What does a practising paediatrician want to to know about the Flu vaccination? Talk for Abbott Vaccines (Influvac Tetra) in Oct 2020 about common queries that doctors have about the flu vaccine in India, including how it may help in COVID-19?

1. 10 Practical questions about
Flu Vaccination
Dr. Gaurav Gupta,
Practising Pediatrician
Charak Clinics, Mohali, Punjab

2. Common queries
• Is flu really a problem in India?
• What is the best time for Flu vaccine in India?
• Incomplete vaccination (2 doses v/s single dose)?
• Covid-19 & Flu vaccine
• QIV v/s TIV
• Split virion v/s Sub-unit vaccine
• Dose of 0.25 v/s 0.5 ml
• Present IAP guidelines
• Strain changes this year
• Should doctors take the Flu vaccine?

3. Is flu really a
problem, in
INDIA?

4. Sources: 1. Integrated Disease Surveillance Programme; Seasonal Influenza (H1N1)– State/UT- wise, Year- wise number of cases
and deaths from 2010 to 2017. Available from http://www.idsp.nic.in/showfile.php?lid=3933 ; accessed on 28th June 2018 .
2. Integrated Disease Surveillance Programme; Seasonal Influenza (H1N1)– State/UT- wise, Year- wise number of cases and
deaths from 2012 to 2019. Available from https://ncdc.gov.in/showfile.php?lid=280 ; accessed on 11th May 2020.
Year
Cases (Lab
confirmed)
Deaths
2010 20604 1763
2011 603 75
2012 5044 405
2013 5253 699
2014 937 218
2015 42592 2990
2016 1786 265
2017 38811 2270
2018 15266 1113
2019 28798 1218
2020 (As on 23rd Feb
2020)
1132 18
INDIA - SEA SONA L INFLUENZA CA SES - 2 010 TO 2 02 0

5. What is the
best time for
Flu vaccine
in India?

6. W.H.O. Influenza NORTHERN HEMISPHERE/ SOUTHERN HEMISPHERE
Not the same as Geographical North & South Hemispheres

7. Seasonality
of Flu
• India has distinct seasonality that might be
related to latitude and environmental factors
• Rainfall correlates with influenza peaks in
many of the cities
• A seasonal pattern with year-round low-level
influenza virus circulation with peaks occurring
during the monsoon (rainy) season & winters
in some cities in India.
Source: 1) Chadha MS et al. Dynamics of influenza seasonality at sub-regional levels in India and implications for vaccination timing. PLoS One. 2015 May
4;10(5):e0124122. 2) Saha S et al. Divergent seasonal patterns of influenza types A and B across latitude gradient in Tropical Asia. Influenza Other Respir Viruses. 2016
May;10(3):176-84.

8. Seasonality of Influenza and Timing of vaccine in India
Yellow flags show peaks of Influenza activity
Chadha et al,PLOS ONE | DOI:10.1371/journal.pone.0124122 May 4, 2015

9. Koul PA, Broor S, Saha S, et al. Differences in influenza seasonality by latitude, northern India. Emerg
Infect Dis. 2014;20(10):1723-1726. doi:10.3201/eid2010.140431
• India should review local city data before
implementing influenza interventions.
• Cities in India located north of 30°N latitude can
continue vaccination in the winter. (parts of Punjab,
Haryana, Uttarakhand)
• But those south of 30°N, including New Delhi,
should consider vaccination in April–May
(at least 2 – 4 weeks before the start of monsoon
peak )

11. Incomplete vaccination previously – 1 or 2 doses?

12. In a child previously “primed by 2 doses of SH vaccine in May” , in India, do
we need to give additional NH vaccine in winters?
• Though antibody titres wane after 6 months, CDC and WHO do not
recommend additional dose in the same year.
• Whether, cold regions in the North of 30 Deg latitude should choose
to give the new NH strain in winter, is debatable.

13. Flu vaccine & COVID?
• Not burdening the health services
• S/S are the same – hence avoidable anxiety relieved
• Flu disease may worsen COVID outcome
• ACE- 2 m-RNA upregulation in alveolar epithelial cells after an Influenza virus
infection.
• Flu vaccine may help against COVID
• Brazil data – over 92,000 COVID pt, vaccinated had 20 % less chances of dying,
also less ICU & ventilator need. Interestingly 27 % reduction if given after
COVID symptoms
• USA – 10 % increase in Flu vaccine coverage -> mortality dec by 28 %
• Italy – Similar effect

14. Do we need QIV v/s TIV?

16. Landmark study proving QIV better than TIV

17. Chadha, Mandeep S et al. “Multisite virological influenza surveillance in India: 2004-2008.”
Influenza and other respiratory viruses vol. 6,3 (2012): 196-203. doi:10.1111/j.1750-
2659.2011.00293.x
Do we need QIV in India?

18. Whole virus
vaccine (1945)
Split virus vaccine
(1964)
3rd generation
1st generation
2nd generation
Subunit vaccine (1976)
1. Wood JM, Williams MJ. Textbook of Influenza 1998; pg no 317-323.
2. Shah R et al. Asian Journal of Paediatric Practice. 2018; 1(5): 19-28.
Subunit v/s Split Virion Vaccine – differences?
SU Vaccine presents better tolerability and lower reactogenicity as
compared to other vaccine types.
SPL may be slightly more effective in older adults.

19. Comparison of immunogenicity of Subunit (SU) vs Split
vaccine(SPL)
GMR, geometric mean ratio; SPL, split-virus vaccine; SU, aqueous subunit vaccine; VIR, virosomal, subunit vaccine Beyer et al. Vaccine 2011

20. Comparison of local and systemic side effects of
Subunit (SU) vs Split vaccine(SPL)

21. 0.25 ml or 0.5 ml dose for children < 3 yr
In US
• Currently Fluzone Quadrivalent 0.25 mL or 0.5 mL (Sanofi Pasteur),
FluLaval Quadrivalent 0.5 mL (GSK), Fluarix Quadrivalent 0.5 mL
(GSK), and Afluria Quadrivalent 0.25 mL (Seqirus) are the only
inactivated influenza vaccines approved for use in children age 6
months through 35 months.

22. Proprietary and confidential — do not distribute
Time to change the dose of Flu vaccine to 0.5ml for all children > 6 months?
Year
(Country)
Vaccines Used Vaccine Dose Results
2014-15
(US & Mexico)
Investigational QIV (GSK
Vaccines) & Fluzone
Quadrivalent (Sanofi Pasteur)
0.5 ml VS 0.25 ml
Single dose in primed
0.5 ml offers better protection
than 0.25 ml2
2013-14 (US) Investigational QIV (GSK
Vaccines) & licensed TIV
(Sanofi Pasteur)
0.5 ml QIV VS 0.25 ml
TIV; Single dose in
primed
0.5 ml QIV was immunogenic with
acceptable safety1
2018
(Europe, Central
America, and Asia,
including India)
Quadrivalent vaccine
(GSK)
0.5 ml vs Non influenza
control; Single dose in
primed
QIV prevented influenza A and B in
children aged 6-35 months3
2018
(India)
Influvac Tetra (Abbott) 0.5 ml Single dose in
primed; 2 doses in
unprimed
Influvac® Tetra elicited an
adequate immune response in both
age groups and demonstrated a
favorable safety profile with
generally a low level of
inconvenience.4
Source: 1. Wang L et al. Immunogenicity and Safety of an Inactivated Quadrivalent Influenza Vaccine in US Children 6-35 Months of Age During 2013-2014: Results From A Phase II
Randomized Trial. J Pediatric Infect Dis Soc. 2016 Jun;5(2):170-9. 2. Jain VK et al. Time to Change Dosing of Inactivated Quadrivalent Influenza Vaccine in Young Children: Evidence
From a Phase III, Randomized, Controlled Trial. J Pediatric Infect Dis Soc. 2017 Mar 1;6(1):9-19. 3. Claeys C et al. Prevention of vaccine-matched and mismatched influenza in children
aged 6−35 months: a multinational randomised trial across five influenza seasons. Lancet Child Adolesc Health. 2018 May;2(5):338-349. 4. Influvac Tetra Synopsis (Data on file).

24. INFLUENZA IN CHILDREN 25
G L O B A L R E C O M M E N D A T I O N S & G U I D E L I N E S
Source: 1. https://www.who.int/wer/2012/wer8747.pdf?ua=1 ; 2. https://www.cdc.gov/flu/pdf/professionals/acip/acip-2018-19_summary-of-recommendations.pdf ;
3. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733840/Influenza_green_book_chapter19.pdf ;
WHO Position Paper (2012) 0.25 ml or 0.5 ml
CDC ACIP (2018-19) 0.25 ml or 0.5 ml
The Green Book (UK) (2017) 0.5 ml dose
Canadian Immunization Guide
Chapter
0.5 mL dosage
NSIG, New Zealand full 0.5 mL dose

25. Proprietary and confidential — do not distribute
IAP guidebook on immunization
Source: IAP Guidebook on Immunization 2018–2019. Available from: https://iapindia.org/pdf/124587-IAP-GUIDE-BOOK-ON-IMMUNIZATION-18-19.pdf ; accessed on 18th August
2020 @ 11:40 AM.
Subunit Vaccine

26. What are current guidelines and recommendations for
influenza vaccines?

27. INFLUENZA IN CHILDREN 28
• All persons 6 months and older should be
vaccinated annuallyCDC
• All healthy children 6-59 months
• All high risk children >6 months
• All school going children
ACIP
• All children between 6 months to 5 years of
age
Indian Academy
of Pediatrics
• Everyone 6 months and older,
including children and adolescents
American
academy of
pediatric
I N F L U E N Z A V A C C I N E R E C O M M E N D A T I O N : P E D I A T R I C A G E G R O U P S

28. Which is latest strain for influenza vaccines?

29. INFLUENZA IN CHILDREN 30
DIFFERENCES IN STRA IN COMPOSITIONS
SH 2020:
 an A/Brisbane/02/2018 (H1N1)
pdm09-like virus
 an A/South Australia/34/2019
(H3N2)-like virus
 a B/Washington/02/2019-like
(B/Victoria lineage) virus
 a B/Phuket/3073/2013-like virus
(B/Yamagata/16/88 lineage)
NH 2020-21:
 an A/Guangdong-Maonan/
SWL1536/2019 (H1N1) pdm09-like virus
 an A/Hong Kong/2671/2019 (H3N2)-like
virus
 a B/Washington/02/2019 (B/Victoria
lineage)-like virus
 a B/Phuket/3073/2013 (B/Yamagata
lineage)-like virus
Source: 1) WHO Recommended composition of influenza virus vaccines for use in the 2020 southern hemisphere influenza season. Available from:
https://www.who.int/influenza/vaccines/virus/recommendations/2020_south/en/ ; accessed on 11th August 2020 @ 11:30 AM. 2) WHO
Recommended composition of influenza virus vaccines for use in the 2020 - 2021 northern hemisphere influenza season. Available from:
https://www.who.int/influenza/vaccines/virus/recommendations/2020-21_north/en/ ; ; accessed on 11th August 2020 @ 11:30 AM.

30. Why should doctors take the flu vaccine?
• Exposed to more pt with Flu
• Virus is shed during incubation period – exposing pt
• Doctors like to work even when they are sick!
• Please vaccinate staff also
• Finally, don’t forget to counsel

31. Missed something ?
My presentations
Acknowledgements:
www. slideshare.com/gauravg
docgaurav@gmail.com
www.youtube.com/charakclinics
Your Personal Child Specialist!
Dr. Shailesh Mehta, Chandigarh
Dr. Himpriya, Abbott Vaccines
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