2018-2019 ACIP Recommendations for Seasonal Influenza Vaccination Save

The current issue of the CDC's MMWR reviews the new seasonal recommendations for vaccination against influenza. This is an update to the previous recommendations of the Advisory Committee on Immunization Practices (ACIP). 

Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. Available products for this season include the inactivated influenza vaccines (IIVs), recombinant influenza vaccine (RIV), and live attenuated influenza vaccine (LAIV).

Standard-dose, unadjuvanted, inactivated influenza vaccines will be available in quadrivalent (IIV4) and trivalent (IIV3) formulations. Recombinant influenza vaccine (RIV4) and live attenuated influenza vaccine (LAIV4) will be available in quadrivalent formulations. High-dose inactivated influenza vaccine (HD-IIV3) and adjuvanted inactivated influenza vaccine (aIIV3) will be available in trivalent formulations.

There are four new items in this report stemming from recent meetings of the ACIP.

1. The 2018–19 U.S. trivalent influenza vaccines will be directed against A/Michigan/45/2015 (H1N1)pdm09–like virus, an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus, and a B/Colorado/06/2017–like virus (Victoria lineage). Quadrivalent influenza vaccines will contain these three viruses and an additional influenza B vaccine virus, a B/Phuket/3073/2013–like virus (Yamagata lineage).
2. FluMist Quadrivalent recommendations (LAIV4) have been updated. This product was not recommended in the last 2 years. LAIV4 is now an option for those for whom it is appropriate.
3. Those with a history of egg allergy of any severity may receive any licensed, recommended, and age-appropriate influenza vaccine (IIV, RIV4, or LAIV4).
4. There has been an expansion of the age indication for Afluria Quadrivalent (IIV4) from ≥18 years to ≥5 years and expansion of the age indication for Fluarix Quadrivalent (IIV4), previously licensed for ≥3 years, to ≥6 months.

Timing of Vaccination

• It is recommended that vaccination should be offered by the end of October. Children aged 6 months through 8 years who require 2 doses (see Children Aged 6 Months Through 8 Years) should receive their first dose as soon as possible after vaccine becomes available, to allow the second dose (which must be administered ≥4 weeks later) to be received by the end of October.
• Revaccination later in the season of persons who have already been fully vaccinated is not recommended.
• Vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available.
• To avoid missed opportunities for vaccination, providers should offer vaccination during routine health care visits and hospitalizations.

Higher Risk Populations

• All persons aged ≥50 years;
• Adults and children who have chronic pulmonary (including asthma) or cardiovascular (excluding isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);
• Persons who are immunocompromised due to any cause (including immunosuppression caused by medications or by HIV infection);
• Women who are or will be pregnant during the influenza season;
• Children and adolescents (aged 6 months through 18 years) who are receiving aspirin- or salicylate-containing medications and who might be at risk for experiencing Reye syndrome after influenza virus infection;
• Residents of nursing homes and other long-term care facilities;
• American Indians/Alaska Natives; 
• Persons who are extremely obese (body mass index ≥40).

Immunocompromised Persons

• ACIP recommends that the live attenuated influenza vaccine (LAIV4) not be used for immunocompromised persons because of the uncertain but biologically plausible risk for disease attributable to the vaccine virus. In addition to potential safety issues, immune response to live or inactivated vaccines might be blunted in some clinical situations, such as for persons with congenital immune deficiencies, persons receiving cancer chemotherapy, and persons receiving immunosuppressive medications.
• Timing of vaccination might be a consideration (e.g., vaccinating during some period either before or after an immunocompromising intervention).
• The Infectious Diseases Society of America (IDSA) has published detailed guidance for the selection and timing of vaccines for persons with specific immunocompromising conditions, including congenital immune disorders, stem cell and solid organ transplant, anatomic and functional asplenia, and therapeutic drug-induced immunosuppression, as well as for persons with cochlear implants or other conditions leading to persistent cerebrospinal fluid-oropharyngeal communication .
• IIV or RIV4 should be used instead of LAIV for these persons. ACIP will continue to review accumulating data on use of influenza vaccines in these contexts.