Flu Vaccines for 2023-24
This chart reviews approved influenza vaccines for the 2023-2024 season. It includes approved ages for use, route of administration, dose, cost (US), and egg and thimerosal content. The FAQ that follows answers questions about efficacy, administration with other vaccines, use in patients who are immunocompromised or pregnant, and more.
--None of the available flu vaccines for 2023-24 contain latex.--
Brand Name Manufacturera |
Routea |
Approved Ages for Usea |
Availabilitya (US Cost/doseb) |
Contains Thimerosal?a |
Dosea |
Commentsa |
Quadrivalent inactivated (IIV4): protects against two influenza A-like viruses and two influenza B-like viruses.4,24,27 |
||||||
US: Afluria Quadrivalent Canada: Afluria Tetra Seqirus |
IM |
US: ≥6 months Canada: ≥5 years |
0.5 mL PFS (~$20) 5 mL MDV (~$19) |
Yes (MDV only) |
6 to 35 months:
≥36 months:
|
|
Fluad Quadrivalent (US only) Seqirus |
IM |
≥65 years |
0.5 mL PFS (~$67) |
No |
0.5 mL |
|
Fluarix Quadrivalent (US only) GSK |
IM |
≥6 months |
0.5 mL PFS (~$19) |
No |
0.5 mL |
None |
US: Flucelvax Quadrivalent Canada: Flucelvax Quad Seqirus |
IM |
≥6 months |
0.5 mL PFS (~$30) 5 mL MDV (~$28) |
Yes (MDV only) |
0.5 mL |
|
US: FluLaval Quadrivalent Canada: FluLaval Tetra GSK |
IM |
≥6 months |
US
Canada
|
US:
Canada:
|
0.5 mL |
None |
Fluzone Quadrivalent Sanofi Pasteur |
IM |
≥6 months |
(~$18 to $19) |
Yes (MDV only) |
6 to 35 months:
≥36 months:
|
None |
Fluzone Quadrivalent High-Dose Sanofi Pasteur |
IM |
≥65 years |
0.7 mL PFS (~$64) |
No |
0.7 mL |
|
Influvac Tetra (Canada only) BGP Pharma |
IM or deep subcutaneous injection |
≥6 months |
0.5 mL PFS |
No |
0.5 mL |
|
Quadrivalent recombinant (RIV4): protects against two influenza A-like viruses and two influenza B-like viruses.4,24,27 |
||||||
US: Flublok Quadrivalent Canada: Supemtek Sanofi Pasteur |
IM |
≥18 years |
0.5 mL PFS (~$64) |
No |
0.5 mL |
|
Quadrivalent live-attenuated (LAIV4): protects against two influenza A-like viruses and two influenza B-like viruses.4,24,27 |
||||||
FluMist Quadrivalent MedImmune (US) AstraZeneca (Canada) |
Intranasal |
2 to 49 years (2 to 59 years [Canada]) |
0.2 mL prefilled intranasal sprayer (~$24) |
No |
0.1 mL per nostril |
|
Trivalentinactivated (IIV3) (Only available in Canada): protects against two influenza A-like viruses and one influenza B-like viruses.24 |
||||||
Fluad and Fluad Pediatric (Canada only) Seqirus |
IM |
Pediatric: 6 to 23 months Adult: ≥65 years |
Pediatric: 0.25 mL PFS Adult: 0.5 mL PFS |
No |
6 to 23 months:
≥65 years:
|
|
- FDA-approved product information is from the following US product labeling unless otherwise specified: Afluria Quadrivalent (June 2023); Fluad Quadrivalent (June 2023); Fluarix Quadrivalent (June 2023); Flucelvax Quadrivalent (June 2023); FluLaval Quadrivalent (June 2023); Fluzone Quadrivalent (June 2023); Fluzone Quadrivalent High-Dose (June 2023); Flublok Quadrivalent (June 2023); FluMist Quadrivalent (August 2023). Information for Health Canada-approved products is from the Government of Canada (https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/national-advisory-committee-immunization-statement-seasonal-influenza-vaccine-2023-2024.html) unless otherwise specified.24
- Pricing based on wholesale acquisition cost (WAC). Medication pricing by Elsevier, accessed July 2023.
Abbreviations: IM = intramuscular; MDV = multidose vial; PFS = pre-filled syringe; SDV = single-dose vial.
Communicating About Flu Vaccination
Use this FAQ to answer common questions about flu vaccines.
Question |
Answer/Pertinent Information |
Who should receive a flu vaccine? |
Flu vaccination is recommended for everyone ≥6 months without contraindications, using any age-appropriate vaccine.24,27
In light of COVID-19, it’s more important than ever for patients to get a flu vaccine. The flu vaccine won’t protect against COVID-19 but getting the flu vaccine can help conserve healthcare resources, by reducing the risk of flu illnesses, hospitalizations, and death.21,27 For patients who cannot remember if they received this season’s flu vaccine, avoid missed opportunities to vaccinate by giving the flu vaccine even if this means giving a second dose to some patients.11 |
Which flu vaccine is preferred? |
Avoid delaying vaccination in order to use a specific “preferred” flu vaccine.16,24 In the US:22
In Canada:24
|
When are two doses of a flu vaccine needed? |
To provide optimal protection, children 6 months through eight years should receive two doses of flu vaccine (separated by at least four weeks) if they have not received at least two doses of flu vaccine (separated by at least four weeks) prior to July 1 of the current year (US) or if they have not previously received the seasonal flu vaccine (Canada).24,28
|
When should flu vaccines be given? |
In the US, encourage patients to try to complete vaccination by the end of October. Generally, avoid starting vaccinations before September, due to the possibility of reduced effectiveness later in the flu season.27
In Canada, start vaccinations as soon as possible based on availability.24 Don’t miss an opportunity to vaccinate due to fears the vaccine’s effectiveness will not last throughout the entire flu season.
Continue to vaccinate as long as flu viruses are circulating.11,24 |
Can flu vaccines be given with other vaccines? |
Live-attenuated and inactivated flu vaccines can be given with other vaccines, using separate administration sites.5,24
Data are limited for coadministration of two adjuvanted vaccines (e.g., Fluad Quadrivalent, Heplisav-B, Shingrix).24,34 There are theoretical concerns about more side effects. If a patient is receiving another adjuvanted vaccine, don’t delay flu vaccination if an adjuvanted flu vaccine (i.e., Fluad Quadrivalent) is the only flu vaccine available.16,35 |
Can the flu vaccine be given to someone who is acutely ill? |
Continue to give the flu vaccine to patients with mild (and moderate in Canada) acute illnesses to avoid missed opportunities to vaccinate.12,24 Most acute illness with or without fever (e.g., diarrhea, upper respiratory infection) is not a contraindication to receiving the vaccine.12,24 Severe (and moderate in the US) acute illness is a precaution for administering any vaccine.12 Vaccination side effects (e.g., fever, malaise) may make it difficult to assess management of acute illness.12Assess the risks and benefits of delaying vaccination in patients with moderate to severe illness.12 In Canada, it is recommended to usually delay vaccination until serious acute illness symptoms have improved.24 Generally, delay flu vaccination in anyone with symptomatic COVID-19 infection, until they are no longer moderately or severely ill and have completed their COVID-19 isolation period.30,31 |
Can immuno-compromised patients receive the flu vaccine? |
Immunocompromised patients may receive any licensed, recommended, age-appropriate injectable flu vaccine.14,24
|
Can pregnant or lactating patients receive the flu vaccine? |
Vaccinate pregnant women (any trimester) with any licensed, recommended, age-appropriate injectable flu vaccine, regardless of thimerosal content.6,11
Flu vaccination is safe while breastfeeding.9 Vaccinate post-partum women who did not receive a flu vaccine while pregnant, especially if breastfeeding an infant <6 months old, as these infants are too young to receive a flu vaccine.6,10
|
Can patients with an egg allergy receive a flu vaccine? |
Patients with a history of severe egg allergy (symptoms more severe than hives [e.g., angioedema, respiratory distress, requiring epinephrine]) do not have higher reaction rates to egg-containing vaccines compared to non-egg allergic patients.16 Patients with an egg allergy may receive any age-appropriate flu vaccine, including FluMist, without prior flu vaccine skin test and with the full dose, irrespective of a past severe reaction to egg, and in any setting where vaccines are routinely administered.16,24 Refer to the chart above comparing available flu vaccines for egg-free vaccine options. |
Should unvaccinated people who had the flu this season still get the flu vaccine? |
Yes. Vaccinate unvaccinated people who have already had the flu during this season. The vaccine might protect against other circulating flu viruses. |
How effective are flu vaccines? |
Flu vaccination is typically about 40% to 60% effective (e.g., reduces flu illness, reduces laboratory confirmed flu).18,19,27 Generally, flu vaccines are more effective against influenza B and influenza A (H1N1) strains compared to influenza A (H3N2) strains.18
|
Who should NOT receive the LIVE-attenuated flu vaccine (FluMist)? |
Avoid use of the live-attenuated flu vaccine (FluMist) in the following patients:
|
Can the LIVE-attenuated flu vaccine (FluMist) be given to someone who received an antiviral? |
Most advise avoiding FluMist within 48 hours of an antiviral.24 However, based on antiviral half-lives, it is possible antivirals could interfere with FluMist effectiveness if FluMist is given within the following timeframes AFTER an antiviral:17
Antivirals may interfere with FluMist effectiveness. Recommend revaccination with an age-appropriate inactivated flu vaccine or recombinant flu vaccine (US only) if a patient receives a flu antiviral medication within two weeks of vaccination with FluMist (or revaccinating with FluMist 48 hours after completing antiviral therapy [Canada only]).11,24 |
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
- Government of Canada. Immunization of persons with chronic diseases: Canadian immunization guide. May 2022. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-7-immunization-persons-with-chronic-diseases.html. (Accessed July 20, 2023).
- Dunkle LM, Izikson R, Patriarca P, et al. Efficacy of Recombinant Influenza Vaccine in Adults 50 Years of Age or Older. N Engl J Med. 2017 Jun 22;376(25):2427-2436.
- DiazGranados CA, Dunning AJ, Kimmel M, et al.Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med. 2014 Aug 14;371(7):635-45.
- Merced-Morales A, Daly P, Abd Elal AI, et al. Influenza Activity and Composition of the 2022-23 Influenza Vaccine - United States, 2021-22 Season. MMWR Morb Mortal Wkly Rep. 2022 Jul 22;71(29):913-919.
- Immunize.org. Ask the experts: administering vaccines. June 19, 2023. https://www.immunize.org/askexperts/administering-vaccines.asp. (Accessed July 20, 2023).
- CDC. Flu vaccine safety and pregnancy. December 2, 2022. https://www.cdc.gov/flu/highrisk/qa_vacpregnant.htm. (Accessed July 21, 2023).
- Zerbo O, Modaressi S, Chan B, et al.No association between influenza vaccination during pregnancy and adverse birth outcomes. Vaccine. 2017 May 31;35(24):3186-3190.
- CDC. Addressing concerns pregnant people might have about influenza vaccine safety. December 2, 2022. https://www.cdc.gov/flu/professionals/vaccination/vaccination-possible-safety-signal.html. (Accessed July 21, 2023).
- Government of Canada. Immunization in pregnancy and breastfeeding: Canadian immunization guide. March 1, 2023. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-4-immunization-pregnancy-breastfeeding.html#p3c3a6. (Accessed July 21, 2023).
- The American College of Obstetricians and Gynecologists. The flu vaccine and pregnancy. Reviewed December 2021. https://www.acog.org/patient-resources/faqs/pregnancy/the-flu-vaccine-and-pregnancy. (Accessed July 21, 2023).
- Immunization Action Coalition. Ask the experts: influenza. Updated June 19, 2023. https://www.immunize.org/askexperts/experts_inf.asp. (Accessed July 20, 2023).
- Immunization Action Coalition. Ask the experts: contraindications and precautions. Updated June 19, 2023. http://www.immunize.org/askexperts/precautions-contraindications.asp. (Accessed July 21, 2023).
- Goldberg R. Do influenza vaccines that are mismatched to flu viruses protect children? February 11, 2022. https://www.pulmonologyadvisor.com/home/topics/influenza/do-flu-vaccines-mismatched-to-flu-viruses-protect-children/. (Accessed July 26, 2023).
- CDC. Altered immunocompetence: general best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Last reviewed February 10, 2023. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. (Accessed July 21, 2023).
- Ray GT, Lewis N, Klein NP, et al.Intraseason Waning of Influenza Vaccine Effectiveness. Clin Infect Dis. 2019 May 2;68(10):1623-1630.
- Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023-24 Influenza Season. MMWR Recomm Rep 2023;72(No. RR-2):1-25.
- CDC. Influenza (flu). Live attenuated influenza vaccine [LAIV] (the nasal spray flu vaccine). Reviewed August 25, 2022. https://www.cdc.gov/flu/prevent/nasalspray.htm. (Accessed July 21, 2023).
- CDC. Influenza (flu) vaccine effectiveness: how well do flu vaccines work? Reviewed February 8, 2023. https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm. (Accessed July 24, 2023).
- Government of Canada. FluWatch annual report: 2019-2020 influenza season. November 1, 2022. https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2022-48/issue-10-october-2022/national-influenza-annual-report-canada-2021-2022-brief-late-influenza-epidemic.html. (Accessed July 24, 2023).
- Reuters. Fact check: COVID-19 and influenza vaccines too different to be directly compared. December 8, 2020. https://www.reuters.com/article/uk-factcheck-covid-influenza-vaccines/fact-check-covid-19-and-influenza-vaccines-too-different-to-be-directly-compared-idUSKBN28I2UE. (Accessed July 24, 2023).
- Government of Canada. Guidance on the use of influenza vaccine in the presence of COVID-19. November 26, 2021. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/guidance-use-influenza-vaccine-covid-19.html. (Accessed July 29, 2022).
- CDC. Influenza (Flu). Who should and who should not get a flu vaccine. Reviewed August 25, 2022. https://www.cdc.gov/flu/prevent/whoshouldvax.htm. (Accessed July 24, 2023).
- Domnich A, Arata L, Amicizia D, et al.Effectiveness of MF59-adjuvanted seasonal influenza vaccine in the elderly: A systematic review and meta-analysis. Vaccine. 2017 Jan 23;35(4):513-520.
- Government of Canada. National Advisory Committee on Immunization (NACI). Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 2023-2024. May 31, 2023. https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/national-advisory-committee-immunization-statement-seasonal-influenza-vaccine-2023-2024.html. (Accessed July 20, 2023).
- Public Health Agency of Canada. An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). A review of the literature of high dose seasonal influenza vaccine for adults 65 years and older. Modified April 11, 2016. http://www.phac-aspc.gc.ca/naci-ccni/influenza-vaccine-65-plus-vaccin-contre-la-grippe-65-plus-eng.php. (Accessed July 24, 2023).
- Product monograph for Supemtek. Sanofi Pasteur. Toronto, ON M2R 3T4. May 2022.
- CDC. Influenza (flu). Key facts about seasonal flu vaccine. Reviewed December 19, 2022. https://www.cdc.gov/flu/prevent/keyfacts.htm. (Accessed July 24, 2023).
- Immunize action coalition. Guide for determining the number of doses of influenza vaccine to give children age 6 months through 8 years. October 2021. https://www.immunize.org/catg.d/p3093.pdf. (Accessed July 24, 2023).
- CDC. Influenza (flu). Seasonal influenza vaccine safety: a summary for clinicians. Reviewed September 14, 2022. https://www.cdc.gov/flu/professionals/vaccination/vaccine_safety.htm. (Accessed July 24, 2023).
- National Institutes of Health. Influenza and COVID-19. September 20, 2022. https://www.covid19treatmentguidelines.nih.gov/special-populations/influenza/. (Accessed July 24, 2023).
- Government of Canada. Guidance on the use of influenza vaccine in the presence of COVID-19. February 6, 2023. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/guidance-use-influenza-vaccine-covid-19.html#a20. (Accessed July 24, 2023).
- Olson SM, Newhams MM, Halasa NB, et al. Vaccine Effectiveness Against Life-Threatening Influenza Illness in US Children. Clin Infect Dis. 2022 Jan 13:ciab931. doi: 10.1093/cid/ciab931.
- CDC. Vaccines & immunizations. Interim clinical considerations for use of COVID-19 vaccines currently approved or authorized in the United States. Updated May 12, 2023. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html. (Accessed July 26, 2023).
- CDC. Vaccines and preventable disease. Administering Shingrix. January 24, 2022. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/administering-vaccine.html. (July 26, 2023).
- Washington State Department of Health. Office of Immunization and Child Profile Vaccine Advisory Committee. High-dose and adjuvanted flu vaccine for persons 65 years and older. March 2020. https://doh.wa.gov/sites/default/files/legacy/Documents/Pubs//348-518-SupplementalGuidance.pdf?uid=624bc0743191e. (Accessed July 26, 2023).
- CDC. National center for immunization and respiratory diseases. Influenza vaccines for persons aged ≥65 years: evidence to recommendations framework. June 22, 2022. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-06-22-23/03-influenza-grohskopf-508.pdf. (Accessed July 26, 2023).
- American College of Rheumatology. 2022 American College of Rheumatology (ACR) guideline for vaccinations in patients with rheumatic or musculoskeletal diseases: guideline summery. https://www.rheumatology.org/Portals/0/Files/Vaccinations-Guidance-Summary.pdf. (Accessed July 26, 2023).
- Caldera F, Mercer M, Samson SI, et al. Influenza vaccination in immunocompromised populations: Strategies to improve immunogenicity. Vaccine. 2021 Mar 15;39 Suppl 1:A15-A23.
- See KC. Vaccination for the Prevention of Infection among Immunocompromised Patients: A Concise Review of Recent Systematic Reviews. Vaccines (Basel). 2022 May 18;10(5):800.
Cite this document as follows: Clinical Resource, Flu Vaccines for 2023-24. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights.September 2023. [390901]