INFLUENZA VACCINE 2015-2016

Mark H. Sawyer MD

UCSD School of Medicine/Rady Children’s Hospital San Diego

San Diego Immunization Partnership

DISCLOSURES

I have no financial disclosures to make related to this

presentation

My family and I are fully immunized

I already received my influenza vaccine this year

OBJECTIVES

Explain how influenza strains get their names and why you care

Explain the differences between available influenza vaccines so that you can choose the best vaccine for your patients

Describe how we measure influenza vaccine effectiveness so that you can convince your patients that it is not a terrible vaccine

Provide a summary of the effectiveness of the 2014-2015 influenza vaccines so that you will be prepared to compare it to this year's vaccine

Describe what is different about the use of influenza vaccine in children so that you Immunize them correctly

Tell your colleagues how we are doing immunizing our community with influenza vaccine so that they will try harder to get all their patients immunized

INFLUENZA ON EARTH-WHY DUCKS MATTER

Influenza Viral Nomenclature

1. CDC. Atkinson W, et al. Chapter 13: Influenza. In: Epidemiology and Prevention of Vaccine-Preventable Diseases, 4th ed. Department of Health and Human Services, Public Health Service, 1998, 220

A / Sydney / 184 / 93 (H3N2)

Type of Nuclear Material

Virus type

Geographic origin

Strain number

Year of isolation

Hemagglutinin

Virus subtype

Neuraminidase

2015-2016 INFLUENZA VACCINE STRAINS?

THIS?

A/California/7/2009 (H1N1)

A/Texas/50/2012 (H3N2)

B/Massachusetts/2/2012-like (Yamagata)

B/Brisbane/60/2008-like (Victoria)

OR THIS?

A/California/7/2009 (H1N1)

A/Switzerland/9715293/2013

(H3N2)

B/Phuket/3073/2013 (Yamagata)

B/Brisbane/60/2008 (Victoria)

2014-2015 INFLUENZA VACCINES

INFLUENZA VACCINES HOW DO YOU KEEP THEM STRAIGHT?

Is it trivalent or quadrivalent?

Is it injectable or nasal?

Is it made in eggs or in cell culture?

Is it a special product?

What are its age restrictions?

Who makes it/brand name?

IS IT TRIVALENT OR QUADRIVALENT?

Currently there are 4 quadrivalent IIV vaccines expected for

2015-2016.

There are 3 trivalent IIV vaccines that are standard dose and are

not special products or cell culture based

Fluzone (Sanofi) comes in both quadrivalent and trivalent

formulations

LAIV only available as quadrivalent

IS IT INJECTABLE OR NASAL?

IIV-injectable influenza vaccine

o Includes both trivalent (IIV3) and quadrivalent (IIV4) vaccines

o Includes cell culture vaccines

o Includes high dose and intradermal

LAIV-live attenuated influenza vaccine

o Only quadrivalent (LAIV4)

o Only one manufacturer

IS IT MADE IN EGGS?

All are except FluBlok/Protein Sciences Corp and

Flucelvax/Novartis

Flublok is a recombinant vaccine (like Hep B vaccine) and may

be referred to as RIV

Flucelvax is a whole virus vaccine but made in cells and may be

referred to as ccIIV

IS IT A SPECIAL PRODUCT?

IIV High dose-Fluzone High Dose/Sanofi

o Recommended for those 65 years of age and over

o More antigen

o More local side effects

o Slightly better effectiveness in seniors

IIV Intradermal-Fluzone Intradermal/Sanofi

o Licensed for 18-64 years of age

HIGH DOSE INFLUENZA VACCINE

• One industry sponsored randomized trial

• Outcome=laboratory confirmed influenza

• High dose vaccine did decrease study-defined ILI

• No difference in hospitalization rate, pneumonia rate, or exacerbation of cardiopulmonary disease

• ACIP recommendations state no product preference

Diazgranados, N Engl J Med 2014; 371:635

WHAT ARE THE AGE RESTRICTIONS?

Vaccine >6 mon

>3 yrs

>4 yrs

>5 yrs

>18 yrs

2-49 yrs

18-49 yrs

18-64 yrs

>65 yrs

Fluzone/Sanofi X

Fluarix/GSK X Fluvirin/Novartis X

Afluria/CSL X Agriflu/Novartis X

Flucelvax/Novartis X

FluLaval/ID Biomed X

FluMist/MedImmune

X

FluBlok/Protein Sciences

X

Fluzone-Intradermal X

Fluzone-High dose X

CDPH VACCINE TABLE

EZIZ.ORG

CDPH VACCINE TABLE

EZIZ.ORG

CDPH VACCINE TABLE

EZIZ.ORG

INFLUENZA 2014-2015:IT WASN’T A VERY GOOD YEAR

http://www.cdc.gov/flu/weekly/

http://www.cdc.gov/flu/weekly/

http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2015-06/flu-02-flannery.pdf

CDC.GOV/Vaccines

INFLUENZA VACCINE DIDN’T WORK VERY WELL IN 2014-2015

INFLUENZA VACCINE EFFECTIVENESS DEPENDS ON:

How you decide if someone has influenza

What population you study-most vaccines work less well in the very young

and very old

What you mean by effective:

Prevents death

Prevents hospitalization

Prevents a visit to the doctor or emergency rom

Prevents any symptoms

WHAT IS EFFECTIVENESS?

The same vaccine could be:

100% effective at preventing death

80% effective at preventing hospitalization

60% effective at preventing you from having symptoms and a

positive test for influenza

40% effective at preventing an illness that looks like influenza

20% effective at preventing transmission

IN 2014-2015 INFLUENZA VACCINE WORKED BETTER FOR INFLUENZA B TYPES

Flannery-ACIP presentation February 2015

Flannery-ACIP presentation February 2015

LAIV DIDN’T WORK LAST YEAR!

HOW WELL DOES INFLUENZA VACCINE WORK?

Overall effectiveness

50-70% in healthy adults

< 65 years of age

60% ISN’T VERY GOOD !?!

60% protection from a potentially deadly infection is much better than 0!

EFFECTIVENESS OF THE INTRANASAL INFLUENZA VACCINE FOR CHILDREN

LIVE ATTENUATED INFLUENZA VACCINE (LAIV): CDC 2014-2015 RECOMMENDATION

Preferential use of LAIV over IIV for children 8 years and younger based on older studies that showed better effectiveness

No change in recommendation for older children and adults

Emphasis on not missing opportunities if a provider doesn’t have LAIV

So give what you have but if you have both give LAIV

But wait!!! At the end of the 2013-2014 season…..

MMWR August 15, 2014 / 63(32);691-697

LAIV VACCINE EFFECTIVENESS 2013-2014

29 http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2014-10/flu-03-flannery.pdf

Data showing LAIV ineffective in young children-June 2014

Previous data showed the opposite

Recommendation for 2014-2015 had to be made in June 2014

IT’S TOUGH TO MAKE PREDICTIONS, ESPECIALLY ABOUT THE FUTURE.

Yogi Berra

LAIV NOT VERY EFFECTIVE IN 2014-2015 EITHER

Flannery-ACIP presentation February 2015

RECOMMENDATIONS FOR 2015-2016

If you’ve seen one influenza season, you’ve seen one influenza season

Continued recommendation for routine immunization of all children

No preference for either IIV or LAIV for this coming flu season

2-doses required for vaccine-naïve children under 9 years of age

Stay tuned for more information on LAIV effectiveness

BASIC INFLUENZA VACCINATION RULES FOR CHILDREN <9 YEARS OF AGE

Need to have had 2 doses of influenza

vaccine to prime the immune system

Now that pandemic H1N1 strain has

been in the vaccine since 2010 we no

longer need to specifically ask about it

Effectiveness of 1 dose is <20%

Everyone 6 months of age and

older!

WHO SHOULD GET A FLU VACCINE?

Table 3. Flu Vaccination Coverage* by Age Group, Adults 18 years and older, United States,† 2014–15 Season Age Group Unweighted

Sample Size %‡ ± 95% CI§ Difference from

the 2013-14 Season ± 95%

CI

≥18 years 323,215 43.6 ± 0.4 1.4 ± 0.6|| 18−64 years 208,124 38.0 ± 0.6 1.3 ± 0.8|| 18−64 years at high risk¶

53,795 47.6 ± 1.2 1.3 ± 1.6

18−64 years not at high risk

152,107 35.3 ± 0.6 1.4 ± 0.8||

18−49 years 105,619 33.5 ± 0.8 1.2 ± 1.0|| 18−49 years at high risk

18,269 39.3 ± 1.8 0.6 ± 2.5

18−49 years not at high risk

86,101 32.6 ± 0.8 1.5 ± 1.1||

50−64 years 102,505 47.0 ± 0.8 1.7 ± 1.0|| ≥65 years 115,091 66.7 ± 0.8 1.7 ± 1.0||

Table 2. Flu Vaccination Coverage* by Age Group, Children 6 months–17 years, United States,† 2014–15 Season

Age Group Unweighted Sample Size

%‡ ± 95% CI§ Difference from the 2013-14

Season ± 95% CI

6 months−17 years 128,143 59.3 ± 0.8 0.4 ± 1.1

6 months−4 years

37,626 70.4 ± 1.3 0.0 ± 1.8

6−23 months 14,126 74.6 ± 1.9 0.3 ± 2.8

2−4 years 23,500 67.8 ± 1.7 -0.3 ± 2.5 5−17 years 90,517 55.8 ± 0.9 0.5 ± 1.3 5−12 years 59,075 61.8 ± 1.1 0.8 ± 1.6

13−17 years 31,442 46.6 ± 1.4 0.2 ± 2.1

WHO GOT THEIR INFLUENZA VACCINE LAST YEAR?

http://www.cdc.gov/flu/fluvaxview/coverage-1415estimates.htm

IMMUNIZATION OF YOUNGER ADULTS PROTECTS SENIORS

Taksler, Clin Infect Dis 2015

HEALTHCARE PERSONNEL INFLUENZA VACCINATION 2010-2015

MMWR 2015; 64:1000-1005

WHY HCWS DO OR DO NOT GET INFLUENZA VACCINE

MMWR 2011; 60:1073-1077

INFLUENZA VACCINE DURING PREGNANCY

CHANGES IN PREGNANCY THAT INCREASE RISK OF INFECTION

Gestation Risk of Hospitalization

1st trimester 7.6/10,000 2nd trimester 15.8/10,000 3rd trimester 26.2/10,000

Modulation of immune

response

Expansion of vascular volume

Decreased lung capacity

Increased oxygen

consumption

Neuzil et al Am J Epidemiol. 1998; 148:1094-1102

IMMUNIZATION OF PREGNANT WOMEN PROTECTS THEIR BABIES

316 mother-infant pairs in Bangladesh in 2004-2005

Mothers immmunized randomly with influenza vaccine or pneumococcal vaccine

63% vaccine effectiveness in

preventing lab-confirmed

influenza in babies

36% reduction in febrile respiratory

illness in mothers Zaman, N Engl J Med 2008; 359

INFLUENZA COVERAGE RATES DURING PREGNANCY

MMWR 2015; 64:1000-1005

I CAN’T GET A FLU SHOT BECAUSE I’M ALLERGIC

TO EGGS….

WRONG!

INFLUENZA VACCINE IN EGG ALLERGIC INDIVIDUALS

CDC.GOV/FLU

SUMMARY

Influenza vaccine and circulating strains of influenza virus change over time

There are multiple influenza vaccines on the marker, some for special characteristics and

intended for specific populations

Influenza vaccine did not work well in 2014-2015

Partial protection from influenza is better than no protection

We can do better at immunizing our community

Pregnant women and healthcare personnel especially need influenza vaccine

WHERE TO GO FOR MORE INFORMATION

San Diego HHSA Immunization Branch (SDIZ.org)

California Department of Public Health (www.cdph.ca.gov)

CDC (cdc.gov/vaccines)

EXTRA SLIDES

WHAT YOU HEAR ABOUT INFLUENZA VACCINE

Influenza vaccine doesn’t work

Influenza vaccine makes me sick

Influenza isn’t that big a deal

Influenza vaccine shouldn’t be

given to pregnant women

LAIV (nasal flu vaccine) can’t be used in healthcare workers because they

might spread the virus

COMMON REACTIONS TO INFLUENZA VACCINE

Usually only seen the first time you are immunized

Begin 6-12 hours after immunization

Mostly local pain and swelling

Do not last more than 2 days

Do not include cough CDC NIP Web site http://www.cdc.gov/flu/professionals

COMMON SYMPTOMS AFTER AN LAIV

Children

Runny nose (48% vs 44% in placebo)

Headache (18% vs 12%)

Vomiting (5% vs 3%)

Myalgia (6% vs 4%)

4 fold increase in wheezing in one study.

Not seen in other studies

Adults

Runny nose (45% vs 27%)

Sore throat (28% vs 17%)

Chills (9% vs 6%)

Tiredness (26% vs 22%)

MMWR 2008 Jul 17; Early Release:1-60.

VACCINE WHO SHOULD NOT RECEIVE IT? Those under 2 and over 50 years of age

Those with underlying health conditions

o Heart and lung disease

o Diabetes

o Asthma

o Immunosuppression

2-4 year old children with wheezing

Pregnant women

USE OF LAIV AMONG CLOSE CONTACTS OF HIGH RISK PERSONS

Inactivated influenza vaccine is preferred for close contacts of severely

immunosuppressed persons who require care in a protective environment

Persons who receive LAIV should refrain from contact with severely

immunosuppressed persons for 7 days after vaccination

Persons who receive LAIV do not need to be excluded from visitation of

patients who are not severely immunosuppressed

MMWR 2007;56 (RR-6)

FOLLOW YOUR HEALTHCARE WORKER’S EXAMPLE