenza vaccine effectiveness varies from season to season and is affected by many factors, including the age and health of the recipient, influenza type and subtype, prior influenza vaccination history and the degree of the match between the vaccine and the circulating strain.  However, product specific comparative effectiveness data are lacking for most vaccines.
      Although U.S. national influenza coverage during the 2016-2017 season among children did not decline substantially, there was decrease seen in those 5-12 years of age.  In MA, this decrease was seen in that same age group.  Coverage data from the 2017-2018 season is not yet available.  Overall vaccination coverage remains suboptimal and additional options for the use of non-injectable such as LAIV in some settings, like schools, might improve coverage. 
    • For the 2018-2019 influenza season, the American Academy of Pediatrics (AAP) recommends IIV as the primary choice for influenza vaccination for all children and adolescents 6 months of age and older.  LAIV4 may be used for children who would not otherwise receive an influenza vaccine (e.g., refusal of an IIV) and for whom it is appropriate according to age. (i.e., 2 years of age and older) and health status (i.e., healthy and without any underlying chronic medical condition).
      The American Academy of Family Physicians similarly will be recommending IIV as preferred to LAIV.
  • Differences in the ACIP recommendations and the AAP’s recommendations.
    • ACIP make no preferential recommendation for any one vaccine type over another;
    • AAP recommend IIV as the primary choice for children.
  • Shared Principles and Goals.
    The CDC and AAP recommendations share the same principle that influenza vaccination is an important preventive strategy.  They also share the same goal of increasing influenza vaccination coverage to protect as many individuals as possible.
    • The burden of disease is great.  CDC estimates that influenza has resulted in between 9 million and 36 million illnesses, between 140,000 and 710,000 hospitalizations and between 12,000 and 56,000 deaths annually since 2010.

The good news is this year’s influenza vaccines have been updated to better match circulating viruses and there are many formulations to choose from.

Your Strong Recommendation is Important!
A health care provider’s strong recommendation is a critical factor affecting whether your patent gets influenza vaccine.  Patients listen to providers when providers strongly recommend vaccination. Below are some data that might inform your conversations with patients in the upcoming months:

  • Flu vaccine offers the best protection against flu-related illness, hospitalization, and death. During the 2016–2017 season, vaccination prevented an estimated 5.3 million illnesses, 2.6 million medical visits, and 85,000 influenza-associated hospitalizations.  When more people get vaccinated against the flu, less flu can spread through the community.
  • Influenza vaccination was found to reduce deaths in children. A study in Pediatrics was the first of its kind to show that influenza vaccination is effective in preventing influenza-associated deaths among children. As of August 25, 2018, a total of 180 pediatric deaths had been reported to CDC during the 2017-2018 season. This number exceeds the previously highest number of flu-associated deaths in children reported during a regular flu season (171 during the 2012-2013 season). Approximately 80% of these deaths occurred in children who had not received a flu vaccination.
  • Influenza vaccination may make illness milder. While some people who get vaccinated may develop influenza, vaccination may make their illness milder. A 2017 study in Clinical Infectious Diseases (CID) showed that influenza vaccination reduced deaths, intensive care unit (ICU) admissions, ICU length of stay, and overall duration of hospitalization among hospitalized influenza patients.

For more information on questions and answers related to this flu season, please see the Flu Highlights 2018-2019 website.

Massachusetts Resources

Control of Influenza and Pneumococcal Disease in Long-Term Care Facilities (DOC) discusses specific recommendations for long-term care residents and staff as well as other vaccines applicable to this population.

In addition, the Flu Guide for Diverse Communities (DOC) is an outreach guide to help health department or community-based organizations truly reach the communities that need flu vaccine.

Vaccine Supply

For the 2018-2019 season, manufacturers projected they would provide between 163 million and 168 million doses of influenza vaccine nationwide.  MDPH universally provides influenza vaccine, as well as other routinely recommended vaccines, to all children through 18 years of age. MDPH only provides influenza vaccine for uninsured adults seen at public sites. For more information on state-supplied vaccine, please see the Vaccine Management website. MDPH created a table outlining the current state-supplied influenza formulations (DOC) to ensure you are using the age appropriate formulation and dose for the person you are vaccinating.

When to Vaccinate

Optimally, vaccination should occur before onset of influenza activity in the community. We recommend vaccination by the end of October, if possible. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health care visits and hospitalizations when vaccine is available. Vaccination efforts should continue throughout the season because the duration of the influenza season varies and influenza activity might not occur in certain communities until February or March. Vaccine administered in December or later is likely to be beneficial even if given after the influenza season has begun. In New England, flu activity usually lasts until April and May.

Safe Vaccine Administration

When you “know the site and get it right,” you can help prevent one type of vaccine administration error—shoulder injuries such as deltoid bursitis—generally caused when vaccines are injected high on the shoulder and the needle enters a shoulder bursa. This is an error reported to occur mostly among adults. CDC provides comprehensive vaccine administration resources on their Vaccine Administration website.

Vaccine Information Statement

The inactivated influenza vaccine information statement (VIS)  developed in August 2015 remains applicable and will be used again this season.

Vaccine Guidelines and Tools

This page contains standing orders, screening forms, consent forms, vaccine information sheets (VIS), and other resources.

Infection Control, Testing, and Surveillance

This page contains information on infection control, testing, and surveillance, including the blog link to the weekly flu reports.

Information for School and Childcare Professionals

This page contains educational materials for parents, CDC pages for schools and influenza, information on running school-based vaccination clinics, and other helpful information.

Avian Flu

This page contains frequently asked questions about avian influenza, avian influenza in humans, avian influenza in birds, and additional resources.