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2. Flu vaccination in CKD

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Renal failure is associated with alterations in the immune
functions. The immunological changes in these patients
include abnormal phagocytosis and B &T-cell response.
Also there are alterations in the chemotaxis mechanism and
abnormalities in the functions of monocytes &macrophages.
These changes along with frequent exposure to medical
interventions increases the risk of frequency and severity
of infections.

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End-stage renal disease (ESRD) patients have high rates of
infection related complications.
End-stage renal disease(ESRD) patients have higher mortality
rate compared to those with without ESRD .
These patients visit healthcare providers more often than other
CKD patients providing opportunities for preventive healthcare.

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People with chronic kidney disease (CKD) are at increased
risk of becoming seriously ill, being hospitalised and even
dying if they contract influenza. There are a number of
reasons for this:
In chronic kidney disease elements of the immune system
that deal with infections like influenza are less active
therefore their recovery is compromised.

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Renal failure is associated with alterations in the immune
functions. The immunological changes in these patients
include abnormal phagocytosis and B &T-cell response.
Influenza infection predisposes to infection with
pneumococcal bacteria which pose an additional serious
risk to kidney disease sufferers (pneumococcal vaccine is
also important in this group)
Those suffering CKD are likely to have other diagnosed
or undiagnosed risk factors that can lead to poor outcomes
from infection.

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Patients receiving hemodialysis have higher risk of
hospitalization for infection related complications such
as bacteremia and pneumonia.
Moreover, immunosuppressive therapies also increase
the risk of infections in chronic kidney disease patients.

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Flu Virus and People with Chronic Kidney
Disease
Children and adults with chronic kidney disease (CKD)
and kidney transplant recipients are high risk groups for
infection from the flu virus and should, therefore,
consider vaccination

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Recommendations
 All patients with chronic kidney disease (CKD) and all
kidney transplant recipients should be advised to receive
annual influenza vaccine.
 Household contacts and health care workers should
also be vaccinated annually to decrease the transmission
to high risk CKD or post-transplant patients .

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Benefits of influenza vaccination in dialysis patients are
documented.
Vaccination against influenza and pneumococcal disease
has shown to be associated with better survival in dialysis
patients with an independent effect of both vaccines on
mortality .

25. If I have a transplant, which vaccines should I avoid?
Inactive vaccines are considered safe for transplant
recipients, but live vaccines should be avoided.
In general, if you have a transplant, you should avoid:
1. Influenza nasal (Flu Mist). The flu shot that is injected is an
inactive vaccine, unlike the nasal mist.
2. Chicken-pox (varicella)
3. Shingles (Herpes Zoster)
4. Measles, Mumps, Rubella (MMR)
5. Yellow Fever

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Special Considerations in Renal Disease Dialysis
No difference in the serological response to influenza
vaccines was noted in peritoneal dialysis (PD) and
hemodialysis (HD) patients,
The present evidence suggests that both PD and HD
patients should receive the standard annual dose of
the vaccine.

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Kidney Transplant:
Inactivated influenza vaccine may be given to transplant
recipients despite intensive immunosuppression.
It is best to wait until the first 3–6 months after kidney
transplantation, the period of intense immunosuppression,
before attempting vaccination.
However, inactivated influenza vaccination can be
administered as early as one month after kidney transplant
to time it before onset of the flu season

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In the event of an outbreak in the community, injectable
vaccine can be given after one month of transplant. Live
vaccines are not advised in this group of patients.
Vaccine should be given prior to the immunosuppressive
therapy if possible. Inactivated vaccines can be given
two weeks or more prior to immunosuppression.

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Concerns about influenza vaccine triggering an immune
response and increase the risk of acute rejections have
not been substantiated in large scale studies that
demonstrated no increase in acute rejection episodes
when influenza vaccine was used.
In large registry data, influenza vaccine use in transplant
recipients was associated with lower rates of allograft
loss and death.

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If you have Chronic Kidney Disease at Stage 3, 4 or 5 –
sometimes known as Established Renal Failure (ERF)
you have a greater risk of becoming more seriously ill
from flu than the general population.
If you have had a kidney transplant or are waiting for one
you are more at risk of developing complications if you
catch flu.

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Evidence suggests people with chronic kidney disease
are 19 times more likely to die from flu complications
than a person who is healthy.
Many of these deaths could have been prevented by
having the flu vaccination.

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Vaccination is the single most effective way for anyone to
protect themselves against influenza infection.
Influenza vaccination in people with kidney disease has
been shown to reduce infection rates and lower the risk
of hospitalisation and death.

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Some medications used to treat flu may not be suitable
for people with chronic kidney disease.
Some medications used to treat flu can increase your
risk of heart problems and stroke.
Many people with chronic kidney disease have other long
term conditions such as heart disease or diabetes. These
can also become worse if you catch flu.

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51. Wild birds are “natural” reservoir for all
influenza A subtypes

52. H1 N1
H2 N2
H3 N3
H4 N4
H5 N5
H6 N6
H7 N7
H8 N8
H9 N9
H10
H11
H12
H13
H14
H15
H16
Haemagglutinin subtype Neuraminidase subtype

53. Avian Influenza A
viruses
H1 - H16
N1 - N9
H1 - H3
N1 –N2
Human Influenza
A Viruses

56. How influenza virus change
●Type A viruses undergo changes in their surface
antigens or proteins
● Minor changes Antigenic drift
● Major changes Antigenic shift

57. 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
• Incomplete protection; still get sick
• Need new flu vaccine every year
H3N2 H3N2
Immune
System: “Do I
know you? You
look vaguely
familiar!”

60. What drives the occurrence of a pandemic?
Answer:
Instead of antigenic DRIFT occurring,
an antigenic…
…happens.
Immune System:
“Oh my gosh…I
don’t know you at
all!”
H?N?

61. Antigenic ShiftAntigenic Shift

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Antigenic drift occurs in both influenza A and influenza
B viruses.
Antigenic drift is the reason that 1 or more of the three virus
strains in the vaccine are updated every year based on
what’s been circulating around the world.
This necessitates the creation of a new seasnal influenza
vaccine every year.

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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.

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There are two types of influenza vaccine:
1. Inactivated (killed) vaccine, the “flu shot,” is given
by injection with a needle.
2. Live, attenuated (weakened) influenza vaccine,
the “flu mist,” is sprayed into the nostrils.

71. Trivalent Inacivated
Seasonal Influenza Vaccine
2017 - 2018

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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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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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According to CDC
TIV Dosage & frequency of administration

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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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Standard Technique for Injection

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Who should get a seasonal
flu shot?

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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:
oPregnant women
oChildren younger than age 5 years
oAdults aged 65 years or older
oPeople of any age with certain chronic medical conditions,
or weakened immune systems .
Is Flu Serious ?

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All people 6 months of age and older should get flu vaccine.

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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 or immuosuppression
•

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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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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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Other important things in protecting yourself from
getting influenza?
1. Wash your hands often and thoroughly with soap and
warm water, or use a hand sanitizer.
2. Avoid touching your eyes, nose or mouth. You can get
infected by touching something that is contaminated with
influenza and then touching your eyes,nose, or mouth.
3. Avoid close contact with people who are sick.
4. Follow good health habits

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