Seasonal influeza vaccine 2018

Inactivated
Seasonal Influenza vaccine

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Hemagglutinin (HA)–18 subtypes
Neuraminidase (NA)–11 subtypes
Influenza A Virus is subtyped by surface proteins

Influenza A is subtyped by surface proteins
 Heamagglutinin (HA)
● 18 different types
● help virus enter cells “key in”
● antibody to HA is protective
 Neuraminidase (NA)
● 11 different types
● help virus leave cells to infect others “key out”

Influenza A viruses of all subtypes have
been detected in more than 90 species
of apparently healthy wild birds .
Wild water fowl , gulls , shore birds are
the natural reservoir of all influenza A
viruses .

Wild birds are “natural” reservoir for all
influenza A subtypes

Natural hosts of influenza viruses
Haemagglutinin subtype Neuraminidase subtype
H 1
H 2
H 3
H 4
H 5
H 6
H 7
H 8
H 9
H 10
H 11
H 12
H 13
H 14
H 15
H 16
N 1
N 2
N 3
N 4
N 5
N 6
N 7
N 8
N 9

H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15
H16
Haemagglutinin subtype Neuraminidase subtype

Avian Influenza A
viruses
H1 - H18
N1 – N11
H1 - H3
N1 –N2
Human Influenza
A Viruses

All subtypes of influenza A are maintained
in aquatic birds
In human
H1, H2, H3 N1, N2
The current subtypes of influenza A viruses found in humans are
A (H1N1) and A (H3N2).

 Current subtypes of influenza A viruses found in people are
influenza A (H1N1) and influenza A (H3N2) viruses.
 Influenza B viruses are not divided into subtypes, but can be
further broken down into lineages and strains.
 Currently circulating influenza B viruses belong to one of two
lineages: B/Yamagata and B/Victoria..

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Influenza viruses
 Influenza A is subtyped by surface proteins .
 The subtypes of influenza A virus demonstrate species
specificity and those, which infect animals do not
usually cause infection in humans.
 Influenza B and C viruses are not divided into subtypes.

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 Seasonal influenza viruses cause annual epidemics that
peak during winter in temperate regions
 Influenza A and influenza B are responsible for most clinical
illness, can cause seasonal influenza epidemics in humans.
 Influenza type C usually causes either a very mild respiratory
illness or no symptoms at all; it does not cause epidemics
and does not have the severe public health impact of
influenza types A and B.

Influenza – A Microbial Chameleon
 Influenza has thrived over the millennia by adhering the
one simple principle – adapt or die.
 If this constant process of genetic shuffling didn’t frequently
result in new types of HA or NA, many humans would
become immune & the virus would die out.
 Most of us will experience repeated influenza infections in
our life time.
www.ems-solutionsinc.com

How influenza virus change
Type A viruses undergo changes in their surface
antigens or proteins
● Minor changes Antigenic drift
● Major changes Antigenic shift

How do yearly epidemics occur?
• Answer: A process called antigenic DRIFT.
• Imperfect “manufacturing” of virus
• Small changes in H and N
• Partial immunity in population
• Incomplete protection; still get sick
• Need new flu vaccine every year
H3N2 H3N2
Immune System:
“Do I know you?
You look vaguely
familiar!”

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Antigenic Drift
This term denotes MINOR changes in hemagglutinin and
neuraminidase of influenza virus.
This results from mutation in the RNA segments coding for
either the HA or NA
There is merely an alteration in amino acid sequence of HA
or NA leading to change in antigenicity (point mutation).

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Antigenic Drift
 Gradual & continuous change in influenza virus
hemagglutinin (HA) & neuraminidase (NA) during
replication
 Occurs with influenza A & B
 Leads to new strains, allowing repeated infections
 Causes annual epidemics of seasonal influenza

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Antigenic drift occurs in both influenza A and influenza
B viruses.
The mutations that cause the antigenic drift are the molecular
explanation for the seasonal influenza epidemics during
winter time in temperate climatic zones.

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 Antigenic drift is the reason that 1 or more of the three
virus strains in the vaccine are updated every year
based on what’s been circulating around the world.
 This necessitates the creation of a new flu vaccine
every year. New virus strains may not be recognized by
the body's immune system.

What drives the occurrence of a pandemic?
Answer:
Instead of antigenic DRIFT occurring,
an antigenic…
…happens.
Immune System:
“Oh my gosh…I
don’t know you at
all!”
H?N?

Antigenic ShiftAntigenic Shift

Reassortment (in humans)
Avian virus + Human virus
Migratory
water birds
Pandemic potential

New subtype influenza
Reassortment : (in Pigs)

H1N1 H2N2 H3N2
1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
40-50 million deaths 2-4 million deaths 1 million deaths
Credit: US National Museum of Health and Medicine
Source: WHO
Pandemic influenza in the 20th Century

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Antigenic Shift
 An abrupt change, infrequent & unpredictable
 Process whereby existing surface HA and/or NA
proteins are replaced by HA and NA proteins that
are significantly different
 Occurs only with influenza A
 Results in a a new subtype (novel virus)
 Can result in pandemic influenza

• Seasonal influenza viruses circulate worldwide and can
cause disease in humans every year
• Seasonal influenza viruses can affect anybody in any age
group.
The disease tends to occur seasonally in the winter months
Seasonal influenza

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 Seasonal influenza is characterized by a sudden onset of
high fever, cough, headache, muscle and joint pain, severe
malaise , sore throat and runny nose.
 Most people recover from fever and other symptoms within
a week without requiring medical attention.
 But influenza can cause severe illness or death especially
in people at high risk .
The clinical burden of Seasonal influenza

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 Seasonal influenza epidemics can cause febrile illnesses
that range in severity from mild to debilitating and can lead
in some instances to hospitalization and even cause death,
mainly among high-risk groups.
 Seasonal influenza is a serious public health problem, it
has been estimated that in developed countries, annual
influenza epidemics infect about 10–20% of the population
each season.
Is Flu Serious ?

 Seasonal influenza viruses evolve continuously,
which means that people can get infected multiple
times throughout their lives.
 Global burden of inter-pandemic influenza is ~1
billion cases of flu, ~3–5 million cases of severe
illness and 300,000–500,000 deaths annually.

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 Although there are medications to treat the flu, they are
expensive, and need to be started within 24-48 hours of
the start of symptoms.
 The single best way to protect against the flu and/or
severe outcomes from the illness is to get vaccinated
each year .
 Safe and effective vaccines are available and have been
used for more than 60 years.

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Every flu season is different, A flu vaccine is needed
every season for two reasons:
1) The body’s immune response from vaccination declines
over time, so an annual vaccine is needed for optimal
protection , Even if the strains have not changed, getting
influenza vaccine every year is necessary to maximize
protection.
2) Antigenic drift (Flu viruses are constantly changing),which
may occur in one or more influenza virus strains.

Each year, the influenza virus can mutate, or change its
structure rapidly, leading to new strains of the virus, making
the vaccine used in previous years ineffective.
Each year, a new vaccine must be prepared that will be
effective against the expected type of influenza virus.
The trick is to be able to predict which influenza viruses
are going to cause infection and to prepare a vaccine
against those viruses .

Influenza vaccine development
 Currently, 136 national influenza centers in 106 countries
conduct year-round surveillance for influenza viruse and
disease activity.
 Each year, based on global surveillance data, the World
Health Organization recommends the strains that they
believe will be circulating in the upcoming influenza
season

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Influenza vaccine development
 In February, the WHO makes recommendations concerning
the virus strains to be included in vaccine production for the
forthcoming winter in the Northern Hemisphere .
 It takes about 6 months for vaccine manufacturers to grow
the viruses in chicken eggs .
 Shipments began in August and will continue throughout
September and October until all vaccine is distributed.

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Vaccine Manufacturing Time Lines
M A M J J A S O N D J FF M
WHO
(Northern hemisphere)
PRODUCTION
INTERNATIONAL SURVEILLANCE NETWORK
VACCINE MANUFACTURER
MELBOURNE
(Southern hemisphere)
PRODUCTION
Choice of strains Vaccine on time

Viruses for both vaccines are grown in
eggs

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Traditional flu vaccines (called "trivalent" vaccines) are
made to protect against three flu viruses :
1. Influenza A (H1N1) virus
2. Influenza A (H3N2) virus
3. Influenza B virus.
There are also flu vaccines made to protect against four
flu viruses (called "quadrivalent" vaccines). These
vaccines protect against the same viruses as the
trivalent vaccine and an additional B virus.

Is the vaccine that contains 4 viruses preferred
over the vaccine that contains 3 viruses?
 Vaccines that contain four strains of influenza virus
may eventually replace 3-virus vaccines.
 CDC and other groups do not have a preference for
use of the 4-virus vaccine over the 3-virus vaccine.

There are two types of influenza vaccine:
1. Inactivated (killed) vaccine, the “flu shot,” is
given by injection with a needle.
2. Live, attenuated (weakened) influenza vaccine,
the “flu mist,” is sprayed into the nostrils.

Seasonal Influenza Vaccines
Inactivated subunit (TIV)
Intramuscular
Trivalent
Annual
Live attenuated vaccine (LAIV)
Intranasal
Trivalent
Annual

Trivalent Inactivated Influenza Vaccine (TIV) OR
The "flu shot“
Most
Commonly used – Given IM (shot)
 Containing killed virus
 Injected into the muscle of the upper arm or thigh.
 It can be used for people 6 months of age or older, including
healthy people, those with chronic medical conditions,
and pregnant women
CDC

Live Attenuated Influenza Vaccine (LAIV)
OR Flu Mist
 Made with live, weakened flu viruses
 Given as a nasal spray.
 Is an option for healthy people 2-49 years of age who are not
pregnant.
 In June 2003, a live virus influenza vaccine was first licensed
CDC

Right Route for Right Vaccine
Live Attenuated Influenza Vaccine
Intranasal only

Trivalent Inacivated
Seasonal Influenza Vaccine

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When should I get Seasonal Influenza Vaccine?
 People get vaccinated against influenza as soon as vaccine
becomes available in their community, if possible by October.
 In general vaccination before December is best since this
timing ensures that protective antibodies are in place before flu
activity is typically at its highest.
 However, flu season can last as late as May so getting
vaccinated later throughout the flu season, even in January or
later, could still provide protective benefit.

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Seasonal Occurrence of Influenza
J F M A M J J A S O N D
Southern hemisphere Tropical Northern hemisphere
The peak of influenza attacks occurs between October and May in the Northern
Hemisphere and between April and September in the Southern Hemisphere.

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How does inactivated influenza vaccine work?
 Both humoral and cell-mediated responses play a role in
immunity .
 Administration of inactivated influenza vaccine results in
the production of circulating IgG antibodies to the viral
haemagglutinin as well as a cytotoxic T lymphocyte response .
 Humoral antibody levels, which correlate with vaccine
protection, are generally achieved 2 weeks after immunization
and immunity usually lasts less than 1 year .
.

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How much protection does the seasonal
influenza vaccine provide?

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The effectiveness of influenza vaccine depends primarily
on:
1 . The age and health status of the person getting the
vaccine .
2 . The similarity or "match" between the viruses in the
vaccine and those in circulation
Vaccine effectiveness is not 100%, and some people can still
get the flu after being vaccinated.

105
Does the Flu Vaccine Work?
YES!
Studies have shown that flu vaccine is
70-90% effective
in healthy adults
less than 65 years of age.

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Adults < 65 years
• 70-90% protection against influenza
Adults > 65 years
• 30 - 40% effective among frail elderly persons
• 50-60% effective in preventing hospitalization
• 80% effective in preventing death

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 Remember that even when the viruses are not closely
matched, the vaccine can still protect many people and
prevent flu-related complications.
 Such protection is possible because antibodies made
in response to the vaccine can provide some protection
(called cross-protection) against different, but related
strains of influenza viruses.
.

109
Even though circulating influenza viruses may “drift”
or change from the time the vaccine composition is
recommended, the vaccine may cross-protect
against circulating viruses.
The mismatch may result in reduced effectiveness against
the variant viruses, but it still can provide some protection.
.

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Seasonal influenza vaccine provides the best protection
available from seasonal flu –even when the vaccine does not
closely match circulating flu strains, and even when the
person getting the vaccine has a weakened immune system.
Vaccination can lessen illness severity and is particularly
important for people at high risk for serious flu-related
complications .

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Vaccine Storage
Store vaccine between 2º and 8º C at all times.
Vaccine should be placed on the middle shelves of the
refrigerator
Influenza vaccine should never be exposed to freezing
temperature!.
The vaccine effectiveness can be decreased by exposure
to light

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Note: Influenza Vaccine must not be frozen.
It should never come into direct contact with ice.
Transporting Vaccine
Use insulated containers with a temperature
monitoring device and appropriate cooling agents
Keep vaccine in insulated bags – do not carry it in your pocket!

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90° Angle
Dermis
Fatty tissue
(subQ)
Muscle tissue
Trivalent Inactivated Influenza Vaccine is Administered
by the Intramuscular Route
Needle length & Site depend on:
Muscle size, Fatty tissue thickness,
Vaccine volume, Injection technique
Aspiration is NOT required

x
x
Anterolateral thigh
Inactivated Influenza Vaccine IM Injections
Deltoid

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Anterolateral thigh
Needle gauge
- 22 - 25 gauge
Needle length
- 1 inch
Inactivated seasonal Influenza Vaccine
IM Injections – Infant (6-12 months)

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Inactivated seasonal Influenza Vaccine
IM Injections – Toddlers (1-2 years)
Needle size
- 22 - 25 gauge
Needle length
- anterolateral thigh – 1 inch
- deltoid – 1 inch

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.
 For adults and older children, the
recommended site of vaccination is
the deltoid muscle.
 The preferred site for infants (< 12
months old ) and young children (older
than 12 months of age with inadequate
deltoid muscle mass)is the anterolateral
aspect of the thigh.

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Standard Technique for Injection

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 Shake vaccine vial before withdrawing a dose
 Discard vaccine if it contains particulates, appears discolored
 Do not administer into buttock muscle because of potential
for injection-associated injury to sciatic nerve
 ACIP states that aspiration (i.e., pulling back on the syringe
plunger after needle insertion and before injection) is not
required because large blood vessels are not present at
recommended IM injection sites
 Do not mix with any other vaccine or solution
Precautions

125
According to CDC
TIV Dosage and frequency of administration

 Children younger than 6 months of age cannot receive a flu
vaccine, so they must rely on the adults around them to be
vaccinated for protection from influenza.
 Some children 6 months through 8 years of age need 2 doses
of flu vaccine if they have never been vaccinated or if they had
not received at least 2 doses of any trivalent or quadrivalent
influenza vaccine before July 1, 2018. The interval between
the 2 doses should be at least 4 weeks.
Vaccine Dosing Recommendations

 A child requires only 1dose if they have previously received 2
or more total doses of any trivalent or quadrivalent influenza
vaccine before July 1, 2018.
 The 2 previous doses do not need to have been received
during the same influenza season or consecutive influenza
seasons.
Vaccine Dosing Recommendations

130
 TIV does not interfere with the effectiveness of other
vaccines, it can be given at the same time or at any time
before or after administration of other inactivated vaccines
(e.g. Hepatitis B vaccine) or live attenuated vaccines (e.g.
Measles, mumps and rubella vaccine).
 For concomitant parenteral injections, different injection
sites and separate needles and syringes should be used.
•
Can TIV be administered simultaneously
with other vaccines?

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Who should get a seasonal
flu shot?

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All people 6 months of age and older should get flu vaccine.

134
WHO recommends annual seasonal influenza vaccine for :
(A) Highest priority group:
Pregnant women (at any stage of pregnancy)
(B) 4 other priority groups (in no order of priority) are:
Health-care workers
Children aged 6 months to 5 years
Elderly(≥65 years of age)
Individuals with specific chronic medical condition or immuosuppression
•

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Pregnant women, both healthy pregnant women and those
with chronic medical conditions, are at increased risk of
influenza related complications& hospitalization .
The risk increases with length of gestation i.e. it is higher in
the third than in the second trimester.
Seasonal Influenza Vaccination & pregnancy

142
Trivalent inactivated Influenza vaccine is considered safe for
use in pregnant women at all stages of pregnancy, in any
trimester , regardless of gestational age
Pregnant women should receive inactivated vaccine (flu shot)
but should NOT receive the live attenuated vaccine (nasal
spray).
There is no evidence that influenza vaccine causes any harm
to mother or baby when administered to a pregnant woman.

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Children aged <6 months are not eligible to receive currently
licensed influenza vaccines and should be protected against
influenza through vaccination of their mothers during
pregnancy (via passive transfer of antibodies across the
placenta and through breast milk).
The benefit of vaccination far outweighs any possible risk
from the vaccine itself.. The risk is actually in not getting
a flu shot .
•

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The trivalent inactivated vaccine (TIV) is also safe for breast
feeding mothers and their babies (via breast milk)
Women who are breast feeding may receive either either
inactivated vaccine or live attenuated vaccine (nasal spray)

145
Health care workers should use every opportunity to give
Inactivated seasonal influenza vaccine to individuals at
risk of serious influenza complications, who have not
been immunized during the current season, even
after influenza activity has been documented in
the community

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Health-care workers are an important priority group for
influenza vaccination, not only to protect the individual
and maintain health-care services during influenza
epidemics, but also to reduce spread of influenza to
vulnerable patient groups.
Vaccination of HCWs should be considered part of a broader
infection control policy for health-care facilities.

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In the absence of contraindications, refusal of HCWs who
have direct patient contact, to be immunized annually
against influenza , implies failure in their duty of care
to their patients.”

156
Is Flu Vaccine Safe?
YES! The flu shot and nasal spray are very safe , serious
side effects are rare.
Their benefits far outweigh any possible side effects.

165
Influenza Vaccination for the Hajj and Umrah
The Hajj and Umrah are considered recurrent mass gatherings when
millions of Muslims from all over the world come to the holy places in
Mecca and Madinah in Saudi Arabia.
Infections with influenza viruses are commonly found during these
gatherings.
In a study that compared the incidence of respiratory tract infections
among pilgrims coming from Saudi Arabia and the United Kingdom (UK),
the incidence of influenza was 10% in pilgrims from Saudi Arabia and 7%
and 14% among vaccinated and nonvaccinated from the UK, respectively.

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As influenza vaccination is generally considered effective in reducing influenza-
related infections, the SCIPV recommends that pilgrims get vaccinated at least 2
weeks before performing the Hajj or Umrah (evidence A).
It is recommended to pay special attention to those suffering from chronic
diseases The Hajj seasons for the next few years will fall during the months of
June to September. This raises special concern for the Hajj pilgrims arriving from
tropical and subtropical areas, e.g., South and Southeastern Asia, where
influenza positivity rates are higher during June to November compared with
December to May.
By collecting a weekly influenza surveillance data from 2006 to 2011 in these
countries, Saha et al. reported the positivity rates during June to November to be
86% in Bangladesh, 80% in the Philippines, 70% in India, 43% in Indonesia, and
41% in Malaysia.[107] Therefore, the SCIPV recommends the administration of
the Southern Hemisphere influenza vaccine prior to the Hajj and Umrah for
pilgrims arriving from the Southern Hemisphere (evidence C).

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Furthermore, as the Northern Hemisphere influenza vaccine is not
expected to be available prior to the Hajj in the next seasons for
pilgrims from the Northern Hemisphere, the SCIPV also
recommends the administration of the Southern Hemisphere
influenza vaccine to those pilgrims prior to the Hajj session
(evidence D).
This should receive special attention when the composition of the
current Southern Hemisphere vaccine is based on different
characteristics of circulating influenza viruses utilized for
the development of the Northern Hemisphere vaccine for the
previous season.[108

Seasonal influeza vaccine 2018

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Seasonal influeza vaccine 2018