What type of influenza vaccine is recommended for individuals with different ages, health statuses, and allergies?

Influenza Vaccine Types by Age, Health Status, and Allergies

Standard Recommendations by Age

All persons aged ≥6 months should receive annual influenza vaccination, with specific vaccine types determined primarily by age, not by preference among age-appropriate options. 1

Infants and Young Children (6 months - 35 months)

• Any age-appropriate inactivated influenza vaccine (IIV3) is acceptable, including standard-dose egg-based vaccines (Afluria, Fluarix, FluLaval, Fluzone) or cell culture-based vaccine (Flucelvax) 1
• Dose volume varies by product: 0.25 mL or 0.5 mL depending on manufacturer and availability 1
• Children receiving influenza vaccine for the first time require two doses administered at least 4 weeks apart 2

Children and Adolescents (3-17 years)

• Standard-dose IIV3s (egg-based or cell culture-based) administered intramuscularly 1
• Live attenuated influenza vaccine (LAIV3) administered intranasally for ages 2-49 years in healthy, non-pregnant individuals 1
• Recombinant influenza vaccine (RIV3) for ages ≥18 years 1

Adults (18-64 years)

• Any age-appropriate vaccine: standard-dose IIV3, cell culture-based IIV3 (ccIIV3), or recombinant vaccine (RIV3) 1
• LAIV3 is an option for healthy, non-pregnant adults through age 49 years 1
• No preferential recommendation exists among age-appropriate vaccines for this population 3

Older Adults (≥65 years)

• High-dose inactivated influenza vaccine (HD-IIV3) containing 60 μg hemagglutinin per strain is specifically indicated 1
• Adjuvanted inactivated influenza vaccine (aIIV3) with MF59 adjuvant is an alternative option 1
• Standard-dose vaccines may be used if enhanced vaccines are unavailable 1

Recommendations for Specific Health Conditions

Immunocompromised Patients (18-64 years)

• Solid organ transplant recipients receiving immunosuppressive medications may receive either HD-IIV3 or aIIV3 as acceptable options without preference over other age-appropriate IIV3s or RIV3 1
• Inactivated vaccines are preferred over live attenuated vaccines 1

Asthma and Chronic Medical Conditions

• Any age-appropriate inactivated influenza vaccine is recommended 4
• LAIV3 is contraindicated in children aged 2-4 years with recurrent wheezing or reactive airways disease 5
• LAIV3 should not be used in persons with chronic medical conditions that increase risk of influenza complications 1

Pregnant Women

• Any age-appropriate inactivated influenza vaccine is recommended 5
• LAIV3 is contraindicated during pregnancy 1

Allergy-Specific Guidance

Egg Allergy (Any Severity)

All persons with egg allergy should receive influenza vaccine, and any influenza vaccine (egg-based or non-egg based) that is otherwise appropriate for age and health status can be used. 1, 6

• For patients with history of only hives after egg exposure: Any age-appropriate influenza vaccine can be administered without special precautions 6, 7
• For patients with severe egg allergy reactions (angioedema, respiratory distress, recurrent emesis, or requiring epinephrine): Any age-appropriate vaccine can still be used, but administration should occur in a medical setting supervised by a provider able to recognize and manage severe allergic reactions if egg-based vaccines are chosen 1, 6
• Egg-free alternatives: Recombinant influenza vaccine (RIV3) for ages ≥18 years or cell culture-based vaccine (ccIIV3) for ages ≥6 months contain no or minimal egg protein 6
• No skin testing is required before vaccination 6
• No extended observation period beyond standard 15 minutes is necessary 6

Dairy Allergy

Influenza vaccines do not contain dairy proteins or milk components; therefore, dairy allergy poses no concern for influenza vaccination. 8

• Administer any age-appropriate influenza vaccine using standard protocols 8
• No special screening, extended observation, or restriction to specific medical settings is needed 8
• Refer to allergist only if previous allergic reaction occurred specifically to an influenza vaccine itself, not for dairy allergy history alone 8

Previous Severe Allergic Reaction to Influenza Vaccine

• History of severe allergic reaction (anaphylaxis) to any component of a specific vaccine or to a previous dose of any influenza vaccine is a contraindication 1
• Allergist consultation is recommended to identify the responsible vaccine component 1
• Alternative vaccine formulations may be considered based on the specific allergen identified 1

Key Contraindications and Precautions

Absolute Contraindications

• History of severe allergic reaction to any component of the specific vaccine being considered 1
• History of severe allergic reaction to a previous dose of any influenza vaccine 1
• For LAIV3 specifically: concomitant aspirin or salicylate-containing therapy in children and adolescents, immunosuppression, pregnancy, and certain chronic medical conditions 1

Precautions (Defer Vaccination)

• Moderate or severe acute illness with or without fever 1
• History of Guillain-Barré syndrome within 6 weeks after receipt of influenza vaccine 1

Critical Clinical Pitfalls to Avoid

• Do not unnecessarily delay or withhold vaccination due to egg allergy concerns—current guidelines support vaccination of all egg-allergic individuals with any age-appropriate vaccine 6, 7
• Do not confuse egg allergy with dairy allergy—only egg allergy has relevance to influenza vaccination, and even then, vaccination is still recommended 8
• Do not assume older formulations apply—trivalent vaccines have replaced quadrivalent formulations for the 2024-25 season 1
• Do not forget two-dose series for young children—children aged 6 months through 8 years receiving influenza vaccine for the first time require two doses 2