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3. 3www.slideshare.net/ashraf eladawy

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 Seasonal influenza, or ‘the flu’ as it is often called,
is an acute viral infection caused by an influenza
virus, mainly affects the respiratory system .
 Seasonal influenza viruses circulate worldwide and
can affect anybody in any age group.

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 Influenza viruses are divided scientifically into three types
designated A, B, and C.
 Influenza A viruses are further classified into different
subtypes according to combinations of various virus
surface proteins or antigens : hemagglutinin (HA) &
neuraminidase (NA) .
 There are 16 known H subtypes and 9 known N subtypes.

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Hemagglutinin (HA)–16 subtypes
Neuraminidase (NA)–9 subtypes
Influenza A Virus is subtyped by surface proteins

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 Many different combinations of HA and NA proteins are
possible, all of which have been found in wild birds, which are
the natural reservoir of influenza A viruses.
 Among many subtypes of influenza A viruses,only influenza
A(H1N1) and A(H3N2) are currently circulating among humans
as seasonal Influenza strains.
•

8. Avian Influenza AAvian Influenza A
virusesviruses
H1 - H16
N1 - N9
H1 - H3
N1 –N2
Human Influenza
A Viruses
Natural Reservoir for New Human Influenza A Virus
Subtypes: Waterfowl (Aquatic Ducks, Geese)

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 Type B influenza virus is not categorised into subtypes,
but lineages.
 Currently circulating influenza B viruses belong to one
of two lineages: B/Yamagata and B/Victoria like viruses,
and these can be further broken down into different
strains.

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 Seasonal influenza viruses cause annual epidemics that peak
during winter in temperate regions
 Influenza A and influenza B are responsible for most clinical
illness, can cause seasonal influenza epidemics in humans.
 Influenza type C usually causes either a very mild respiratory
illness or no symptoms at all; it does not cause epidemics and
does not have the severe public health impact of influenza
types A and B.

11. How do yearly epidemics occur?
Answer: A process called antigenic DRIFT.
 Imperfect “manufacturing” of virus
– Small changes in H and N
– Partial immunity in population
o Incomplete protection; still get sick
o Need new flu vaccine every year
H3N2 H3N2
Immune System:
“Do I know you?
You look vaguely
familiar!”

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Antigenic Drift
This term denotes MINOR changes in hemagglutinin and
neuraminidase of influenza virus.
This results from mutation in the RNA segments coding for
either the HA or NA
This involves no change in serotype; there is merely an
alteration in amino acid sequence of HA or NA leading to
change in antigenicity (point mutation(.

13. Children’s Healthcare of Atlanta

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Antigenic Drift
Is a mechanism for variation in viruses that involves the
accumulation of mutations within the genes that code
for antibody-binding sites.
This results in a new strain of virus particles which cannot be
inhibited as effectively by the antibodies that were originally
targeted against previous strains, making it easier for the
virus to spread throughout a partially immune population.
Antigenic drift occurs in both influenza A and influenza B
viruses.

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 Seasonal influenza is characterized by a sudden onset of
high fever, cough (usually dry), headache, muscle and joint
pain, severe malaise (feeling unwell), sore throat and
runny nose.
 Most people recover from fever and other symptoms
within a week without requiring medical attention.
 But influenza can cause severe illness or death especially in
people at high risk .
The clinical burden of influenza

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 Seasonal influenza epidemics can cause febrile illnesses
that range in severity from mild to debilitating and can
lead in some instances to hospitalization and even cause
death, mainly among high-risk groups.
 Seasonal influenza is a serious public health problem, it has
been estimated that in developed countries, annual
influenza epidemics infect about 10–20% of the population
each season.
Is Flu Serious ?

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Worldwide, annual influenza epidemics are estimated to result
in ~1 billion cases of flu, ~3–5 million cases of severe illness
and 300 000–500 000 deaths annually.
Yearly influenza epidemics can seriously affect all populations,
but the highest risk of complications occur among children
younger than age 2 years, adults aged 65 years or older,
pregnant women, and people of any age with certain
chronic medical conditions , or weakened immune systems .
Is Flu Serious ?

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 Although there are medications to treat the flu, they are
expensive, and need to be started within 24-48 hours of
the start of symptoms.
 The single best way to protect against the flu and/or
severe outcomes from the illness is to get vaccinated each
year .
 Safe and effective vaccines are available and have been
used for more than 60 years.

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Every flu season is different, A flu vaccine is needed every
season for two reasons:
1)The body’s immune response from vaccination declines over
time, so an annual vaccine is needed for optimal protection ,
Even if the strains have not changed, getting influenza vaccine
every year is necessary to maximize protection.
2)Antigenic drift (Flu viruses are constantly changing),which
may occur in one or more influenza virus strains, so the
seasonal influenza vaccine must be re-made (updated ) each
year to protect against the most recent and most commonly
circulating viruses.

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Each year, the influenza virus can mutate, or change its
structure rapidly, leading to new strains of the virus, making
the vaccine used in previous years ineffective.
Each year, a new vaccine must be prepared that will be
effective against the expected type of influenza virus.
The trick is to be able to predict which influenza viruses are
going to cause infection and to prepare a vaccine against
those viruses .

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Currently, 136 national influenza centers in 106 countries
conduct year-round surveillance for influenza viruse and
disease activity.
Each year, based on global surveillance data, the World
Health Organization recommends the strains that they
believe will be circulating in the upcoming influenza season
Each year, before influenza season starts, one or more
virus strains in the vaccine might be changed on the basis of
global surveillance data for influenza viruses.
Influenza vaccine development

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Influenza vaccine development
In February, the WHO makes recommendations concerning
the virus strains to be included in vaccine production for the
forthcoming winter in the Northern Hemisphere .
It takes about 6 months for vaccine manufacturers to grow
the viruses in chicken eggs .
Shipments began in August and will continue throughout
September and October until all vaccine is distributed.

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• The Trivalent inactivated seasonal influenza vaccines (TIV) include
a mixture of 2 influenza A strains and 1 influenza B strain
thought most likely to circulate in the upcoming season.

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After a remarkable eight year reign, the original A/California/7/2009-
like H1N1 strain has been retired, and replaced with
an A/Michigan/45/2015 (H1N1)pdm09-like virus .
The H3N2 component -- remains unchanged from last year (A/Hong
Kong/4801/2014 (H3N2)-like virus) .
The primary B component remains the same as last year; a
B/Brisbane/60/2008-like virus .

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When should I get Seasonal Influenza Vaccine?
 People get vaccinated against influenza as soon as vaccine
becomes available in their community, if possible by October.
 In general vaccination before December is best since this
timing ensures that protective antibodies are in place before flu
activity is typically at its highest.
 However, flu season can last as late as May so getting
vaccinated later throughout the flu season, even in January or
later, could still provide protective benefit.

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How does inactivated influenza vaccine work?
 Both humoral and cell-mediated responses play a role in
immunity .
 Administration of inactivated influenza vaccine results in
the production of circulating IgG antibodies to the viral
haemagglutinin as well as a cytotoxic T lymphocyte response .
 Humoral antibody levels, which correlate with vaccine
protection, are generally achieved 2 weeks after immunization
and immunity usually lasts less than 1 year .
.

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How much protection does the seasonal
influenza vaccine provide?

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The effectiveness of influenza vaccine depends primarily
on:
1 . The age and health status of the person getting the
vaccine.
2.The similarity or "match" between the viruses in the
vaccine and those in circulation
Vaccine effectiveness is not 100%, and some people can still
get the flu after being vaccinated.

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Does the Flu Vaccine Work?
YES!
Studies have shown that flu vaccine is
70-90% effective
in healthy adults
less than 65 years of age.

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Adults < 65 years
• 70-90% protection against influenza
Adults > 65 years
• 30 - 40% effective among frail elderly
persons
• 50-60% effective in preventing
hospitalization
• 80% effective in preventing death

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During seasons when most circulating influenza viruses are
similar to the viruses in the influenza vaccine, the vaccine can
reduce the risk of illness caused by influenza virus infection by
about 50-60% among the overall population.
Remember that even when the viruses are not closely
matched, the vaccine can still protect many people and prevent
flu-related complications.
Such protection is possible because antibodies made in
response to the vaccine can provide some protection (called
cross-protection) against different, but related strains of
influenza viruses .

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 Seasonal influenza vaccine provides the best protection
available from seasonal flu –even when the vaccine does not
closely match circulating flu strains, and even when the
person getting the vaccine has a weakened immune system.
 Vaccination can lessen illness severity and is particularly
important for people at high risk for serious flu-related
complications .

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90°
Angle
Dermis
Fatty tissue
(subQ)
Muscle tissue
Trivalent Inactivated Influenza Vaccine is Administered
by the Intramuscular Route
Needle length & Site depend on:
Muscle size, Fatty tissue thickness,
Vaccine volume, Injection technique
Aspiration is NOT required

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Anterolateral thigh
Needle gauge
- 22 - 25 gauge
Needle length
- 1 inch
Inactivated seasonal Influenza Vaccine
IM Injections – Infant (6-12 months)

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Inactivated seasonal Influenza Vaccine
IM Injections – Toddlers (1-2 years)
Needle size
- 22 - 25 gauge
Needle length
- anterolateral thigh – 1 inch
- deltoid – 1 inch

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.
 For adults and older children, the
recommended site of vaccination is
the deltoid muscle.
 The preferred site for infants (< 12
months old ) and young children (older
than 12 months of age with inadequate
deltoid muscle mass)is the anterolateral
aspect of the thigh.

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Standard Technique for Injection

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 Shake vaccine vial before withdrawing a dose
 Discard vaccine if it contains particulates, appears discolored
 Do not administer into buttock muscle because of potential
for injection-associated injury to sciatic nerve
 ACIP states that aspiration (i.e., pulling back on the syringe
plunger after needle insertion and before injection) is not
required because large blood vessels are not present at
recommended IM injection sites
 Do not mix with any other vaccine or solution
Precautions

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Vaccine Storage
Store vaccine between 2º and 8º C at all times.
Vaccine should be placed on the middle shelves of
the refrigerator
Influenza vaccine should never be
exposed to freezing
temperature!.
The vaccine effectiveness can be
decreased by exposure to light

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Note: Influenza Vaccine must not be frozen.
It should never come into direct contact with ice.
Transporting Vaccine
Use insulated containers with a temperature
monitoring device and appropriate cooling agents
Keep vaccine in insulated bags – do not carry it in your
pocket!

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TIV Dosage and frequency of administration
 For trivalent inactivated influenza vaccine (TIV), the dose is
0.5 mL for all age groups .
 Contrary to dosing information in product monographs, the
National Advisory Committee on Immunization (NACI) is no
longer recommending 0.25 mL doses for children 6 to 35
months of age.
 This recommendation is based on evidence showing
improved antibody response without increase in
reactogenicity in children receiving the 0.5 mL dose , so
children receiving 0.25 mL doses will be considered

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According to CDC

51. Children’s Healthcare of Atlanta

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Who should get a seasonal
flu shot?

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WHO recommends annual seasonal influenza vaccine for :
(A) Highest priority group:
Pregnant women (at any stage of pregnancy)
(B) 4 other priority groups (in no order of priority) are:
Health-care workers
Children aged 6 months to 5 years
Elderly(≥65 years of age)
Individuals with specific chronic medical condition
•

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Pregnant women, both healthy pregnant women and those
with chronic medical conditions, are at increased risk of
influenza related complications& hospitalization .
The risk increases with length of gestation i.e. it is higher in
the third than in the second trimester.
Seasonal Influenza Vaccination & pregnancy

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Trivalent inactivated Influenza vaccine is considered safe for
use in pregnant women at all stages of pregnancy, in any
trimester , regardless of gestational age
Pregnant women should receive inactivated vaccine (flu shot)
but should NOT receive the live attenuated vaccine (nasal
spray).
There is no evidence that influenza vaccine causes any harm
to mother or baby when administered to a pregnant woman.

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Children aged <6 months are not eligible to receive currently
licensed influenza vaccines and should be protected against
influenza through vaccination of their mothers during
pregnancy (via passive transfer of antibodies across the
placenta and through breast milk).
The benefit of vaccination far outweighs any possible risk
from the vaccine itself.. The risk is actually in not getting
a flu shot .
•

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The trivalent inactivated vaccine (TIV) is also safe for breast
feeding mothers and their babies (via breast milk)
Women who are breast feeding may receive either either
inactivated vaccine or live attenuated vaccine (nasal spray)

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Health care workers should use every opportunity to
give Inactivated seasonal influenza vaccine to individuals
at risk of serious influenza complications, who have not
been immunized during the current season, even after
influenza activity has been documented in the
community

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Health-care workers are an important priority group for
influenza vaccination, not only to protect the individual
and maintain health-care services during influenza
epidemics, but also to reduce spread of influenza to
vulnerable patient groups.
Vaccination of HCWs should be considered part of a broader
infection control policy for health-care facilities.

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In the absence of contraindications, refusal of HCWs who
have direct patient contact,to be immunized annually
against influenza , implies failure in their duty of care to
their patients.”

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 TIV does not interfere with the effectiveness of other
vaccines, it can be given at the same time or at any time
before or after administration of other inactivated vaccines
(e.g. Hepatitis B vaccine) or live attenuated vaccines (e.g.
Measles, mumps and rubella vaccine).
 For concomitant parenteral injections, different injection
sites and separate needles and syringes should be used.
•
Can TIV be administered simultaneously
with other vaccines?

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Is Flu Vaccine Safe?
YES! The flu shot and nasal spray are very safe , serious
side effects are rare.
Their benefits far outweigh any possible side effects.

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Why Get Vaccinated Against the Flu?
Protect yourself.
Protect your patients.
Protect your family and friends.
Flu vaccination:
• Is safe.
• Is quick and easy.
• Can save you time and money.

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Vaccination is the BEST protection
you have against the flu!

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