International Network of Special Immunization Services

Background

The International Network of Special Immunization Services (INSIS) is a coordinated international collaboration of vaccine safety surveillance systems. By collaborating on a global scale, rare serious adverse events following immunisation (occurring in < 1 per 10,000 vaccine recipients) are more likely to be identified, thoroughly investigated and better understood. The international leads are Karina Top (Canada) and Bob Chen (United States).

Objectives

INSIS aims to promote confidence in the safety of vaccines. Implementing standardised case definitions and protocols can assist with identifying unique molecular signatures and biomarkers associated with rare adverse events following immunisation (AEFI) and improve our understanding of the genetic basis for adverse events (eg. thrombosis with thrombocytopenia syndrome and myocarditis/pericarditis following COVID-19 vaccines). By determining the causes of AEFI and identifying individual risk factors for experiencing AEFIs, it can develop recommendations for the safest way to immunise individuals with a history of or those identified as at higher risk of experiencing an AEFI. This improved understanding will also help in vaccine safety communication and the development of resources through leading websites such as MVEC.

SAEFVIC, in collaboration with AEFI-CAN, leads Australia’s involvement with INSIS.

Funding

INSIS is funded by the Coalition for Epidemic Preparedness Innovations (CEPI), the Canadian Institutes of Health Research (CIHR) and IWK Health Centre.

Resources

Authors: Rachael McGuire (MVEC Education Nurse Coordinator) and Nigel Crawford (Director, SAEFVIC, Murdoch Children's Research Institute)

Date: May 5, 2022

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.

 

 

 

 


Immune thrombocytopenia (ITP)

Background

Immune thrombocytopenia, also previously known as idiopathic thrombocytopenia purpura (ITP), is an uncommon autoimmune condition in which the body’s own immune system attacks platelets (the cells found in the blood which normally help the blood to clot). In ITP, the body produces antibodies which attack and destroy platelets, which decreases their number and can cause symptoms such as bruising, pin-point red spots (petechiae) on the skin or bleeding (e.g. nose bleeds or bleeding from the gums). Some people have no symptoms at all.

ITP is most often triggered by a viral illness, occurring in the weeks prior to symptoms developing. ITP can be acute (lasting less than 6 months) or chronic (lasting longer than 6 months), with acute ITP far more common in children and chronic ITP far more common in adults. The symptoms of acute and chronic ITP are the same. Approximately one in every 10,000 child will be affected by ITP.

Some cases of ITP are discovered by chance. In some instances, ITP may go away without any treatment. However, when platelets are very low or there are symptoms of bleeding treatment may be needed. Corticosteroids and intravenous immunoglobulin are the most common forms of initial treatment.

ITP and measles, mumps and rubella vaccines (MMR)

MMR vaccines have been associated with ITP, with the risk estimated at approximately 1 in 25,000 vaccinations.  However, the risk of ITP following MMR vaccine is much lower than the risk seen with natural measles or rubella infections. Patients with a history of ITP are still recommended to receive the MMR vaccine in line with the National Immunisation Program (NIP) as although there is a small risk of relapse, this risk is still present with the viruses themselves, and it is important that people are protected against these viruses which can cause significant morbidity and mortality.

ITP and COVID-19 vaccines

A link between COVID-19 vaccines and ITP is currently being investigated. This is because of the known link between MMR vaccine and ITP, and also because ITP can be triggered by COVID-19 infection. A study in Scotland reported a link between Vaxzevria (AstraZeneca) and ITP, with rates seen post vaccination higher than background rates of ITP in the community . To date, there has been no association found between mRNA COVID-19 vaccines (Comirnaty or Spikevax) and ITP. Monitoring and investigations are and underway in Australia.

Should patients with a history of ITP receive COVID-19 vaccines?

Yes. The effect of COVID-19 vaccination on pre-existing ITP (acute and chronic) has not been well characterised. Limited and early data indicates that vaccination may worsen thrombocytopenia in approximately 10% of patients with chronic ITP post vaccination. However, it is important to note that ITP is most often triggered by a virus, and that the risk of relapse or worsening of ITP is likely higher if these patients contract COVID-19 than the risk following vaccination itself. Patients with a history of ITP are therefore recommended to proceed with vaccination, however, if clinical symptoms worsen post vaccination (days to weeks) then monitoring of platelets and escalation of therapy may be required.

Can patients who develop ITP following a dose of COVID-19 vaccine receive future doses?

Yes. Patients who develop ITP following receipt of a COVID-19 vaccine can receive future doses (including booster doses) once they are advised that it is safe to do so. Vaccination should be deferred until platelets are stable (>50 x 109/L and off any ITP treatment for >3 months). If a patient remains on immunosuppression (eg. corticosteroids) they should discuss with a heamatologist whether to proceed.

If a patient (> 18 years) has ITP following a dose of Vaxzevria (AstraZeneca), they should receive an mRNA vaccine (eg. Comirnaty or Spikevax) or Nuvaxovid (Novavax) for their subsequent doses. If a patient has ITP following the first dose of an mRNA vaccine or Nuvaxovid they should proceed with the second dose of the same vaccine, as no association has been found between these vaccines and ITP to date. There remains a risk of relapse regardless of vaccine brand, however this risk of relapse is higher with COVID-19 disease itself. Close monitoring should occur following vaccination with dose 2 to ensure that there is no further drop in platelets.

ITP and other vaccines

There are some small studies or case reports which suggest a possible increased risk of ITP and other vaccines, such as influenza, HPV, polio and pneumococcal vaccines. However, to date, no vaccines have been proven to be associated with ITP other than the MMR and Vaxzevria (AstraZeneca) vaccines described above. People with a history of ITP are safe to receive all routine NIP and travel vaccines as required.

Resources

Authors: Sally Gordon (VicSIS Manager, Department of Health), Paul Monagle (Clinical Haematologist, Royal Children’s Hospital), Francesca Machingaifa (MVEC Education Nurse Coordinator), Rachael McGuire (MVEC Education Nurse Coordinator) and Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute)

Reviewed by: Paul Monagle (Clinical Haematologist, Royal Children’s Hospital), Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute) and Rachael McGuire (MVEC Education Nurse Coordinator)

Date: July 21, 2022

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.


Influenza

MVEC influenza recommendations 2022

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 therefore vaccination against the current strains is required each year.

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

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 2022 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
  • with the reopening of international borders and lower levels of influenza vaccine coverage than previous years a resurgence of influenza is expected
  • influenza vaccines and COVID-19 vaccines can be co-administered on the same day
  • reporting of influenza vaccine administration to the Australian Immunisation Register (AIR) is mandatory
  • adjuvanted quadrivalent influenza vaccines are preferentially recommended over standard formulations for adults ≥ 65 years
  • Flucelvax® Quad is a cell-based influenza vaccine registered for use in those aged ≥ 2 years and is available only for private purchase [refer to Table 1]
  • if an individual has received a 2021 influenza vaccine in late 2021 or early 2022, it is still recommended that they still receive a 2022 formulation when it becomes available. Individuals travelling internationally should receive the 2022 influenza vaccine before departure.

Table 1: The influenza strains included in the 2022 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/Darwin/9/2021 (H3N2)-like virusA/Darwin/6/2021 (H3N2)-like virus
B/Austria/1359417/2019-like (B/Victoria lineage) virusB/Austria/1359417/2021-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 2022

Age groupVaccine brand and dose
Vaxigrip
Tetra®
(0.5 ml)
Fluarix® Tetra
(0.5ml)
Afluria® Quad
(0.5ml)
FluQuadri® (0.5ml)
 
Influvac® Tetra
(0.5ml)
Flucelvax® Quad
(0.5ml)
Fluad® Quad
(0.5ml)
Fluzone
High-Dose
Quad (0.7ml)
< 6 months
6 months - < 2 years✓*^✓*^✓*^✓*^
≥ 2 - < 5 years✓*^✓*^✓*^✓*^✓*^
≥ 5 - < 60 years✓*^✓*^✓*^✓*^✓*^✓*^
≥ 60 - < 65 years✓^✓^✓^✓^✓^✓^
≥ 65 years✓β^✓β^✓β^✓β^✓β^✓β^✓#✓#

* 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, a single dose is recommended in subsequent years.
#Adjuvanted quadrivalent influenza vaccines are preferentially recommended for people adults ≥ 65 years.
βFluarix-tetra®/FluQuadri®/Afluria Quad®/Vaxigrip tetra®/Influvac tetra®/ Flucelvax Quad® are registered for use in those aged ≥ 65 years however adjuvanted vaccines are the preferred vaccines for this age group.
^2 doses are recommended in the first year following SOT/HSCT regardless of history of influenza vaccination due to immunosuppression. The exception to this is in individuals receiving an adjuvanted influenza vaccine where only 1 dose is recommended.
shaded boxes indicate vaccines funded under the NIP for eligible individuals.
shaded boxes not registered for use in this age group.
shaded boxes indicate adjuvanted vaccines.

Co-administration of influenza vaccine with other vaccines

Influenza vaccines may be co-administered with any other vaccines on the same day. This includes live-attenuated vaccines (eg. measles and varicella), COVID-19 vaccines and the pertussis vaccine in pregnancy.

The safety of co-administering Fluad® Quad and Shingrix on the same day has not been studied. Whilst these vaccines can be co-administered on the same day if necessary, it is preferred that their administration is separated by a few days.

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.  Flucelvax® Quad is available for private purchase for immunisation of those aged ≥ 2 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. It is for this reason that adjuvanted influenza vaccines continue to be the preferred vaccine type for the older population.

There are two adjuvanted influenza vaccines registered for use in Australia in 2022. Fluad® Quad, is registered for use in adults ≥ 65 years and funded under the NIP; and Fluzone High-Dose Quad which is registered for use in individuals aged ≥ 60 years and privately available on prescription.

Common side effects from either vaccine 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 2022 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. Influenza vaccines can safely be co-administered with pertussis and COVID-19 vaccines.

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 2021, it is recommended to re-vaccinate if the 2022 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.

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

Date: July 14, 2022

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 co-morbidities in the ageing 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) vaccines

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.

There are currently 2 vaccines available in Australia for the prevention of shingles:

  • Zostavax®- a live-attenuated vaccine
  • Shingrix®- an adjuvanted recombinant varicella zoster virus glycoprotein E (gE) subunit (non-live) vaccine

Zostavax®

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 2023). 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.

Shingrix®

Shingrix® is preferred over Zostavax® for the prevention of shingles due to a higher efficacy, particularly in the older population. In those aged ≥ 50 years, Shingrix® provided 97% protection against shingles in immunocompetent individuals and 91% protection in those aged > 70 years. Clinical trials have demonstrated high efficacy up to 4 years following vaccination with immunogenicity data indicating this is likely to persist beyond 10 years.

Shingrix® is registered for use in adults aged ≥ 50 years. It is only available through private prescription and supplies are currently limited. It is a non-live vaccine and as such can safely be administered to immunocompromised individuals. ATAGI recommends a 7 day interval between the administration of COVID-19 vaccines and Shingrix®, and prefers that FluadQuad and Shingrix® are not co-administered on the same day.

Further guidance can be provided by reviewing the Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications 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 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 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.

COVID-19 vaccination requires a 2-dose primary course for immunocompetent individuals, or a 3 -dose primary course for those with immunocompromise. A primary course shoulod be followed by a booster dose ≥ 3 months later, and a further “winter booster” dose ≥ 3 months after that for select individuals.

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.

Considerations for residents of residential aged care facilities (RACF)

Whilst every effort should be made to immunise residents of RACF at risk of vaccine preventable diseases like COVID-19 and influenza, it is important to monitor for adverse events following immunisation (AEFIs). Due to a high incidence of cognitive impairment, elderly residents may not have capacity to self-report any side effects. Any AEFIs experienced within 5 days of vaccination should be reported to SAEFVIC. It is important to monitor for non-specific symptoms seen in the elderly population when unwell such as falls, delirium, functional decline, decrease/loss of appetite or changes in mood/behaviour.

For further information on additional cares that may be required and management of symptoms following vaccination in residents of RACF refer to Guidance for vaccination care of residents of Victorian 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.

Resources

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

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator)

Date: August 5, 2022

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 a 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)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: May 31, 2022

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.

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)

Reviewed by: Mel Addison (SAEFVICResearch Nurse, Murdoch Children’s Research Institute)

Date: May 31, 2022

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 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 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. Real-world evidence has demonstrated no safety concerns relating to the administration of COVID-19 vaccines in immunocompromised individuals however, the level of protection may be reduced. It is for this reason that a 3 dose primary course of COVID-19 vaccination is recommended for optimal protection, with the third dose being administered 2 months after the second dose (a longer interval is acceptable). Following a 3-dose primary course of vaccination, immunocompromised individuals ≥ 12 years should receive a booster dose (4th dose) ≥ 3 months from completion of the primary course. An additional “winter booster dose” (5th dose) is then recommended for those ≥ 16 years ≥ 3 months after receiving the first booster.

Administration of COVID-19 vaccines should be planned with the treating specialist and in some instances the timing of immune suppressive therapies or the interval between vaccine doses may be modified to maximise immune responses to vaccination.

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: Francesca Machingaifa (MVEC Education Nurse Coordinator)

Date: August 5, 2022

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 2022. It has been designed to be used in conjunction with the MVEC influenza reference page.

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 for all individuals ≥ 6 months of age. The peak period of circulating influenza disease is typically June to September, however out of season cases do occur. The influenza season may be atypical in 2022 following the reopening of international borders in the context of COVID-19.  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 is the influenza vaccine recommended annually?

    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.

  • Do healthy people need to be immunised against influenza?

    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.

    Globally, incidences of “flurona”, a co-infection of influenza and COVID-19, have been recorded which places people at higher risks of severe disease or poorer health outcomes. To reduce the risk of co-infection, it is recommended individuals receive the seasonal influenza vaccine annually as well as remaining up to date with COVID-19 vaccination as per current recommendations.

  • How quickly is immunity developed 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.

  • If an individual has had confirmed influenza disease this year, are they still recommended to receive an influenza vaccine and when should they receive 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 was registered for use within Australia for the first time. Flucelvax quad® is available for private purchase for immunisation of those aged ≥ 2 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.

  • Can I give my patient < 60 years of age either of the adjuvanted influenza vaccines available in 2022 to produce a greater immune response?

    No, individuals < 60 years are recommended to receive standard formulation influenza vaccines. Fluad® Quad is only registered for use in peopled aged ≥ 65 years of age and is NIP funded. Fluzone High-Dose Quad is only registered for use in people aged ≥ 60 years of age but is not NIP funded.

  • If a standard QIV formulation has been given to my patient aged ≥ 60 years, do I need to re-vaccinate with an adjuvanted vaccine?

    If a patient aged ≥ 60 years old (including those aged ≥ 65 years) has already received a dose of a 2022 standard QIV vaccine they do not need re-vaccination or booster dosing with an adjuvanted influenza vaccine.

  • Why are adjuvanted formulations of influenza vaccine the preferred vaccine for older people?

    A gradual decline of the immune system occurs as people age (known as immunosenescence), impacting how the immune system responds to immunisation. For older adults the higher-immunogenecity influenza vaccines are preferentially recommended over standard QIVs as the antibody response is increased in comparison to non-adjuvanted QIV influenza vaccines.

    Whilst there is no preference between either of the higher-immunogenicity vaccines available in 2022, they are the preferred choice compared with standard formulations for individuals ≥ 65 years. Fluad® Quad is funded on the NIP for people aged ≥ 65 years of age. FluZone High-Dose Quad is available for private purchase for individuals from ≥ 60 years.

Administration of influenza vaccines

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

    Yes. Influenza vaccines can be co-administered with other vaccines. This includes pneumococcal, meningococcal, COVID-19 and live vaccines, as well as concurrently administering a Boostrix® vaccine (diphtheria-tetanus-pertussis) to pregnant women.

    The only exception to this is the co-administration of Fluad®Quad and Shingrix.  Whilst co-administration of these vaccines is acceptable, there is limited safety data on this and therefore it is preferred to separate their administration by several days.

     

     

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

    Influenza vaccines can be administered on the same day as COVID-19 vaccines.

  • If an individual has had a reaction to a COVID-19 vaccine, can they safely receive an influenza vaccine?

    There are only two absolute contraindications to an influenza vaccine, anaphylaxis to a previous dose of any influenza vaccine or a component of any influenza vaccine.

    Adverse events following a COVID-19 vaccine should be reported to SAEFVIC and referred to VicSIS for specialist advice and follow up if indicated.

    A previous reaction to a COVID-19 vaccine is not a contraindication to receiving an influenza vaccine.

  • Can Fluad®Quad and Shingrix be administered on the same day?

    The safety of co-administering Fluad®Quad and Shingrix has not been studied. Whilst co-administration of these vaccines is acceptable, it is preferred to separate their administration by several days.

  • 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, 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 we 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. Online reporting of adverse events following immunisation can be reported online to SAEFVIC.

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

    Common side effects following the influenza vaccine 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 following immunisation. Cell-based influenza vaccines have a similar side-effect profile to traditional egg-based influenza vaccines. Side effects may occur slightly more commonly following immunisation with adjuvanted quadrivalent formulations 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 have only been available in Australia since 2021. How do we 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 2021, should they also receive a dose of 2022 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 an influenza vaccine with other vaccines when pregnant?

    Influenza vaccines can be safely co-administered with pertussis and COVID-19 vaccines to pregnant individuals.

  • 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.

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 patients receiving high-immunogenicity vaccines where only 1 dose is recommended (refer to immunisation specialist for individual advice in this patient group).

  • Should my older immunosuppressed patient receive 2 doses of an adjuvanted quadrivalent influenza vaccine this year?

    Only one dose of an adjuvanted influenza 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 2022 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.

If you have any further queries or your question has not been answered above, please contact MVEC.

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

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

Date: April 5, 2022

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 (erythema), pain and itch at the site of injection can be a common side effect from any vaccine. Symptoms are usually mild and localised to the site of vaccination, with onset commonly occurring within the first 48 hours of vaccination and symptoms lasting 1-2 days. In some cases, however, injection site reactions (ISR’s) can appear more significant, last up to a week or have delayed onset.

Severe injection site reactions

Severe ISR’s can present with pain, erythema and induration (hard, tight swelling) which extends from “joint to joint” (eg. from the shoulder joint to the elbow joint) or “crossing joints” (eg. swelling that crosses at least one joint). Localised itch is also often reported. Resolution of these symptoms usually occur within 5-7 days with no long-term sequelae. Most affected individuals do not experience a high grade fever and remain systemically well.

Delayed injection site reactions following COVID-19 vaccines

Delayed ISR’s have been reported to occur following COVID-19 vaccination. Symptoms commonly present within 4-11 days of vaccination, with a median onset of 8 days and can last 4-5 days.

Injection site reactions following pneumococcal vaccines

Pneumococcal vaccines are administered to both children and adults via the National Immunisation Program (NIP). In children, injection site reactions are more commonly reported as occurring within 24-48 hours following immunisation. In adults, ISR’s may occur >3 days following the 13vPCV dose given at >70years.

Treatment of injection site reactions

ISR’s can generally be managed at home with symptomatic relief such as oral analgesia and a cold compress. Immobilising the affected limb should be avoided to enhance lymphatic drainage. Antibiotics and antihistamines are generally not required.

Implications for future doses

In any age group, previous experience of an ISR is not a contraindication to future doses of vaccines and vaccine recipients are encouraged to complete the recommended vaccine schedules. Recurrence of symptoms following future vaccination may occur in some individuals but severity is not likely to be worsened.

Reporting to SAEFVIC

Any event felt to be significant following vaccination, including any symptoms which have not gone away after a few days should be reported to SAEFVIC. Providing a photograph of the ISR can assist with SAEFVIC management and advice. For information on how to photograph an injection site reaction please refer to MVEC: Photographing a severe local reaction.

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

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

Date: January 18, 2022

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.