2019-20 Flu Vaccine Updates

Each year, the ACIP provides U.S. flu vaccine recommendations based on available vaccine formulations and updated research findings.

Another year is upon us and brings annual fluvax updates!

The Advisory Committee on Immunization Practices is part of several task forces on vaccines of every kind, and remains the RN authoritative reference for immunizations–a huge part of nursing health promotional priorities.

RN Teaching Trivia: The CDC takes the lead from the ACIP on vaccines.

Nurses rely on these annual updates and apply practice changes so that the public has the latest information and the best care during what is arguably the busiest time of year for primary care offices. A few minor changes and renewed recommendations from last year are summarized.

Keep your CDC and ACIP references handy this season with mobile and web solutions (My Nursing Mastery.com)

So What's Changed in 2020?

  • Childhood dosing continues to be the more complicated than adults, and this year is no exception, ugh. But manufacturers are trying to make dosing simpler, no doubt to further reduce dosing errors. Check for labeling changes for certain inactivated (IM) formulations including: Afluria Quadrivalent and Fluzone Quadrivalent.
  • The age indications for Afluria for children has changed!
  • Getting your flu shot as early as possible is emphasized this year–the CDC recommends everyone receive them by the end of October is possible.
  • Persons with a history of egg allergy of any severity may receive any licensed, recommended, and age-appropriate influenza vaccine including live vaccine. Although this is not a change from the previous year, it is now emphasized, and specific guidance is provided for providers to navigate these situations. There are specific guidelines that hinge on a person's known reaction to eggs, and certain formulations such as high-dose flu vaccines (Flublok or Fluzone High-Dose) are not appropriate for these individuals.
  • Not a change, but the CDC is encouraging awareness to vaccinate all persons ≥ 6 months of age with no contraindications with an age-appropriate vaccine–including live vaccine if appropriate. Choices include IIV, RIV4, or LAIV4.

Who should receive the vaccine?

  • All adults (including those that are unsure whether they have had the vaccine this season)
  • All pregnant women in any trimester
  • All children at least 6 months old
  • Most important groups if vaccine supply is limited (high-risk contacts/caregivers):
    • Children 6–59 months
    • Adults ≥ 50 years
    • Chronic conditions including pulmonary disease (asthma) and diabetes, cardiovascular, renal, hematologic, and neurologic disease (except hypertension with no other conditions)
    • Immunocompromised due to any condition
    • Women planning pregnancy during the flu season
    • Children and adolescents up to age 18 on ASA or salicylate therapy who are at risk for Reye syndrome
    • Long-term care or group-living residents
    • American Indians and Alaska natives
    • Extremely obese persons (≥ 40 BMI)
    • Caregivers and contacts of high-risk persons, including healthcare personnel or household contacts

Who should not receive the vaccine?

  • The vaccine is contraindicated for any person with a history of severe allergic reaction to the flu vaccine.
  • The vaccine should be administered with caution to patients with moderate or severe acute illness with or without fever or Guillain–Barré syndrome within six weeks following a previous dose of influenza vaccine.
  • Flu vaccines are made with egg. In recent years, the CDC has issued guidance for how to vaccinate individuals with moderate to severe egg allergy. (See CDC guidelines for assessing egg allergy.)
  • Refer to guidelines for FluMist for live vaccine contraindications

RN Teaching Trivia: Persons who are able to eat a lightly-cooked egg without an allergic reaction are probably not allergic to eggs and should receive the vaccine.

Same Special Rules for Live Vaccine (LAIV, FluMist)

As always, treat intranasal flu vaccine differently. Guidelines differ between inactivated and live flu vaccines. Because the formulation contains live, weakened virus, the protection against influenza can be very good, and the avoidance of needles is a plus for certain individuals to be sure. However, some individuals cannot safely receive this option.

Vaccine Abbreviations

New abbreviations are created almost every season and can be confusing. Take the time, every time you vaccinate, to understand what you are giving. There are multiple brands for some of these vaccine types; the abbreviation refers to how the vaccine is made and it's actions, and what strains are targeted. Here are the most common formulations:

IM Route
  • IIV = Inactivated Influenza Vaccine
  • IIV3 = Trivalent Inactivated Influenza Vaccine
  • HD IIV3 = High Dose Trivalent Inactivated Influenza Vaccine
  • IIV4 = Quadrivalent Inactivated Influenza Vaccine
  • RIV4 = Quadrivalent Recombinant Influenza Vaccine (Flublok)
Intranasal Route (Flumist)
  • LAIV4 = Quadrivalent Live Attenuated Influenza Vaccine

RN Considerations

  • Persons taking antiviral medications for influenza may receive a flu vaccine.
  • Persons may receive the inactivated or live flu vaccine at the same time as other inactivated or live vaccines.If the live vaccine is not administered on the same day as another live vaccine, allow 4 weeks between the two vaccines.
  • All formulations are available without thimerosol, mercury, and/or latex. Always check package inserts.
  • FluMist (LAIV) is recommended for non-pregnant patients age 2–49 years old. There is a precaution against the use of LAIV for people with specific underlying medical conditions. Refer to those guidelines for a list!
  • Intradermal and high-dose flu vaccines (high-dose "HD" IIV3) are not intended for all adults, but may be more effective for adults over age 65. Check eligibility.
  • Flu vaccine dose differs by manufacturer. Review package inserts.
  • Multi-dose vials may have a labeled Beyond Use Date (BUD) in addition to the expiration date.
  • RIV4 = Quadrivalent Recombinant Influenza Vaccine (Flublok) is approved only for adults at least 18 years old.
  • Patients ages 6 months to 8 years may require 2 doses. (See the interactive Pediatric Vaccine Algorithm in the My Nursing Mastery app!)
  • Flu virus strains change every year. To gain protection, individuals require annual vaccination.

RN Teaching Trivia: For the last several years, every flu vaccine protects against multiple strains including the H1N1 strain.

Preferred IM Sites

  • Adults and older children: upper arm (deltoid)
  • Infants/small children: anterolateral thigh (vastus lateralis)


  • Prepare injections just before administration. Do not draw up doses prior to arriving at clinic site.
  • All flu vaccines should be stored in the refrigerator.
  • Discard unused doses daily.
  • Before administering any vaccine, check the specific vaccine insert for ingredients (latex) to screen for allergies.
  • Use aseptic technique for multi-dose vials. In addition to an expiration date, these vials have a Beyond Use Date (BUD)–the maximum time allowed once they have been opened and accessed before the need to discard.
  • If a patient sneezes following Flumist administration, the dose should not be repeated.
  • Children under 35 months should receive a dose volume specified by manufacturer. Check whether the correct dose is 0.25 mL or 0.5 mL.
  • For inactivated vaccines, children over age 3 receive the 0.5 mL volume dose, regardless of manufacturer. Check your facility's supply!
Learn about Who Needs A Flu Vaccine.


  1. Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2019–20 Influenza Season. MMWR Recomm Rep 2019;68(No. RR-3):1–21. DOI: http://dx.doi.org/10.15585/mmwr.rr6803a1
  2. General Best Practice Guidelines for Immunization (CDC), n.d., https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html
  3. How Influenza (Flu) Vaccines Are Made (CDC), n.d., https://www.cdc.gov/flu/prevent/how-fluvaccine-made.htm