Questions & Answers
Influenza - Seasonal
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Policy and Management

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Department of Defense (DoD) Seasonal Influenza Vaccination Program (IVP)

  1. Who does the Advisory Committee on Immunization Practices (ACIP), recommend receive an annual influenza vaccination?

    ACIP recommends the use of the seasonal influenza vaccinations for all people 6 months and older. Additionally, emphasis on providing routine annual vaccinations to certain groups at higher risk for influenza infection or complications should be a priority:

    • Anyone who is at risk of complications from influenza, or more likely to require medical care.
    • Women who will be pregnant during influenza season.
    • Anyone with long-term health problems including heart disease, kidney disease, liver disease, lung disease, metabolic disease (diabetes), asthma, anemia and other blood disorders.
    • Anyone with a weakened immune system, long-term treatment with drugs such as steroids, and cancer treatment with x-rays or drugs.
    • Anyone with certain muscle or nerve disorders (such as spinal cord injuries, seizure disorders or cerebral palsy) that can lead to breathing or swallowing problems.
    • Anyone 6 months through 18 years of age on long-term aspirin treatment.
    • Residents of nursing homes and other chronic-care facilities.
    • Anyone who lives with or cares for people at high risk for influenza-related complications.
    • Health care providers.
    • Household contacts and caregivers of children from 0-5 years of age and people 50 years and older.


  2. When will the IVP begin?

    Vaccine shipments occur in early August. Your installation seasonal influenza vaccine program should begin immediately upon receipt of influenza vaccine to protect individuals at risk from developing influenza or its complications. All Services will follow Service-specific implementation guidelines. Influenza vaccinations should continue until supply is exhausted or the vaccine expiration is reached.



  3. What documentation is required with influenza immunization?

    It is important to document immunizations properly into electronic immunization and paper-based systems. Vaccine, date of administration, lot number, manufacturer, Vaccine Information Statement version date, name of vaccine administrator and medical exemptions for military personnel must be documented in Service-specific immunization tracking systems.

    All Services will monitor implementation using Service-specific electronic immunization tracking systems (Medical Protection System (MEDPROS), Aeromedical Services Information Management System (ASIMS), Medical Readiness Reporting System (MRRS), Shipboard Automated Medical System (SAMS), and the Defense Eligibility Enrollment Reporting System (DEERS). All Military Health System (MHS) beneficiary immunizations should be documented in the electronic health record.



  4. Where did the DoD get this year's influenza vaccine?

    DoD has arranged with the Defense Logistics Agency – Troop Support (DLA-TS) to contract for influenza vaccine from four different manufacturers. Three manufacturers will provide injectable trivalent inactivated influenza vaccine (IIV3), Sanofi-Pasteur (Fluzone®), CSL Biotherapies/Merck (Afluria®), and Novartis (Fluvirin® and Flucelvax®). MedImmune (FluMist®) produces the intranasal quadravalent live, attenuated influenza vaccine (LAIV4).

    Note: More information regarding this year's influenza vaccines and the presentations available can be found at www.vaccines.mil/documents/1642_Influenza_Vaccines_for_Different_Age_Groups_-_2013-14.pdf



  5. Which personnel are required to receive the influenza vaccine?
    DoD policy requires annual influenza immunizations for all Active Duty, National Guard and Reserve personnel, and health care personnel who provide direct patient care according to Service-specific guidelines.

  6. Will my immunization be monitored by my Service?
    Yes. All Services will monitor implementation using Service-specific immunization tracking systems (MEDPROS, ASIMS, MRRS, and SAMS).

  7. What is the current DoD Seasonal Influenza policy and who should be vaccinated?

    DoD policy states influenza immunizations are mandatory for all Active Duty, National Guard, and Reserve personnel. Influenza immunizations are mandatory for DoD civilian and contract health care personnel who provide direct patient care at military treatment facilities (MTFs).

    Note: more information on DoD influenza policies can be found at www.vaccines.mil/Policies/Influenza_-_Seasonal.

    The Office of the Assistant Secretary of Defense for Health Affairs (HA) Policy 08-005, dated 4 April 2008, mandates all civilian health care personnel who provide direct care to patients in medical treatment facilities must be immunized against seasonal influenza each year as a condition of employment. www.vaccines.mil/documents/1169HCPFluHAPolicy_08_005.pdf.



  8. Who should receive the influenza vaccine and in what order if there is a shortage?
    Should an unanticipated shortage of vaccine occur, HA will provide further direction regarding priority tiers, consistent with recommendations published in the Centers for Disease Control and Prevention (CDC's) Morbidity and Mortality Weekly Report.

  9. Who can I contact if I have a problem after receiving my vaccine?

    If you are having a medical emergency call 911. Contact your healthcare provider or the clinic at which you received your vaccination for appropriate follow-up.

    You may also contact the the DoD 24/7 Vaccine Healthcare Centers Network at (866) 210-6469 or email via at https://askMILVAX-VHCN.wramc.amedd.army.mil. Any clinically significant medical event that occurs after vaccination should be submitted to the Vaccine Adverse Event Reporting System (VAERS) at www.vaers.hhs.gov.



  10. What is the primary goal of DoD's Seasonal Influenza Vaccine Program (IVP)?

    The primary goal is to vaccinate 100 percent of all Active Duty, National Guard, Reserve, and Health Care Providers whom provide direct patient care with a milestone goal of ≥ 90 percent by 16 December this year.



The Disease

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General Information

  1. What is seasonal influenza disease?

    Influenza is a contagious respiratory illness caused by influenza types A or B viruses. Influenza viruses are easily spread by airborne respiratory droplets from person to person (often by sneezing or coughing).

    Symptoms of infection include fever, muscle aches, headache, malaise (a general feeling of sickness), nonproductive cough, sore throat, and runny nose. The flu causes mild illness in most people, the majority of whom will not need medical care or antiviral drugs, and usually recover in less than two weeks. Some people, however, can suffer flu complications that result in being hospitalized. Sometimes influenza infection results in death.

    Pneumonia, bronchitis, sinus infections and ear infections are examples of more severe flu-related complications. The flu also can make chronic health problems worse. For example, people with asthma may experience more frequent asthma attacks while they have the flu. The flu may also worsen congestive heart failure in people with this condition.



  2. How soon will I get sick after exposure to the influenza virus?
    Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Children may pass the virus for longer than 7 days. Symptoms start 1 to 4 days after the virus enters the body. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick. Some persons can be infected with the flu virus but have no symptoms. During this time, those persons may still spread the virus to others.

  3. Will new strains of influenza virus circulate this season?

    Influenza viruses are constantly changing, so it is not unusual for new strains of influenza virus to emerge at any time of the year. This year's influenza vaccines were made using the following strains:

    • A/California/07/2009 (H1N1)-like virus
    • A/Victoria/361/2011 (H3N2)-like virus
    • B/Massachusetts/2/2012-like virus 
    • B/Brisbane/60/2008 like virus (for the quadravalent influenza vaccine)

    The B/Massachusetts and B/Brisbane strains are a change from last year's formulation.



  4. How does influenza spread?
    Influenza spreads from person-to-person through aerosolized respiratory droplets released when a person coughs, sneezes, or breathes. People may also become infected with influenza by touching something contaminated with the virus and then touching their mouth, nose, or eyes.

  5. What should I do if I am infected with the influenza virus?
    Getting plenty of rest, drinking fluids, and avoiding alcohol and tobacco will allow your body to fight off the illness more quickly. If you use over-the-counter medications to relieve symptoms, it is important to follow the manufacturer's instructions. Protect others by covering your mouth when coughing and sneezing, wash your hands frequently, and stay at home if you are feeling ill.

  6. Who is at high risk for developing flu related complications?

    Children younger than 5 but especially children younger than 2 years of age, adult 65 years and older, pregnant women and individuals with various chronic medical conditions are at greatest risk for hospitalization and possibly death related to infection.

    A full list of high-risk conditions can be found at: www.cdc.gov/flu/about/disease/high_risk.htm



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Prevention

  1. Why do I need to be immunized against influenza every year?
    Circulating influenza viruse strains change from year to year. Protection that develops after a person is infected or immunized against the circulating viruses of one season does not provide adequate cross-protection when a new influenza strain develops.

  2. What is the best way to protect myself and my family from getting influenza if we are not vaccinated?
    Vaccination is your best protection against influenza infection. If you are unable to receive the vaccine, avoid close contact with people sick with the flu. Wash your hands often with soap and water or if that is unavailable use alcohol-based hand sanitizer. To prevent the spread of germs, avoid touching your eyes, nose, or mouth and cover your mouth and nose with a tissue when coughing or sneezing.

  3. When should I get vaccinated?
    It is recommended that people get vaccinated against influenza as soon as vaccine becomes available in your community. Vaccinations should occur through the entire influenza season which ends when product expires in early summer or supply is exhausted.

  4. Where can I receive my vaccine?
    The influenza vaccine can be received from many MTF's and clinics within DoD. To find a clinic near use the MILVAX-VHCN clinic finder found at http://www.vaccines.mil/ClinicFinder.

    Additionally, the TRICARE Management Activity issued the final rule authorizing TRICARE retail network pharmacies to administer seasonal influenza at no cost to beneficiaries the for the 2013-2014 influenza season. Soldiers who receive the influenza vaccination from non-military facilities must provide appropriate immunization data to their unit's MEDPROS point of contact NLT COB of the next duty day following vaccination in order to properly document the annual requirement.

The Vaccines

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General Questions

  1. How effective is influenza immunization in protecting me from illness caused by the different strains of influenza?
    Vaccines are developed each year in an attempt to match the predicted virus strains. When they are well-matched, immunization of healthy adults is 70-90% effective in preventing influenza illness. When the majority of circulating influenza strains is not well matched by the vaccine, effectiveness has been as low as 47-77%. Vaccines may be somewhat less effective in elderly persons and very young children, but immunization can still help prevent serious complications from influenza illness.

  2. What if I'm pregnant or breastfeeding? Can I still receive the seasonal influenza vaccine?
    Yes. The ACIP, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians have all recommended the routine vaccination of women who are pregnant, or who become pregnant during the influenza season. Pregnant women, as well as lactating/postpartum women and their newborn babies, are at high risk for influenza complications. Pregnant women may receive the inactivated injectable influenza vaccine, during any point of gestation and postpartum; breastfeeding women may receive the inactivated or live vaccine.

  3. Are influenza vaccines harmful during my pregnancy?

    Pregnant women are at high risk for influenza related complications and are a priority group for vaccination. The FDA has classified Fluzone and Afluria as "Pregnancy Category B", indicating that animal reproduction studies have not demonstrated a fetal risk, but there are no controlled studies in pregnant women.

    The ACIP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians recommends the use of injectable influenza vaccine for immunization of pregnant women because the benefit of protection outweighs the potential risk of any adverse event.



  4. If a child is receiving an influenza vaccination for the first time, what is the appropriate administration schedule?

    According to the ACIP and the American Academy of Pediatrics (AAP):

    Children aged 6 months to 8 years who are receiving the influenza vaccine for the first time or whose previous vaccination status is unknown should receive two (2) doses of vaccine separated by at least four weeks.

    Children aged 6 months through 8 years who have NOT received two (2) or more total doses of seasonal influenza vaccine since July 2010 should receive two (2) doses of vaccine separated by at least four weeks.

    Children aged 6 months through 8 years who received two (2) or more total doses of seasonal influenza vaccine since July 2010 and all children 9 and older should receive one dose of seasonal influenza vaccine.



  5. If a child 6 months - 8 years of age is receiving an influenza vaccination for the first time, must the same type of vaccine be administered for both doses?
    No. The first and second doses can be from different manufactures or age-appropriate formulations. IIV can be used when vaccinating children aged 6 months to 8 years and LAIV (FluMist®) for children aged 2 years and older, who have not been previously vaccinated.

  6. How are injectable and intranasal influenza vaccines shipped and stored?
    All injectable and intranasal vaccines are shipped and should be stored at 2 to 8 degrees Celsius. When the vaccine arrives at your facility, it must immediately be placed in a refrigerator. In addition, protect Afluria, Flucelvax and Fluvirin from light until use. Do not use vaccines past the expiration date printed on the vaccine vial or syringe. Once the Afluria multi-dose vial has been punctured the vaccine must be used within 28 days. Fluzone multi-dose vials may be used after puncture until the expiration date on the vial. Any prefilled syringes, sprayers or single dose vials must be discarded at the end of the day if the tip cap is removed, a needle is placed on the syringe or the cap of the vial has been removed.

  7. If I need to administer a tuberculin skin test (TST), should I be concerned about administering the influenza vaccine at the same time?

    Yes. The live vaccine (FluMist®) may suppress a positive response to a tuberculin skin testing (TST or PPD) in a person who is infected with tuberculosis (TB), resulting in a false negative skin test. If a person needs TB skin testing and LAIV, you can correctly administer both in one of three ways

    • Give the TST (PPD) and the vaccine simultaneously.
    • Give the TST (PPD) first and when the person returns to have the skin test results interpreted, administer the live vaccine.
    • Give the live vaccine and then delay administration of the TST (PPD) for 28 days. Injectable influenza vaccines and tuberculin skin test can be administered concurrently or at any interval.


    • Can live vaccines and the influenza vaccine be administered on the same day?
      The inactivated injectable influenza vaccine may be administered on the same day as live vaccines or at any interval thereafter, but the live intranasal influenza vaccine must be administered on the same day as the other live vaccines or separated by an interval of at least 28 days.

    • Can I get seasonal flu illness from the flu vaccine?
      Influenza vaccine does not cause the flu virus. Some vaccinated people may have mild flu-like symptoms, which are caused by the immune system's response to the vaccine. Other people may feel soreness or have mild, uncomfortable side effects. The most common side effects associated with the injected flu vaccine are redness, swelling, and soreness at the injection site. The nasal spray type of flu vaccine may cause runny nose, nasal congestion, sore throat, and chills in some patients. For more information please visit the CDC flu website or contact the MILVAX-VHCN.

    • Why does my child need to get the flu vaccine?
      Infants and children, as well as the elderly, are more likely to have serious complications from the flu virus. In addition, children may be exposed to flu virus at school and daycare. Please contact the MILVAX-VHCN if you want to discuss the influenza vaccine with a MILVAX-VHCN healthcare provider.

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    Trivalent Inactivated Influenza Vaccine (IIV3), Injectable: Fluzone®, Afluria®, Flurivin® and Flucelvax®

    1. What is Fluzone®?

      Fluzone®, Fluzone® Pediatric, Fluzone® High-Dose (HD), and Fluzone® Intradermal are inactivated injectable influenza virus vaccines manufactured by Sanofi-Pasteur. Presentations available this year include a multi-dose vial and a thimerosal-free single-dose syringe.

      Fluzone and Fluzone Pediatric are licensed for persons aged 6 months and older, Fluzone HD is licensed for persons aged 65 years and older and Fluzone Intradermal is licensed for persons aged 18 through 64 years. DoD only contracted for Fluzone and Fluzone Pediatric this season.



    2. What is Afluria®?
      Afluria® is an inactivated injectable influenza virus vaccine manufactured by CSL Biotherapies. The presentation available this year include a multi-dose vial. Afluria is licensed for persons aged 5 years and older; however, ACIP recommends Afluria be administered to children aged 9 years and older due to increased reports of febrile reactions in children 5 to 8 years of age. Afluria may be given, if no other age-appropriate, licensed seasonal influenza vaccine is available for children aged 5 through 8 years who are at high risk for influenza complications.

    3. Who should receive the injectable vaccines?

      ACIP recommends the use of injectable vaccines for immunization of persons described as eligible in manufacturer package inserts and for whom the live virus vaccine (FluMist®) is contraindicated.

      • Anyone who is at risk of complications from influenza, or more likely to require medical care.
      • Women who are or will be pregnant during influenza season.
      • Anyone with long-term health problems.
      • Anyone with a weakened immune system.
      • Anyone 6 months through 18 years of age on long-term aspirin treatment.
      • Residents of nursing homes and other chronic-care facilities.
      • Anyone who lives with or cares for people at high risk for influenza-related complications.
      • Household contacts and caregivers of children from birth up to 5 years of age and people 50 years and older.


    4. Who should not receive the injectable influenza vaccines?
      • People who have a severe allergy to chicken proteins, eggs, egg products, or any components of the influenza vaccine.
      • People who have had a severe reaction to an influenza vaccination in the past.
      • People who have a history of Guillain-Barré Syndrome.
      • People who are sick with a fever. These individuals may be immunized once their symptoms resolve.
      • Children younger than 6 months of age.


    5. What side effects can I expect when I receive the injectable influenza vaccine?
      The viruses in inactivated influenza vaccine have been killed so you cannot become infected with influenza. Side effects which may occur are: soreness, redness, or swelling at the vaccination site., l fever, weakness, headache, and muscle aches. If these problems occur, they usually begin soon after immunization and typically last for one or two days. Most people who receive influenza vaccine experience no serious problems. In rare instances, serious problems such as a severe allergic reaction can occur.

    6. What is Fluvirin®?
      Fluvirin® is an inactivated injectable influenza virus vaccine manufactured by Novartis. The presentation available this year include a thimerosal-free single-dose syringe. It is licensed for persons 4 years of age and older.

    7. What is Flucelvax®?
      Flucelvax® is a new cell-culture-derived, inactivated injectable influenza virus vaccine manufactured by Novartis. It is presented in a thimerosal-free single-dose syringe. It is licensed for persons 18 years of age and older.

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    Live Attenuated Intranasal Vaccine (LAIV), Intranasal FluMist®

    1. Who should receive the live, attenuated intranasal vaccine?
      FluMist® is approved for all healthy people aged 2-49 years who are not pregnant. For more information, see http://www.vaccines.mil/flu.

    2. What side effects can I expect when I receive FluMist®?
      The viruses in the intranasal vaccine are weakened and do not cause severe symptoms associated with influenza. Common side effects may include runny nose, headache, fever, cough, and sore throat. Other possible side effects are chills, cough, decreased activity, decreased appetite, headache, irritability, muscle aches, and tiredness/weakness. For more information, see http://www.flumist.com.

    3. Who should not receive the live, attenuated intranasal vaccine?

      The following populations should not be immunized with the Live Attenuated Intranasal Vaccine:

      • People less than 2 years old or those 50 years old or older
      • People with asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems
      • People with other underlying medical conditions, including such metabolic diseases as diabetes, cardiac/kidney/liver diseases, and blood disorders
      • People with known or suspected immunodeficiency diseases or who are receiving immunosuppressive therapies
      • Children or adolescents receiving aspirin therapy or other
      • People with a history of Guillain-Barré Syndrome
      • Pregnant women
      • People with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs


    4. What is FluMist®?
      FluMist® is a quadrivalent, live, attenuated influenza virus vaccine manufactured by MedImmune. The only presentation is a thimerosal free single dose sprayer.

    Myths and Facts

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    Myths

    1. Myth #1: Having influenza is similar to getting a cold; therefore, an immunization is not really necessary.
      Fact: On average, more than 226,000 people are hospitalized from flu complications, including 20,000 children; about 36,000 people die from influenza each year. Vaccination provides the best protection available from the influenza virus - even when the vaccine does not closely matchthe circulating flu strains. A vaccination may lessen influenza illness severity and is important for persons at high-risk for serious flu-related complications and for close contacts of high-risk individuals. Ref: http://www.cdc.gov/flu/about/qa/flushot.htm and http://www.cdc.gov/flu/about/qa/disease.htm.

    2. Myth #2: Side effects from the influenza vaccine are worse than influenza itself.
      Fact: The most common side effect you are likely to experience with the injectable influenza vaccine is a sore arm. The risk of a rare allergic reaction is far less than the risk of severe complications from influenza. Live, intranasal influenza vaccine can cause mild symptoms in the recipient. Common side effects can include runny nose, headache, fever, cough, and sore throat. Ref: http://www.cdc.gov/flu/about/qa/flushot.htm

    3. Myth #3: Only elderly people really need the influenza vaccine.
      Fact: Among elderly persons not living in chronic-care facilities (such as nursing homes) and those persons with long-term (chronic) medical conditions (such as asthma, diabetes, or heart disease), influenza vaccinations are 30-70% effective in preventing hospitalization for pneumonia (a lung infection) and influenza. Among elderly nursing home residents, influenza vaccinations are the most effective in preventing severe illness, complications that may follow influenza (like pneumonia), and deaths related to influenza. Because persons aged 65 years and older are at highest risk for serious complications from influenza, it is also important that people who live with or care for those at high risk for serious complications get an influenza vaccination. Children younger than 6 months of age are at the most risk for having complications from influenza. However, they are too young to get the influenza vaccination. To protect these infants, it is very important that their household members and out-of-home caregivers be vaccinated against influenza. Influenza vaccine can prevent 66% or more influenza infections in young children, with even higher estimates for older children, when the vaccine strains are well matched to the flu viruses causing illness. Vaccinating close contacts of children can also help decrease children's risk of getting influenza. Everyone who is healthy and eligible to receive the vaccine should take advantage of the opportunity to boost their immunity to seasonal influenza. Ref: http://www.cdc.gov/flu/about/qa/vaccineeffect.htm

    4. Myth #4: You must get the influenza vaccine before the influenza season, or it is not worth getting.
      Fact: Influenza vaccine can be given before or during the influenza season. Influenza vaccinations provide protection against the influenza strains contained in the vaccine during that influenza season. Vaccinations should begin as soon as vaccine is available and continue throughout the influenza season. Ref: http://www.cdc.gov/flu/about/qa/misconceptions.htm.

    5. Myth #5: I can take medications prescribed by my doctor instead of getting the influenza vaccine.
      Fact: Antiviral medications given within the first few days of symptom onset can reduce the duration and severity of the disease, but cannot cure it. These drugs are not a substitute for the influenza vaccine. Remember, influenza vaccine is the first and best defense against seasonal influenza, but antiviral drugs can be an important second line of defense to treat influenza or prevent influenza infection. Ref: http://www.cdc.gov/flu/protect/antiviral/keyfacts.htm.

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    Facts

    1. Fact #1: Even if I get the influenza vaccine, can I still be infected with influenza?
      Yes. Influenza viruses are always changing. They can change from the time the vaccine is recommended and the beginning of influenza season, or they can even change during a season. Each year, experts study thousands of influenza virus samples from around the world to figure out which viruses are making people sick and how these viruses are changing. With this information, they forecast which three virus strains are most likely to make the most people sick during the next influenza season. Each year, the seasonal influenza vaccine contains three influenza virus strains – one influenza A (H3N2) virus, one influenza A (H1N1) virus, and one influenza B virus. The selection of which viruses to include in the vaccine must be made in February of the prior year in order for vaccine to be produced in time for distribution the following season. When influenza viruses change, they may no longer closely match viruses used to make that season's influenza vaccine. This can make the vaccine less effective. But, even when this happens, the vaccine can still offer some cross-protection: The vaccine contains three viruses, so it can protect you against the other two viruses that may be making people sick. The immune protection you get from the vaccine can provide partial protection against influenza viruses that are related to those used to make the vaccine (this is called cross-protection). So while a less-than-ideal match can reduce vaccine benefit, the vaccine can still provide enough protection to make illness less severe and prevent influenza-related complications. A less-than-perfect vaccine is still the best protection we have against influenza. That is why CDC continues to recommend getting the vaccine even when there is a less-than-perfect match. Ref: http://www.cdc.gov/flu/about/qa/season.htm and http://www.cdc.gov/flu/about/qa/vaccineeffect.htm

    Adapted from the Immunization Action Coalition (with permission)
    and the Centers for Disease Control and Prevention (CDC).