Influenza (flu)
Information about influenza (flu) disease, vaccines and recommendations for vaccination from the Australian Immunisation Handbook.
Recently added
This page was added on 09 June 2018.
Updates made
This page was updated on 15 March 2024. View history of updates
Vaccination for certain groups of people is funded under the National Immunisation Program and by states and territories.
Overview
What
Influenza is a common disease of the respiratory tract. It affects people of all ages.
Who
Annual influenza vaccination is recommended for everyone ≥6 months of age.
Influenza vaccination is particularly recommended for:
- children aged 6 months to <5 years
- adults aged ≥65 years
- Aboriginal and Torres Strait Islander people
- people with medical conditions that increase their risk of severe influenza
- homeless people
- pregnant women
- healthcare workers, carers and household contacts of people in high-risk groups
- residents, staff, volunteers and visitors to aged care and long-term residential facilities
- commercial poultry and pork industry workers
- people who provide essential community services
- people who are travelling during influenza season
People with the following medical conditions have a higher risk of severe influenza:
- immunocompromising conditions, such as HIV, malignancy, functional or anatomical asplenia, and chronic steroid use
- receiving immuno-oncology therapy
- received a haematopoietic stem cell or solid organ transplant
- cardiac disease
- Down syndrome
- obesity
- chronic respiratory conditions
- chronic neurologic conditions
- chronic liver disease
- other chronic illnesses that need medical follow-up or hospitalisation
- long-term aspirin therapy in children (aged 6 months to 10 years)
- preterm infants (<37 weeks gestation)
Also see People at risk of severe disease from influenza.
How
People are recommended to receive influenza vaccine every year.
Most people should receive 1 dose of influenza vaccine each year. However, the following people should receive 2 doses, 4 weeks apart:
- children aged 6 months to <9 years receiving influenza vaccine for the first time
- people of any age receiving influenza vaccine for the first time after haematopoietic stem cell or solid organ transplant or CAR T-cell therapy.
The type of vaccine used depends on the person’s age:
- People aged 6 months to <65 years should receive a standard-dose egg-based or cell-based influenza vaccine.
- People aged ≥65 years should receive adjuvanted (NIP-funded) or high-dose influenza vaccine, but may receive standard-dose egg-based or cell-based influenza vaccine if the adjuvanted or high-dose vaccine is unavailable.
Why
Influenza is the most common vaccine-preventable disease in Australia. Although it can be a mild disease, it can also cause very serious illness in otherwise healthy people. It can require hospitalisation and can cause death.
Recommendations
All people aged ≥6 months
All people ≥6 months of age are recommended to receive annual influenza vaccine.1,2
A single annual dose of influenza vaccine is recommended for most people. Usually, receiving 2 separate doses in the same season is not recommended, but not contraindicated.
The exception is that 2 doses at least 4 weeks apart are recommended for:
- children aged 6 months to <9 years receiving influenza vaccine for the first time
- people of any age receiving influenza vaccine for the first time after haematopoietic stem cell or solid organ transplant
People aged ≥6 months can receive either standard-dose egg-based or cell-based influenza vaccine.
Influenza vaccine is NIP funded for certain groups where the benefits of vaccination in preventing severe disease are higher, including: children 6 months to <5 years, people aged ≥65 years, Aboriginal and Torres Strait Islander peoples aged ≥6 months, people with certain medical conditions aged ≥6 months and pregnant women. See ATAGI advice on seasonal influenza vaccines for 2024 for NIP funded vaccines.
View recommendation detailsInfants and children
Influenza vaccine is funded through the NIP for all children aged ≥6 months to <5 years. For details see the National Immunisation Program Schedule.
Infants and children aged <5 years have a higher risk of hospitalisation and increased morbidity after influenza than older children.3,4 This is true for all children aged <5 years, not just those with pre-existing medical conditions.5-7
The Therapeutic Goods Administration registers specific brands of influenza vaccine for use in children from 6 months of age. These specific brands may change each year. See Vaccine information and Vaccines, dosage and administration.
Preterm infants are recommended to receive influenza vaccine starting at the chronological age of at least 6 months, if the infant is clinically stable. Do not correct the age for prematurity.
View recommendation detailsAdults
The adjuvanted influenza vaccine is funded through the NIP for all adults aged ≥65 years. For details see the National Immunisation Program Schedule.
Either the adjuvanted influenza vaccine, Fluad Quad (NIP-funded) or the high dose influenza vaccine, Fluzone High Dose Quadrivalent is recommended in preference to standard-dose egg-based or cell-based influenza vaccine for adults aged ≥65 years. See also Vaccine information.
Influenza-associated mortality rates are highest among adults aged ≥65 years.4 Vaccinating elderly people reduces hospitalisations from influenza and pneumonia, and all-cause mortality.8
View recommendation detailsAboriginal and Torres Strait Islander people
Aboriginal and Torres Strait Islander people are recommended to receive annual influenza vaccine.
Influenza vaccine is funded through the NIP for all Aboriginal and Torres Strait Islander people aged ≥6 months. For details see the National Immunisation Program Schedule.
The disease burden from influenza is significantly higher among Aboriginal and Torres Strait Islander people than among non-Indigenous Australians in all age groups. See Epidemiology and Vaccination for Aboriginal and Torres Strait Islander people.4
View recommendation detailsPeople with medical conditions that increase their risk of influenza
People aged ≥6 months with medical conditions specified in this Table. Specified medical conditions associated with increased risk of influenza disease and severe outcomes are recommended to receive annual influenza vaccine.
Influenza vaccine is funded through the NIP for people with certain medical conditions that increase their risk of severe influenza complications. For details see the National Immunisation Program Schedule.
People with these specific medical conditions have a higher risk of influenza or severe outcomes from influenza.9-29
People who have received a transplant
People who have received a transplant
People who have had a haematopoietic stem cell transplant, solid organ transplant or CAR T-cell therapy and are receiving influenza vaccine for the first time after transplant are recommended to receive:
- 2 doses at least 4 weeks apart the 1st time they receive influenza vaccine after the transplant
- 1 dose each year after that
Conditions | Example medical conditions | NIP funded |
---|---|---|
Cardiac disease |
|
Yes |
Chronic respiratory condition |
|
Yes |
Immunocompromising conditions |
|
Yes |
Haematological disorder |
|
Yes |
Chronic metabolic disorder |
|
Yes |
Chronic kidney disease |
|
Yes |
Chronic neurological condition |
|
Yes |
Long-term aspirin therapy in children aged 5 to 10 years | Yes | |
Chronic liver disease |
|
No |
Obesity |
|
No |
Chromosomal abnormality |
|
No |
Harmful use of alcohol | No |
Women who are pregnant or breastfeeding
Women who are pregnant are recommended to receive influenza vaccine in each pregnancy.
Influenza vaccine is funded through the NIP for all women who are pregnant. For details see the National Immunisation Program Schedule.
Women who acquire influenza during pregnancy have an increased risk of morbidity and mortality.23 Women who acquire influenza are also at higher risk of preterm birth.30-39
Vaccinating pregnant women also reduces the risks and complications associated with severe influenza in their infants in the first 6 months of life. This is due to transplacental transfer of influenza-specific antibodies.31,40,41
Influenza vaccine can safely be given to pregnant and breastfeeding women.
Timing of influenza vaccination during pregnancy
Timing of influenza vaccination during pregnancy
Pregnant women can receive influenza vaccine during any stage of pregnancy.
Influenza vaccine can be given at the same time as, or separate to, dTpa (reduced antigen content diphtheria-tetanus-acellular pertussis), RSV vaccine and/or COVID-19 vaccines. Data on co-administration with RSV vaccines in pregnant women is still emerging, however there are no theoretical concerns.
Women who received the previous year’s seasonal influenza vaccine early in their pregnancy are advised to receive the current seasonal influenza vaccine (when it becomes available) later in the same pregnancy. Women who received vaccine before becoming pregnant should be revaccinated during pregnancy to protect the unborn infant.
Influenza vaccine can safely be given to breastfeeding women.
See Table. Vaccines that are routinely recommended in pregnancy: inactivated vaccines in Vaccination for women who are planning pregnancy, pregnant or breastfeeding for more details.
Occupational groups
Healthcare workers, carers and household contacts of people in high-risk groups are recommended to receive annual influenza vaccine.
Healthcare workers, carers and household contacts who should be vaccinated include:
- all healthcare providers, particularly those caring for people who are immunocompromised
- household contacts (including children ≥6 months of age) of people in high-risk groups, including people who provide home care to people at high risk of influenza
- people working in early childhood education and care
- staff or volunteers caring for homeless people
This is because people in these groups can transmit influenza to people who have a higher risk of complications from influenza infection.
Because of the high rate of influenza in the general population, vaccinating employees can result in workplace benefits such as increased productivity and reduced absenteeism.42 Employers should consider the benefits of offering influenza vaccine in their workplace, particularly for occupations at higher risk of influenza.
See Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsAll residents, staff, volunteers and visitors to aged care and long-term residential facilities are recommended to receive annual influenza vaccine.
These people include inmates of correctional facilities and people in immigration detention centres.
This is due to high rates of influenza transmission and complications during outbreaks in these facilities.22,43-45
Because of the high rate of influenza in the general population, vaccinating employees can result in workplace benefits such as increased productivity and reduced absenteeism.42 Employers should consider the benefits of offering influenza vaccine in their workplace, particularly for occupations at higher risk of influenza.
View recommendation detailsDuring an outbreak of avian influenza or swine influenza, influenza vaccination is recommended for:46
- people who work in the poultry or pork industries
- people in regular close contact with poultry or pigs
Routine seasonal influenza vaccination does not protect against avian or swine influenza. However, it is possible that, if a person is co-infected with avian or swine and human strains of influenza virus, the 2 strains could reassort and form a virulent strain. This strain could then spread from human to human and start a pandemic. This was the case with the swine influenza pandemic in 2009.47
Influenza vaccination can also prevent humans from transmitting influenza to animals.
View recommendation detailsPeople who provide essential community services are recommended to receive annual influenza vaccine.
Influenza infections can place considerable pressure on both public and private healthcare services. Vaccinating people who provide essential services can minimise disruption of essential activities during influenza outbreaks.
See Recommended vaccines for people at increased risk of certain occupationally acquired vaccine-preventable diseases in Vaccination for people at occupational risk.
View recommendation detailsTravellers
People who are travelling are recommended to receive influenza vaccine, especially if influenza is circulating in the destination region or in settings with increased risk of influenza circulation during the trip, such as:48
- travellers in large tourist groups (especially those including older people)
- travellers on cruises
- travellers participating in mass gatherings (for example travellers on pilgrimage to Mecca)
Australians who have received a current Southern Hemisphere influenza vaccine and are travelling later in the year to the Northern Hemisphere during their influenza season (usually October to May) may receive a second dose of influenza vaccine before departure. Although the relevant formulation for use in the Northern Hemisphere may be preferred, it is generally not available in Australia. Depending on individual circumstances, a Northern Hemisphere influenza vaccine administered overseas should be considered for optimal protection while travelling. However, receiving a dose of the Southern Hemisphere formulation before overseas travel is acceptable.
Factors that should be considered when deciding whether a traveller would receive a second dose of influenza vaccine within the same year in Australia before departure to the Northern Hemisphere include:
- individual assessment of potential risk of influenza and severe outcomes, according to the itinerary and personal risk factors
- similarity between the current Southern and Northern Hemisphere formulations of influenza vaccine
- availability of a reliable influenza vaccine and feasibility of receiving it at the traveller’s destination
See also Vaccination for international travellers.
Similarly, returning residents who have recently received a Northern Hemisphere influenza vaccine may also receive the current Southern Hemisphere influenza vaccine.
View recommendation detailsOther groups
Homeless people are recommended to receive annual influenza vaccine.
The living conditions of homeless people and their prevalence of underlying medical conditions mean that they are predisposed to complications from, and transmission of, influenza.
View recommendation detailsVaccines, dosage and administration
Influenza vaccines available in Australia
All the influenza vaccines available in Australia are either split virion or subunit vaccines. They are prepared from purified inactivated influenza virus that has been cultivated in embryonated hens’ eggs (e.g. standard-dose, high-dose and adjuvanted influenza vaccine) or propagated in Madin-Darby canine kidney (MDCK) cells (cell-based influenza vaccine).
All these vaccines are quadrivalent as they contain 4 influenza virus strains – 2 influenza A subtypes and 2 influenza B lineages.
Standard-dose egg-based influenza vaccines contain 15 µg of haemagglutinin per strain per dose with no adjuvant. Similarly, the available cell-based influenza vaccine contains the standard dose of 15 µg of haemagglutinin per strain per dose with no adjuvant.
The available adjuvanted influenza vaccine is egg-based, and contains the standard 15 µg of haemagglutinin per strain per dose, with MF59 as the adjuvant. The adjuvanted influenza vaccine is formulated to induce a greater immune response than standard-dose influenza vaccines.
High-Dose (egg-based) influenza vaccines contain 60 µg of haemagglutinin per strain per dose with no adjuvant.
Although egg-based vaccines may contain traces of egg-derived protein (ovalbumin), they contain less than 1 μg of ovalbumin per dose. See also Contraindications and precautions, and Vaccinating people with a known egg allergy in Vaccination for people who have had an adverse event following immunisation.
The Therapeutic Goods Administration website provides product information for each vaccine.
See also Vaccine information and Variations from product information for more details.
Always check annual seasonal influenza vaccine statements. Vaccines and age eligibility change from year to year.
All people aged ≥6 months
Registered for use in people aged ≥6 months.
Quadrivalent inactivated influenza vaccine, split virion
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
- ≤0.05 µg ovalbumin
- ≤5 µg formaldehyde
- polysorbate 80
- octoxinol 10
May contain traces of:
- gentamicin
- hydrocortisone
- sodium deoxycholate
For Product Information and Consumer Medicine Information about Fluarix Tetra visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥6 months.
Quadrivalent inactivated influenza vaccine (surface antigen, prepared in cell culture)
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
May contain traces of:
- propiolactone
- cetyltrimethylammonium bromide
- polysorbate 80
For Product Information and Consumer Medicine Information about Flucelvax Quad visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥6 months.
Quadrivalent inactivated influenza vaccine, split virion
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
May contain traces of:
- formaldehyde (≤100 µg)
- octoxinol 9 (≤250 µg)
- ovalbumin (≤1 µg)
For Product Information and Consumer Medicine Information about FluQuadri visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥6 months.
Quadrivalent inactivated influenza vaccine, surface antigen.
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
and not more than:
- ≤100 ng ovalbumin
- ≤0.01 mg formaldehyde
- 0.02 mg cetrimonium bromide
- 1 mg sodium citrate
- 0.2 mg sucrose
- 1 ng gentamicin sulfate
May contain traces of:
- tylosine tartrate
- hydrocortisone
- polysorbate 80
For Product Information and Consumer Medicine Information about Influvac Tetra visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥6 months.
Quadrivalent inactivated influenza vaccine, split virion.
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
May contain traces of:
- ovalbumin (≤ 0.05 µg)
- neomycin (≤ 10.1 pg)
- formaldehyde (≤ 30 µg)
- octoxinol-9 (≤ 222.5 µg)
For Product Information and Consumer Medicine Information about Vaxigrip Tetra visit the Therapeutic Goods Administration website.
View vaccine detailsAll people aged ≥5 years only
Registered for use in people aged ≥5 years.
Quadrivalent inactivated influenza vaccine, split virion
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains
May contain traces of:
- sodium taurodeoxycholate (≤5 µg)
- ovalbumin (<1 µg)
- sucroseneomycin
- sulfate
- polymyxin B sulfate
- propiolactone
- hydrocortisone
For Product Information and Consumer Medicine Information about Afluria Quad visit the Therapeutic Goods Administration website.
View vaccine detailsAdults aged ≥60 years only
Registered for use in people aged ≥60 years.
Quadrivalent inactivated influenza vaccine, split virion.
Each 0.7 mL monodose pre-filled syringe contains:
- 60 µg haemagglutinin of each of the 4 recommended influenza virus strains
May contain traces of:
- formaldehyde (≤ 140 µg)
- ovalbumin (≤ 1 µg)
For Product Information and Consumer Medicine Information about Fluzone High-Dose Quadrivalent visit the Therapeutic Goods Administration website.
View vaccine detailsAdults aged ≥65 years only
Registered for use in people aged ≥65 years.
Adjuvanted quadrivalent inactivated influenza vaccine, surface antigen.
Each 0.5 mL monodose pre-filled syringe contains:
- 15 µg haemagglutinin of each of the 4 recommended influenza virus strains.
These are adjuvanted with MF59C.1. The adjuvant includes:
- 9.75 mg squalene
- 1.175 mg polysorbate 80
- 1.175 mg sorbitan trioleate
- 0.66 mg sodium citrate dihydrate
- 0.04 mg citric acid monohydrate
May contain traces of:
- kanamycin
- neomycin
- formaldehyde
- barium sulfate
- cetrimonium bromide
- ovalbumin
- hydrocortisone
For Product Information and Consumer Medicine Information about Fluad Quad visit the Therapeutic Goods Administration website.
View vaccine detailsAnnual changes to influenza vaccines
Influenza vaccines can change from year to year with regard to:
- which vaccines are registered by the Therapeutic Goods Administration
- the indicated ages for each vaccine
Always check annual seasonal influenza statements published by the Australian Technical Advisory Group on Immunisation on the health.gov.au website as well as any state-based recommendations and program details and consult the product information for each vaccine.
Dose and route
Influenza vaccines available in Australia come in pre-filled syringes of 0.5 mL.
Shake the pre-filled syringe before injection. Influenza vaccines are preferably given by intramuscular injection. However, they may also be given subcutaneously (refer to Administration of vaccines).
Age | Dose | Number of doses needed in 1st year of influenza vaccination | Number of doses needed if person received 1 or more doses of influenza vaccine in a previous season |
---|---|---|---|
6 months to <9 years | 0.5 mL | 2 (given 4 weeks apart) | 1 |
≥9 years | 0.5 mL | 1 | 1 |
People of any age who have recently had a haematopoietic stem cell transplant or solid organ transplant | 0.5 mL | 2 (given 4 weeks apart) in 1st year after transplant | 2 (given 4 weeks apart) in 1st year after transplant |
Doses for children <9 years of age
Children aged 6 months to <9 years receiving influenza vaccine for the first time are recommended 2 doses at least 4 weeks apart. This maximises the immune response to the vaccine strains.
Children who received 1 or more doses of influenza vaccine in a previous season only need 1 dose of influenza vaccine in the current and future seasons. 49,50
Follow standard recommendations when giving any extra dose(s) during the current or future seasons (see Table. Recommended doses of influenza vaccine by age group).
Doses for children ≥9 years and adults
People aged ≥9 years need 1 dose of influenza vaccine every year, regardless of whether they have ever had influenza vaccine before.
For adults aged ≥65 years who have already received an adjuvanted influenza vaccine in the current influenza season, an extra dose of any influenza vaccine in the same season is not recommended.
Similarly, if they have received a standard-dose influenza vaccine, an extra dose of adjuvanted influenza vaccine in the same season is not recommended.
Follow standard recommendations when giving any extra dose(s) during the current or future seasons (see Table. Recommended doses of influenza vaccine by age group).
Co-administration with other vaccines
People can receive influenza vaccines at the same time as, or separate to, most other vaccines, including dTpa, RSV, pneumococcal and COVID-19 vaccines.
For more information refer to the COVID-19 handbook chapter.
The safety of concomitant administration of the adjuvanted vaccines Fluad Quad and Shingrix has not been studied. It is acceptable to co-administer these vaccines on the same day if necessary. However, given the lack of data on co-administration of these adjuvanted vaccines, it is currently considered preferable to separate their administration by a few days.
Co-administration of influenza and RSV vaccines predominantly show non-inferior immune responses to influenza or RSV vaccines, with the exception of concomitant administration of Arexvy (RSV vaccine) with adjuvanted influenza vaccine where slightly lower immunogenicity was seen with one of 4 influenza vaccine strains (A/H3N2).51-53 This lower immunogenicity was not seen in co-administration studies with unadjuvanted quadrivalent influenza vaccine.51,53,54 The clinical significance of the lower immunogenicity is not known.
An increase in local and systemic adverse events with co-administration is possible, based on safety data regarding concomitant administration of RSV and influenza vaccines in older adults.51,53 Data on co-administration with RSV vaccines in pregnant women is still emerging, however there are no theoretical concerns. Benefits of co-administration should be weighed against the potential for increased local and systemic adverse events.
There is a possible small increased risk of fever in children if 13vPCV is given at the same time as influenza vaccine. See Contraindications and precautions and Pneumococcal disease.
Interchangeability of influenza vaccines
Different age-appropriate brands are interchangeable for people who need 2 doses of influenza vaccine in a single season (see Table. Recommended doses of influenza vaccine by age group).
Timing of influenza vaccination
Annual influenza vaccination is recommended before the influenza season starts. Influenza circulation usually peaks between June and September in most parts of Australia. However, influenza can occur year-round.
Protection is expected to last for the whole season, but optimal protection is within the first 3–4 months after vaccination. Deferring vaccination to the beginning of winter may result in greater immunity later in the season, but may also result in missed opportunities for vaccination and lack of protection if the influenza season starts early.
Immunisation providers need to weigh up these factors for each person and balance them with the challenge of vaccinating large numbers of people in a short time.
Offer vaccination throughout the influenza season. It is never too late to vaccinate, because influenza can circulate all year. In particular, pregnant women and travellers can benefit from vaccination at any time of the year.
Children aged 6 months to <9 years who are receiving their 1st lifetime dose should receive the vaccine as soon as possible after it becomes available. This helps to ensure enough time to receive a 2nd dose (recommended ≥4 weeks later) before the influenza season starts.
Following the COVID-19 pandemic there was a resurgence of influenza virus circulation with the reopening of international borders. The importance of influenza vaccination should continue to be emphasised.
COVID-19 vaccines can be co-administered (i.e. on the same day) with an influenza vaccine.
If a person had a 2023 influenza vaccine in late 2023 or early 2024, they are still recommended to receive a 2024 formulation of influenza vaccine.
Contraindications and precautions
Contraindications
The only absolute contraindications to influenza vaccines are:
- anaphylaxis after a previous dose of any influenza vaccine
- anaphylaxis after any component of an influenza vaccine
See Precautions for more details about influenza vaccination for people with a known egg allergy.
Precautions
People with egg allergy
None of the available influenza vaccines contain >1 µg of ovalbumin.
People with egg allergy, including a history of anaphylaxis, can be safely vaccinated with any influenza vaccines (including egg-based and cell-based vaccines) unless they have reported a serious adverse reaction to influenza vaccines. See also Vaccinating people with a known egg allergy in Vaccination for people who have had an adverse event following immunisation.
People with known anaphylaxis egg allergy
People with a history of anaphylaxis to egg should:
- receive a full age-appropriate vaccine dose; do not split the dose into multiple injections (for example, a test and then the rest of the dose)
If there is significant parental or health professional anxiety, the vaccine may be administered in primary care settings with a longer post vaccination observation period of 30 minutes.
Several published reviews, guidelines and reports suggest a very low risk of anaphylaxis associated with influenza vaccination of egg-allergic people.55-60
A 2012 review of published studies included 4172 egg-allergic patients. 513 of these patients reported a history of severe allergic reaction to egg. The review found no cases of anaphylaxis after receiving an inactivated influenza vaccine.59
The largest study in the review included 830 egg-allergic patients. 164 of these patients reported a history of severe allergic reaction to egg. Only 17 (2%) of these patients experienced any adverse event.61 All adverse events were mild, and included abdominal pain, hives and respiratory symptoms such as wheezing.
People with known non-anaphylaxis egg allergy
People with a history of egg allergy (non-anaphylaxis) can receive an age-appropriate full dose of vaccine in any immunisation setting. This includes sensitised children (that is, children who are skin-prick or RAST-test positive) who have not yet eaten egg.
People with latex allergy
Although the product information for Fluarix Tetra states that some preparations of the vaccine cannot be considered latex-free, these preparations are not supplied in Australia.
People with a history of Guillain–Barré syndrome
People with a history of Guillain–Barré syndrome (GBS) whose first episode was not after influenza vaccination have an extremely low risk of recurrence of GBS after vaccination. Influenza vaccination is recommended for these people.62-64
Influenza vaccination is generally not recommended for people with a history of GBS whose first episode occurred within 6 weeks of receiving an influenza vaccine. There is limited data on the risk of recurrence of GBS in people where the first episode occurred within 6 weeks of influenza vaccination (i.e. the first episode was possibly triggered by the vaccine). In these people, discuss the potential for recurrence if vaccinated, the potential for exacerbation following influenza infection, and other protective strategies (e.g. vaccination of household members). Vaccination can be considered in special circumstances, such as when an alternative cause for GBS, such as Campylobacter jejuni infection, was found or the risk of influenza disease is considered high.
People receiving immuno-oncology therapy
Some studies that included a small number of patients reported that people receiving cancer immuno-oncology therapies (checkpoint inhibitors) may have a higher risk of immune-related adverse events following immunisation with influenza vaccine,65,66 but a more recent study on patients receiving treatment with a single checkpoint inhibitor did not.67-70
Checkpoint inhibitors include:
- CTLA-4 inhibitors (such as ipilimumab)
- PD-1 and PD-L1 inhibitors (such as nivolumab or pembrolizumab)
Consult the person’s treating oncologist about the risks and benefits of influenza vaccination in people taking more than one of these treatments.
Children who need both influenza vaccine and 13vPCV
Children can receive 13vPCV and influenza vaccine at the same visit if they need both vaccines.
One study found a slightly higher risk of fever and febrile convulsions in children aged 6 months to <5 years (especially those aged 12–24 months) when they received influenza vaccine and 13vPCV at the same time, compared with receiving the vaccines separately. 71 The risk of febrile convulsions as about 18 more cases per 100,000 doses in children aged 6 months to <5 years. The highest risk was 45 per 100,000 doses in children aged 16 months. This is a relatively small risk increase.
A later study did not show an association between co-administering these 2 vaccines and febrile seizures.72
Immunisation providers should advise parents and carers of the possible risk.
See Pneumococcal disease.
Adverse events
Post-vaccination symptoms may mimic influenza infection. None of the influenza vaccines available in Australia contain live influenza viruses, so they cannot cause influenza.
Injection site reactions
Injection site reactions occur in more than 10% of people who receive standard-dose influenza vaccine intramuscularly. These include:73-75
- induration
- swelling
- redness
- pain
Studies directly comparing inactivated trivalent and quadrivalent formulations in children and adults showed that the safety profiles were similar.76-79
Systemic adverse events
1–10% of people who receive standard-dose influenza vaccines will develop:73-75, 80-82
- fever
- malaise
- myalgia
These adverse events may start a few hours after vaccination and may last for 1–2 days.73,74,80
Immediate adverse events following influenza vaccination are very rare. They can include hives, angioedema or anaphylaxis.55,60
People with a history of anaphylaxis after eating eggs or a history of a severe allergic reaction after occupational exposure to egg protein may receive influenza vaccination.55,60 See People with egg allergy in Contraindications and precautions.
Adverse events after adjuvanted influenza vaccine
Clinical trials show a higher rate of injection site reactions in adults aged ≥65 years after receiving the adjuvanted influenza vaccine, compared with standard-dose influenza vaccines.
Around 30% of people who received Fluad reported injection site reactions, compared with around 20% of people who received standard-dose influenza vaccine. Both groups reported similar rates (about 30%) of systemic reactions.83 Overall, a similar proportion of people vaccinated with Fluad Quad experience injection site and systemic reactions as those vaccinated with Fluad.84
Rates of severe or serious adverse events do not increase after receiving the adjuvanted vaccine. This has been shown in clinical trials and post-licensure surveillance studies.83-86
Adjuvanted influenza vaccine is only registered for use in people aged ≥65 years. This vaccine is not recommended in younger people. However, clinical trials in some younger populations and post-licensure safety data after an adjuvanted vaccine was inadvertently given to younger people suggest a similar safety profile to that seen in people aged ≥65 years.87-89
Adverse events after High-Dose influenza vaccine
Clinical trials show a higher rate of mild to moderate injection site reactions in adults aged ≥65 years after receiving the High-Dose influenza vaccine, compared with standard-dose influenza vaccines. There were no differences in the frequency of severe local adverse events.
Some studies reported a slightly higher frequency of systemic events among High-Dose influenza vaccine recipients compared with standard-dose influenza vaccines recipients, however events were mostly mild-moderate.
In a large active surveillance study, the frequency of any adverse event was 8.9% among High-Dose influenza vaccine recipients compared with 6.3% among standard-dose egg-based influenza vaccine recipients. However the frequency who sought medical attention was similar between the groups.
Adverse events after cell-based influenza vaccine
Cell-based influenza vaccines have a similar safety profile to standard-dose egg-based influenza vaccines. In a study of children aged 6 months through 4 years, rates of adverse events were similar between those who received cell-based and egg-based vaccines with no serious adverse events related to vaccination.90 In study among children and adolescents aged 4–17 years, injection site reactions were reported in 53% of people receiving cell-based vaccine compared with 43% receiving standard-dose egg-based influenza vaccine. Systemic reactions were reported by 37% and 30%, respectively.91 Both injection site and systemic reactions were typically mild to moderate; <1% were reported as severe.
In another study in adults aged 18–60 years, injection site reactions were reported in 29% of people receiving cell-based vaccine compared with 25% receiving standard-dose egg-based influenza vaccine. Systemic reactions were reported by 25% and 23%, respectively.92 Injection site reactions were typically mild to moderate; <1% were reported as severe. No severe systemic reactions were reported.
Fever and febrile convulsions in children aged <5 years
In 2010, higher rates of fever and febrile convulsions were reported in children aged <5 years after influenza vaccination, especially in children aged <3 years.
Only the Seqirus (previously bioCSL) vaccines Fluvax and Fluvax Junior were associated with this side effect. After vaccination with Fluvax or Fluvax Junior, children <5 years of age had febrile convulsions at a rate of 4.4 per 1000 doses, compared with no such events reported among children who received an alternative vaccine in the same year.93
The Fluvax and Fluvax Junior vaccines are no longer available in Australia and available Seqirus vaccines have been reformulated.
Safety of influenza vaccine during pregnancy or breastfeeding
Influenza vaccine is safe to give during any stage of pregnancy or while breastfeeding for both the mother and her baby.94-97 Several systematic reviews have shown no association between influenza vaccination in pregnancy and adverse birth outomes.98,99
Standard-dose egg-based influenza vaccines are currently preferred for use in pregnancy because a large body of evidence supports their safety in pregnant women. While the use of cell-based influenza vaccines in pregnancy has not been assessed, there are no theoretical concerns regarding their safety in pregnant women.
Guillain–Barré syndrome
In 1976, a small increased risk of Guillain–Barré syndrome (GBS) was associated with a specific formulation of influenza vaccine in the United States. Since then, close surveillance has shown that GBS occurs at a very low rate of up to 1 in 1 million doses of influenza vaccine.100 The risk of GBS following influenza illness is estimated to be much higher to about 15 times the risk of GBS following influenza vaccine.101,102 If GBS is suspected it is preferable that an experienced clinician confirms the diagnosis so recommendations can be made regarding future influenza vaccination.
See also People with a history of Guillain–Barré syndrome, and Uncommon and rare adverse events following immunisation in After vaccination.
Narcolepsy
Narcolepsy (sudden sleeping illness) has been associated with AS03-adjuvanted pandemic influenza vaccines. This was mainly seen in the Scandinavian population, and affected children especially.103-105 These vaccines were not used, and have never been available, in Australia.
The only registered adjuvanted influenza vaccine in Australia contains a different adjuvant (squalene-based MF59 oil-in-water emulsion adjuvant). Narcolepsy has not been associated with influenza vaccine containing MF59 adjuvant, although the number of subjects aged <20 years in these studies was limited.106,107
Nature of the disease
Influenza viruses are single-stranded RNA orthomyxoviruses. They are classified antigenically as types A, B, C or D. Generally, only influenza A and B cause severe disease in humans.108
Surface glycoprotein antigens
Influenza viruses have 2 surface glycoprotein antigens:
- haemagglutinin (H), which is involved in cell attachment during infection
- neuraminidase (N), which facilitates the release of newly synthesised virus from the cell
Influenza A viruses can be classified into subtypes based on differences in these surface antigens, but influenza B viruses cannot. There are 2 distinct influenza B lineages that previously co-circulated in varying proportions from year to year: B/Victoria and B/Yamagata.109,110 However, B/Yamagata strain has not been detected in global circulation since 2020.111
Antibodies against the surface antigens, particularly haemagglutinin, reduce infection or severe illness due to influenza.
Antigenic drift and seasonal influenza
The surface antigens of influenza A and influenza B viruses change often. The changes involve stepwise mutations of genes coding for H and N glycoproteins. This results in cumulative changes in influenza antigens, called antigenic drift. Antigenic drift is responsible for the annual outbreaks and epidemics of influenza. The composition of influenza vaccines needs to be reviewed every year because of antigenic drift.
Antigenic shift and pandemic influenza
Antigenic shift is a dramatic change in the H antigen (and other antigens) of influenza A. This occurs unpredictably and infrequently.108Antigenic shift gives rise to pandemic influenza subtypes by 1 of 2 ways:
- an avian or other animal (such as swine) virus directly adapts so that it can infect humans
- an avian or other animal (such as swine) virus mixes with a human virus, called genetic reassortment
There have been 5 influenza pandemics in the 20th and 21st centuries:
- 1918 (H1N1)
- 1957 (H2N2)
- 1968 (H3N2)
- 1977 (H1N1)
- 2009 (H1N1)
Each of these pandemic strains replaced the previously circulating influenza A subtype and went on to circulate as seasonal influenza.
More recently, various avian influenza A virus subtypes have caused human infections. Examples are H5N1, H7N9 and H9N2. Sustained human-to-human transmission of these subtypes has not been reported.112,113
Pathogenesis
The incubation period for influenza is usually 2 days, but ranges from 1 to 4 days. Virus can be detected in the upper airway for up to 1 day before symptoms start and around 3–5 days after illness finishes in adults. Children may shed virus for up to 2 weeks. Severely immunocompromised people can shed virus for months.108
Transmission
People transmit influenza from person to person:
- through virus-containing respiratory aerosols produced during coughing or sneezing
- by direct contact with respiratory secretions108
Interspecies transmission (such as from birds to humans) can result in severe illness. In rare cases, transmission of a novel virus into the human population from animals can cause a pandemic.108
Clinical features
Symptoms of influenza
Influenza virus infection causes a wide spectrum of disease. People may have:
- no or minimal symptoms
- respiratory illness with systemic features
- multisystem complications and death from primary viral or secondary bacterial pneumonia
Symptoms in adults
Fever is an obvious sign of infection and peaks at the height of the systemic illness. Other symptoms are similar for influenza A and B viruses, and include:
- malaise
- fever
- chills
- headache
- anorexia
- myalgia
- cough
- nasal discharge
- sneezing
Symptoms in children
The clinical features of influenza in infants and children are similar to those in adults. However, children may have: 114
- higher fevers
- febrile convulsions
- otitis media
- gastrointestinal symptoms
Infection in young infants may be associated with more non-specific symptoms.114,115
Complications of influenza
Complications of influenza include:
- acute bronchitis
- croup/laryngotracheobronchitis
- acute otitis media
- pneumonia (primary viral and secondary bacterial pneumonia)
- cardiovascular complications, including myocarditis and pericarditis
- encephalitis and/or encephalopathy
- Reye syndrome
- various haematological abnormalities
Secondary bacterial pneumonia is a common complication in people whose medical condition makes them vulnerable to influenza. These people are at high risk during epidemics, and may die of pneumonia or cardiac decompensation.
People at risk of severe disease from influenza
Severe disease from seasonal influenza is more likely in:9-29
- older people
- infants
- Indigenous populations (Aboriginal and Torres Strait Islander people in Australia)
- people who have never been exposed to an antigenically related influenza virus
- people who are infected with a highly virulent viral strain
- people with chronic conditions, such as heart or lung disease, renal failure, diabetes and chronic neurologic conditions
- people who are immunocompromised
- people with obesity (BMI ≥30 kg per m2)
- pregnant women
- people who smoke
Severe disease may also occur in otherwise healthy children and young adults. Annual attack rates in the general community are typically 5–10%, but may be up to 20% in some years. In households and ‘closed’ populations, attack rates may be 2–3 times higher.116,117 However, because asymptomatic or mild influenza illness is common and symptoms are non-specific, many influenza infections are not detected.
Infections due to influenza A (H3N2) strains are more likely to lead to severe morbidity and increased mortality than influenza B or seasonal influenza A (H1N1) strains.108,118-120
Epidemiology
Minor or major epidemics of influenza A or influenza B influenza occur in most years, usually during the winter months in temperate regions. The impact of influenza is often substantially underestimated.
Influenza activity varies from year to year, and depends on the circulating virus and the population’s susceptibility.114 Changes in influenza detection methods have affected influenza detection and notification patterns.121 This includes an increase in the routine use of PCR-based laboratory testing in recent years.
During annual epidemics, morbidity and mortality are higher among older adults, pregnant women and people with comorbidities.5,23,122,123
Influenza in Australia
On average each year in Australia, influenza causes approximately 100 deaths and 5100 hospitalisations.4 These numbers are widely believed to under-represent the true burden of influenza disease in Australia.
In 2019, an Australian modelling study conducted a comprehensive measurement of influenza disease burden during 2006–2015 in Australia.124 In this study, the average excess influenza-associated respiratory mortality rate was 2.61 per 100,000 population, with the highest rates among those aged ≥65 years, at 16.4 per 100,000.124 The annual excess influenza-associated hospitalisation rates were similarly highest in adults aged ≥65 years at 195.42 per 100,000 population, followed by children aged <6 months at 153.84 per 100,000 population.124
Another mathematical modelling study estimated the annual rate of seasonal influenza-associated mortality to be as high as 26.8 per 100,000 population in Australians aged ≥75 years.125 In Australia, as in other developed countries, older people and children <5 years of age have the highest rates of influenza hospitalisation.4,121,126,127 The disease burden from influenza is also greater in Aboriginal and Torres Strait Islander people than in non-Indigenous Australians across all age groups.4
During the 2009 A(H1N1)pdm09 pandemic, the predominant clinical presentation was mild to moderate illness. However, young healthy adults, pregnant women, and Aboriginal and Torres Strait Islander people were over-represented among severe cases compared with previous seasonal outbreaks.4,128,129
In 2017, a severe influenza season with the highest levels of activity since the 2009 pandemic year was recorded. New South Wales hospitals introduced rapid influenza testing, which may have partly contributed to the increased number of laboratory-confirmed notifications of influenza. Nationally, there were about 750 deaths among notified cases of laboratory-confirmed influenza in 2017,130 while Australian modelling has demonstrated that at least twice the average number of deaths occurred in 2017 compared to the average for 2010–2018.125
During the COVID-19 pandemic there was reduced circulation of influenza virus and lower levels of influenza vaccine coverage compared to previous years. COVID-19 related public health measures and the community’s adherence to public health messages have also likely had an effect on transmission of acute respiratory infections, including influenza.131 As the international borders reopened from November 2021 and greater population movement occurred, a resurgence of influenza activity was observed in 2022 with early season circulation.132 Ongoing seasonal circulation of influenza, as seen in 2023, is expected to continue emphasising that vulnerable groups are at high risk of influenza complications if they are not vaccinated.
Vaccine information
Each year, the World Health Organization recommends the strains to be included in influenza vaccines based on global influenza epidemiology.133,134 The Australian Influenza Vaccine Committee uses this recommendation to determine the influenza virus composition of vaccines for use in Australia.135
Efficacy and effectiveness of influenza vaccines
The efficacy and effectiveness of influenza vaccines of similar composition depend on the:
- age and immunocompetence of the vaccine recipient
- degree of similarity between the virus strains in the vaccine and those circulating in the community44,136-143
Quadrivalent influenza vaccines and trivalent influenza vaccines
Most evidence regarding the efficacy of quadrivalent influenza vaccines was established on the basis of non-inferior immune responses against the 3 strains in common with trivalent influenza vaccines.
A systematic review estimated the efficacy of trivalent standard-dose egg-based influenza vaccine to be 59% against laboratory-confirmed influenza in healthy adults <65 years old; this varies with influenza season.144 Based on studies comparing the immune response of quadrivalent and trivalent standard-dose egg-based influenza vaccines, the overall efficacy of the quadrivalent vaccines is expected to be similar to the trivalent vaccines, noting that quadrivalent vaccines protect against an extra influenza B lineage. In one season in the United States when the circulating and vaccine strains were well matched, quadrivalent standard-dose egg-based influenza vaccines were about 54% effective against laboratory-confirmed influenza.145
The World Health Organization (WHO) and the Australian Influenza Vaccine Committee (AIVC) have recommended that the B Yamagata lineage component is no longer warranted in seasonal influenza vaccines, as this lineage has not been seen for several years. However, the quadrivalent vaccines available in Australia continue to include the B Yamagata component, and ATAGI supports the use of these vaccines in 2024.
Influenza vaccines in young children
The influenza vaccine is registered for use from 6 months of age at which time young children can be vaccinated. Because these children are immunologically naive to influenza, they need 2 doses of influenza vaccine when immunised for the first time. This maximises the immune response to all vaccine strains.146,147
Young children gain similar levels of protection as older children and adults. Vaccine effectiveness is approximately 65% against laboratory-confirmed influenza in children aged 6–59 months in a season when the vaccine and circulating strains are well matched.148,149-154
Influenza vaccines in adults aged ≥60 years
It is important to note that adjuvanted influenza vaccine is not registered for 60 to 64 years. High dose influenza vaccine is the only enhanced influenza vaccine registered for use in adults 60-64 years of age.
Standard-dose egg-based influenza vaccines were shown to provide less protection against influenza in people aged ≥65 years than in younger people. Because of this, ‘enhanced’ formulations were developed to increase the immune system’s response to the vaccine. These enhanced vaccines increase protection compared with standard-dose egg based and cell-based vaccines, especially against influenza A (H3N2), which is more common and severe in older people.85,155,156
Most evidence on the effectiveness of adjuvanted influenza vaccine compares trivalent adjuvanted vaccine with trivalent or quadrivalent standard-dose egg-based influenza vaccines. There are no studies directly comparing quadrivalent adjuvanted and standard-dose egg-based influenza vaccines. However, a study comparing quadrivalent and trivalent adjuvanted influenza vaccines showed that the quadrivalent vaccine was not inferior in terms of generating immune responses against the shared strains, and was superior for the B strain not included in the trivalent vaccine.84 In large post-licensure studies of community-dwelling adults aged ≥65 years, adjuvanted influenza vaccine was between 4.7% and 33% more effective in preventing hospitalisation from influenza or pneumonia than standard influenza vaccine.157-160
Most evidence on the effectiveness of high-dose influenza vaccines compares trivalent high dose vaccine with trivalent or quadrivalent standard-dose egg-based influenza vaccines and with trivalent adjuvanted influenza vaccine. There are no studies measuring effectiveness outcomes that directly compare quadrivalent high-dose vaccine and standard-dose egg-based influenza vaccines. However, a study comparing quadrivalent and trivalent high-dose influenza vaccines showed that the quadrivalent vaccine was not inferior in terms of generating immune response against the shared strains, and was superior for both B strains not included in the trivalent vaccine.161
Two post-licensure studies in adults aged ≥65 years found that the high-dose influenza vaccine was between 23% and 47% more effective at preventing influenza or penumonia associated mortality than standard-dose egg-based influenza vaccines.162,163 High-dose influenza vaccine was also found to be between 2.0% and 27.0% more effective in preventing hospitalisation from influenza or pneumonia than standard-dose egg-based influenza vaccines in large post-licensure studies of adults aged ≥65 years.156,164-173 A meta-analysis of 15 studies confirms this greater protection against a range of influenza disease related outcomes.174
There are no studies that directly compare quadrivalent high-dose influenza vaccine and quadrivalent adjuvanted influenza vaccine. Large post-licensure studies comparing trivalent high-dose influenza vaccine and trivalent adjuvanted influenza vaccine in adults aged ≥65 years, show little to no difference between these two vaccines in effectiveness aginst a range of influenza outcomes (relative vaccine effectiveness ranged from -3.0% and 7.7%).156,168
Influenza vaccines in pregnant women
In pregnant women, standard-dose egg-based influenza vaccine is:175,176
- approximately 50% effective in reducing laboratory-confirmed influenza
- 65% effective against inpatient hospital admissions for acute respiratory illness
Vaccinating pregnant women against influenza also protects their infants against laboratory-confirmed influenza. This is due to transplacental transfer of high-titre influenza-specific antibodies. A recent systematic review concluded that maternal influenza vaccination reduces laboratory-confirmed influenza in infants <6 months of age by about 48%.177 The vaccine protects infants for up to 6 months after birth.
Cell-based compared with egg-based vaccines
The cell-based influenza vaccine, Flucelvax Quad, is prepared in Madin-Darby canine kidney (MDCK) cells. The virus is inactivated, disrupted and purified through several steps. Eggs are not used in the manufacturing process. Antigenic mismatch may be less likely to occur for cell-based influenza vaccines than for egg-based influenza vaccines. Repeated passages in eggs can result in an antigenic mismatch with the circulating influenza strains. This issue has been particularly problematic with some strains of A/H3N2 virus, which requires many passages in eggs to achieve high virus titres.178,179
Studies have generally shown that cell-based influenza vaccine has similar effectiveness against laboratory-confirmed influenza to standard-dose egg-based influenza vaccine. It has been noted, for some influenza seasons, that cell-based vaccines had a small observed increased benefit in protection against influenza-associated hospitalisations.156,180-185 This small benefit has been variable and the studies have the limitations associated with observational studies.
Duration of immunity
Protection against influenza requires annual vaccination with a vaccine containing the most recent strains. Recent evidence suggests that protection after influenza vaccination may begin to wane after 3–4 months.146,147,152,186-189 Low levels of protection may last another year for some strains, if the prevalent circulating strain remains the same or if there is only minor antigenic drift.44,143
It is not clear whether repeated annual vaccination affects year-to-year vaccine effectiveness. An Australian study reported sustained or increased vaccine effectiveness against influenza A and B illness and hospitalisation, particularly among children aged 2–8 years who received influenza vaccine in previous seasons.190 Also, data collected over 6 influenza seasons show that repeated annual influenza vaccination among older people who live in the community is associated with a 15% reduction in the risk of annual mortality compared with first-time vaccination.191
However, a few studies, mainly in the United States, suggest that influenza vaccines are not as effective if they are repeated year after year.192,193 Reduced effectiveness following repeated annual vaccination has not been observed consistently across studies. Better understanding of these effects is needed to determine clinical significance and guide recommendations.
Despite conflicting opinion about the impact of repeated annual vaccination on vaccine effectiveness, vaccinated people are still better protected against influenza than unvaccinated people.
Transporting, storing and handling vaccines
Transport according to National Vaccine Storage Guidelines: Strive for 5.194 Store at +2°C to +8°C. Do not freeze. Protect from light.
Discard influenza vaccines appropriately when they reach their expiry date. This is to avoid accidentally using a product with the incorrect formulation the following year.
Public health management
Laboratory-confirmed cases of influenza are notifiable in all states and territories in Australia.
The Communicable Diseases Network Australia national guidelines for influenza infection195 have details about the management of influenza cases and contacts.
State and territory public health authorities can provide further advice about the public health management of influenza, including in residential care facilities.
Variations from product information
Egg allergy
The product information for Influvac Tetra lists allergy to egg as a contraindication.
The product information for Afluria Quad state that people with egg allergy (non-anaphylaxis) can receive an age-appropriate dose.
The Australian Technical Advisory Group on Immunisation recommends that all people with egg allergies can receive an age-appropriate influenza vaccine. See Precautions.
Fluad Quad
The product information for Fluad Quad states that Fluad Quad should be given intramuscularly.
The Australian Technical Advisory Group on Immunisation recommends that Fluad Quad can also be given subcutaneously.
FluQuadri
The product information for FluQuadri states that FluQuadri should be given intramuscularly.
The Australian Technical Advisory Group on Immunisation recommends that FluQuadri can also be given subcutaneously.
Flucelvax Quad
The product information for Flucelvax Quad states that Flucelvax Quad should be given intramuscularly. The Australian Technical Advisory Group on Immunisation recommends that Flucelvax Quad can also be given subcutaneously.
Fluzone High-Dose
The product information for Fluzone High-Dose states that Fluzone High-Dose should be given intramuscularly.
The Australian Technical Advisory Group on Immunisation recommends that Fluzone High-Dose can also be given subcutaneously.
References
- Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices – United States, 2016–17 influenza season. MMWR. Recommendations and Reports 2016;65(RR-5):1-54.
- World Health Organization (WHO). Vaccines against influenza WHO position paper – November 2012. Weekly Epidemiological Record 2012;87:461-76.
- Li-Kim-Moy J, Yin JK, Blyth CC, et al. Influenza hospitalizations in Australian children. Epidemiology and Infection 2017;145:1451-60.
- Li-Kim-Moy J, Yin JK, Patel C, et al. Australian vaccine preventable disease epidemiological review series: influenza 2006 to 2015. Communicable Diseases Intelligence 2016;40:E482-95.
- Izurieta HS, Thompson WW, Kramarz P, et al. Influenza and the rates of hospitalization for respiratory disease among infants and young children. New England Journal of Medicine 2000;342:232-9.
- Coffin SE, Zaoutis TE, Rosenquist AB, et al. Incidence, complications, and risk factors for prolonged stay in children hospitalized with community-acquired influenza. Pediatrics 2007;119:740-8.
- Ampofo K, Gesteland PH, Bender J, et al. Epidemiology, complications, and cost of hospitalization in children with laboratory-confirmed influenza infection. Pediatrics 2006;118:2409-17.
- Jefferson T, Di Pietrantonj C, Al-Ansary LA, et al. Vaccines for preventing influenza in the elderly. Cochrane Database of Systematic Reviews 2010;(2):CD004876. doi:10.1002/14651858.CD004876.pub3.
- Nokleby H, Nicoll A. Risk groups and other target groups – preliminary ECDC guidance for developing influenza vaccination recommendations for the season 2010–11. Eurosurveillance 2010;15(12):pii=19525.
- Siriwardena AN, Gwini SM, Coupland CA. Influenza vaccination, pneumococcal vaccination and risk of acute myocardial infarction: matched case-control study. CMAJ Canadian Medical Association Journal 2010;182:1617-23.
- Dao CN, Kamimoto L, Nowell M, et al. Adult hospitalizations for laboratory-positive influenza during the 2005–2006 through 2007–2008 seasons in the United States. Journal of Infectious Diseases 2010;202:881-8.
- Pérez-Padilla R, Fernández R, García-Sancho C, et al. Pandemic (H1N1) 2009 virus and Down syndrome patients. Emerging Infectious Diseases 2010;16:1312-4.
- Ciszewski A. Why young healthy adults should become a target group for the influenza vaccination: a cardiologist's point of view [letter]. Vaccine 2008;26:4411-2.
- Morgan OW, Bramley A, Fowlkes A, et al. Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease. PLoS One 2010;5(3):e9694.
- Van Kerkhove MD, Vandemaele KA, Shinde V, et al. Risk factors for severe outcomes following 2009 influenza A (H1N1) infection: a global pooled analysis. PLoS Medicine 2011;8:e1001053.
- Phung DT, Wang Z, Rutherford S, Huang C, Chu C. Body mass index and risk of pneumonia: a systematic review and meta-analysis. Obesity Reviews 2013;14:839-57.
- Kok J, Blyth CC, Foo H, et al. Viral pneumonitis is increased in obese patients during the first wave of pandemic A(H1N1) 2009 virus. PLoS One 2013;8(2):e55631.
- Louie JK, Acosta M, Samuel MC, et al. A novel risk factor for a novel virus: obesity and 2009 pandemic influenza A (H1N1). Clinical Infectious Diseases 2011;52:301-12.
- González-Candelas F, Astray J, Alonso J, et al. Sociodemographic factors and clinical conditions associated to hospitalization in influenza A (H1N1) 2009 virus infected patients in Spain, 2009–2010. PLoS One 2012;7(3):e33139.
- Dixon GA, Moore HC, Kelly H, et al. Lessons from the first year of the WAIVE study investigating the protective effect of influenza vaccine against laboratory-confirmed influenza in hospitalised children aged 6–59 months. Influenza and Other Respiratory Viruses 2010;4:231-4.
- Poole P, Chacko EE, Wood-Baker R, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006;(1):CD002733. doi:10.1002/14651858.CD002733.pub2.
- Schembri S, Morant S, Winter JH, MacDonald TM. Influenza but not pneumococcal vaccination protects against all-cause mortality in patients with COPD. Thorax 2009;64:567-72.
- Mertz D, Kim TH, Johnstone J, et al. Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis. BMJ 2013;347:f5061.
- Zhang PJ, Cao B, Li XL, et al. Risk factors for adult death due to 2009 pandemic influenza A (H1N1) virus infection: a 2151 severe and critical cases analysis. Chinese Medical Journal 2013;126:2222-8.
- Allard R, Leclerc P, Tremblay C, Tannenbaum TN. Diabetes and the severity of pandemic influenza A (H1N1) infection. Diabetes Care 2010;33:1491-3.
- Sullivan-Bolyai JZ, Corey L. Epidemiology of Reye syndrome. Epidemiologic Reviews 1981;3:1-26.
- Glasgow JF. Reye's syndrome: the case for a causal link with aspirin. Drug Safety 2006;29:1111-21.
- Gill PJ, Ashdown HF, Wang K, et al. Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis. The Lancet Respiratory Medicine 2015;3:139-49.
- Paranjothy S, Dunstan F, Watkins WJ, et al. Gestational age, birth weight, and risk of respiratory hospital admission in childhood. Pediatrics 2013;132:e1562-9.
- Irving WL, James DK, Stephenson T, et al. Influenza virus infection in the second and third trimesters of pregnancy: a clinical and seroepidemiological study. BJOG: An International Journal of Obstetrics and Gynaecology 2000;107:1282-9.
- Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza immunization in mothers and infants. New England Journal of Medicine 2008;359:1555-64.
- Mak TK, Mangtani P, Leese J, Watson JM, Pfeifer D. Influenza vaccination in pregnancy: current evidence and selected national policies. The Lancet Infectious Diseases 2008;8:44-52.
- Black SB, Shinefield HR, France EK, et al. Effectiveness of influenza vaccine during pregnancy in preventing hospitalizations and outpatient visits for respiratory illness in pregnant women and their infants. American Journal of Perinatology 2004;21:333-9.
- American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. ACOG Committee Opinion No. 468: Influenza vaccination during pregnancy. Obstetrics and Gynecology 2010;116:1006-7.
- MacDonald NE, Riley LE, Steinhoff MC. Influenza immunization in pregnancy. Obstetrics and Gynecology 2009;114:365-8.
- Eick AA, Uyeki TM, Klimov A, et al. Maternal influenza vaccination and effect on influenza virus infection in young infants. Archives of Pediatrics and Adolescent Medicine 2011;165:104-11.
- France EK, Smith-Ray R, McClure D, et al. Impact of maternal influenza vaccination during pregnancy on the incidence of acute respiratory illness visits among infants. Archives of Pediatrics and Adolescent Medicine 2006;160:1277-83.
- Tamma PD, Steinhoff MC, Omer SB. Influenza infection and vaccination in pregnant women. Expert Review of Respiratory Medicine 2010;4:321-8.
- Englund JA, Mbawuike IN, Hammill H, et al. Maternal immunization with influenza or tetanus toxoid vaccine for passive antibody protection in young infants. Journal of Infectious Diseases 1993;168:647-56.
- Benowitz I, Esposito DB, Gracey KD, Shapiro ED, Vázquez M. Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clinical Infectious Diseases 2010;51:1355-61.
- Poehling KA, Szilagyi PG, Staat MA, et al. Impact of maternal immunization on influenza hospitalizations in infants. American Journal of Obstetrics and Gynecology 2011;204(6 Suppl 1):S141-8.
- Nichol KL, D'Heilly SJ, Greenberg ME, Ehlinger E. Burden of influenza-like illness and effectiveness of influenza vaccination among working adults aged 50–64 years. Clinical Infectious Diseases 2009;48:292-8.
- Savulescu C, Valenciano M, de Mateo S, Larrauri A, cycEVA Study Team. Estimating the influenza vaccine effectiveness in elderly on a yearly basis using the Spanish influenza surveillance network – pilot case-control studies using different control groups, 2008–2009 season, Spain. Vaccine 2010;28:2903-7.
- Dean AS, Moffatt CR, Rosewell A, et al. Incompletely matched influenza vaccine still provides protection in frail elderly. Vaccine 2010;28:864-7.
- Centers for Disease Control and Prevention (CDC), Robinson S, Smith P, et al. Influenza outbreaks at two correctional facilities – Maine, March 2011. MMWR. Morbidity and Mortality Weekly Report 2012;61:229-32.
- World Health Organization (WHO), Western Pacific Region. WHO interim recommendations for the protection of persons involved in the mass slaughter of animals potentially infected with highly pathogenic avian influenza viruses. Manila, Philippines: WHO Western Pacific Region; 2004. http://www.wpro.who.int/emerging_diseases/documents/WHO_interim_recommendation_26012004/en/index.html
- Ma W, Kahn RE, Richt JA. The pig as a mixing vessel for influenza viruses: human and veterinary implications. Journal of Molecular and Genetic Medicine 2009;3:158-66.
- Marti F, Steffen R, Mutsch M. Influenza vaccine: a travelers' vaccine? Expert Review of Vaccines 2008;7:679-87.
- Walter EB, Neuzil KM, Zhu Y, et al. Influenza vaccine immunogenicity in 6- to 23-month-old children: are identical antigens necessary for priming? Pediatrics 2006;118:e570-8.
- Englund JA, Walter EB, Gbadebo A, et al. Immunization with trivalent inactivated influenza vaccine in partially immunized toddlers. Pediatrics 2006;118:e579-85.
- Friedland L. GSK’s RSVPreF3 OA vaccine (AREXVY) : AREXVY was approved by FDA on May 3, 2023, and is indicated for the prevention of LRTD disease caused by RSV in adults 60 and older, as a single dose. Centers for Disease Control and Prevention (CDC); 2023. (Accessed 3/3/2024). https://stacks.cdc.gov/view/cdc/129993
- Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR. Morbidity and Mortality Weekly Report 2023;72:793-801.
- Gurtman A. RSVpreF older adults : clinical development program updates. United States of America: Centers for Disease Control and Prevention (CDC),; 2023. (Accessed 30/3/2024). https://stacks.cdc.gov/view/cdc/129992
- GlaxoSmithKline (GSK). RSVPreF3 OA - Sponsor briefing document, Vaccines and Related Biological Products Advisory Committee 2023. (Accessed 3/3/2024). https://www.fda.gov/media/165621/download
- Greenhawt MJ, Li JT, Bernstein DI, et al. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Annals of Allergy, Asthma and Immunology 2011;106:11-6.
- Mullins RJ, Gold MS. Influenza vaccination of the egg-allergic individual [letter]. Medical Journal of Australia 2011;195:52-3.
- Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the administration of influenza vaccine in children allergic to egg. BMJ 2009;339:912-5.
- Kelso JM. Administration of influenza vaccines to patients with egg allergy: update for the 2010–2011 season [letter]. Journal of Allergy and Clinical Immunology 2010;126:1302-4.
- Des Roches A, Paradis L, Gagnon R, et al. Egg-allergic patients can be safely vaccinated against influenza [letter]. Journal of Allergy and Clinical Immunology 2012;130:1213-6.e1.
- Australasian Society of Clinical Immunology and Allergy (ASCIA). Guidelines: vaccination of the egg-allergic individual. Sydney: ASCIA; 2017. https://www.allergy.org.au/health-professionals/papers/vaccination-of-t…
- Gagnon R, Primeau MN, Des Roches A, et al. Safe vaccination of patients with egg allergy with an adjuvanted pandemic H1N1 vaccine. Journal of Allergy and Clinical Immunology 2010;126:317-23.
- Baxter R, Lewis N, Bakshi N, et al. Recurrent Guillain-Barre syndrome following vaccination. Clinical Infectious Diseases 2012;54:800-4.
- Kuitwaard K, van Koningsveld R, Ruts L, Jacobs BC, van Doorn PA. Recurrent Guillain-Barre syndrome. Journal of Neurology, Neurosurgery and Psychiatry 2009;80:56-9.
- Wijdicks EF, Fletcher DD, Lawn ND. Influenza vaccine and the risk of relapse of Guillain–Barre syndrome. Neurology 2000;55:452-3.
- Laubli H, Balmelli C, Kaufmann L, et al. Influenza vaccination of cancer patients during PD-1 blockade induces serological protection but may raise the risk for immune-related adverse events. Journal for ImmunoTherapy of Cancer 2018;6:40.
- Schenk EL. Clinical outcomes of patients on check point inhibitor therapy who receive routine vaccinations. Journal of Clinical Oncology 2017;35 Suppl:e14597.
- Chong CR, Park VJ, Cohen B, et al. Safety of inactivated influenza vaccine in cancer patients receiving immune checkpoint inhibitors. Clinical Infectious Diseases 2020;70:193-9.
- Bersanelli M, Verzoni E, Cortellini A, et al. Impact of influenza vaccination on survival of patients with advanced cancer receiving immune checkpoint inhibitors (INVIDIa-2): final results of the multicentre, prospective, observational study. EClinicalMedicine 2023;61:102044.
- Grima AA, Kwong JC, Richard L, et al. The safety of seasonal influenza vaccination among adults prescribed immune checkpoint inhibitors: A self-controlled case series study using administrative data. Vaccine 2024.
- Wijn DH, Groeneveld GH, Vollaard AM, et al. Influenza vaccination in patients with lung cancer receiving anti-programmed death receptor 1 immunotherapy does not induce immune-related adverse events. European Journal of Cancer 2018;104:182-7.
- Tse A, Tseng HF, Greene SK, Vellozzi C, Lee GM. Signal identification and evaluation for risk of febrile seizures in children following trivalent inactivated influenza vaccine in the Vaccine Safety Datalink Project, 2010–2011. Vaccine 2012;30:2024-31.
- Kawai AT, Martin D, Kulldorff M, et al. Febrile seizures after 2010–2011 trivalent inactivated influenza vaccine. Pediatrics 2015;136:e848-55.
- Mahajan D, Roomiani I, Gold MS, et al. Annual report: surveillance of adverse events following immunisation in Australia, 2009. Communicable Diseases Intelligence 2010;34:259-76.
- Mahajan D, Menzies R, Cook J, Macartney K, McIntyre P. Supplementary report: surveillance of adverse events following immunisation among children aged less than 7 years in Australia, 1 January to 30 June 2010. Communicable Diseases Intelligence 2011;35:21-8.
- Wood NJ, Blyth CC, Willis GA, et al. The safety of seasonal influenza vaccines in Australian children in 2013. Medical Journal of Australia 2014;201:596-600.
- Kieninger D, Sheldon E, Lin WY, et al. Immunogenicity, reactogenicity and safety of an inactivated quadrivalent influenza vaccine candidate versus inactivated trivalent influenza vaccine: a phase III, randomized trial in adults aged ≥18 years. BMC Infectious Diseases 2013;13:343.
- Domachowske JB, Pankow-Culot H, Bautista M, et al. A randomized trial of candidate inactivated quadrivalent influenza vaccine versus trivalent influenza vaccines in children aged 3–17 years. Journal of Infectious Diseases 2013;207:1878-87.
- Pépin S, Donazzolo Y, Jambrecina A, Salamand C, Saville M. Safety and immunogenicity of a quadrivalent inactivated influenza vaccine in adults. Vaccine 2013;31:5572-8.
- Greenberg DP, Robertson CA, Landolfi VA, et al. Safety and immunogenicity of an inactivated quadrivalent influenza vaccine in children 6 months through 8 years of age. Pediatric Infectious Disease Journal 2014;33:630-6.
- Kelly H, Carcione D, Dowse G, Effler P. Quantifying benefits and risks of vaccinating Australian children aged six months to four years with trivalent inactivated seasonal influenza vaccine in 2010. Eurosurveillance 2010;15(37):pii=19661.
- Li-Kim-Moy J, Yin JK, Rashid H, et al. Systematic review of fever, febrile convulsions and serious adverse events following administration of inactivated trivalent influenza vaccines in children. Eurosurveillance 2015;20(24):pii=21159.
- Pillsbury A, Cashman P, Leeb A, et al. Real-time safety surveillance of seasonal influenza vaccines in children, Australia, 2015. Eurosurveillance 2015;20(43):pii=30050.
- Frey SE, Reyes MR, Reynales H, et al. Comparison of the safety and immunogenicity of an MF59(R)-adjuvanted with a non-adjuvanted seasonal influenza vaccine in elderly subjects. Vaccine 2014;32:5027-34.
- Essink B, Fierro C, Rosen J, et al. Immunogenicity and safety of MF59-adjuvanted quadrivalent influenza vaccine versus standard and alternate B strain MF59-adjuvanted trivalent influenza vaccines in older adults. Vaccine 2020;38:242-50.
- Novartis Vaccines and Diagnostics, Inc. FDA advisory committee briefing document: Fluad – seasonal adjuvanted trivalent influenza vaccine (aTIV). Vaccines and Related Biological Products Advisory Committee, meeting date: September 15, 2015. (Accessed Apr 2018). http://wayback.archive-it.org/7993/20170404142718/https://www.fda.gov/d…
- Villa M, Black S, Groth N, et al. Safety of MF59-adjuvanted influenza vaccination in the elderly: results of a comparative study of MF59-adjuvanted vaccine versus nonadjuvanted influenza vaccine in northern Italy. American Journal of Epidemiology 2013;178:1139-45.
- Vesikari T, Kirstein J, Devota Go G, et al. Efficacy, immunogenicity, and safety evaluation of an MF59-adjuvanted quadrivalent influenza virus vaccine compared with non-adjuvanted influenza vaccine in children: a multicentre, randomised controlled, observer-blinded, phase 3 trial. The Lancet Respiratory Medicine 2018;6:345-56.
- Vesikari T, Knuf M, Wutzler P, et al. Oil-in-water emulsion adjuvant with influenza vaccine in young children. New England Journal of Medicine 2011;365:1406-16.
- Heikkinen T, Young J, van Beek E, et al. Safety of MF59-adjuvanted A/H1N1 influenza vaccine in pregnancy: a comparative cohort study. American Journal of Obstetrics and Gynecology 2012;207:177.e1-8.
- Essink B, Sabharwal C, Cannon K, et al. Pivotal phase 3 randomized clinical trial of the safety, tolerability, and immunogenicity of 20-valent pneumococcal conjugate vaccine in adults aged ≥18 years. Clinical Infectious Diseases 2022;75:390-8.
- Nolan T, Chotpitayasunondh T, Capeding MR, et al. Safety and tolerability of a cell culture derived trivalent subunitinactivated influenza vaccine administered to healthy children andadolescents: A Phase III, randomized, multicenter, observer-blindstudy. Vaccine 2016;34:230-6.
- Ambrozaitis A, Groth N, Bugarini R, et al. A novel mammalian cell-culture technique for consistent production of a well-tolerated and immunogenic trivalent subunit influenza vaccine. Vaccine 2009;27:6022–9.
- Armstrong PK, Dowse GK, Effler PV, et al. Epidemiological study of severe febrile reactions in young children in Western Australia caused by a 2010 trivalent inactivated influenza vaccine. BMJ Open 2011;1:e000016.
- Moro PL, Broder K, Zheteyeva Y, et al. Adverse events in pregnant women following administration of trivalent inactivated influenza vaccine and live attenuated influenza vaccine in the Vaccine Adverse Event Reporting System, 1990–2009. American Journal of Obstetrics and Gynecology 2011;204:146.e1-7.
- Munoz FM, Greisinger AJ, Wehmanen OA, et al. Safety of influenza vaccination during pregnancy. American Journal of Obstetrics and Gynecology 2005;192:1098-106.
- Pool V, Iskander J. Safety of influenza vaccination during pregnancy [letter]. American Journal of Obstetrics and Gynecology 2006;194:1200.
- Tamma PD, Ault KA, del Rio C, et al. Safety of influenza vaccination during pregnancy. American Journal of Obstetrics and Gynecology 2009;201:547-52.
- Giles ML, Krishnaswamy S, Macartney K, Cheng A. The safety of inactivated influenza vaccines in pregnancy for birth outcomes: a systematic review. Human Vaccines and Immunotherapeutics 2019;15:687-99.
- Jeong S, Jang EJ, Jo J, Jang S. Effects of maternal influenza vaccination on adverse birth outcomes: A systematic review and Bayesian meta-analysis. PLoS One 2019;14:e0220910.
- Nelson KE. Invited commentary: influenza vaccine and Guillain-Barré syndrome – is there a risk? American Journal of Epidemiology 2012;175:1129-32.
- Kwong JC, Vasa PP, Campitelli MA, et al. Risk of Guillain-Barre syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled study. The Lancet Infectious Diseases 2013;13:769-76.
- Vellozzi C, Iqbal S, Broder K. Guillain-Barre syndrome, influenza, and influenza vaccination: the epidemiologic evidence. Clinical Infectious Diseases 2014;58:1149-55.
- Nohynek H, Jokinen J, Partinen M, et al. AS03 adjuvanted AH1N1 vaccine associated with an abrupt increase in the incidence of childhood narcolepsy in Finland. PLoS One 2012;7(3):e33536.
- Dauvilliers Y, Montplaisir J, Cochen V, et al. Post-H1N1 narcolepsy-cataplexy [letter]. Sleep 2010;33:1428-30.
- World Health Organization (WHO). Global Vaccine Safety: statement on narcolepsy and vaccination. 2011. (Accessed Apr 2018). http://www.who.int/vaccine_safety/committee/topics/influenza/pandemic/h…
- Kim WJ, Lee SD, Lee E, et al. Incidence of narcolepsy before and after MF59-adjuvanted influenza A(H1N1)pdm09 vaccination in South Korean soldiers. Vaccine 2015;33:4868-72.
- Tsai TF, Crucitti A, Nacci P, et al. Explorations of clinical trials and pharmacovigilance databases of MF59®-adjuvanted influenza vaccines for associated cases of narcolepsy. Scandinavian Journal of Infectious Diseases 2011;43:702-6.
- Bresee JS, Fry AM, Sambhara S, Cox NJ. Inactivated influenza vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin's vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
- Barr IG, Jelley LL. The coming era of quadrivalent human influenza vaccines: who will benefit? Drugs 2012;72:2177-85.
- Moa AM, Muscatello DJ, Turner RM, MacIntyre CR. Epidemiology of influenza B in Australia: 2001–2014 influenza seasons. Influenza and Other Respiratory Viruses 2017;11:102-9.
- World Health Organization (WHO). Recommended composition of influenza virus vaccines for use in the 2024 southern hemisphere influenza season. Geneva: WHO; 2023. (Accessed 3/3/2024). https://cdn.who.int/media/docs/default-source/influenza/who-influenza-r….
- Webster RG, Peiris M, Chen H, Guan Y. H5N1 outbreaks and enzootic influenza. Emerging Infectious Diseases 2006;12:3-8.
- Peiris M, Yuen KY, Leung CW, et al. Human infection with influenza H9N2. The Lancet 1999;354:916-7.
- Lester-Smith D, Zurynski YA, Booy R, et al. The burden of childhood influenza in a tertiary paediatric setting. Communicable Diseases Intelligence 2009;33:209-15.
- Iskander M, Kesson A, Dwyer D, et al. The burden of influenza in children under 5 years admitted to The Children's Hospital at Westmead in the winter of 2006. Journal of Paediatrics and Child Health 2009;45:698-703.
- Neuzil KM, Zhu Y, Griffin MR, et al. Burden of interpandemic influenza in children younger than 5 years: a 25-year prospective study. Journal of Infectious Diseases 2002;185:147-52.
- Hurwitz ES, Haber M, Chang A, et al. Effectiveness of influenza vaccination of day care children in reducing influenza-related morbidity among household contacts. JAMA 2000;284:1677-82.
- Kwok KO, Riley S, Perera RA, et al. Relative incidence and individual-level severity of seasonal influenza A H3N2 compared with 2009 pandemic H1N1. BMC Infectious Diseases 2017;17:337.
- Lee BE, Mukhi SN, Drews SJ. Association between patient age and influenza A subtype during influenza outbreaks. Infection Control and Hospital Epidemiology 2010;31:535-7.
- Centers for Disease Control and Prevention (CDC), Thompson MG, Shay DK, et al. Estimates of deaths associated with seasonal influenza – United States, 1976–2007. MMWR. Morbidity and Mortality Weekly Report 2010;59:1057-62.
- Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292:1333-40.
- Nielsen J, Mazick A, Glismann S, Mølbak K. Excess mortality related to seasonal influenza and extreme temperatures in Denmark, 1994–2010. BMC Infectious Diseases 2011;11:350.
- Meijer WJ, van Noortwijk AG, Bruinse HW, Wensing AM. Influenza virus infection in pregnancy: a review. Acta Obstet Gynecol Scand 2015;94:797-819.
- Milne G. Mathematical modelling to inform national seasonal influenza vaccination policy. Canberra: 2018.
- Muscatello DJ, Nazareno AL, Turner RM, Newall AT. Influenza-associated mortality in Australia, 2010 through 2019: High modelled estimates in 2017. Vaccine 2021;39:7578-83.
- Chiu C, Dey A, Wang H, et al. Vaccine preventable diseases in Australia, 2005 to 2007. Communicable Diseases Intelligence 2010;34 Suppl:ix-S167.
- Poehling KA, Edwards KM, Weinberg GA, et al. The underrecognized burden of influenza in young children. New England Journal of Medicine 2006;355:31-40.
- Flint SM, Davis JS, Su JY, et al. Disproportionate impact of pandemic (H1N1) 2009 influenza on Indigenous people in the Top End of Australia's Northern Territory. Medical Journal of Australia 2010;192:617-22.
- ANZIC Influenza Investigators, Webb SA, Pettila V, et al. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. New England Journal of Medicine 2009;361:1925-34.
- Australian Government Department of Health. Information brief: 2017 influenza season in Australia – a summary from the National Influenza Surveillance Committee. Canberra: Australian Government Department of Health; 2017. http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surve…
- Olsen SJ, Azziz-Baumgartner E, Budd AP, et al. Decreased influenza activity during the COVID-19 pandemic - United States, Australia, Chile, and South Africa, 2020. MMWR Morbidity and Mortality Weekly Report 2020;69:1305-9.
- Australian Government Department of Health and Aged Care. National 2022 Influenza Season Summary. Canberra: Australian Government Department of Health and Aged Care; 2022. https://www.health.gov.au/sites/default/files/2022-12/aisr-2022-nationa…
- World Health Organization (WHO). WHO consultation on the composition of influenza virus vaccines for use in the 2023 Southern Hemisphere influenza season. Geneva: WHO; 2022. (Accessed 23 Feb 2023). https://www.who.int/news-room/events/detail/2022/09/19/default-calendar…-virus-vaccines-for-use-in-the-2023-southern-hemisphere-influenza-season
- World Health Organization (WHO). WHO recommendations on the composition of influenza virus vaccines. (Accessed May 2018). http://www.who.int/influenza/vaccines/virus/recommendations/en/
- Therapeutic Goods Administration. Australian Influenza Vaccine Committee (AIVC). 2020. (Accessed Feb 2023). https://www.tga.gov.au/about-tga/advisory-bodies-and-committees/austral…
- Kelly H, Carville K, Grant K, et al. Estimation of influenza vaccine effectiveness from routine surveillance data. PLoS One 2009;4(3):e5079.
- Kelly H, Jacoby P, Dixon GA, et al. Vaccine effectiveness against laboratory-confirmed influenza in healthy young children: a case-control study. Pediatric Infectious Disease Journal 2011;30:107-11.
- Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V, Ferroni E. Vaccines for preventing influenza in healthy children. Cochrane Database of Systematic Reviews 2012;(8):CD004879. doi:10.1002/14651858.CD004879.pub4.
- Shuler CM, Iwamoto M, Bridges CB, et al. Vaccine effectiveness against medically attended, laboratory-confirmed influenza among children aged 6 to 59 months, 2003–2004. Pediatrics 2007;119:e587-95.
- Joshi AY, Iyer VN, St Sauver JL, Jacobson RM, Boyce TG. Effectiveness of inactivated influenza vaccine in children less than 5 years of age over multiple influenza seasons: a case-control study. Vaccine 2009;27:4457-61.
- Heinonen S, Silvennoinen H, Lehtinen P, et al. Effectiveness of inactivated influenza vaccine in children aged 9 months to 3 years: an observational cohort study. The Lancet Infectious Diseases 2011;11:23-9.
- Jick H, Hagberg KW. Effectiveness of influenza vaccination in the United Kingdom, 1996–2007. Pharmacotherapy 2010;30:1199-206.
- Monto AS, Ohmit SE, Petrie JG, et al. Comparative efficacy of inactivated and live attenuated influenza vaccines. New England Journal of Medicine 2009;361:1260-7.
- Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet Infectious Diseases 2012;12:36-44.
- Jackson ML, Chung JR, Jackson LA, et al. Influenza vaccine effectiveness in the United States during the 2015–2016 season. New England Journal of Medicine 2017;377:534-43.
- Andrews N, McMenamin J, Durnall H, et al. Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results. Eurosurveillance 2014;19(27):pii=20851.
- Castilla J, Martínez-Baz I, Martínez-Artola V, et al. Decline in influenza vaccine effectiveness with time after vaccination, Navarre, Spain, season 2011/12. Eurosurveillance 2013;18(5):pii=20388.
- Carlson SJ, Blyth CC, Beard FH, et al. Influenza disease and vaccination in children in Australia. Medical Journal of Australia 2021;215:64-7.e1.
- Blyth CC, Macartney KK, Hewagama S, et al. Influenza epidemiology, vaccine coverage and vaccine effectiveness in children admitted to sentinel Australian hospitals in 2014: the Influenza Complications Alert Network (FluCAN). Eurosurveillance 2016;21(30):pii=30301.
- Blyth CC, Jacoby P, Effler PV, et al. Effectiveness of trivalent flu vaccine in healthy young children. Pediatrics 2014;133:e1218-25.
- Heikkinen T, Heinonen S. Effectiveness and safety of influenza vaccination in children: European perspective. Vaccine 2011;29:7529-34.
- Pebody R, Andrews N, McMenamin J, et al. Vaccine effectiveness of 2011/12 trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: evidence of waning intra-seasonal protection. Eurosurveillance 2013;18(5):pii=20389.
- Treanor JJ, Talbot HK, Ohmit SE, et al. Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains. Clinical Infectious Diseases 2012;55:951-9.
- Fu C, He Q, Li Z, et al. Seasonal influenza vaccine effectiveness among children, 2010–2012. Influenza and Other Respiratory Viruses 2013;7:1168-74.
- Falsey AR, Treanor JJ, Tornieporth N, Capellan J, Gorse GJ. Randomized, double-blind controlled phase 3 trial comparing the immunogenicity of high-dose and standard-dose influenza vaccine in adults 65 years of age and older. Journal of Infectious Diseases 2009;200:172-80.
- Izurieta HS, Lu M, Kelman J, et al. Comparative effectiveness of influenza vaccines among US Medicare beneficiaries ages 65 years and older during the 2019-2020 season. Clinical Infectious Diseases 2021;73:e4251-e9.
- Mannino S, Villa M, Apolone G, et al. Effectiveness of adjuvanted influenza vaccination in elderly subjects in northern Italy. American Journal of Epidemiology 2012;176:527-33.
- Cocchio S, Gallo T, Del Zotto S, et al. Preventing the Risk of Hospitalization for Respiratory Complications of Influenza among the Elderly: Is There a Better Influenza Vaccination Strategy? A Retrospective Population Study. Vaccines 2020;8:344.
- Izurieta H, Chillarige Y, Kelman J, et al. Relative Effectiveness of Influenza Vaccines Among the United States Elderly, 2018-2019. Journal of Infectious Diseases 2020;222:278-87.
- Izurieta HS, Chillarige Y, Kelman J, et al. Relative Effectiveness of Cell-Cultured and Egg-Based Influenza Vaccines Among Elderly Persons in the United States, 2017-2018. Journal of Infectious Diseases 2019;220:1255-64.
- Chang LJ, Meng Y, Janosczyk H, Landolfi V, Talbot HK. Safety and immunogenicity of high-dose quadrivalent influenza vaccine in adults ≥65 years of age: a phase 3 randomized clinical trial. Vaccine 2019;37:5825-34.
- Shay DK, Chillarige Y, Kelman J, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccines among US Medicare beneficiaries in preventing postinfluenza deaths during 2012-2013 and 2013-2014. Journal of Infectious Diseases 2017;215:510-7.
- Young-Xu Y, Thornton Snider J, Mahmud SM, et al. High-dose influenza vaccination and mortality among predominantly male, white, senior veterans, United States, 2012/13 to 2014/15. Euro Surveillance 2020;25.
- Doyle JD, Beacham L, Martin ET, et al. Relative and Absolute Effectiveness of High-Dose and Standard-Dose Influenza Vaccine Against Influenza-Related Hospitalization Among Older Adults-United States, 2015-2017. Clinical Infectious Diseases 2021;72:995-1003.
- Gravenstein S, Davidson HE, Taljaard M, et al. Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial. The Lancet - Respiratory Medicine 2017;5:738-46.
- Young-Xu Y, Snider J, Mahmud S, et al. Clinical effectiveness of high-dose versus standard-dose influenza vaccination among veterans health administration patients: a crossover study. Pharmacoepidemiology and Drug Safety 2018;27:392-3.
- Young-Xu Y, Russo E, Neupane N, Lewis M, Halchenko Y. Clinical effectiveness of high-dose trivalent vs. quadrivalent influenza vaccination among veterans health administration patients. Open Forum Infectious Diseases 2018;5:S292-S3.
- Izurieta HS, Chillarige Y, Kelman J, et al. Relative effectiveness of cell-cultured and egg-based influenza vaccines among elderly persons in the United States, 2017-2018. Journal of Infectious Diseases 2019;220:1255-64.
- Richardson DM, Medvedeva EL, Roberts CB, Linkin DR. Comparative effectiveness of high-dose versus standard-dose influenza vaccination in community-dwelling veterans. Clinical Infectious Diseases 2015;61:171-6.
- Young-Xu Y, Van Aalst R, Mahmud SM, et al. Relative vaccine effectiveness of high-dose versus standard-dose influenza vaccines among veterans health administration patients. Journal of Infectious Diseases 2018;217:1718-27.
- Young-Xu Y, Snider JT, van Aalst R, et al. Analysis of relative effectiveness of high-dose versus standard-dose influenza vaccines using an instrumental variable method. Vaccine 2019;37:1484-90.
- Paudel M, Mahmud S, Buikema A, et al. Relative vaccine efficacy of high-dose versus standard-dose influenza vaccines in preventing probable influenza in a Medicare Fee-for-Service population. Vaccine 2020;38:4548-56.
- Izurieta HS, Chillarige Y, Kelman J, et al. Relative effectiveness of influenza vaccines among the United States elderly, 2018-2019. Journal of Infectious Diseases 2020;222:278-87.
- Lee JKH, Lam GKL, Shin T, et al. Efficacy and effectiveness of high-dose influenza vaccine in older adults by circulating strain and antigenic match: An updated systematic review and meta-analysis. Vaccine 2021;39 Suppl 1:A24-a35.
- Madhi SA, Cutland CL, Kuwanda L, et al. Influenza vaccination of pregnant women and protection of their infants. New England Journal of Medicine 2014;371:918-31.
- Regan AK, de Klerk N, Moore HC, et al. Effectiveness of seasonal trivalent influenza vaccination against hospital-attended acute respiratory infections in pregnant women: a retrospective cohort study. Vaccine 2016;34:3649-56.
- Nunes MC, Madhi SA. Influenza vaccination during pregnancy for prevention of influenza confirmed illness in the infants: a systematic review and meta-analysis. Human Vaccines and Immunotherapeutics 2017: [Epub ahead of print] doi:10.1080/21645515.2017.1345385.
- Barr IG, Donis RO, Katz JM, et al. Cell culture-derived influenza vaccines in the severe 2017-2018 epidemic season: a step towards improved influenza vaccine effectiveness. NPJ Vaccines 2018;9:44.
- Harding AT, Heaton NS. Efforts to Improve the Seasonal Influenza Vaccine. Vaccines 2018;6:19.
- Bruxvoort KJ, Luo Y, Ackerson B, et al. Comparison of vaccine effectiveness against influenza hospitalization of cell-based and egg-based influenza vaccines, 2017–2018. Vaccine 2019;37:5807–11.
- DeMarcus L, Shoubaki L, Federinko S. Comparing influenza vaccine effectiveness between cell-derived and egg-derived vaccines, 2017–2018 influenza season. Vaccine 2019;37:4015–21.
- Nolan T, Fortanier AC, Leav B, et al. Efficacy of a cell-culture-derived quadrivalent influenza vaccine in children. New England Journal of Medicine 2021;385:1485-95.
- Martin ET, Cheng C, Petrie JG, et al. Low influenza vaccine effectiveness against A(H3N2)-associated hospitalizations in 2016-2017 and 2017-2018 of the Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN). Journal of Infectious Diseases 2021;223:2062-71.
- Divino V, Ruthwik Anupindi V, DeKoven M, et al. A real-world clinical and economic analysis of cell-derived quadrivalent influenza vaccine compared to standard egg-derived quadrivalent influenza vaccines during the 2019-2020 influenza season in the United States. Open Forum Infectious Diseases 2022;9:ofab604.
- Imran M, Ortiz JR, McLean HQ, et al. Relative effectiveness of cell-based versus egg-based quadrivalent influenza vaccines in adults during the 2019-2020 influenza season in the United States. Open Forum Infectious Diseases 2022;9:ofac532.
- Gherasim A, Pozo F, de Mateo S, et al. Waning protection of influenza vaccine against mild laboratory confirmed influenza A(H3N2) and B in Spain, season 2014–15. Vaccine 2016;34:2371-7.
- Kissling E, Nunes B, Robertson C, et al. I-MOVE multicentre case-control study 2010/11 to 2014/15: is there within-season waning of influenza type/subtype vaccine effectiveness with increasing time since vaccination? Eurosurveillance 2016;21(16):pii=30201.
- Kissling E, Valenciano M, Larrauri A, et al. Low and decreasing vaccine effectiveness against influenza A(H3) in 2011/12 among vaccination target groups in Europe: results from the I-MOVE multicentre case-control study. Eurosurveillance 2013;18(5):pii=20390.
- Sullivan SG, Komadina N, Grant K, et al. Influenza vaccine effectiveness during the 2012 influenza season in Victoria, Australia: influences of waning immunity and vaccine match. Journal of Medical Virology 2014;86:1017-25.
- Cheng AC, Macartney KK, Waterer GW, et al. Repeated vaccination does not appear to impact upon influenza vaccine effectiveness against hospitalization with confirmed influenza. Clinical Infectious Diseases 2017;64:1564-72.
- Voordouw AC, Sturkenboom MC, Dieleman JP, et al. Annual revaccination against influenza and mortality risk in community-dwelling elderly persons. JAMA 2004;292:2089-95.
- McLean HQ, Thompson MG, Sundaram ME, et al. Impact of repeated vaccination on vaccine effectiveness against influenza A(H3N2) and B during 8 seasons. Clinical Infectious Diseases 2014;59:1375-85.
- Ohmit SE, Thompson MG, Petrie JG, et al. Influenza vaccine effectiveness in the 2011–2012 season: protection against each circulating virus and the effect of prior vaccination on estimates. Clinical Infectious Diseases 2014;58:319-27.
- National vaccine storage guidelines: Strive for 5. 2nd ed. Canberra: Australian Government Department of Health and Ageing; 2013. https://beta.health.gov.au/resources/publications/national-vaccine-stor…
- Communicable Diseases Network Australia (CDNA). Influenza infection: CDNA national guidelines for public health units. Canberra: Australian Government Department of Health; 2011. http://www.health.gov.au/cdnasongs
Page history
Updates include:
- Updates throughout the chapter with wording changed from the "standard vaccine" to "standard-dose egg-based" and "standard-dose cell-based" vaccine to differentiate between egg-based and cell-based standard-dose influenza vaccines.
- Addition of a new table replacing the list of specified medical conditions associated with increased risk of influenza disease and severe outcomes.
- Updates to recommendations for co-administration with examples including the new RSV vaccines.
Updates to clinical guidance have been made throughout the chapter in line with the 2023 ATAGI annual statement for seasonal influenza vaccines.
Updated information is provided on influenza vaccination and influenza activity in the context of COVID-19 vaccination and the COVID-19 pandemic.
- Updated advice on co-administration of Fluad Quad and Shingrix vaccine has been provided
- Fluzone High-Dose Quadrivalent is registered for use in Australia and is indicated in adults ≥60 years of age.
- The indicated ages for Flucelvax Quad and Influvac Tetra have been extended. Flucelvax Quad can now be used in children ≥2 years of age. Influvac Tetra can now be used in children ≥6 months of age.
Updated advice on co-administration of influenza vaccine and COVID-19 vaccine has been provided.
2021 Influenza seasonal updates.
Updates to influenza information in line with the ATAGI annual statement for seasonal influenza vaccines. Flucelvax Quad is now registered for use in Australia and is indicated in children and adults ≥9 years of age.
2020 Influenza seasonal updates.
- The indicated ages for FluQuadri and Influvac Tetra, have been extended. FluQuadri can now be used in children ≥6 months of age. Influvac Tetra can now be used in children aged ≥3 years of age.
- Vaxigrip Tetra is now registered for use in Australia and is indicated in adults and children ≥6 months of age.
- Fluad Quad (aQIV) is now registered for use in Australia and is indicated in adults ≥65 years of age.
- Fluad TIV and FluQuadri Junior have been discontinued.
- Fluzone High-Dose is not available in 2020.
Editorial changes to recommendations for preterm infants, people travelling in the influenza season, and co-administration with other vaccines.
Wording of recommendation for preterm infants updated to include recommended age for vaccination.
Recommendation for people travelling in the influenza season updated to include more specific guidance on vaccinating returning travellers who have received the Northern Hemisphere vaccine.
Guidance under Co-administration with other vaccines updated.
Updates to influenza information in line with the ATAGI annual statement for seasonal influenza vaccines
ATAGI annual statement for seasonal influenza vaccines is available here: https://health.gov.au/resources/publications/atagi-advice-on-seasonal-influenza-vaccines-in-2019
- The indicated ages for Fluarix Tetra and Afluria Quad have been extended. Fluarix Tetra can be used as a 0.5 mL dose in children aged 6 months and older, down from 3 years.
- The recommendation for administration during pregnancy has been updated. Pregnant women can receive influenza vaccine during any stage of pregnancy. The timing of vaccination should be considered in relation to the influenza season and vaccine availability. Please refer to the recommendation for further details.
- 'People who are travelling during the influenza season are strongly recommended to receive influenza vaccine, especially if influenza is circulating in the destination region or in settings with increased risk of influenza circulation during the trip. Please refer to the recommendations for travellers for further details.
2018 Influenza seasonal updates. Updating the text to reflect the 2018 influenza season (Refer to Chapter 4.7 Influenza)
Updates include:
- Updates throughout the chapter with wording changed from the "standard vaccine" to "standard-dose egg-based" and "standard-dose cell-based" vaccine to differentiate between egg-based and cell-based standard-dose influenza vaccines.
- Addition of a new table replacing the list of specified medical conditions associated with increased risk of influenza disease and severe outcomes.
- Updates to recommendations for co-administration with examples including the new RSV vaccines.
Updates to clinical guidance have been made throughout the chapter in line with the 2023 ATAGI annual statement for seasonal influenza vaccines.
Updated information is provided on influenza vaccination and influenza activity in the context of COVID-19 vaccination and the COVID-19 pandemic.
- Updated advice on co-administration of Fluad Quad and Shingrix vaccine has been provided
- Fluzone High-Dose Quadrivalent is registered for use in Australia and is indicated in adults ≥60 years of age.
- The indicated ages for Flucelvax Quad and Influvac Tetra have been extended. Flucelvax Quad can now be used in children ≥2 years of age. Influvac Tetra can now be used in children ≥6 months of age.
Updated advice on co-administration of influenza vaccine and COVID-19 vaccine has been provided.
2021 Influenza seasonal updates.
Updates to influenza information in line with the ATAGI annual statement for seasonal influenza vaccines. Flucelvax Quad is now registered for use in Australia and is indicated in children and adults ≥9 years of age.
2020 Influenza seasonal updates.
- The indicated ages for FluQuadri and Influvac Tetra, have been extended. FluQuadri can now be used in children ≥6 months of age. Influvac Tetra can now be used in children aged ≥3 years of age.
- Vaxigrip Tetra is now registered for use in Australia and is indicated in adults and children ≥6 months of age.
- Fluad Quad (aQIV) is now registered for use in Australia and is indicated in adults ≥65 years of age.
- Fluad TIV and FluQuadri Junior have been discontinued.
- Fluzone High-Dose is not available in 2020.
Editorial changes to recommendations for preterm infants, people travelling in the influenza season, and co-administration with other vaccines.
Wording of recommendation for preterm infants updated to include recommended age for vaccination.
Recommendation for people travelling in the influenza season updated to include more specific guidance on vaccinating returning travellers who have received the Northern Hemisphere vaccine.
Guidance under Co-administration with other vaccines updated.
Updates to influenza information in line with the ATAGI annual statement for seasonal influenza vaccines
ATAGI annual statement for seasonal influenza vaccines is available here: https://health.gov.au/resources/publications/atagi-advice-on-seasonal-influenza-vaccines-in-2019
- The indicated ages for Fluarix Tetra and Afluria Quad have been extended. Fluarix Tetra can be used as a 0.5 mL dose in children aged 6 months and older, down from 3 years.
- The recommendation for administration during pregnancy has been updated. Pregnant women can receive influenza vaccine during any stage of pregnancy. The timing of vaccination should be considered in relation to the influenza season and vaccine availability. Please refer to the recommendation for further details.
- 'People who are travelling during the influenza season are strongly recommended to receive influenza vaccine, especially if influenza is circulating in the destination region or in settings with increased risk of influenza circulation during the trip. Please refer to the recommendations for travellers for further details.
2018 Influenza seasonal updates. Updating the text to reflect the 2018 influenza season (Refer to Chapter 4.7 Influenza)