Kuwait flu vaccine booklet for workshop

Ministry of Health
State of Kuwait
Kuwait 2nd
workshop for Clinical Management of Influenza
IInnaaccttiivvaatteedd IInnfflluueennzzaa VVaacccciinnee
By
Dr. Ashraf El-Adawy
Consultant Chest Physcian
Consultant Expert – WHO
Inactivated Seasonal Influenza Vaccine
(Flu Shots) 2016/2017

2016 / 2017 Inactivated Influenza Vaccine
22 Ministry of Health - State of Kuwait
Intoduction :
 The influenza virus is an enveloped RNA orthomyxovirus, that is classified antigenically as
type A, B and C ,on the basis of antigenic differences between their matrix and
nucleoproteins (M and NP) .
 The A and B viruses contain two major envelope glycoproteins,haemagglutinin (HA) and
neuraminidase (NA) .
 Haemagglutinin (HA) is responsible for infectious entry of the virus into cells, it is also the
virus most important surface antigen, against which virus- neutralizing antibodies are
directed.
 Neuraminidase (NA) cleaves the sialic acid receptor, thus releasing progeny virus from the
infected cell surface , it is the target for the antiviral drugs Zanamivir and Oseltamivir
(Neuraminidase inhibitors ), which are sialic acid analogues and inhibit release of progeny
virus from infected cells.
 Type A influenza viruses are further classified into subtypes according to the combinations
of two kinds of virus surface antigens mainly : 16 different Haemagglutinin (HA) subtypes
and 9 different Neuraminidase (NA) subtypes.
 Many different combinations of HA and NA proteins are possible, all of which have been
found in wild birds, which is the natural reservoir of influenza A viruses.
 Only some influenza A subtypes (i.e., H1N1 and H3N2) are currently circulating among
humans as seasonal Influenza strains.
 Type B influenza virus is not categorized into subtypes, but lineages. Currently circulating
influenza B viruses belong to one of two lineages: B/Yamagata and B/Victoria, and these
can be further broken down into different strains.
 Influenza A virus infects humans and other animals e.g Avian species and pigs, in humans it
causes moderate to severe illness and affects all age groups.
 In humans ,Influenza A viruses are responsible for all pandemics and most epidemic
outbreaks.
 Influenza B viruses affects only humans, generally causes milder disease than type A and
primarily affects children.
 Influenza A and influenza B are responsible for most clinical illness, can cause seasonal
influenza epidemics in humans.
 Influenza C is rarely reported as a cause of human illness , is of little clinical importance ,
probably because most cases are subclinical.
 Influenza caused by type C virus is not thought to cause seasonal epidemics ,that is why
only influenza A and B viruses are included in seasonal influenza vaccines.

 There are many different strains of influenza B viruses and of influenza A subtypes and by
time new strains of influenza viruses appear and replace older strains,this process occurs
through a type of change is called “Antigenic Drift ”
Q.How can influenza viruses change ?
 Influenza viruses can change in two different ways , both antigenic drift and antigenic shift
are terms used to describe ways in which the flu viruses change over time , A drift is a minor
change while a shift is a major one.
 Influenza viruses are constantly changing , The antigenic evolution of influenza viruses
forms the primary basis for the occurrence of seasonal influenza epidemics and occasional
pandemics.
"Antigenic drift" - Continual, Small Changes
o Occurs through relatively minor genetic changes to the HA and NA genes of both influenza
A and B (point mutation)that happen continually over time, and
o
as they lack a poof-reading mechanism , the small errors that occur when the virus copies
itself are left uncorrected.
o When a flu virus mutates or changes slightly, new strains of influenza viruses appear and
replace older strains.
o As it looks different to our immune system, when a new strain of human influenza virus
emerges, antibody protection that may have developed after infection or vaccination with
an older strain may not provide protection against the new strain. Thus, the influenza
vaccine is updated on a yearly basis to keep up with the changes in influenza viruses.
o Seasonal influenza viruses evolve continuously (antigenic drift), which means that people
can get infected multiple times throughout their lives. Therefore the components of
seasonal influenza vaccines are reviewed frequently (currently biannually) and updated
periodically to ensure continued effectiveness of the vaccines.
o In most years, one or two of the three virus strains in the influenza vaccine are updated to
keep up with the changes in the circulating flu viruses, this usually requires seasonal
influenza vaccines to be reformulated annually.
o Antigenic drift may result in an epidemic, since the protection that remains from past
exposures to similar viruses is incomplete.
o Scientists try to predict which changes are likely to occur to currently circulating flu viruses,
they create a vaccine designed to fight the predicted virus.
o Sometimes the prediction is accurate, and the flu vaccine is effective,
Other times the prediction misses the mark, and the vaccine won’t prevent disease.
" Antigenic shift"

o An abrupt, major change in the influenza A viruses, resulting in a new influenza virus
subtype that can infect humans and has a hemagglutinin protein or hemagglutinin and
neuraminidase protein combination that has not been seen
in humans before & to which general populations are immunologically naïve..
o New subtypes of influenza A virus can emerge among humans through direct transmission
of an animal influenza virus to humans “Adaptive mutation ” or through “Re-assortment ”
or genetic exchange of genes derived from an animal influenza virus (e.g avian viruses) and
a human influenza virus during co-infection of a human or pig (serving as a mixing vessel) .
o Antigenic shift results in a new influenza A subtype , If it is introduced into the human
population, if most people have little or no protection against the new virus, and if the virus
can spread easily from person to person, a pandemic (worldwide spread) may occur .
o Influenza viruses are changing by antigenic drift all the time, but antigenic shift
happens only occasionally.
o Influenza type A viruses undergo both kinds of changes, influenza type B viruses change
only by the more gradual process of antigenic drift.
o influenza B viruses do not cause pandemics , this property may be a consequence of the
limited host range of the virus – humans only – which limits the generation of new
strains by re-assortment.
Q. What is flu ?
 Seasonal influenza, or ‘the flu’ as it is often called, is an acute viral infection caused by an
influenza virus, mainly affects the respiratory system.
 The disease is characterized by the sudden onset of fever, cough (usually dry) , headache,
myalgia and extreme fatigue ,other common symptoms include a sore throat and stuffy
nose.
 For otherwise healthy individuals, influenza is an unpleasant but usually self-limiting disease
with recovery usually within two to seven days without requiring medical attention.
 The illness may be complicated by (and may present as) bronchitis, secondary bacterial
pneumonia or, in children, otitis media.
 Influenza can be complicated more unusually by meningitis, encephalitis or
meningoencephalitis.
Q. Is Flu Serious
 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.

 Worldwide, annual influenza epidemics are estimated to result in ~1 billion cases of flu,
~3–5 million cases of severe illness and 300 000–500 000 deaths annually.
 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.
Influenza Complications
 Pneumonia
o Secondary bacterial
o Primary influenza viral
 Reye syndrome
 Myocarditis
 Death is reported in less than 1 per 1,000 cases
 The most frequent complication of influenza is pneumonia, most commonly secondary
bacterial pneumonia (e.g. Streptococcus pneumoniae, Haemophilus influenzae,
or Staphylococcus aureus).
 Primary influenza viral pneumonia is an uncommon complication with a high fatality rate.
Q.Who can get influenza?
 Seasonal influenza viruses circulate worldwide and can affect anybody in any age group
 The highest risk of complications from influenza occurs especially, in the very young children,
the elderly, those with pre-existing medical conditions and pregnant women but even healthy
people can get severe influenza.
 Anyone, including healthy people, can get the flu, and people of any age can develop serious
problems related to flu.
Q.When is influenza activity highest?
 Although influenza epidemics occur yearly, the timing, severity, and length of the season vary
from year to year.
 In the Northern Hemisphere, the season is generally from October to May, with peak activity in
January or February, whereas in the Southern Hemisphere, it is generally from May to October,
with peak activity in July or August.
Q. What is the best way to prevent influenza?
 Influenza vaccination is the most effective way to prevent influenza infection and/or severe
outcomes from the illness, rather than antiviral chemoprophylaxis.
 The protection of influenza vaccine depends on inducing humoral immunity, namely
neutralizing antibodies against viral capsular antigens, which boost the immune system
against the serotypes included in the vaccine.

 Safe and effective vaccines are available and have been used for more than 60 years.
Q. Why do I need a flu vaccine every year?
Every flu season is different; A flu vaccine is needed every season for two reasons:
1) First, 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) Second, because flu viruses are constantly changing (Antigenic drift), which may occur in
one or more influenza virus strains. The seasonal influenza vaccine must be re-made
(updated ) each year to protect against the most recent and most commonly circulating
viruses.
Q. What is the recommended composition of seasonal influenza vaccines?
 Influenza vaccines are manufactured in two forms: Inactivated influenza vaccines (IIVs) and
live-attenuated virus vaccines (LAIVs).
 As the LAIV is not yet available in the Middle east, influenza vaccination guidelines will
focus on IIV (mainly TIV).
 Traditional seasonal flu vaccines (called "trivalent" vaccines) protects against the influenza
viruses that research indicates will be most common during the upcoming season & are
made to protect against three strains, an influenza A (H1N1) , an influenza A (H3N2) , and an
influenza B virus.
 Because the trivalent vaccine contains an influenza B strain from a single lineage,
mismatches between the vaccine and the circulating B strain occur more frequently.
Recommended composition of influenza virus vaccines for use
in the 2016-2017 Northern hemisphere influenza season.
The Trivalent inactivated seasonal influenza vaccines (TIV)
include a mixture of 2 influenza A strains and 1 influenza B
strain thought most likely to circulate in the upcoming season.
– an A/California/7/2009 (H1N1) pdm09-like virus
– an A/Hong Kong/4801/2014 (H3N2)-like virus
– a B/Brisbane/60/2008-like virus (B/Victoria lineage).
Influenza (flu) is a contagious respiratory disease that can lead to serious complications,
hospitalization, or even death. Anyone can get the flu, including people who are
otherwise healthy and vaccination is the single best way to prevent influenza and its
complications.

 The use of quadrivalent influenza vaccines containing a B strain from each lineage is
expected to improve the matching of the vaccine in the future.
 Recently, from 2015 in USA & Australia, a newer quadrivalent influenza vaccines (QIV)
contain the same strains as trivalent vaccine (TIV) plus an additional second B strain has
been introduced.
Q.How are the vaccines made?
 Each year, before influenza season starts, one or more virus strains in the vaccine might be
changed and based on the global surveillance data for influenza viruses, The World Health
Organization recommends the strains that they believe will, be circulating in the upcoming
influenza season.
 To ensure optimal vaccine efficacy against prevailing strains in both the northern and
southern hemispheres, the antigenic composition of the vaccines is revised twice annually
and adjusted to the antigenic characteristics of circulating influenza viruses.
 The recommendations are based on information collected from more than 100 national
influenza centers in over 100 countries that conduct year-round influenza surveillance.
 In February, The World Health Organization 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.
 Flu vaccine is produced by private manufacturers, and the timing of availability depends on
when production is completed, shipments began in August and will continue throughout
September and October until all vaccine is distributed.
 A second recommendation is made in September which relates to vaccines to be used for
the winter in the Southern Hemisphere
Q. 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.
Q. How do seasonal influenza vaccines work?
 The standard flu vaccine (or, the "flu shot") is made from flu viruses that have been grown on
fertilized chicken eggs.

 The viruses are killed during manufacturing, a process known as “inactivation” These
inactivated viruses are a source of proteins or antigens that trigger a protective antibody
response.
 The vaccine is generally effective against the influenza virus within two weeks of
administration, Antibodies against flu viruses may last for six months or longer, and sometimes
even up to one year.
 The vaccine is only effective against the strains of the virus that match the vaccine
Q.What does vaccine “match” and “mismatch” mean?
 Influenza viruses are constantly changing, including during the time between vaccine virus
selection and the influenza season or they can even change within the course of one flu season.
 If these changes lead to antigenic differences between the circulating seasonal influenza viruses
and those viruses that are included in the seasonal influenza vaccine, then the vaccine and
circulating viruses may not be closely related “vaccine mismatch”.
 The degree of similarity or difference between the circulating viruses and the viruses in the
vaccines is often referred to as “vaccine match” or “vaccine mismatch”.
Q. Can the vaccine provide protection even if the vaccine is not a "good" match?
 It's not possible to predict with certainty which flu viruses will predominate during a given
season, there is always the possibility of a less than optimal match between circulating viruses
and the viruses in the vaccine.
 It’s important to 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.
 In addition, even when there is a less than optimal match or lower effectiveness against one
virus, it's important to remember that the flu vaccine is designed to protect against three flu
viruses.
 For these reasons, even during seasons when there is a less than optimal match, it is
recommended to give annual flu vaccination (or re-vaccination, if the vaccine strains are
identical) , This is particularly important for people at high risk for serious flu complications, and
their close contacts.
Q. How much protection does the seasonal influenza vaccine provide?
 The ability of flu vaccine to protect a person (vaccine effectiveness) depends on various
factors, including the age and health status of the person being vaccinated, and also the
similarity or “match” between the viruses used to make the vaccine and those circulating in
the community.

 During seasons when most circulating influenza viruses are similar to the viruses in the
influenza vaccine, the vaccine can reduce the risk of illness caused by influenza virus
infection by about 50-60% among the overall population.
 The vaccine effectiveness may be lower among persons with chronic medical conditions
and among the elderly, as compared to healthy young adults and children.
 It is important to understand that although the vaccine is not as effective in preventing
influenza disease among the elderly, it is effective in preventing complications and death.
Q. Can people still get influenza if they have had the influenza vaccine?
 Protection is never 100%, and some people can still get the flu after being vaccinated. It is
possible to get influenza-like illness even if you have been vaccinated because of the
following reasons:
1) Since it takes about two weeks to build protective antibodies after receiving the
vaccine, it is possible for someone to become infected in that time period or shortly
before getting vaccinated. This can result in someone erroneously believing they
developed the disease from the vaccination.
2) You may be exposed to a virus not included in the vaccine and develop illness.
3) Respiratory pathogens that are not related to influenza viruses can cause “flu-like”
symptoms (such as rhinovirus). The influenza vaccine does not protect you against
these pathogens.
4) Unfortunately, some people can remain unprotected from flu despite getting the
vaccine, this is more likely to occur among people that have weakened immune
systems, However, even among people with weakened immune systems, the flu
vaccine can still help prevent influenza complications.
Q. WHO should get vaccinated?
 WHO recommends annual seasonal influenza vaccination for:
a) Highest priority group.:
Pregnant women at any stage of pregnancy(first, second or third trimesters).
b) Four other priority groups (in no order of priority) are:
1. Health-care workers
2. Children aged 6 months to 5 years
3. Elderly (≥65 years of age)
4. Individuals with specific chronic medical condition as follows:
Medical conditions that are associated with an increased risk of influenza
disease complications and for which individuals are eligible for vaccination
Cardiac diseases
 Coronary artery disease
 Congestive heart failure
 Cyanotic congenital heart disease

Chronic pulmonary disorders
 Bronchial asthma that requires continuous or repeated use of
inhaled or systemic steroids or with previous exacerbations
requiring hospital admission.
 Chronic obstructive pulmonary disease (COPD)
including chronic bronchitis and emphysema
 Cystic fibrosis
 Bronchiectasis
 Interstitial lung fibrosis
 Pneumoconiosis
 Bronchopulmonary dysplasia (BPD)
Chronic neurological
conditions
 Hereditary and degenerative CNS diseases (including multiple
sclerosis)
 Stroke, transient ischemic attack (TIA).
 Conditions in which respiratory function may be compromised due
to neurological disease (e.g. polio syndrome sufferers).
 Cerebral palsy
 learning disabilities
 Seizure disorders
 Spinal cord injuries
 Neuromuscular disorders
Immunocompromising
conditions
 Immunocompromised due to disease or treatment (e.g.
malignancy, transplantation and /or chronic steroid use,
immunosuppressive drugs)
 Asplenia or splenic dysfunction
 HIV infection at all stages
 Multiple myeloma
Diabetes & metabolic
disorders
 Type 1 diabetes, type 2 diabetes requiring insulin or oral
hypoglycemic drugs, diet controlled diabetes.
Hematological disorders  Haemoglobinopathies
Chronic Renal disease
 Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure
 Nephrotic syndrome
 kidney transplantation.
Chronic liver disease
 Defined as histological evidence of fibrosis or cirrhosis, or clinical
evidence of chronic liver cell failure.
 Chronic hepatitis
 Biliary atresia
Morbid Obesity  Defined as body mass index (BMI) ≥40 kg/m2
Health care workers (HCWs) should use every opportunity to give
Inactivated seasonal influenza vaccine to individuals at risk who have not been immunized during
the current season, even after influenza activity has been documented in the community

Q. Should pregnant women receive the trivalent inactivated influenza vaccine?
 When compared with non-pregnant women, pregnant women infected with influenza virus are
prone to severe illnesses with higher morbidity and mortality. They also have a greater risk for
serious problems for their infants and during delivery.
 Pregnant women, both healthy pregnant women and those with chronic health conditions, are
at increased risk of influenza related complications and hospitalization. (The risk increases with
length of gestation i.e. it is higher in the third than in the second trimester)
 Infants born during influenza season to vaccinated women are less likely to be premature, small
for gestational age, and low birth weight, there is no evidence that influenza vaccine causes any
harm to mother or baby when administered to a pregnant woman.
 Trivalent inactivated Influenza vaccine is considered safe for use in pregnant women at any
stage of pregnancy, WHO considers pregnant women as a high priority group and recommends
immunization.
 Furthermore, 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).
 Pregnant women should receive inactivated vaccine (flu shot) but should NOT receive the live
attenuated vaccine (nasal spray).
Q. Is trivalent inactivated influenza vaccine safe for breastfeeding mothers?
 Yes. The trivalent inactivated vaccine (TIV) is safe for breastfeeding mothers and their babies
(via breast milk), Women who are breastfeeding may receive either inactivated vaccine or live
attenuated vaccine (nasal spray) .
 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.
 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
patients.

Q. How does trivalent inactivated influenza vaccine given & What is the dosage and
frequency of administration ?
Dose:
 A full dose (0.5 mL) of trivalent inactivated seasonal influenza vaccine should be used for all
age groups, including children 6 to 35 months of age who are receiving influenza
immunization.
 Contrary to dosing information in product monographs, the National Advisory Committee
on Immunization (NACI) is no longer recommending 0.25 mL doses for children 6 to 35
months of age.
 This recommendation is based on evidence showing improved antibody response without
increase in reactogenicity in children receiving the 0.5 mL dose, so children receiving 0.25
mL doses will be considered inadequately immunized.
Site of administration:
 TIV should be administered intramuscularly (IM).
 The anterolateral thigh is the recommended site in infants 6 -12 months of age.
 The deltoid muscle is the recommended site in adults and children over 12 months of age
(nursing assessment is required to determine if the deltoid muscle mass is of sufficient size).
Frequency of administration:
 Children 6 months to <9 years of age receiving seasonal influenza vaccine for the first time
should be given two doses, with a minimum interval of four weeks between doses, they are
then recommended to receive one dose per year thereafter.
 Adults and Children who have been previously immunized with seasonal influenza vaccine
are to receive one dose of influenza vaccine each year.
Age group Dosage Number of doses Route
6-35 months 0.25 ml 1* or 2* Anterolateral thigh
3-8 years 0.5 ml 1* or 2* Deltoid
< 9 years 0.5 ml 1 Deltoid
**Children less than 9 years of age require 2 doses given at a minimum of 4 weeks apart if they have never
received seasonal influenza vaccine in a previous year.
Q. How should influenza vaccines be stored?
 Inactivated influenza vaccines for intramuscular administration are supplied as suspensions
in pre-filled syringes. They should be shaken well before they are administered.
 All influenza vaccines must be maintained at refrigerator temperature (2°C to 8°C) at all
times during handling, storage and transport.
Pregnancy and breast-feeding are not considered contraindications to
Inactivated seasonal influenza vaccination

 Vaccine should not be stored in the refrigerator door or crisper compartment and frequent
opening of the refrigerator door should be avoided.
 The vaccine should not be frozen.
 Vaccine should be transported in an insulated container with ice packs.
 Vaccine should be stored in original packaging in order to be protected from light.
Q. Can inactivated seasonal influenza vaccine be administered simultaneously with
other vaccines?
 Injectable inactivated seasonal influenza vaccine 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, preferably in different limbs
and separate needles and syringes should be used.
Q. Can the inactivated vaccine cause influenza?
 No. Neither the injectable (inactivated) vaccine nor the live attenuated (nasal spray) vaccine
can cause influenza, the injectable influenza vaccine contains only killed viruses and cannot
cause influenza disease.
 Fewer than 1% of people who are vaccinated develop influenza-like symptoms, such as mild
fever and muscle aches, after vaccination, these side effects are not the same as having the
actual disease.
Q. What are the side effects of the flu shot?
In general, Flu shots are safe and well-tolerated
1. local side effects (Injection site reactions) :
o Swelling, redness and pain at the injection site, are common after receiving inactivated
influenza vaccine and occur in more than 10% of people.
o Injection site reactions are common but are generally classified as mild and transient,
these side effects may commence within a few hours of vaccination and can last for 1–2
days.
2. low grade fever, malaise, shivering, fatigue, headache, myalgia and arthralgia are
among the commonly reported symptoms after intramuscular Injection (1–10%) ,can
last for 1 to 2 days following the vaccination .
Post-vaccination symptoms may mimic influenza, experiencing these non-specific side
effects does not mean that you are getting influenza.
3. As with any vaccine, there is an extremely rare possibility of a life-threatening allergic
reaction called anaphylaxis:

o This can include hives, difficulty breathing, or swelling of the throat, tongue or lips. For
this reason, it is important to stay in the clinic for 15 minutes after getting any vaccine.
o This reaction can be treated, and occurs in less than 1 in a million people who get the
vaccine.
4. Guillain-Barre syndrome:
o In very rare instances, the flu shot has been associated with Guillain-Barre Syndrome
(GBS) , about 1 case per million doses /year from influenza vaccine.
o The potential risk of GBS associated with influenza vaccination must be balanced
against the risk of GBS associated with influenza infection itself.
o Actually the risk of GBS associated with influenza infection is larger than that
associated with influenza vaccination.
5. Oculo-respiratory syndrome (ORS):
o During the 2000/2001 influenza season, Health Canada had received an increased
number of reports of vaccine-associated symptoms and signs that were subsequently
described as oculo-respiratory syndrome (ORS)
o ORS is defined as the presence of bilateral red eyes plus one or more respiratory
symptoms (cough, wheeze, chest tightness, difficulty breathing, difficulty swallowing,
hoarseness or sore throat) with or without facial edema ,that starts within 24 hours of
vaccination, , and generally resolving within 48 hours of symptom onset.
o Symptoms are typically mild and resolve quickly without specific treatment.
o Oculo-respiratory Syndrome (ORS) was found during the 2000-2001 influenza season,
few cases have been reported since then.
o Recommendations for subsequent immunization following a report of ORS are based
on a risk/benefit assessment and the severity of symptoms as perceived by the
individual who experienced the symptoms.
Q. Who should NOT be given the trivalent inactivated influenza vaccine?
Anyone who has:
1. Had a life-threatening anaphylactic reaction to a previous dose of influenza vaccine, or to
any of the vaccine components with the exception of egg.
( NOTE - Egg allergy is no longer considered a reason not to get the flu vaccine).
o Confirmed anaphylaxis is rare. Other allergic conditions such as rashes may occur more
commonly and are not contraindications for further immunization.
2. Had developed Guillain-Barre Syndrome (GBS) within six weeks of a previous dose influenza
vaccination
3. Had experienced severe Oculo-respiratory Syndrome (ORS ) that included lower respiratory
symptoms within 24 hours of receiving influenza vaccine.
4. Inactivated influenza vaccines are not licensed for use in infants less than 6 months of age.

Precautions:
 Postpone vaccination in persons with serious acute illness until their symptoms have resolved
(there is no need to delay vaccination because of minor illness, such as a cold, with or without
fever) .
Administration of influenza vaccine to egg allergic persons:
 Influenza vaccines are grown in eggs and there has been concern that residual egg protein
(ovalbumin) could cause allergic reactions in egg-allergic recipients. However, all studies to date
have suggested that this risk is very low.
 Due to changes in vaccine manufacturing, the amount of egg protein in the majority of
influenza vaccines has been reduced.
 The Product Information of the vaccine to be given should be checked for the vaccine’s
ovalbumin content prior to vaccine administration.
 The risk of an allergic reaction to influenza vaccine in patients with egg allergy is very low, likely
due to the very low amount of ovalbumin in the vaccines. Any such theoretical risk is far
outweighed by the very real risk of such patients remaining unvaccinated. Thus all patients with
egg allergy of any severity, including anaphylaxis, should receive influenza vaccine.
 Skin testing with the vaccine and dividing the dose are not necessary.
 Even though the risk of anaphylaxis associated with influenza vaccination of a person with egg
allergy is very low, it is essential that such patients are vaccinated in facilities with staff that are
able to recognize and treat anaphylaxis.
 Egg-allergic individuals should receive inactivated influenza vaccine in a setting where
anaphylaxis can be recognized and treated and should be observed for 30 minutes after
vaccination.. Egg allergic individuals should not receive their influenza vaccine from a pharmacy
or other non-medical office setting
 To deal with anaphylactic or hypersensitivity reactions, immediate treatment, including
epinephrine 1:1000, should be easily accessible during the administration of the vaccine.
Egg allergy is no longer considered a contraindication for TIV.
Those with confirmed egg anaphylaxis and non-anaphylactic
egg allergy can be given an influenza vaccine with an ovalbumin
content <0.1μg per dose.
People with egg allergy, including egg-induced anaphylaxis, can
usually be safely vaccinated with inactivated influenza vaccines
that have less than 1 μg of residual egg ovalbumin per dose.

What can you tell me about the preservative thimerosal that is in some injectable
influenza vaccines and the claim that it might be associated with the development of
autism?
o Thimerosal is a very effective preservative that has been used to prevent bacterial
contamination in vaccines for more than 50 years.
o It is comprised of a type of mercury known as ethyl-mercury. It is different from
methylmercury, which is the form that is in fish and seafood.
o Very high levels, methy-lmercury can be toxic to people, especially to the neurological
development of infants.
o In recent years, several large scientific studies have determined that thimerosal in vaccines
does not lead to serious neurologic problems, including autism.
o However, because we generally try to reduce people’s exposure to mercury if at all possible,
the vaccine manufacturers have voluntarily changed their production methods to produce
vaccines that are now free of thimerosal or have only trace amounts.
o They have done this because it is possible to do, not because there was any evidence that
the thimerosal was harmful.
Flu Vaccines are very safe, effective and have been used for more than
60 years, it is much safer to get the vaccine than to get Influenza illness.

Multiple choice questions
1. Which of the following statements is CORRECT? Influenza is an acute febrile respiratory
illness:
a) It is caused by influenza type A or type B viruses that occur in outbreaks and epidemics every
year.
b) Influenza B strains are predominant over Influenza A strains
c) WHO is unable to predict the appropriate influenza viruses to be included in vaccines yearly
d) Anyone, including healthy people, can get the flu, and people of any age can develop serious
problems related to flu.
2. Which of the following is/are true:
a) Influenza is caused by type A, B or C viruses
b) Influenza A is the usual cause of epidemics
c) Minor changes in the surface antigens of influenza A occur every year
d) ‘Antigenic shift’ means a major change in the influenza A virus has occurred
e) The burden of influenza B disease is mostly in adults
3. Antigenic shift is seen in :
a) Influenza A
b) Influenza B
c) Influenza C
d) All of the above
4. What chance does a healthy person have of getting the flu during an average year?
a) About 75%
b) About 50%
c) Between 10 and 20 per cent
d) Less than 2 per cent.
5.What are hemagglutinin and neuraminidase?
a) Exotoxins produced by the influenza virus
b) Glycoprotein receptors on influenza's target cells
c) Glycoproteins on influenza virus that contribute to virulence
d) Proteins found in the nucleus of influenza virus
e) Proteins that surround each segment of the nucleic acid in influenza
6. A number of complications are associated with influenza ,which of the following is NOT one
of these complications?
a) Nephritis.
b) Pneumonitis.
c) Myocarditis.
d) Encephalitis.
e) Death.

7. Patients at high risk for developing complications from seasonal influenza include all of the
following except:
a) > 65 years old
b) A 35 year old busy mother who does not want the flu
c) Diabetics
d) Asthmatics
8. The most common complication of seasonal influenza is:
a) Bacterial pneumonia
b) Death
c) Meningitis
d) Reye syndrome
9. Which of the following is/are true about seasonal Influenza vaccines:
a) They must be given annually
b) Most current vaccines have two influenza B subtypes and one A subtype in them
c) A quadrivalent vaccine with an additional influenza A virus has been developed
d) Most of the vaccines are prepared from viruses grown in embryonated hens’ eggs
e) There is only live attenuated influenza vaccine registered for use in the gulf.
10. Influenza vaccine is specifically indicated in individuals with:
a) COPD
b) Cochlear implants
c) Congenital cyanotic heart disease
d) Cerebral palsy
e) Chronic kidney conditions (including hemodialysis)
11. The inactivated seasonal influenza vaccine contains:
A. Thimerosal
B. Two influenza A viruses, and one influenza B virus
C. Two influenza B viruses, and one influenza A virus
D. Both A and B
12. _________ week(s) is the minimum interval between administration of two live vaccines, if
not administered simultaneously.
A. 1
B. 4
C. 6
D. 8
13. The most suitable site(s) for intramuscular vaccination is/are:
a) Anterolateral aspect of the thigh
b) Deltoid area of the upper arm
c) Fatty area of buttock
d) Anywhere in buttock
e) All of the above
14. Patients with the following conditions should have seasonal influenza vaccine:
a) Type 1 diabetes

b) Stage 2 chronic renal disease
c) Diabetes controlled by diet
d) Cystic Fibrosis
e) Severe learning disability
15. What is the best time of year for a person to be vaccinated against influenza?
a) In Autumn, just before the peak flu season
b) In summer, well before the next peak flu season.
c) As soon as flu symptoms develop.
d) Anytime; it makes no difference.
16. Which of the following is/are true about inactivated influenza vaccine administration:
a) It is better to inject vaccine into fat than muscle
b) The deltoid area of the upper arm is generally preferred for infants under 1-year-old
c) The anterolateral region of the thigh is generally preferred for older children and adults
d) Influenza vaccine should not be given at the same time as pertussis vaccine as it might affect
response to that vaccine
e) Non of the above
17. Among the overall population, the chance of avoiding catching seasonal flu after being
vaccinated is:
a) 100 per cent.
b) 50-60 per cent.
c) 40 per cent.
d) 10 per cent
18. Annual influenza vaccination should be recommended for which of the following groups?
a) Children aged 6 months to 5 years.
b) Patients with chronic liver cell failure.
c) Health care workers.
d) Pregnant women at any trimester
e) All of the above.
19. Choose the correct statements you, can still get flu after you get a flu shot?
Maybe if:
a) You are exposed to flu before or right after you get a flu shot,
b) The flu shot vaccine does not match all the flu viruses that are spreading
c) Flu viruses change after the flu shot is made
d) You have an illness or weak immune system that causes your body to take longer to make
antibodies
e) All of the above
20. Which of the following statements regarding seasonal influenza vaccine is CORRECT?
a) Fever is a rare side effect of influenza vaccination.
b) Booster doses are required for children less than 9 years.
c) Should not be given to children below 1 year of age.
d) Should not be given to children with peanut allergy.

21. The most common reactions to inactivated vaccines include:
a) Pain at the injection site
b) Erythema
c) Swelling
d) All of the above e) None of the
above
22. Contraindications to Influenza vaccination include:
a) Confirmed anaphylactic reaction to a previous dose of influenza vaccine
b) Confirmed anaphylactic reaction to egg products
c) A rash following a previous vaccination
d) Pregnancy
e) Aged less than two years
23. The following is/are true about flu vaccine in pregnancy:
a) Influenza vaccine is contraindicated in the first trimester of pregnancy
b) Influenza vaccine should be offered from the third trimester of pregnancy
c) Pregnant women who have received influenza vaccine are at slightly increased risk of
miscarriage
d) Influenza vaccine given to the mother may provide passive immunity to the infant in the first
few months of life
e) Inactivated influenza vaccines are preferred to live attenuated vaccine in pregnancy
24. Adverse reactions to inactivated flu vaccine may include:
a) Pain and swelling at the injection site
b) High grade fever
c) Myalgia
d) Shivering
e) Clinical influenza
25. An example of a permanent contraindication to vaccination is:
a) Moderate or severe illness
b) HIV
c) Anaphylactic reaction to a previous dose
d) Concurrent antibiotic therapy

References
1. Recommended composition of influenza virus vaccines for use in the 2016-2017 northern
hemisphere influenza season -WHO February 2016
2. Key Facts About Seasonal Flu Vaccine CDC-May 2016
3. Vaccine effectiveness estimates for seasonal influenza vaccines -WHO February 2015
4. Global Advisory Committee on Vaccine Safety (GACVS) ,information sheet ,observed rate
of influenza vaccine reactions -WHO July 2012
5. Vaccines against influenza , WHO position paper – November 2012
6. Seasonal Influenza - Fact sheet –WHO-March 2014
7. National Advisory Committee on Immunization (NACI) -Statement on Seasonal Influenza
Vaccine for 2013-2014- Public Health Agency of Canada
8. Influenza Surveillance Protocol For Ontario Hospitals-July 2014
9. Influenza (Flu) Vaccines Fact sheet- Toronto Public Health - September 2014
10. Immunization Action Coalition Saint Paul, Minnesota-2015
11. Alberta Health Services Immunization Program Revised December 2014
12. Canadian Immunization Guide - National Advisory Committee on Immunization (NACI)†
Statement on Seasonal Influenza Vaccine for 2015-2016
13. Update on Egg Allergy and Influenza Vaccine (Nov 2011) - Centers for Disease Control and
Prevention(CDC) Advisory Committee on Immunization Practices (ACIP) 2011 and the
American Academy of Pediatrics’ (AAP) Committee on Infectious Diseases 2011
14. Centers for Disease Control and Prevention(CDC) - ACIP 2015-2016 influenza vaccine
guidelines
15. Influenza vaccines for Australians | NCIRS Fact sheet: July 2015
16. Community case management during an influenza outbreak- WHO 2011
17. Immunisation against infectious disease -The Green Book - Updated version October 2015
18. The Kroger Pharmacy Vaccine Administration Training Program
19. Respiratory MCQ’s
20. Multiple choice questions on immunisation against infectious disease- updated version
October 2015
21. Questions and answers on seasonal influenza - Regional Office for the Americas of the
World Health Organization 2015
22. The scientific basis for offering seasonal influenza immunisation to risk groups in Europe.
Euro Surveill-2008
23. The Joint Committee for Vaccination and Immunisation statement on the annual influenza
vaccination programme – UK July 201

.
Flu vaccine can:
Keep you from getting flu,
Make flu less severe if you do get it,
Keep you from spreading flu to your family and other people.
Health care workers (HCWs) should use every opportunity to give
Inactivated seasonal influenza vaccine to individuals at risk who have not
been immunized during the current season, even after influenza activity has
been documented in the community

Kuwait flu vaccine booklet for workshop

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