Influenza vaccine recommendations

MVEC influenza recommendations 2021

MVEC strongly supports annual influenza immunisation for anyone who wishes to be protected from influenza disease and its complications. The circulating strains of influenza disease change frequently and as such vaccination against the current strains are required each year.

Influenza vaccines are provided for free on the National Immunisation Program (NIP) for specific at-risk groups including:

  • Children aged 6 months to < 5-years
  • People aged ≥ 6 months of age with certain medical risk factors
  • All adults ≥ 65 years of age
  • Pregnant women (at any stage of pregnancy)
  • All Aboriginal & Torres Strait Islander people ≥ 6 months of age

For people who do not meet the criteria for funded doses, the influenza vaccine is still strongly encouraged and is available to purchase for a small fee. Influenza vaccines are available from a variety of providers, such as your GP, local council or local pharmacy (pharmacist immunisers are authorised to administer influenza vaccines to people aged 10-years and over in Victoria).

Key messages for the 2021 season

  • Annual influenza immunisation is strongly recommended for all people ≥ 6 months of age as the most important measure of preventing influenza disease and its complications.
  • COVID-19 vaccines and influenza vaccines should not be co-administered on the same day. A minimum interval of 14 days between vaccines is recommended.
  • Reporting of influenza vaccine administration to the Australian Immunisation Register (AIR) is now mandatory.
  • Fluad® Quad is the preferred vaccine brand for those aged ≥ 65 years
  • Flucelvax® Quad is a cell-based influenza vaccine registered for use in those aged ≥ 9 years and is available only for private purchase [refer to Table 1]

Table 1: The influenza strains included in the 2021 influenza vaccines for the Southern Hemisphere

Egg-based influenza vaccinesCell-based influenza vaccines
A/Victoria/2570/2019 (H1N1)pdm09-like virusA/Wisconsin/588/2019 (H1N1)pdm09-like virus
A/Hong Kong/2671/2019 (H3N2)-like virusA/Hong Kong/2671/2019 (H3N2)-like virus
B/Washington/02/2019-like (B/Victoria lineage) virusB/Washington/02/2019-like (B/Victoria lineage) virus
B/Phuket/3073/2013-like (B/Yamagata lineage) virusB/Phuket/3073/2013-like (B/Yamagata lineage) virus

Table 2: Influenza brand registered for each age group in 2021

Age groupVaccine brand and dose
Vaxigrip Tetra® (0.5 ml)Fluarix® Tetra (0.5ml)FluQuadri® (0.5ml)Influvac® Tetra (0.5ml)Afluria® Quad (0.5ml)Flucelvax® Quad (0.5ml)Fluad® Quad (0.5ml)
< 6 monthsNA
6-35 months (< 3 years)✓*✓*✓*NANANANA
3 - ≤ 4 years✓*✓*✓*✓*NANANA
5 years - ≤ 8 years✓*✓*✓*✓*✓*NANA
9 years - ≤ 64 yearsNA
≥ 65 years✓§

N/A not registered for use in this age group.
* 2 doses, minimum of 4-weeks apart should be given to children < 9 years of age in the first year of receiving the influenza vaccine. Only a single dose is recommended in subsequent years.
§
Fluad® Quad is the preferred influenza vaccine brand for this patient group and is funded on the NIP for those ≥ 65 years of age. Fluarix® Tetra/FluQuadri®/Afluria® Quad/Vaxigrip Tetra®/Influvac® Tetra/ Flucelvax® Quad are licensed for those ≥ 65 years of age but are not the preferred vaccine of choice.
Purple shaded boxes indicate the vaccine is funded under the NIP for eligible people.

Table 3: Number of influenza doses recommended for individuals in 2021

AgeNumber of doses of influenza vaccine
required in the first year of vaccination
Number of doses of influenza vaccine
required in subsequent years
6 months - < 9 years2 doses minimum of 4 weeks apart)*1
≥ 9 years11
People of any age who received a solid organ transplant (SOT) or haematopoietic stem cell transplant (HSCT) in the last 12 months2 doses (minimum of 4 weeks apart)^1

* If a patient inadvertently only received 1 dose of influenza vaccine in a previous year, then only 1 dose is required in future years.
^2 doses are recommended in the first year following SOT/HSCT regardless of history of influenza vaccination due to immunosuppression.

Co-administration of influenza vaccine with other vaccines

Due to a lack of safety and immunogenicity data on the co-administration of influenza vaccines and COVID-19 vaccines, it is currently recommended that these vaccines are not administered on the same day, but with a minimum interval of 14 days. There is no preference regarding the order of vaccine administration, noting that both the Oxford/AstraZeneca and Pfizer/BioNTech COVID-19 vaccines require a 2-dose schedule. If you have started with a Pfizer/BioNTech vaccine, it would be appropriate to first complete this course (following the recommended 21 day interval between doses), then waiting 14 days before receiving the seasonal influenza vaccine. The Oxford/AstraZeneca vaccine has a wider recommended interval between dose 1 and 2 (up to 12 weeks), so the influenza vaccine can be scheduled between these doses.

If influenza and COVID-19 vaccines are inadvertently administered on the same day or are administered within a shorter timeframe than 14 days, revaccination with either vaccine is not recommended.

Influenza vaccines may be co-administered with any other vaccines on the same day. This includes live-attenuated vaccines (e.g. measles and varicella), as well meningococcal and pneumococcal vaccines, and pertussis vaccine in pregnancy.

Cell-based influenza vaccines vs egg-based influenza vaccines

Traditional influenza vaccines are made by cultivating influenza viruses in chicken eggs. Cell-based influenza vaccines are made by growing influenza viruses in animal cells lines (canine kidney). By using a cell-based platform, influenza vaccines have the potential to provide protection against influenza strains that are more closely matched to the circulating influenza strains in the community.

Cell-based influenza vaccines have been used internationally since 2012 and in 2021 a cell-based influenza has been registered for use within Australia for the first time. Flucelvax® Quad is available for private purchase for immunisation of those aged ≥ 9 years.

Expected side effects from cell-based influenza vaccines are consistent to the side effects expected from traditional egg-based influenza vaccines. The most commonly reported symptoms are local injection site reactions, including pain and redness.

Influenza vaccine in the ≥ 65 year age group

Due to a gradual decline in effectiveness of the immune system of older people (a process known as immunosenescence) immunity following vaccination with standard QIVs can be suboptimal. In addition, those aged ≥ 65 years have the highest rates of influenza disease burden and associated complications including pneumonia and death. Adjuvanted influenza vaccines continue to be the preferred vaccine type for the older population. Common side effects include injection site reactions and fever and these may occur slightly more frequently compared with standard QIV formulations.

Latex allergies

All influenza vaccines available in Australia in 2021 are latex free. People with a latex allergy can safely be vaccinated with influenza vaccines.

Influenza vaccine and egg allergy

Based on prospective and retrospective studies of influenza vaccination in those with and without egg allergy (including egg anaphylaxis), the presence of egg allergy does not increase the risk of allergic reactions to the influenza vaccine.

The influenza vaccine can be administered in community vaccination clinics (which may or may not have direct medical practitioner supervision), general practitioner surgeries or immunisation clinics, as a single dose followed by the recommended 15 minute observation period.

Influenza vaccine and pregnancy, planning pregnancy and breastfeeding

Influenza vaccination is safe and strongly recommended for all pregnant women in every pregnancy at any stage of the pregnancy.

Pregnant women are at greater risk of morbidity and mortality from influenza disease than non-pregnant women. They are more than twice as likely to be hospitalised with influenza disease as other people with influenza. Babies less than 6 months of age are at greatest risk of disease and death from influenza. Vaccinating pregnant women will also provide protection to babies for the first few months of life until they can be immunised against influenza from 6 months of age.

For pregnant women who received an influenza vaccine during pregnancy in 2020, it is recommended to re-vaccinate if the 2021 influenza vaccine becomes available before the end of pregnancy.

For women who receive an influenza vaccine before becoming pregnant, it is recommended to re-vaccinate during pregnancy to protect the unborn infant.

It is safe for women who are planning a pregnancy and for those who are breastfeeding to receive an influenza vaccine.

Vaccine safety

SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community) would be happy to discuss any vaccine safety queries and we encourage online reporting of AEFI via our website.

Telephone: 1300 882 924 (option 1)
Email: saefvic@mcri.edu.au
Website: www.saefvic.org.au

Authors: A/Prof Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Rachael McGuire (Research Nurse SAEFVIC, Murdoch Children’s Research Institute), Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children’s Research Institute) and Mel Addison (Research Nurse SAEFVIC, Murdoch Children’s Research Institute).

Reviewed by: A/Prof Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Dr Daryl Cheng (Paediatrician, the Royal Children’s Hospital, Parkville), Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator).

Date: March 2021

Materials in this section are updated as new information becomes available. The Melbourne Vaccine Education Centre (MVEC) staff regularly review materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Immunisation recommendations for the older population

There are a variety of factors that need to be considered in relation to the vaccination of the older population. A gradual decline of the immune system occurs as people age (known as immunosenescence), impacting how the immune system responds to new infections, as well as the effectiveness of long-term immune memory. It is for this reason that some vaccines are specifically designed for the older population and aim to enhance the immune response by using higher immunogenicity formulations or by containing adjuvants. Providing optimal protection can also be complicated due to the increasing prevalence of multiple comorbidities in the aging population. Specific medical conditions or targeted therapies (eg. chronic renal conditions, chemotherapy for cancers etc) can also cause older adults to be more vulnerable to infections and their complications. Further to this, relying on patient recall, as well as a lack of awareness for the recommended vaccines for the older population, can result in either missed vaccines or additional unnecessary doses being administered.

There are multiple vaccines recommended for the older population as outlined below.

Herpes zoster (Shingles) vaccine

Shingles is caused by a reactivation of the varicella virus and will occur in approximately 20-30% of people in their lifetime. Older people (> 70 years of age) are more likely to suffer post-herpetic neuralgia (PHN) following a shingles infection than younger people. PHN is a chronic neuropathic pain which can affect 1 in 4 cases of shingles diagnosed in those > 80 years. It can persist for months to years with pain control being difficult to manage, impacting quality of life.

Zostavax® has been shown to reduce the incidence of developing shingles by up to 50%, as well as the incidence of PHN in those ≥ 60 years of age by 66%. It is currently funded under the National Immunisation Program (NIP) for persons aged 70 years, with a catch-up program for those aged 71–79 years also funded (until October 2021). As it is a live-attenuated vaccine, it is contraindicated for use in those who are immunosuppressed, or on immunosuppressive medications (eg; Rituximab, Azathioprine, Prednisolone, chemotherapy etc). Prior to administering Zostavax® it is important to take a thorough patient history to determine suitability for immunisation. Further guidance can be provided by reviewing MVEC’s Zostavax GP decision aid or by contacting SAEFVIC prior to immunisation.

Pneumococcal vaccines

Invasive pneumococcal disease (IPD) can manifest as meningitis, pneumonia and bacteremia, with severe disease requiring hospitalisation, causing significant morbidity and even death. The elderly (along with infants) are at the highest risk of developing IPD. Recommendations for pneumococcal vaccines in adults vary according to age and medical condition [refer to ATAGI clinical advice on vaccination recommendations for people with risk conditions from 1 July 2020]. Pneumococcal vaccines are currently provided for free on the NIP for the following people:

  • Aboriginal and Torres Strait Islander adults with NO risk condition - 1 dose of Prevenar 13® at 50 years of age, followed 8 weeks later by 2 doses of Pneumovax 23®, given 5 years apart
  • Non-indigenous adults with NO risk condition - 1 dose of Prevenar 13® at >70 years
  • Non-indigenous adolescents/adults diagnosed with a risk condition - 1 dose of Prevenar 13® at diagnosis, followed by 2 doses of Pneumovax 23®, given 5 years apart

In adults, injection site reactions may occur > 3 days following the Prevenar 13® dose given at > 70 years, particularly in those who have previously received Pneumovax 23 ®. A history of large local injection site reactions following previous pneumococcal vaccines is not a contraindication to further doses.

Refer to MVEC: Pneumococcal vaccines and diseases for more information.

Influenza vaccines

For older adults, and those with certain medical conditions (eg. chronic lung disease, cardiac disease, immunosuppression), influenza disease can cause serious morbidity and mortality. Annual influenza vaccination is strongly encouraged and it is available for free on the NIP for those ≥ 65 years of age and/or adults with certain medical conditions. Due to a reduced immune response to routine influenza vaccines, those aged ≥ 65 years should receive higher-immunogenicity influenza vaccines.

Refer to MVEC: Influenza vaccine recommendations for specific information on brands and dosing.

COVID-19 vaccines

Older people and those with comorbidities (eg. hypertension, diabetes, chronic lung disease etc) are much more likely to suffer from severe COVID-19 disease if infected. Of those who are > 80 years of age and have COVID-19 disease, approximately 1 in 3 will die from it.

Currently in Australia there are 2 vaccines approved for use to prevent severe COVID-19 disease. They are available for free, with older populations in the earlier priority groups identified for eligibility. Both vaccines have been recommended by the TGA for use in older people, with no upper age limit for either vaccine.

Clinical trial data has shown that Comirnaty™ has the same efficacy for the older population as it does for younger people. COVID-19 AstraZeneca™ also induces a strong immune response in the older population, however currently available clinical trial data has not been able to conclusively determine vaccine efficacy in this age group due to the small numbers of > 65 year old adults enrolled in initial trials. Further data on older people in AstraZeneca trials will be available in the coming months.

The current recommendation for COVID-19 immunisation of adults > 65 years with underlying health conditions should be decided on a case by case basis, in consultation with a medical professional

For more information on COVID-19 vaccination for older people please refer to COVID-19 vaccination – COVID-19 vaccination decision guide for frail older people, including those in residential aged care facilities.

Reporting to the Australian Immunisation Register (AIR)

The AIR provides a record of all vaccine doses given, the date of administration as well as the specific brands used. Since 2016 vaccines administered to Australians of any age have been recorded onto the AIR. Patient recall, particularly in the older population, is not reliable and as such it important that immunisation records are accurately maintained and reviewed regularly.

From March 2021, new legislation came into effect making reporting vaccines to AIR mandatory. This includes all COVID-19 vaccines, influenza vaccines and all National Immunisation Program vaccines.

Refer to MVEC: Australian Immunisation Register for more information.

Resources

Authors: Daryl Cheng (Paediatrician, The Royal Children’s Hospital), Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator)

Date: March 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Identifying AEFI in diverse skin colour

Background

The assessment of skin for clinical signs and symptoms is important when identifying adverse events following immunisation (AEFI). Most dermatological assessment guidelines commonly refer to the presentation of symptoms in patients with light skin tones.

The skin is one of the most complex organs in the body. It consists of 3 layers, with each layer performing different roles. The colour of a person’s skin is influenced by the amount of melanin (natural pigment) which is produced by the melanocytes located in the epidermis (outer layer of the skin), with darker toned skin having more melanin present than lighter toned skin. The amount of melanin will affect the appearance of AEFI on a patient’s skin and therefore AEFI, such as pallor, cyanosis, erythema and urticaria, may appear differently in varied skin tones. This can pose a challenge for immunisation providers to identify symptoms of AEFI in a timely manner.

Pallor

Pallor refers to the pale appearance of the skin, nail beds and mucous membranes. Pallor is not always a symptom of disease.

Pallor may be difficult to detect in dark toned skin and may present as ashen or grey. In brown toned skin the skin will present more yellowish in colour. An alternative method for identifying pallor in darker skin tones can be assessing the palmer surface which can appear paler.

Following immunisation, pallor can be noted in events such as vasovagal syncope (fainting) and hypotonic hypo-responsive episodes (HHE). 

Cyanosis

Cyanosis is a symptom of decreased oxygen in the bloodstream. There are 2 types of cyanosis:

  • Peripheral cyanosis, which is observed in the extremities including hands, fingertips and feet.
  • Central cyanosis, which is detected in central parts of the body including head, torso and mucous membranes and is often more serious.

In those with light skin tones, cyanosis will present as a bluish/purple hue. In patients with naturally yellow toned skin, cyanosis may cause a grayish-greenish appearance. In those with darker skin tones, cyanosis may be trickier to assess and may be observed as grey or white.

Following immunisation, cyanosis may occur in the setting of HHE, apnoea, breath holding episode or high fever.

Erythema

Erythema describes a red appearance of skin caused by the dilation of superficial blood vessels and increased blood flow. It often occurs with skin trauma, inflammation, infection or rash.

Erythema is clearly visible on light toned skin. It may appear red or cause a purplish discoloration on some darker toned skins however it is difficult to see on very dark skin. Assessing the affected site or area for other signs including warmth, swelling or induration can assist in clinical assessment and diagnosis of erythema.

Following immunisation, erythema can be widespread or localised at the injection site.

Urticaria

Urticaria, or hives, occur when the mast cells that lie within the skin release histamine that irritates nerve endings and causes local blood vessels to dilate and leak fluid. They can appear anywhere on the body and can be transient in nature. The cause is often not known however, they may be associated with infections or allergy.

On light toned skin, hives appear as itchy, raised red welts. They often have a white center or wheal which looks like a mosquito bite and are surrounded by an erythematous ring. In darker toned skin, hives appear as raised lumps however the colour changes to the skin may not be as obvious.

Following immunisation, hives can occur anywhere on the body and may occur in the setting of an allergic reaction.

Resources

Images

Other resources

Authors: Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children's Research Institute), Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute), Francesca Machingaifa (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute)

Date: September 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 


Injection site nodules

The development of a nodule at the injection site is a known but rare adverse event following immunisation (AEFI). Nodules are defined as the presence of a palpable, firm, discrete or well-demarcated soft tissue lump at the site of immunisation in the absence of heat, erythema (redness) or signs of abscess.

Nodules can occur following any vaccine.  They usually present in the days or weeks following immunisation and are most often reported following vaccines given in infancy or childhood. A nodule can persist for weeks and sometimes months. They are usually asymptomatic but can be tender and/or itchy. They are often reported by parents to feel like a ‘pea’ size lump under the skin. They usually resolve spontaneously without treatment or investigation.

It is unclear what causes a nodule however, vaccine components (e.g. aluminium), local inflammatory reactions or immune-mediated responses have been implicated as possible contributing factors.

Very rarely, a nodule may persist and become symptomatic for the vaccinee (see rare or persisting subcutaneous nodules below).

Implications and considerations for future vaccines

It is recommended that future vaccines continue to be given according to the immunisation schedule. The history of, or presence of, a nodule is not a contraindication to future vaccines.

Ensure correct vaccine administration for both intramuscular and subcutaneous vaccines. Deep intramuscular (IM) injection for IM vaccines should be considered to minimise the risk of potential recurrence of a nodule. Where possible, avoid vaccination at a site of an existing nodule.

Rare or persisting subcutaneous nodules

Some nodules can become symptomatic and last for months or even years and are referred to as persisting subcutaneous nodules. Pruritus (itch) is the most concerning symptom that motivates parents to seek medical attention. Ongoing pruritus can alter the appearance of the skin leading to excoriation, hair growth and pigmentation changes. Intensified itching and a change in size of the nodule has been reported when a child is unwell with a viral infection or even following subsequent vaccinations given at a different anatomical site.

Treatment of persisting subcutaneous nodules

A conservative approach to treatment is recommended and is usually to provide symptomatic relief of pruritus. Any treatments would need to be provided following medical review and can include topical corticosteroids or dressings to protect the area from rigorous scratching. Referral to a Specialist Immunisation Clinic should be considered for specialist consultation.

Any AEFI should be reported to the vaccine safety service in your state. In Victoria reports can be made to SAEFVIC online via saefvic.org.au or by telephone on 1300 882 924 (option 1) during business hours.

Resources

Authors: Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute), Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute)

Date: September 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Immunosuppression and vaccines

Immunosuppression occurs when a person's immune system is weakened, resulting in a decreased ability to fight infections. Causes of immunosuppression may include having certain medical conditions (e.g. autoimmune disease, cancer, transplants, functional or anatomical asplenia, advancing age and HIV) or taking specific medications (e.g. corticosteroids, disease-modifying antirheumatic drugs [DMARDs] or cancer therapies). Seroprotection from immunisation can be suboptimal in this patient group and therefore additional doses of vaccines may be recommended. Some vaccines (live-attenuated vaccines) may be contraindicated.

The degree of immune compromise should be assessed to determine individual vaccination strategies.

Many vaccines can be given pre-emptively to people who anticipate immune compromise in the future (e.g. a patient undergoing a planned splenectomy should be immunised prior to surgery).

Recommended vaccines

Inactivated vaccines are safe to administer to the immunocompromised individual but efficacy may be reduced.

Influenza

Annual influenza vaccination is recommended for all immunocompromised patients.

Those < 9 years of age are recommended to receive 2 doses of influenza vaccine, administered a minimum of 4 weeks apart, in the first year of influenza immunisation. Transplant recipients (solid organ or haematopoietic stem cell) should also receive 2 doses of influenza vaccine, a minimum of 4 weeks apart, in the first year following transplant. This is regardless of age or previous influenza vaccine history.

Where a major shift in the circulating influenza virus occurs, such as in an influenza pandemic situation, 2 doses a minimum of 4 weeks apart, should be considered regardless of patient age or immunisation history to ensure optimal immune response.

Refer to MVEC: Influenza vaccine recommendations for more information.

Pneumococcal

The timing of vaccination, the number of doses and the type of vaccine(s) depend on a person's age and underlying risk for invasive pneumococcal disease (IPD).

Refer to MVEC: Pneumococcal disease and vaccines for more information.

Meningococcal

Those taking certain therapies or with specific medical conditions (particularly those with asplenia) require extra doses of meningococcal vaccines. This applies to both MenACWY (quadrivalent) and MenB (meningococcal B) vaccines.

Refer to MVEC: Meningococcal vaccines in special risk and immunosuppressed patients for more information.

COVID-19

COVID-19 vaccination is recommended for all immunosuppressed people due to an increased risk of developing severe disease if infected with SARS-CoV-2. Due to limitations in clinical trials there is currently no data on the safety and efficacy of COVID-19 vaccination in this group, however in principle there are no theoretical risks. It is anticipated that immune responses to vaccination may be reduced and therefore continued use of other prevention measures, such as social distancing and mask wearing, are encouraged.

Administration of COVID-19 vaccines should be planned with the treating specialist and in some instances the timing of immune suppressive therapies may be altered to maximise immune responses to vaccination. Reducing the interval between COVID-19 vaccine doses to allow for planning of treatment can also be considered. The interval between Comirnaty™ doses may be reduced from 21 days to 19 days. The interval between doses of COVID-19 AstraZeneca may reduced from 12 weeks to 28 days. There is currently no recommendation for booster doses at this time.

For more information on COVID-19 vaccine administration in the setting of immune suppression please refer to ATAGI- COVID-19 vaccination decision guide for people with immunocompromise or ATAGI- Provider guide to COVID-19 vaccination of people with immunocompromise.

Contraindicated vaccines

Live-attenuated vaccines (see Table 1) are contraindicated in the majority of immunocompromising situations due to the risk of adverse events or vaccine-related disease. It is important to carefully review a patient's history to identify suitability to receive a live-attenuated vaccine. Specialist immunisation advice can be sought by contacting the Victorian immunisation hotline on 1300 882 924 if clarification is required.

Table 1: Live-attenuated vaccines

Disease Brand name
Rotavirus^ Rotarix®
MMR (measles-mumps-rubella)^ Priorix®, MMR II®
MMRV (measles-mumps-rubella-varicella)^ Priorix-tetra®, ProQuad®
Varicella (chickenpox)^ Varilrix®, Varivax®
Zoster (shingles)^ Zostavax®
Tuberculosis BCG (varying brands)
Yellow fever¥ Stamaril®
Typhoid Vivotif®
Japanese encephalitis¥ Imojev®

^recommended vaccine on the National Immunisation Program (NIP)
#recommended vaccine on NIP for select patient group only
¥available vaccine for travel

Household contacts of immune suppressed individuals should be up to date with all vaccines (including annual influenza). It is safe for household contacts to receive live-attenuated vaccines.

Precaution: Mothers who are receiving immunosuppressive therapy and breastfeeding (or those who received immunosuppressive medication during pregnancy) should seek advice from an Specialist Immunisation Clinic around the safety of live-attenuated vaccines for their child (e.g.oral rotavirus vaccine or BCG). Inactivated vaccines should be administered as per the NIP.

Inadvertent administration of a live-attenuated vaccine to an immunosuppressed person

In the event that a live-attenuated vaccine has been administered inadvertently the following steps should take place:

  • Establish how severely they are immunocompromised and the level of risk for vaccine-associated adverse effects. This will inform appropriate management (e.g. need for antiviral therapy)
  • Open disclosure with the patient and discuss the implications as well as any signs and symptoms to monitor for.
  • Seek specialist advice and notify state or territory public health authorities (refer to MVEC: Adverse events reporting Australia). In Victoria, you can seek advice from SAEFVIC.

Resources

Authors: Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute), Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator

Reviewed: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: March 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

 


Intradermal vaccination

What is it?

Intradermal vaccination is the delivery of vaccines into the outer layers of the skin. Most vaccines are delivered via the intramuscular (IM) or subcutaneous (SC) route. The intradermal (ID) route is used for only a small number of vaccines. This method of vaccine delivery requires trained health professionals to ensure safety and efficacy.

Anatomy and function of the skin

The skin is a very complex organ that is made up of 3 main layers – the epidermis, dermis and the hypodermis. Each layer has its own anatomy and specific function. The epidermal and dermal layers contain many different cells including the antigen-presenting cells (APC’s) that are thought to play a significant role in mediating an efficient and protective immune response to specific vaccines. The 3 main APC’s are macrophages, dendritic cells and B cells. The APC’s as the name suggests, presents specific antigens to particular cells in the immune system that are responsible in eliciting an immune mediated response that in turn creates memory cells and antibodies. This is how some vaccines are thought to work when given via the ID route with enhanced immunogenicity compared to the IM or SC routes.

Which vaccines can be given intradermally?

Examples of vaccines given by the ID route include BCG and hepatitis B (for non-responders). Mantoux and Q Fever tests are also performed intradermally.   

Hepatitis B vaccine is usually given by the IM route however there is a small percentage of the population who do not mount a protective immune response to the IM course of hepatitis B vaccines. If they have been deemed by their provider as a non-responder the intradermal route is considered as an alternative [refer to MVEC: Hepatitis B for more information].

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Table 1: Intradermal vaccines, doses and recommended sites

Vaccine Dose Recommended site
BCG (tuberculosis)

< 12-months 0.05ml
≥ 12-months 0.1ml

Left upper arm over the region where the deltoid muscle inserts into the humerus§
Tuberculin skin test (TST/Mantoux) 0.1ml Volar surface of mid-forearm
Engerix®-B Adult (hepatitis B)¥ 0.25ml (20mcg/1.0ml) per dose Left upper arm over the deltoid region
Q-Vax skin test (Q fever test) 0.1ml of diluted Q-Vax skin test Volar surface of mid-forearm

§This is the recommended site to minimise the risk of keloid formation
¥Refer to MVEC: Hepatitis B for more information on the management of non-responders

How do you administer an intradermal vaccine?

  • Use a short (10mm) 26-27 gauge needle with a short bevel and a 1ml insulin syringe
  • Wear protective eye wear when administering BCG vaccine as eye splashes can ulcerate
  • Identify the correct injection site (see Table 1 above)
  • Stretch the skin between a finger and your thumb
  • Insert the bevel into the dermis with the bevel facing upwards, to a distance of approx. 2mm. The bevel should be visible through the epidermis

You should feel resistance as you inject, if you don’t, the needle may be in subcutaneous tissue. If the injection is not intradermal, withdraw the needle and repeat at a new site. When given correctly, an intradermal injection should raise a blanched bleb.

Who can administer intradermal vaccines?

Only medical or nursing professionals who are trained in the correct administration of intradermal vaccines.

Resources

Authors: Francesca Machingaifa (Research Nurse SAEFVIC, Murdoch Children’s Research Institute), Mel Addison (Research Nurse SAEFVIC, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children’s Research Institute). 

Date: April 2020

Materials in this section are updated as new information becomes available. The Melbourne Vaccine Education Centre (MVEC) staff regularly review materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Influenza vaccine: frequently asked questions

MVEC’s influenza vaccine FAQ’s provide answers to commonly asked questions on the use of the influenza vaccine in 2021. It has been designed to be used in conjunction with MVEC’s influenza vaccine recommendations.

General influenza vaccine questions

  • When is the ideal time to be immunised against the flu?

    Annual vaccination before the onset of influenza season is recommended. The peak period of circulating influenza disease is typically June to September, however out of season cases do occur. Optimal protection against influenza occurs within the first 3-4 months following vaccination. It is never too late in the season to vaccinate.

  • Should we have a dose of the vaccine early in the season and a second dose later in the season?

    For healthy individuals, the recommendation is to receive one dose of influenza vaccine annually. Re-vaccination later in the same year is not routinely recommended but may benefit some individuals due to circumstances such as travel or pregnancy. The decision to recommend a second dose should take into account a person’s medical risk factors, risk of disease exposure and the current circulating virus strains.

  • Why do I need an influenza vaccine every year?

    The circulating strains of influenza virus varies each year and therefore influenza vaccines are modified annually to provide protection against those more commonly circulating strains. Optimal influenza disease protection occurs in the first 3-4 months following immunisation before it begins to wane. Annual influenza immunisation is therefore strongly recommended to have the best possible protection against influenza disease and its complications.

  • I am a healthy person, do I need a flu vaccine?

    Influenza can be a very serious disease resulting in hospitalisation and death. Even in cases where disease and its complications are not severe, it can cause a great inconvenience for the individual, including the cost of GP visits and medications, as well as time off work for themselves or to care for their sick child.

    In some cases, a person may not get severe disease however infection can be spread to other people. This can be significant when it is spread to those who are too young to be immunised or are at higher risk of complications of disease.

  • How quickly will I develop immunity after receiving the influenza vaccine?

    Most people will develop immunity within two to three weeks of vaccination providing optimal protection for the first 3-4 months thereafter. As influenza disease usually occurs from June, with the peak around August, vaccinating from mid-April will allow people to develop immunity before influenza transmission is at its peak. You can also speak with your doctor for advice on the best time to receive your vaccine, based on your individual circumstances.

  • I have already had confirmed influenza disease this year. Do I still need the influenza vaccine and when should I have it?

    The influenza vaccine would still be recommended for someone with a history of confirmed influenza infection as the vaccine protects against multiple strains of influenza disease. The influenza vaccine can be administered as soon as the patient has recovered from their illness.

  • What is the difference between egg-based and cell-based influenza vaccines?

    Traditional influenza vaccines are made by cultivating influenza viruses in chicken eggs. Cell-based influenza vaccines are made by growing influenza viruses in animal cells lines (canine kidney). By using a cell-based platform, influenza vaccines have the potential to provide protection against influenza strains that are more closely matched to the circulating influenza strains in the community.

    Cell-based influenza vaccines have been used internationally since 2012 and in 2021 a cell-based influenza has been registered for use within Australia for the first time. Flucelvax quad® is available for private purchase for immunisation of those aged ≥ 9 years.

    Expected side effects from cell-based influenza vaccines are consistent to the side effects expected from traditional egg-based influenza vaccines. The most commonly reported symptoms are local injection site reactions, including pain and redness.

  • Why are the strains included in the egg-based influenza vaccines different to the strains included in the cell-based influenza vaccines?<

    The method of manufacture differs for egg-based influenza vaccines and cell-based influenza vaccines. This can impact the ability to produce the same strains of virus for both platforms. In cases where it is not possible to produce the same strains, strains with similar properties are selected.

    The recommendation for which strains should be included in influenza vaccines is made by the World Health Organization’s Global Influenza Surveillance and Response System (GISRS) based on epidemiological data, genetic characteristics of the virus, antiviral resistance, vaccine effectiveness and the availability of candidate vaccine viruses.

Administration of influenza vaccines

  • Can I give my patient < 65 years of age the adjuvanted influenza vaccine Fluad® Quad to produce a greater immune response?

    No. Adjuvanted formulations are currently only registered for use in those ≥ 65 years of age. They are designed to illicit a better immune response in the older population where response to the standard QIV formulations have been found to be less effective. Standard QIV formulations are recommended for those aged < 65 years.

  • When is it too late in the season to get the influenza vaccine?

    It is never too late in the season to be immunised as disease can circulate all year round. Immunisation should still be offered while vaccine expiry date remains valid. Some brands have an expiry date of February the following year.

  • Can the influenza vaccine be given at the same time as other vaccines?

    With the exception of COVID-19 vaccines (see below question), people can safely receive inactivated influenza vaccines at the same time as other vaccines. This includes pneumococcal, meningococcal and live vaccines, as well as concurrently administering a Boostrix® vaccine (diphtheria-tetanus-pertussis) to pregnant women.

  • What is the process when a patient requires both influenza and COVID-19 vaccines?

    Due to a lack of safety and immunogenicity data on the co-administration of influenza vaccines and COVID-19 vaccines, it is currently recommended that these vaccines are not administered on the same day, but with a minimum interval of 14 days. There is no preference regarding the order of vaccine administration, noting that both the Oxford/AstraZeneca and Pfizer/BioNTech COVID-19 vaccines require a 2-dose schedule. If you have started your COVID-19 schedule with a Pfizer/BioNTech vaccine, it would be appropriate to first complete this course (following the recommended 21 day interval between doses), then waiting 14 days before receiving the seasonal influenza vaccine. The Oxford/AstraZeneca vaccine has a wider recommended interval between dose 1 and 2 (up to 12 weeks), so the influenza vaccine can be scheduled between these doses.

  • What is the advice if influenza vaccines and COVID-19 vaccines are inadvertently co-administered on the same day, or administered with a shorter interval than the recommended 14 days?

    If influenza and COVID-19 vaccines are inadvertently administered on the same day or are administered within a shorter timeframe than 14 days, revaccination with either vaccine is not recommended. If this was the first dose of a COVID-19 vaccine, it is recommended to complete the second dose of COVID-19 vaccine as planned with no need to alter the timeframe for the second dose.

  • Can influenza vaccines be given to someone who has had Guillain-Barre Syndrome (GBS)?

    Influenza vaccination has been identified as a possible cause of GBS following H1N1 containing vaccines, but the evidence is variable and at a very low rate, lower than the rate of GBS caused by ‘wild type’ influenza. As per the AusVaxSafety clinical resources flow chart [see resources], influenza immunisation is generally not recommended for people with a history of GBS occurring within 6 weeks of receiving a previous influenza vaccine. However specialist immunisation advice should be sought to discuss the potential benefit of vaccination and the risk for GBS recurrence post vaccination or GBS recurrence post influenza disease. There are no concerns administering influenza vaccines to patients who have a history of developing GBS more than 6 weeks following an influenza vaccine.

  • In children (< 9 years) who received the influenza vaccine for the first time last year but only received 1 dose, how many doses are required this year?

    Only 1 dose is required in this instance. 2 doses of the influenza vaccine are recommended for children < 9 years of age in the first year of receiving the vaccine, however if the second dose was inadvertently missed, it does not require catch up and only 1 dose is required in future years.

  • Children (< 9 years) need 2 doses of the influenza vaccine in their first year of being immunised. Do they need to receive the same brand for both doses?

    Influenza vaccine brands are interchangeable. Always ensure that the age-appropriate brands are administered.

  • What is the recommended site for injection when giving multiple vaccines in the same visit?

    The preferred injection site for adults and children ≥ 12 months of age is the deltoid. For infants < 12 months of age the recommended injection site is the middle third of the vastus lateralis (anterolateral thigh). More than 1 vaccine can be given into each site for injection ensuring a 2.5cm spacing between each vaccine. In some circumstances in children ≥ 12 months of age, the anterolateral aspect of the thigh may also be considered as an alternate site if required. For more information please refer to MVEC: Administration of injected vaccines-correct technique.

Safety of influenza vaccines

  • How do I know that influenza immunisation is safe in children?

    Surveillance of influenza vaccine safety continues to occur via AusVaxSafety which monitors post influenza immunisation outcomes. In children 6 months to < 5 years of age, it has been found that children in this age group experience only low rates of fevers (2%) and medical attendance (1%) post influenza immunisation. SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community) would be happy to discuss any vaccine safety queries and online reporting of AEFI via the website is encouraged [www.saefvic.org.au].

  • What are the expected side effects of the flu vaccine?

    Common side effects following the influenza vaccination include pain, redness and swelling at the injection site as well as fever, malaise and myalgia. Symptoms usually occur within the first 24-48 hours. Cell-based influenza vaccines have a similar side-effects profile as traditional egg-based influenza vaccines. Following immunisation with adjuvanted quadrivalent formulations, side effects may occur slightly more commonly than with standard QIV formulations.

  • Is it safe to receive the influenza vaccine during pregnancy?

    It is safe and recommended to receive the influenza vaccine during pregnancy. Immunisation not only provides protection for the mother against disease, but maternal antibodies are also transmitted to the baby, which will provide protection against disease for the first few months of life. Influenza immunisation is funded on the National Immunisation Program (NIP) for all pregnant women.

  • Is it safe to receive the influenza vaccine whilst breastfeeding?

    Annual influenza immunisation is safe and recommended for breastfeeding mothers. Babies less than 6 months of age are at greatest risk from disease yet cannot receive influenza vaccines until they are 6 months of age. Maternal immunisation will provide protection for mothers as well as providing some passive protection for babies through the secretion of antibodies until they are old enough to receive their own influenza vaccine.

  • Cell-based influenza vaccines are available in Australia for the first time this year. How do I know they are safe?

    All vaccines must pass through strict safety and efficacy criteria before the Therapeutic Goods Administration (TGA) will grant approval for use within Australia. To read more about the vaccine development process please refer to MVEC: Development of vaccines.

    Cell-based influenza vaccines have been used internationally since 2012. Expected side effects from cell-based influenza vaccines are consistent to the side effects expected from traditional egg-based influenza vaccines. The most commonly reported symptoms are local injection site reactions, including pain and redness.

Pregnancy, breastfeeding and influenza vaccines

  • My pregnant patient received last year’s influenza vaccine when in early pregnancy in 2020, should they also receive a dose of 2021 influenza vaccine now during the same pregnancy?

    Yes, women who received the previous year’s seasonal influenza vaccine early in their pregnancy are also recommended to receive the current year’s seasonal influenza vaccine to ensure protection against the current circulating strains.

  • When is the ideal time to receive a flu vaccine in pregnancy?

    Pregnant women can receive influenza vaccine during any stage of pregnancy. Timing is often dependent on seasonality and availability of the vaccine.

  • Is it safe to receive the influenza vaccine during pregnancy?

    It is safe and recommended to receive the influenza vaccine during pregnancy. Immunisation not only provides protection for the mother against disease, but maternal antibodies are also transmitted to the baby, which will provide protection against disease for the first few months of life. Influenza immunisation is funded on the National Immunisation Program (NIP) for all pregnant women.

  • Is it safe to receive the influenza vaccine whilst breastfeeding?

    Annual influenza immunisation is safe and recommended for breastfeeding mothers. Babies less than 6 months of age are at greatest risk from disease yet cannot receive influenza vaccines until they are 6 months of age. Maternal immunisation will provide protection for mothers as well as providing some passive protection for babies through the secretion of antibodies until they are old enough to receive their own influenza vaccine.

  • Why is influenza vaccination recommended in pregnancy?

    Pregnant women are at greater risk of morbidity and mortality from influenza disease than non-pregnant women. They are more than twice as likely to be hospitalised with influenza disease as other people with influenza. Babies less than 6 months of age are at greatest risk of disease and death from influenza. Vaccinating pregnant women will also provide protection to babies for the first few months of life until they can be immunised against influenza from 6 months of age.

Adjuvanted QIV (Fluad® Quad) influenza vaccines

  • Why are adjuvanted formulations of influenza vaccine the preferred vaccine for those ≥ 65 years?

    A gradual decline of the immune system occurs as people age (known as immunosenescence), impacting how the immune system responds to immunisation. For adults aged ≥ 65 years the adjuvanted QIV, Fluad® Quad is preferentially recommended over standard QIVs as the antibody response is increased in comparison to non-adjuvanted QIV influenza vaccines.

  • If a standard QIV formulation has been given to my patient aged ≥ 65 years, do I need to re-vaccinate with the recommended adjuvanted vaccine (Fluad® Quad)?

    If a patient aged ≥ 65 years old has already received a dose of a 2021 standard QIV vaccine they do not need re-vaccination or booster dosing with Fluad® Quad.

Special risk patients

  • Do immunosuppressed people require 2 doses of influenza vaccines?

    People with certain immunocompromising conditions (ie: solid organ transplant, stem cell transplant etc) should receive 2 doses, a minimum of 4 weeks apart, of QIV formulation of influenza vaccine in the first year of being immunosuppressed. Only 1 dose is required annually thereafter. An exception to this is in patients ≥ 65 years, as they are recommended to only receive 1 dose of the higher-immunogenicity QIV (refer to immunisation specialist for individual advice in this patient group).

  • Should my ≥ 65 year old immunosuppressed patient receive 2 doses of adjuvanted QIV this year?

    Only 1 dose of Fluad® Quad vaccine is recommended per year, regardless of medical conditions.

Vaccine components

  • My patient is allergic to egg, how can they receive a flu vaccine safely?

    Based on prospective and retrospective studies of influenza vaccination in those with and without egg allergy (including egg anaphylaxis), the presence of egg allergy does not increase the risk of allergic reactions to the influenza vaccine. Egg-based influenza vaccines can be administered in community vaccination clinics (which may or may not have direct medical practitioner supervision), General Practitioner surgeries or immunisation clinics, as a single dose followed by the recommended 15 minute observation period. It is not necessary to preferentially administer cell-based influenza vaccines in this patient group. For further information refer to MVEC: Allergy and immunisation.

  • Can patients with latex allergies receive the influenza vaccine?

    All influenza vaccines available under the NIP in 2021 are latex free. People with a latex allergy can safely be vaccinated with influenza vaccines that are available under the NIP.

  • What are cell-based influenza vaccines?

    Cell-based influenza vaccines are made by growing influenza viruses in animal cell lines (canine kidney). This is a different method of manufacture compared with traditional influenza vaccines which are created by cultivating influenza viruses in chicken eggs.

Authors: Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute), Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Daryl Cheng (Senior Research Fellow, Murdoch Children’s Research Institute)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator)

Date: March 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Injection site reactions

Swelling, redness and pain at the site can be a common side effect from any injection. Most episodes post vaccines are expected, small, local reactions and are very short lived. In some cases, however, swelling at the injection site can be more extensive and potentially classified as a severe Injection Site Reaction (ISR).

Severe ISR can be defined as “joint to joint swelling” e.g. swelling extending from the shoulder joint to the elbow joint or “crossing joints” e.g. swelling that crosses at least one joint. Resolution of these symptoms usually occur within 5-7 days. Treatment can include oral pain relief and cold compress if required. Therapies such as antibiotics and antihistamines are generally not required if a child remains systemically well. Most cases do not experience a high grade fever.

Severe ISR can be seen in around 3-4% of children receiving the 4th dose of DTPa (whooping cough booster vaccine) which is scheduled to be given at 18-months of age. It is much lower for other vaccines on the National Immunisation Program.

Regarding recurrence of severe ISR, a 5th dose of DTPa is due to given at 4 years of age and it is estimated that up to 50% of children receiving this dose may have another severe ISR. Despite a previous report of severe ISR, it is still recommended for children to continue with the scheduled vaccines, to ensure protection from important vaccine preventable diseases. For more detailed discussion please contact SAEFVIC.

Resources

Author: Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children's Research Institute)

Reviewed by: Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children's Research Institute)

Date: July 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.