Seasonal Influenza (Flu)

Dosage, Administration, and Storage

TIV: Dosage, Administration, and Storage

The composition of TIV varies according to manufacturer, and package inserts should be consulted. TIV formulations in multidose vials contain the vaccine preservative thimerosal; preservative-free, single-dose preparations also are available. TIV should be stored at 35°F--46°F (2°C--8°C) and should not be frozen. TIV that has been frozen should be discarded. Dosage recommendations and schedules vary according to age group (Table 2). Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season.

The intramuscular route is recommended for TIV. Adults and older children should be vaccinated in the deltoid muscle. A needle length of 1 inch or longer (>25 mm) should be considered for persons in these age groups because needles of <1 inch might be of insufficient length to penetrate muscle tissue in certain adults and older children. When injecting into the deltoid muscle among children with adequate deltoid muscle mass, a needle length of 7/8--1.25 inches is recommended.

Infants and young children should be vaccinated in the anterolateral aspect of the thigh. A needle length of 7/8--1 inch should be used for children aged <12 months.

LAIV: Dosage, Administration, and Storage

Each dose of LAIV contains the same three vaccine antigens used in TIV. However, the antigens are constituted as live, attenuated, cold-adapted, temperature-sensitive vaccine viruses. Providers should refer to the package insert, which contains additional information about the formulation of this vaccine and other vaccine components. LAIV does not contain thimerosal. LAIV is made from attenuated viruses that are able to replicate efficiently only at temperatures present in the nasal mucosa. LAIV does not cause systemic symptoms of influenza in vaccine recipients, although a minority of recipients experience nasal congestion or fever, which is probably a result of effects of intranasal vaccine administration or local viral replication or fever.

LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal, or intravenous route. LAIV is not licensed for vaccination of children aged <2 years or adults aged >49 years. LAIV is supplied in a prefilled, single-use sprayer containing 0.2 mL of vaccine. Approximately 0.1 mL (i.e., half of the total sprayer contents) is sprayed into the first nostril while the recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. LAIV is shipped at 35°F--46°F (2°C--8°C). LAIV should be stored at 35°F--46°F (2°C--8°C) on receipt and can remain at that temperature until the expiration date is reached. Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season.

TABLE 2. Approved influenza vaccines for different age groups --- United States, 2009–10 season
Vaccine	Trade name	Manufacturer	Presentation	Mercury content (mcg Hg/0.5 mL dose)	Age group	No. of doses	Route
TIV*	Fluzone	Sanofi Pasteur	0.25mL prefilled syringe	0	6–35 mos	1 or 2†	Intramuscular §
			0.5 mL prefilled syringe	0	36 mos and older	1 or 2	Intramuscular
			0.5 mL vial	0	36 mos and older	1 or 2	Intramuscular
			>5.0 mL multidose vial	25	6 mos and older	1 or 2	Intramuscular
TIV	Fluvirin	Novartis Vaccine	5.0 mL multidose vial	25	4 yrs and older	1 or 2	Intramuscular
TIV	Fluvirin	Novartis Vaccine	0.5 mL prefilled syringe	<1.0	4 yrs and older	1 or 2	Intramuscular
TIV	Fluarix	GlaxoSmithKline	0.5 mL prefilled syringe	0	18 yrs and older	1	Intramuscular
TIV	FluLaval	GlaxoSmithKline	5.0 mL multidose vial	25	18 yrs and older	1	Intramuscular
TIV	Afluria	CSL Biotherapies	0.5 mL prefilled syringe	0	18 yrs and older	1	Intramuscular
TIV	Afluria	CSL Biotherapies	5.0 mL multidose vial	25	18 yrs and older	1	Intramuscular
LAIV¶	FluMist**	MedImmune	0.2 – mL sprayer	0	2–49 yrs	1 or 2 ††	Intranasal
* Trivalent inactivated vaccine. A 0.5-mL dose contains 15 mcg each of A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens. † Two doses administered at least 1 month apart are recommended for children aged 6 months--8 years who are receiving TIV for the first time and those who only received 1 dose in their first year of vaccination should receive 2 doses in the following year. §For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh. ¶Live attenuated influenza vaccine. A 0.2-mL dose contains 106.5--7.5 fluorescent focal units of live attenuated influenza virus reassortants of each of the three strains for the 2008--09 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Brisbane/60/2008. ** FluMist is shipped refrigerated and stored in the refrigerator at 2°C--8°C (36° F to 46°F) after arrival in the immunization clinic. The dose is 0.2 mL divided equally between each nostril. FluMist should not be administered to persons with asthma. Health-care providers should consult the medical record, when available, to identify children aged 2--4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving FluMist, parents or caregivers of children aged 2--4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive FluMist. †† Two doses administered at least 4 weeks apart are recommended for children aged 2--8 years who are receiving LAIV for the first time, and those who only received 1 dose in their first year of vaccination should receive 2 doses in the following year.