The flu shot is here (well the standard quadrivalent is here, the high dose trivalent is still coming), and ALL of your patients should get it! Why?
The flu is bad! Though most healthy people get through the flu without problems, the CDC estimates that influenza is responsible for 140K-710K hospitalizations and 12K-56K deaths each year. Elderly patients, very young children, pregnant women and patients with underlying health problems are at greatest risk.
The flu vaccine gives pretty good coverage! While it is impossible to know vaccine effectiveness until the flu season is over, vaccine effectiveness in recent years has ranged around 40-60% — though its not perfect, this protection significantly decreases the incidence of flu cases and complications.
…and has relatively few side effects! Pain at the injection site is noted in about 65% of people, but it usually does not interfere with activity. Though some patients will tell you that the vaccine has given them the flu, flu-like symptoms are similar after receiving the vaccine and placebo; perhaps some of them were actually exposed to a URI after getting the vaccine. Allergic reactions to vaccine components are rare and Guillain-Barre after the flu vaccine is very rare.
“But I am allergic to eggs.” You can still get the flu vaccine! Per the CDC, “persons with a history of egg allergy of any severity may receive any licensed, recommended and age appropriate flu vaccine.” Some of the vaccines do contain egg proteins (including the one we have in clinic), but the risk of an allergic reaction is minimal and the benefits of the vaccine are thought to outweigh this risk. However, in patients who have a history of angioedema, respiratory distress, lightheadedness or recurrent emesis from egg exposure should receive the vaccine in the presence of health care professional (i.e. in clinic rather than a pharmacy); those who have just had hives do not need special precautions. Only the RIV4 (Flublok Quadrivalent) vaccine is considered egg-free; th ccIIV4 (Flucelvax Quadrivalent) vaccine has minimal egg exposure.
“I’m afraid of needles.” Although the intranasal vaccine has not been available for the past two seasons, it is this year. The intranasal vaccine is a live attenuated virus so it is contraindicated for: immunocompromised patients, close contacts of immunocompromised persons, pregnant women, patients who have receive influenza antiviral meds within the past 48 hours, and parents or caregivers whose child has asthma or wheezing within the past 12 months. Also note that there are additional precautions for patients with egg-allergy who receive the intranasal vaccine.
Which one do I give – the standard dose quadrivalent or the high dose trivalent?
For individuals ≥ 65 years of age, UpToDate suggests the high-dose trivalent IIV (Fluzone High-Dose) where available rather than a standard-dose quadrivalent inactivated vaccine, particularly in those taking a statin. It should be noted that the ACIP has not stated a preference for this vaccine over other influenza vaccines in older adults, although several studies have shown that the high-dose vaccine is more effective than the standard-dose trivalent vaccine in older adults (including a mortality benefit). Mild to moderate local reactions are more common with the high-dose vaccine than with standard-dose trivalent vaccine, but the incidence of serious adverse events is similar.
What about my transplant patients?
There is a preference for the HIGH-DOSE trivalent rather than the standard dose quadrivalent influenza vaccine for all pre-transplant patients >65 years old and all post-transplant patients (regardless of age). For pre-transplant patients <65 years old, and others for whom the high-dose trivalent vaccine is not feasible, standard dose quadrivalent inactivated vaccine is recommended. Pre transplant patients and potential living donors should be vaccinated as soon as possible. For post-transplant patients we recommend:
- Defer vaccination until 1 month after either transplant or ATG administration
- Routine vaccination with the injectable high-dose trivalent inactivated vaccine, regardless of age
- Do NOT use the live attenuated nasal vaccine (“Flumist”)
- For all close contacts transplant candidates or post-transplant patients, any of the
- available flu vaccines (other than the live “FluMist” vaccine) should be given.
Also, please find here a recent study that may inform decision-making around optimal timing of flu vaccination given potential for waning immunity.