Influenza Vaccine Review

Colleen Terriff, PharmD, BCPS (AQ-ID), AAHIVP

Clinical Associate ProfessorWSU College of Pharmacy

Spokane, WashingtonOctober 2013

Objectives• Given a case be able to state:

• Vaccine dose• Timing with other vaccines

• Differentiate:• trivalent, quadrivalent• live, inactivated• IM, ID, intranasal• standard-dose, high-dose• recombinant, cell-culture, egg-based

New Guidelines

• CDC. (2013). Summary* Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- (ACIP)- United States, 2013-14. [Online] Available from: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm (Accessed: August 15, 2013)

Influenza• Respiratory pathogenRespiratory pathogen• ZoonoticZoonotic• Primary viral pneumoniaPrimary viral pneumonia• Other complications:Other complications:

– Infectious Diseases:Infectious Diseases:• PneumoniaPneumonia

– secondary bacterial (Staph and secondary bacterial (Staph and Strep)Strep)

• Sinusitis and otitis media Sinusitis and otitis media – Neurological:Neurological:

• Reye syndrome, Reye syndrome, encephalitis, seizuresencephalitis, seizures

– Myocarditis and Myocarditis and pericarditispericarditis

– Others:Others:• Dehydration, worsening of Dehydration, worsening of

chronic med conditionschronic med conditions

Seasonal Influenza Stats• Hospitalization rates (1% of infected):1

– 226,000/year (mean)

• Deaths:1

– 34,000/year (mean)– highest risk:

65 years and < 5 years• medical condition putting pt at complication risk

• 2010-20112

– Peak activity- early February– Higher hospitalization rates ≥ 65 years– Outpatient visits for ILI lower than 2009-2010

pandemic1. Centers for Disease Control and Prevention. Prevention and Control of Influenza.

Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Morb Mortal Wkly Rep 2007;56:1-60.

2. CDC (2011). ‘Update: influenza activity– United States, 2010-11 season, and composition of the 2011-2012 influenza vaccine’ [Online} Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6021a5.htm#Fig1 [Accessed: 13 July 2011]

Influenza Strains• Type A (70-80%)

– 16 hemaglutinin (H); 9 neuraminidase (N)– moderate to severe illness– all age groups– humans and other animals

• Type B (20-30%)– milder epidemics (usually)– humans only– primarily affects children

• Type C– rarely reported in humans– no epidemics or significant disease

CDC. (2011). ‘Chapter 11: influenza’ Pink Book. 12th ed. [Online] Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf. (Accessed: 9 March 2012).

CDC. (2013). ‘2012-2013 influenza season week 20 ending May 18, 2013.’ [Online] Available from: www.cdc.gov/flu/weekly. (Accessed: 29 May 2013).

Change of Influenza• Antigenic drift:

– gradual mutation– may result in epidemic; widespread illness– A/Panama/2007/1999 (H3N2) 2002-2003 replaced by– A/Fujian/411/2002 (H3N2) in late 2003- widespread

• Antigenic shift:– more precipitous genetic recombo of 2 different

strains– occurs at unpredictable intervals; pandemic may

result– In 1957-67 H2N2 virus circulated– In 1968 H3N2 virus appeared and replaced H2N2

virus

Influenza Season• Northern hemisphere (i.e. U.S.):

– Oct to March

• Southern hemisphere:– April-Sept

• Tropics:1

– year-round; epidemics intermediate months

• Pandemics:– waves can occur outside of season– i.e. new strain appeared in April 2009 (1st

wave)

1. Viboud C, Alonso WJ, Simonsen L. (2006). Influenza in tropical regions. PLoS Med 3(4): e89. 10.1371/journal.pmed.0030089.

Month of Peak Influenza Activity United States, 1976-

2008

0

5

10

15

20

25

30

35

40

45

50

Nov Dec Jan Feb Mar Apr May

Pe

rce

nt

CDC. (2011). ‘Chapter 11: influenza’ Pink Book. 12th ed. [Online] Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf. (Accessed: 9 March 2012).

Spread of Influenza• Primary:Primary:

– inhale droplets (sneezing, coughing, inhale droplets (sneezing, coughing, talking)talking)

– up to 6 ft awayup to 6 ft away

• Minor:Minor:– direct contactdirect contact– indirect contact (possibly):indirect contact (possibly):

• stethoscope- hospitalstethoscope- hospital• computer keyboards, phonescomputer keyboards, phones

Influenza Clinical Features• Time from infection to symptoms:Time from infection to symptoms:

– 2 days (range 1-4 days)2 days (range 1-4 days)• Some patient have little/no symptomsSome patient have little/no symptoms• Abrupt onset (symptoms last 2-5 Abrupt onset (symptoms last 2-5

days):days):– fever (low or high grade)fever (low or high grade)– coughcough– sore throatsore throat– shortness-of-breathshortness-of-breath– myalgiamyalgia– headacheheadache– malaisemalaise– rhinitis or stuffy noserhinitis or stuffy nose– vomiting and diarrhea (25% pts have GI vomiting and diarrhea (25% pts have GI

symptoms)symptoms)CDC (2011). ‘Questions and answers: seasonal influenza’ [Online] Available from: http://www.cdc.gov/flu/about/qa/disease.htm (Accessed: 13 July 2011).

Who are We Worried About?

• Children < 5, esp. <2 yrsChildren < 5, esp. <2 yrs• PregnantPregnant• Elderly (Elderly (>>65 years)65 years)• Chronic medical conditions:Chronic medical conditions:

– Pulmonary (asthma, COPD, cystic fibrosisPulmonary (asthma, COPD, cystic fibrosis– Neurological/neurodevelopment conditionsNeurological/neurodevelopment conditions– Heart diseaseHeart disease– Blood, endocrine, kidney, liver, metabolic Blood, endocrine, kidney, liver, metabolic

disordersdisorders– Weakened immune systemWeakened immune system– Persons < 19 yrs on long-term aspirin Persons < 19 yrs on long-term aspirin

therapytherapy

CDC. (2009). Use of Influenza A (H1N1) 2009 Monovalent Vaccine. MMWR. August 28, 2009;58. [Online] Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm.

ACIP Recs- Influenza

CDC. (2013). ‘ACIP recommended adult immunization schedule for adults aged 19 years and older- United States, 2013’ [Online] Available from: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/mmwr-adult-schedule.pdf (Accessed: 25 March 2013)

Flu Vaccines

ACIP Influenza Vaccine Recommendation

• Previously CDC has vaccine priority groups.Previously CDC has vaccine priority groups.– focus of campaignsfocus of campaigns– tiers of priorities (subgroups) when vaccine shortagetiers of priorities (subgroups) when vaccine shortage

• Historically vaccine uptake in recommended Historically vaccine uptake in recommended groups- <50%groups- <50%

• 19-49 yr olds were hit hard by 2009 H1N1 virus19-49 yr olds were hit hard by 2009 H1N1 virus• All people ages 6 months and older!All people ages 6 months and older!• Vaccination message becomes simple and clearVaccination message becomes simple and clear• Still need to focus on high risk groupsStill need to focus on high risk groups

CDC. (2010). ‘Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011’ [Online] Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm?s_cid=mm6033a3_w (Accessed 9 Mar 2012)

Seasonal Influenza Vaccines

• Yearly vaccination (and as needed for pandemics)

• Contains 3 (tri) or 4 strains (quad):– 2 A (H3N2, H1N1) and 1 or 2 B

• 10-14 days for antibodies to develop• May contain small amount of egg protein• Peds (6 months to ≤ 8 yrs):

– 1st vaccination- 2 doses (at least 1 month apart)

• Decreased efficacy in high-risk groups:– i.e. elderly, nursing home patients,

immunocompromised

Formulations• Standard-dose, inactivated• Nasal influenza spray, live• High-dose, inactivated• Intradermal, inactivated• Quadrivalent, live and inactivated• Egg-free (recombinant, cell-culture)

Vaccine Acronyms

• Past:– TIV: Trivalent

Influenza Vaccines– LAIV: Live

Attenuated Influenza Vaccine

• Now– IIV: Inactivated

Influenza Vaccine:• IIV3- trivalent• IIV4- quadrivalent

– LAIV3 vs. LAIV4– RIV: Recombinant

Influenza Vaccine– CC: Cell-Culture

Vaccine Matching Process

• WHO surveillance:– year-round– 180 labs: 110 National Influenza Centers

plus others; 83 countries

• Some virus isolates sent to CDC:– determine antigenic, molecular make-up

• FDA, WHO and CDC (Jan-March) decide strains for vaccine production

• Manufacture: eggs to vaccine (Aug/Sept)

• Match: at best- 90% (over the years)

Influenza B Mismatch• 2 lineages:

– B/Yamagata– B/Victoria

• 1999-2000 to 2008-2009 seasons– 5 seasons vaccine B strain did not match

seasonal strain– 2007-2008:

• nearly 30% B- 98% not vaccine lineage• 1.1 million fewer cases, 7,500 fewer

hospitalizations, 300 fewer deathsCDC. (2012). ‘Public health impact of including two influenza B strains in seasonal influenza vaccines’ [Online] Available from: http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2012/05-influenza-reed.pdf (Accessed: August 15, 2013).

2013-2014 Seasonal Flu Vaccine

• WHO and FDA have recommended that the influenza vaccine for the Northern Hemisphere contain:– A/California/7/2009 (H1N1)- like– A/Victoria/361/2011 (H3N2)- like– B/Massachusetts/2/2012- like (trivalent)-

Yamagata– B/Brisbane/60/2008 – like (quadrivalent)- Victoria

CDC. (2013). Summary* Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- (ACIP)- United States, 2013-14. [Online] Available from: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm (Accessed: August 15, 2013)

IM Flu Vaccines• Killed (inactivated)

virus• Different approved age-

groups for different products

• Single use syringes/vials, multi-dose vials

• Gently shake• Dosing:

– 0.25 mL IM 6-35 months– 0.5 mL IM ≥ 36 months

• Side effects:– injection site reaction– fever (low grade)– aches

Immunocompromised Patients

HIV+• Data:

– adults children, pregnant women, HIC, LIC– LAIV and IIV– Standard dose vs. HD; IM vs. ID;

• Trends:– Lower vaccine response patients CD4+

<200– Lower responses in HIV+ compared to HIV-

Intradermal: Data in HIV+

• Patients:– Immunocompromised (IC): RA (anti-TNF

txment), HIV+, and stem cell (HSCT)– Controls (HC): healthy

• Safety and efficacy• Vaccine- IIV trivalent, InfluvacTM:

– IM: left deltoid (15 µg each strain); G not reported

– ID: forearm, palmar side (3 µg each strain) 29G insulin syringe

• Samples day 0 and day 28:– GMT– Protection rates: % titer >1:40 (HI)

Gelinck, L., et al. (2009). Intradermal influenza vaccination in immunocompromised patients is immunogenic and feasible. Vaccine. 27. pp. 2469-2474.

ID HIV+ Data Continued• Funding: LUMC, Netherlands• Response (efficacy):

– ID similar GMT as IM in all 4 groups– GMT: HC > anti-TNF > HIV+ > HSCT– % >1:40: HC > anti-TNF > HIV+ > HSCT– Poorest response: HIV+ CD4 <200, HSCT within

past 11 months• Safety:

– IM: muscle pain, fever 11-48%– ID: transient painless erythema– Local reactions: ID > IM; HC > IC

Gelinck, L., et al. (2009). Intradermal influenza vaccination in immunocompromised patients is immunogenic and feasible. Vaccine. 27. pp. 2469-2474.

Gelinck, L., et al. (2009). Intradermal influenza vaccination in immunocompromised patients is immunogenic and feasible. Vaccine. 27. pp. 2469-2474.

IM ID

Fluzone-HD• Quad-strength, trivalent, inactivated flu vaccine• For 65 years and older (option)• Addressing need- lower response rate in elderly• Dose: 0.5 mL IM x 1• Efficacy:

– Superiority endpoints met for antibody responses to H1N1 and H3N2 (non-inferior for B) vs. standard dose

– Clinical trials terminated early- lack of cases (2009/10)

• Side effects: higher % injection site reactions compared to standard dose

1. Sanofi Pasteur Inc. (2012). Fluzone® High-Dose (influenza Virus Vaccine). [Online] Available from: http://www.fda.gov/downloads/biologicsbloodvaccines/.../ucm195479.pdf. (Accessed: 1 April 2013)

2. ClinicalTrial.gov. (2012). ‘Multi-year study of Fluzone High-Dose influenza vaccine compared with Fluzone vaccine in adults aged 65 years and old’ [Online] Available from: http://clinicaltrials.gov/ct2/show/NCT00976027 (Accessed: 1 April 2013)

Fluzone® Intradermal• 18-64 years of age• 0.1 mL intradermal• Trivalent (2A, 1B)• Microinjection system• Injection site reactions:

– less local pain and bruising than IM– but more local inflammatory reactions

(redness, swelling) than IM

• Systemic rxns:– similar in frequency and severity as IM (yet,

less myalgia)Fluzone®; Fluzone® High-Dose, Fluzone® Intradermal Package Insert (2011). Available from: http://www.fda.gov/downloads/biologicsbloodvaccines/.../ucm195479.pdf. [Accessed: 13 July 2011]

Flumist™ • Intranasal (spray), single-use• Quadrivalent (IIV4) for 2013-2014• Refrigerate• Live, attenuated, cold-adapted virus• Healthy children and adults (2-49 yrs):• Dose:

– 0.1 mL in 1 nostril; then 0.1 mL in other• Large list of contraindicated patients• Side effects:

– runny or stuffy nose– headache– sore throat– cough

Quadrivalent (QIV)• Available for 2013-2014 season• 2 influenza A strains (i.e. H1N1, H3N2)• 2 influenza B strains (i.e. Yamagata,

Victoria)• Current products:

– FluMist Quad (approved Feb 29, 2012): 2- 49 yrs.

– Fluarix Quad (approved Dec 14, 2012): ≥ 3 yrs.

– Fluzone Quad (approved Jun 3, 2013): ≥ 6 months

FDA. (2013). ‘Influenza virus vaccine, quadrivalent, types A and types B’ [Online] Available from: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm295057.htm (Accessed: 25 April 2013)

FluBlok®

• Approved Jan 16, 20131

• 18-49 years of age1,2

• Trivalent, recombinant HA (RIV3), egg-free2

• Advantages:1,2

– Faster start-up (i.e. response to new strain)– Egg-free (safe for severely allergic patients?)– Highly-purified, preservative, antibiotic,

adjuvant-free

• Disadvantage:1

– Shorter shelf-life (16 weeks from production)1. CDC. (2013). ‘Flublock seasonal influenza (flu) vaccination’ [Online] Available from:

http://www.cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm (Accessed: 25 March 2013)2. PR Newswire. (2013). ‘U.S. FDA approves Flublok®, the world’s first recombinant, highly purified, egg-free

influenza vaccine’ [Online] Available from: http://www.prnewswire.com/news-releases/us-fda-approves-flublok-the-worlds-first-recombinant-highly-purified-egg-free-influenza-vaccine-187206411.html (Accessed: 25 March 2013)

Flucelvax®

• Cell-culture based vaccine (animal cells)

• Miniscule amount of egg protein• Seed virus grown in eggs• IIV trivalent• ≥ 18 years• Similar advantages as recombinant

vaccine• Assess egg allergy history…

FDA. (2013). ‘FDA approves first seasonal influenza vaccine manufactured using cell culture technology.’ [Online] Available from: http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm328982.htm (Accessed: 10 Sept 2013)

Egg Allergies

CDC. (2013). Summary* Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- (ACIP)- US, 2013-14. [Online] Available from: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm (Accessed: Aug 15, 2013)

Flu and Other Vaccines• Inactivated vaccines OK with:

– other inactivated vaccines– live vaccine

• LAIV OK simultaneously with:– inactivated or– other live vaccines

• After live vaccine administered:– wait ≥ 4 weeks before another live

vaccine givenCDC. (2013). Summary* Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- (ACIP)- US, 2013-14. [Online] Available from: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm (Accessed: Aug 15, 2013)

Flu Vaccine and Antivirals

• Inactivated vaccine + flu antivirals OK

• Live vaccine 48 hours after antiviral completion

• Repeat vaccine (as above) if antivirals:– 2 days prior or– within 2 weeks of live vaccine

CDC. (2013). Summary* Recommendations: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices- (ACIP)- US, 2013-14. [Online] Available from: http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm (Accessed: Aug 15, 2013)

Injectable Vaccination Sites

• IM 6- 11 months- anterolateral aspect of thigh

• IM ≥ 12 months- deltoid

• Intradermal- deltoid

Pediatric Flu “Numbers” Game

Situation AgeYears

Comments

AL thigh < 1 Also < 3½ dose < 3 0.25 mLBooster < 9 First

time; new

strain

Vaccine Concerns and Misconceptions

Pediatric Concerns• FluMist (LAIV):

– 2-4 year olds with asthma or history of wheezing (recurrent or within past 12 months) use injectable

• Afluria:– although indicated ≥ 5 years old– wait until >8 years; due to risk in

febrile reactions

• Options:Age Trivalent Quad

6-35 months Fluzone Fluzone Quad

≥ 3 years Fluarix Fluarix Quad

Flu Vaccine Myths• “I’ve never gotten the flu.”

– 10% population infected/year– flu mutates!!!

• “I got sick right/flu after the flu shot.”– killed or ineffective/weakened virus– can not get influenza from vaccine– might have had an immune reaction– might have already been in the throws of

illness or flu already (2 weeks to protect)

Why get Vaccinated?• Direct protection:

– pediatric influenza-related mortality and increase in Staph. aureus co-infection1

• 2004-2005 1 in 47; 2005-2006 3/46; 2006-2007 22/73 deaths associated with S. aureus (58%- MRSA)

– elders, immunocompromised, unvaccinated…

• Indirect protection/vectors:– daycares/schools, healthcare facilities

• Protect your hearts (secondary CV protection)2

1. CDC (2008). ‘Key points: Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus co-infection’ [Online] Available from: http://www.preventinfluenza.org/newsletters/PediatricsKeyPoints.pdf [Accessed: 13 July 2011]

2. AHA/ACC. Influenza vaccination as secondary prevention for cardiovascular disease. Circulation. 2006;114:1549-53.

Secondary CV Prevention• FLUVASC (Flu Vaccine in ACS)

– 301 hospitalized patients (MI or planned angioplasty/stent) randomized:• vaccine (IM) or no vaccine

– Results:• CV mortality: 2% vs. 8% (RR 0.25; CI 0.07-

0.86) at 1 yr.• composite (CV death, nonfatal MI or severe

ischemia): 11% vs. 23% (RR 0.59; CI 0.3- 0.86) at 1 yr

• Other evidence: 3 cohorts

AHA/ACC. (2006). Influenza vaccination as secondary prevention for cardiovascular disease. Circulation. 114:1549-53.

Healthcare Personnel Vaccination Rates and Issues• High risk for acquiring infection1

• Exposed to pts at greatest risk of developing complications (we are vectors!)1

• Annual influenza vaccination rates- 42%1

• Rate varies:2

– level of training, occupational group, and type of facility

• Reported barriers:2

– fear of vaccine side effects, inconvenience, perceived ineffectiveness of the vaccine, and perceived low personal risk for infection

1. APIC Position Paper: Influenza immunization of healthcare personnel. 2008 APIC Public Policy Committee. Nov 7, 2008. Available at: http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Topics/Influenza/APIC_Position_Paper_Influenza_11_7_08final_revised.pdf.

2. Health Care Providers and Influenza Vaccination. EpiTrends. Feb 2006. Available at: http://www.doh.wa.gov/ehsphl/epitrends/06-epitrends/06-02-epitrends.pdf.

Mandatory Vaccination HCW

• Loyola University Medical Center, IL• Goal: 100% vaccination rate (prior: 65%)• Reasons: medical (i.e. egg allergies),

religious• Requirement:

– Condition of employment– Official exemption:

• Letter from doctor, pastor/priest/rabbi/guru• plus phone number for further discussion

• Result: 99%; rest- exempt

Fowry, F. (2013). ‘Mandatory vaccination of healthcare workers a success.’ [Online] Available from: http://www.medscape.com/viewarticle/806433. (Accessed: 15 October 2013).

Vaccine Concerns- Thimerosal

• Preservative• 50% mercury by wt; metabolized/degraded:

– Ethylmercury (t ½ < 1wk; actively excreted in gut)

– thiosalicylate

• No causal link to neuro-development disorders (i.e. autism)- animal data, large-scale epi studies1, 2

• None/trace in single use vials/syringes, mist• www.vaccinesafety.edu/components.htm

1. Thimerosal in vaccines questions and answers. Vaccines, blood and biologics. FDA U.S. Food and Drug administration. Updated 07/10/2009. Available at: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm070430.htm

2. Statement on thimersal. Global advisory committee on vaccine safety. World Health Organization. July 2006. Available at:: http://www.who.int/vaccine_safety/topics/thiomersal/statement_jul2006/en/index.html.

Vaccine Concerns- GBS• Rare, serious neurological condition1

• Body’s immune system attacks part of peripheral nerves1

• Associated with respiratory or GI infections (i.e. campylobacter, influenza!)1,2

• Annual rate in pop: 10-20 cases/million2

• 1976 swine vaccine was associated with risk2

• Vaccine studies (data from 1992-): , , no risk2

• Estimated increase risk: 1 case/million vaccinations

1. NINDS Guillain-Barre Syndrome Information. National Institute of Neurological Disorders and Stroke. Updated Sept 15, 2009. Available at: http://www.ninds.nih.gov/disorders/gbs/gbs.htm.

2. Prevention and control of seasonal influenza with vaccines. Recommendations of the advisory committee on immunization practices (ACIP), 2009. MMWR. July 24, 2009;58:1-52. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr58e0724a1.htm.

Influenza Vaccine Summary

• Inactivated (IIV) trivalent- standard• Intranasal- live, attenuated- limited

patient pop.• Consider HD for older patients• Intradermal- option for adults• Future: trivalent quadrivalent• Egg-free:

– Niche- allergies– Pandemics

Image from: NPR. (2009). ‘Flu vaccine’s egg-free future’ [Online] Available from: http://www.npr.org/blogs/thetwo-way/2009/10/flu_vaccines_eggfree_future.html (Accessed: 6 May 2013)

Self-Assessment Questions

1. Select the CORRECT statement regarding influenza vaccination for a 6 month old child:a. The child will receive a 0.5 mL

intramuscular dose inactivated vaccine.b. The child will receive the dose in his/her

deltoid muscle.c. The child will need a booster (2nd dose)

at least one month after the first dose.d. The child is too young to receive an

influenza vaccine.

Self-Assessment Questions

2. A 37 year old otherwise healthy customer presents to your pharmacy requesting a flu vaccine. This patient could receive any of the following vaccines EXCEPT:a. Flumist (intranasal)b. Fluzone (intramuscular)c. Fluzone (intradermal)d. Fluzone-HD (high-dose, intramuscular)

Self-Assessment Questions

3. All of the following are advantages of FluBlok (recombinant influenza vaccine) EXCEPT:a. Option for adult patient severely

allergic to eggs or egg proteinb. Quadrivalentc. Preservative freed. Faster start-up and manufacturing

process after a new strain (epidemic or pandemic)