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Influenza Vaccine - Clinical FAQs
doctor at laptop

Where do I direct clients to find nearby influenza vaccine clinics?

Clients can call SafeNet at 211 to find a nearby vaccine clinic or use the Oregon Flu Vaccine Finder at flu.oregon.gov.

Where can I find information about handling vaccine or vaccine administration?

The Oregon Public Health Division has developed a health care provider Web page for Oregon-specific vaccine information. If you are unable to find the information you need, call 971-673-0300 to speak with an Immunization Health Educator.

The Centers for Disease Control and Prevention also has flu information for health care providers. Go to: www.cdc.gov/flu.

When should we start giving flu vaccinations?

Begin vaccination for seasonal influenza as soon as vaccine is available. Early season clinics are an effective way to reduce influenza virus community transmission. Children under 9 years old need two doses of flu vaccine if this is the first season they get vaccinated for influenza. Beginning vaccination early will allow time for those children to get the second dose four or more weeks after the first dose, and still be protected during times of peak influenza transmission.

1. The American Academy of Pediatrics policy statement:
"Trivalent seasonal influenza vaccine should be offered to all children as soon as vaccine is available, even as early as August or September; a protective response to immunization remains throughout the influenza season."

2. ACIP Influenza Vaccination Recommendations:
"Vaccination efforts should be structured to ensure the vaccination of as many persons as possible over the course of several months, with emphasis on vaccinating before influenza activity in the community begins. ..... In general, health care providers should begin offering vaccination soon after vaccine becomes available and if possible by October."

3. Epidemiology and Prevention of Vaccine Preventable Diseases (CDC Pinkbook) influenza chapter:
"It should be offered annually, beginning in September for routine patient visits. The optimal time for vaccination efforts is usually during October and November. In October vaccination in provider-based settings should start or continue for all patients,-both high risk and healthy-and extend through November. Vaccination of children aged 6 months through 8 years of age who are receiving vaccine for the first time should also begin in October, if not done earlier, because those children need a second dose 4 weeks after the initial dose. Organized vaccination campaigns should be scheduled no earlier than mid-October."

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf (CDC 11th Edition)

4. Oregon standing orders for TIV:
"Healthcare providers should begin offering vaccination to all patients, both high-risk and healthy, as soon as vaccine becomes available. (1): Do not defer vaccination of any person who requests influenza vaccine."

https://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/Pages/stdgordr.aspx

5. CDC website:
[you can begin vaccination] “-as soon as vaccine becomes available, usually mid-to-late summer. Early vaccination of children younger than age 9 years who are first time vaccines (or who failed to get their second dose in the preceding season) can be helpful in assuring routine second doses before the influenza season begins.”

http://www.cdc.gov/flu/professionals/acip/timing.htm

How long does flu vaccination protection last?

The duration of vaccine effectiveness is related to both the body’s waning immunity and to ongoing genetic drift of the influenza viruses. Annual vaccination protects you and your community from the dominant influenza strains that are currently circulating. A recent article from the Pediatric Infectious Disease Journal states: "children from 6 months to 18 years retained efficacy 9 months post-vaccination at 77%." This supports the need for an annual vaccination to maintain levels of immunity. It also supports providing vaccination as early as possible before flu disease is widely circulating without concern for administering the vaccine 'too early.'

Ambrose, C. et al. Pediatr Infect Dis J 2008;27: 744-748

When should we stop vaccinating for seasonal influenza?

Continue to provide influenza vaccination up to the vaccine’s expiration date. In Oregon, the peak times for influenza transmission typically vary between January and March. However, influenza virus continues to circulate into spring and summer.

What are the requirements for Vaccine Information Statements (VIS) when administering influenza vaccination?

It is a Federal Law (under the National Childhood Vaccine Act) that clients are provided a copy of the most current VIS prior to being given a vaccine. You should give a VIS for all vaccines being administered that day and allow the client (or parent) to read it and have an opportunity to speak with a clinician before vaccination.

CDC instructions for use of VIS sheets:
http://www.cdc.gov/vaccines/pubs/vis/vis-facts.htm

IAC explanation of VIS sheets:
http://www.immunize.org/catg.d/p2027.pdf

Updated copies of VIS documents are available for download in multiple languages at this site:
http://www.immunize.org/vis

What are the requirements for reporting a potential adverse event related to vaccination?

The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program of the CDC and FDA. This system collects reports of potential side effects or unexpected outcomes following a vaccination. This data is used to evaluate vaccine safety and to disseminate findings to the public.

The VAERS site can be found at:
http://vaers.hhs.gov/esub/index

VAERS seeks reports of any clinically significant medical event that occurs after vaccination, even if the reporter cannot be certain that the event was caused by the vaccine. A VAERS report can be filed by a parent, clinician, patient, or a vaccine manufacturer, even if it is not among the events that are mandatorily reported.

Oregon public clinics must submit using the following VAERS form:
Oregon Public Clinics VAERS Form (pdf)

We have heard of a new type of flu vaccine for use in elders. Can we still give the regular flu shot or do we need to order this new vaccine?

You are referring to the Fluzone High-Dose; influenza vaccine which was licensed by the FDA in 2010 for persons aged 65 and older. The high-dose vaccine contains four times the amount of virual antigens in a .5ml dose than other injectable influenza vaccines.

Clinical trials for Fluzone High-Dose; indicate a stronger immunologic response when it is given to elders. It is not yet known whether this response will lead to greater levels of protection against influenza disease.

Neither Oregon Public Health nor the CDC recommend the high-dose formula over other injectable influenza vaccines. The decision of which vaccine to use for elders is left up to individual providers.

More information can be found at the CDC web site:
http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm

Can the nasal spray flu vaccine be given to health care workers or people working in daycare settings?

Intranasal flu vaccine, also called LAIV or Flumist;, can be administered to all persons for whom it is indicated based on age and health history - except to those who care for severely immunocompromised patients in a protective environment. Protective environment is defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes.

CDC addressed this issue in the recommendations for use of the live attenuated influenza vaccine as follows:
“Concerns about the theoretic risk posed by transmission of live attenuated vaccine viruses contained in LAIV to patients should not be used to justify preferential use of TIV in health-care settings other than inpatient units that house severely immunocompromised patients requiring protective environments. Some health-care facilities might choose to not restrict use of LAIV in close contacts of severely immunocompromised persons, based on the lack of evidence for transmission in health-care settings since [LAIV's] licensure in 2004.”

“Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices [ACIP], 2010” MMWR 2010; 59(No. RR-8):35-37 at:
www.cdc.gov/mmwr/PDF/rr/rr5908.pdf

Is it okay to draw up vaccine into syringes at the beginning of the day?

Pre-filling vaccine is discouraged. At the end of the clinic day, any remaining vaccine in syringes prefilled by staff should be discarded.

1. CDC discourages the practice of prefilling vaccine into syringes for several reasons, including:
-Increased possibility of administration and dosing errors
-Increased risk of inappropriate storage
-Probability of bacterial contamination since the syringe will not contain a bacteriostatic agent
-Probability of reducing the vaccine’s potency over time because of its interaction with the plastic syringe components

2. Pre-filling vaccine into syringes also violates basic medication administration guidelines, which state that an individual should administer only those medications he or she has prepared and drawn up.

3. Although pre-drawing vaccine is discouraged, a limited amount of vaccine may be pre-drawn in a mass-immunization clinic setting under the following conditions:
-Only a single type of vaccine (e.g., influenza) is administered at the mass-immunization clinic setting
-Vaccine is not drawn up in advance of its arrival at the mass-vaccination clinic site
-These pre-drawn syringes are stored at temperatures appropriate for the vaccine they hold
-No more than 1 vial or 10 doses (whichever is greater) is drawn into syringes, and
-Clinic staff monitor patient flow carefully and avoid drawing up unnecessary doses or delaying administration of pre-drawn doses.

When a vaccine vial is new and the cap has just been removed, is the rubber stopper sterile, or should it be cleansed with alcohol before inserting the needle?

The rubber stopper is not sterile. When you remove the protective cap from a vaccine or diluent vial, always clean the stopper with an alcohol wipe. This practice is covered in CDC's online vaccine storage and handling toolkit.

http://www2a.cdc.gov/vaccines/ed/shtoolkit

Is it true that some people can be infected with influenza and spread it without having any symptoms?

Yes. Not everyone will display the commonly accepted symptoms of influenza even while they are contagious. There are periods after infection where a person is contagious but does not yet feel ill. A person may also begin feeling well before they stop being contagious. Some young, healthy people may not display any symptoms of influenza during their infection.

1. The CDC Pinkbook influenza chapter:
“Adults can transmit influenza virus from the day before symptoms begin through 5 days after symptoms begin. Children can transmit influenza virus from the day before symptoms begin to 10 days after the symptoms begin”. Page 137 of the 11th Edition states that “In general, only about 50 percent of infected persons will develop the classic clinical symptoms of influenza.”

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf

2. 2006 MMWR dedicated to health care worker vaccination:
“A limited number of prospective and cross-sectional studies provide estimates of incidence of influenza and influenza-like illness (ILI) among HCP. In one serosurvey of HCP, 23% of HCP had documented serologic evidence of influenza infection after a mild influenza season; however, of these, 59 percent could not recall having influenza, and 28% could not recall any respiratory infection, suggesting a high proportion of asymptomatic illness.”

Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr55e209a1.htm

Where can I find an exact number of patients infected by influenza so far this year? All I can find are studies with estimates.

1. A recently published MMWR estimates that approximately 23, 607 people in the United States die each year from influenza disease and its complications. Based on the current population of Oregon, the average deaths would be about 290 persons per year. These estimates are based on aggregated data from 1976 - 2007.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5933a1.htm

It is important to understand that the actual number of cases, hospitalizations, and deaths vary widely from season-to-season and vary widely between different strains.

2. Influenza is not a mandatory reportable disease. Influenza tracking in Oregon is accomplished through a system of clinical providers that voluntarily submit data about clients that present with ‘influenza like illnesses’. To learn more about becoming a Surveillance Network Provider, visit this page:
http:/public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/Influenza/Pages/OregonILINet.aspx

Can you provide more details about the shipping and distribution of VFC and 317 Flu Vaccine Orders?

Each year, approximately 10% of all flu vaccine doses are purchased on the CDC vaccine contracts for use in the VFC and Section 317 programs. These doses are distributed as part of the same centralized vaccine distribution program that is used to distribute all other childhood and adult vaccine doses purchased on the CDC contracts. However, there are three unique aspects to flu vaccine distribution:

  1. These orders are filled and shipped out on a shorter timeline than other routine vaccines in response to the limited window for flu vaccine administration.
  2. For most products, flu vaccine shipments to the distribution depots come in multiple shipments over time, rather than arriving all at once. This is standard practice by most flu vaccine manufacturers in order get vaccine to as many providers as possible early in the season. The number of shipments to fill an order usually varies by the size of the order as well as the product.
  3. Within each of the two distribution depots, flu vaccine doses are allocated to public health jurisdictions as each bulk shipment arrives at the depot to provide equitable access to the flu vaccine products.

The allocation process, which assigns each public health jurisdiction within a depot a percentage of each shipment based on that jurisdiction’s % of the product ordered, requires additional steps in comparison to the distribution of privately purchased vaccine. The steps are:

-shipment to McKesson from the manufacturer
-receipt of doses at the distribution center
-update of CDC's allocation functionality
-placement of orders by public health jurisdictions
-shipment of doses to provider

This means that even if a manufacturer ships doses to a private provider and to one of the CDC distribution centers on the same day, it is not possible for the provider to receive his or her private and public doses in the same day. Under the best case scenario for each of the steps above, this adds approximately two and half weeks to the delivery time. To the extent that public health jurisdictions may wait to place orders until additional doses/additional products arrive at the depot, this time period increases. In addition, because the distribution depots do not receive shipments for every vaccine order on the same day or even in the same week, there can be regional differences as well.

In summary, the distribution process of vaccine flu doses purchased on the CDC contracts is different than the process for privately purchased vaccines. This difference is intentional because it allows CDC to allocate flu vaccine doses across public health jurisdictions in a way that is equitable. Because this difference in distribution process and timeline exists, it is important for providers to be aware of it so that they can incorporate it into their planning, including the timing for which they plan flu vaccination clinics or active recall of patients for flu vaccination.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

I received my flu vaccine for insured patients in August, but I am still waiting for my VFC flu vaccine. Why does the public sector receive vaccine after the private sector?

The allocation process, which assigns each public health jurisdiction within a depot a percentage of each shipment based on that jurisdiction’s percent of the product ordered, requires additional steps in comparison to the distribution of privately purchased vaccine. The steps are:

-shipment to McKesson from the manufacturer
-receipt of doses at the distribution center
-update of CDC's allocation functionality
-placement of orders by public health jurisdictions
-shipment of doses to provider

This means that even if a manufacturer ships doses to a private provider and to one of the CDC distribution centers on the same day, it is not possible for the provider to receive his or her private and public doses in the same day.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

Why can't I receive all of my VFC vaccine at one time. It seems like it takes months for me to get it all?

CDC places large flu vaccine orders each spring for doses that will arrive at its vaccine depots beginning in the fall. In order to get vaccine to as many providers as possible early in the season, most manufacturers send partial shipments of vaccines, particularly for large orders. As each shipment arrives at the CDC depots, doses are allocated so that each public health jurisdiction receives their fair share of the product that has arrived. Public health jurisdictions then do a similar allocation among their immunization providers so that all providers get initial shipments of vaccine as early as possible.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

Why can't you give me a reliable estimate for when I can receive my vaccine?

It is hard to give reliable estimates for when a provider can expect to receive his/her flu vaccine. Since manufacturers produce a new flu vaccine each year, there are the inherent uncertainties about vaccine production that make it challenging to estimate delivery dates. In addition, other issues may arise that impact estimates for flu vaccine timing. For example, during the current 2010-11 flu season, an issue related to the latex content in the syringes of a number of flu vaccine products resulted in the need for additional packaging/labeling steps that impacted the timing of availability of several products. Several products from several manufacturers were affected and impact on distribution timing was not identical across the products or manufacturers.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

How can I plan my flu clinics when I do not know when I will receive the vaccine?

Because of the uncertainties about flu vaccine distribution each year and the difficulties in rescheduling large flu clinics, it may not make sense for providers to plan such clinics until vaccine has been received.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

The vaccine manufacturers say that most of the flu vaccine has been distributed, yet my colleagues and I have only received a small percentage of our request. Where is the vaccine?

Although a large amount of flu vaccine has been distributed to date this season, not all products have been distributed at the same rate. One important cause of this during the 2010-2011 season is the issue related to the latex content in the syringes of a number of flu vaccine products. This issue resulted in the need for additional packaging/labeling steps that impacted the timing of availability of several products for several manufacturers.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

I expected a much earlier delivery for my VFC flu vaccine. What happened to those estimates?

Estimates for flu vaccine delivery that are made prior to the flu season are generally very preliminary and subject to change. In addition, not all products are distributed at the same rate, so the timing of shipments to providers can depend on what products you have ordered.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

Why can't I receive my VFC flu vaccine before or at the same time as when I receive my vaccine for privately insured patients?

The allocation process, which assigns each public health jurisdiction within a depot a percentage of each shipment based on that jurisdiction’s % of the product ordered, requires additional steps in comparison to the distribution of privately purchased vaccine. The steps are:

-shipment to McKesson from the manufacturer
-receipt of doses at the distribution center
-update of CDC's allocation functionality
-placement of orders by public health jurisdictions
-shipment of doses to provider

This means that even if a manufacturer ships doses to a private provider and to one of the CDC distribution centers on the same day, it is not possible for the provider to receive his or her private and public doses in the same day.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

Why is flu vaccine available at the local pharmacy but I haven't received mine yet?

The distribution process of vaccine flu doses purchased on the CDC contracts for the VFC program is different than the process for privately purchased vaccines in order to allow CDC to allocate flu vaccine doses ordered on its contracts across public health jurisdictions in a way that is equitable. The process involves several additional steps that are not part of the distribution process for vaccine that is privately purchased and results in a timeline for publicly purchased flu vaccines that is longer than that for private purchased flu vaccines, which may come directly from manufacturer to customer.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

Why can't the federal government make flu companies deliver public sector vaccine before pharmacies get theirs?

The CDC works closely with influenza vaccine manufacturers and distributors to encourage that their distribution planning prioritize getting vaccine doses to all provider types in a comparable time frame.

However, the distribution process of vaccine flu doses purchased on the CDC contracts for the VFC program is different than the process for privately purchased vaccines in order to allow CDC to allocate flu vaccine doses ordered on its contract across public health jurisdictions in a way that is equitable. The process involves several additional steps that are not part of the distribution process for vaccine that is privately purchased and results in a timeline for publicly purchased flu vaccines that is longer than that for privately purchased flu vaccines, which may come directly from manufacturer to customer.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)

The VFC flu vaccine delays seem to occur every year. What is the federal government doing to solve this recurring problem?

The CDC works closely with influenza vaccine manufacturers and distributors to encourage that their distribution planning prioritize getting vaccine doses to all provider types in a comparable time frame.

However, the distribution process of vaccine flu doses purchased on the CDC contracts for the VFC program is different than the process for privately purchased vaccines in order to allow CDC to allocate flu vaccine doses ordered on its contract across public health jurisdictions in a way that is equitable. The process involves several additional steps that are not part of the distribution process for vaccine that is privately purchased and results in a timeline for publicly purchased flu vaccines that is longer than that for private purchased flu vaccines, which may come directly from manufacturer to customer.

(from CDC Public Flu Sector Q/A document draft release 11.2.2010)