Vaccine Information: Afluria Quadrivalent (Page 2 of 6)

6.2 Postmarketing Experience

Because postmarketing reporting of adverse events is voluntary and from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure. The adverse events described have been included in this section because they: 1) represent reactions that are known to occur following immunizations generally or influenza immunizations specifically; 2) are potentially serious; or 3) have been reported frequently. There are limited postmarketing data available for AFLURIA QUADRIVALENT. The adverse events listed below reflect experience in both children and adults and include those identified during post-approval use of AFLURIA (trivalent formulation) outside the U.S. since 1985.

The post-marketing experience with AFLURIA (trivalent formulation) included the following:

Blood and lymphatic system disorders


Immune system disorders

Allergic or immediate hypersensitivity reactions including anaphylactic shock and serum sickness

Nervous system disorders

Neuralgia, paresthesia, convulsions (including febrile seizures), encephalomyelitis, encephalopathy, neuritis or neuropathy, transverse myelitis, and GBS

Vascular disorders

Vasculitis which may be associated with transient renal involvement

Skin and subcutaneous tissue disorders

Pruritus, urticaria, and rash

General disorders and administration site conditions

Cellulitis and large injection site swelling

Influenza-like illness


No interaction studies have been performed on interaction between influenza vaccines in general and other vaccines or medications.


8.1 Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to AFLURIA QUADRIVALENT during pregnancy. Women who are vaccinated with AFLURIA QUADRIVALENT during pregnancy are encouraged to enroll in the registry by calling 1-855-358-8966 or sending an email to Seqirus at

Risk summary

All pregnancies have a risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data for AFLURIA (trivalent formulation) administered to pregnant women are relevant to AFLURIA QUADRIVALENT because both vaccines are manufactured using the same process and have overlapping compositions (see Description [11]). There are limited data for AFLURIA QUADRIVALENT administered to pregnant women, and available data for AFLURIA (trivalent formulation) administered to pregnant women are insufficient to inform vaccine-associated risks in pregnancy.

There were no developmental toxicity studies of AFLURIA QUADRIVALENT performed in animals. A developmental toxicity study of AFLURIA (trivalent formulation) has been performed in female rats administered a single human dose [0.5 mL (divided)] of AFLURIA (trivalent formulation) prior to mating and during gestation. This study revealed no evidence of harm to the fetus due to AFLURIA (trivalent formulation) (see 8.1 Data).

Clinical Considerations

Disease-associated Maternal and/or Embryo-Fetal Risk

Pregnant women are at increased risk for severe illness due to influenza compared to non-pregnant women. Pregnant women with influenza may be at increased risk for adverse pregnancy outcomes, including preterm labor and delivery.


Animal Data

In a developmental toxicity study, female rats were administered a single human dose [0.5 mL (divided)] of AFLURIA (trivalent formulation) by intramuscular injection 21 days and 7 days prior to mating, and on gestation day 6. Some rats were administered an additional dose on gestation day 20. No vaccine-related fetal malformations or variations and no adverse effects on pre-weaning development were observed in the study.

8.2 Lactation

Risk Summary

It is not known whether AFLURIA QUADRIVALENT is excreted in human milk. Data are not available to assess the effects of AFLURIA QUADRIVALENT on the breastfed infant or on milk production/excretion.

The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for AFLURIA QUADRIVALENT and any potential adverse effects on the breastfed child from AFLURIA QUADRIVALENT or from the underlying maternal condition. For preventive vaccines, the underlying maternal condition is susceptibility to disease prevented by the vaccine.

8.4 Pediatric Use

The safety and effectiveness of AFLURIA QUADRIVALENT in persons less than 6 months of age have not been established.

The PharmaJet Stratis Needle-Free Injection System is not approved as a method of administering AFLURIA QUADRIVALENT to children and adolescents less than 18 years of age due to lack of adequate data supporting safety and effectiveness in this population.

8.5 Geriatric Use

In clinical studies, AFLURIA QUADRIVALENT has been administered to, and safety information collected for, 867 subjects aged 65 years and older (see Adverse Reactions [6]). The 65 years and older age group included 539 subjects 65 through 74 years and 328 subjects 75 years and older. After administration of AFLURIA QUADRIVALENT, hemagglutination-inhibiting antibody responses were non-inferior to comparator trivalent influenza (TIV-1 and TIV-2) in persons 65 years of age and older, but were lower than younger adult subjects (see Clinical Studies [14]).

The PharmaJet Stratis Needle-Free Injection System is not approved as a method of administering AFLURIA QUADRIVALENT to adults 65 years of age and older due to lack of adequate data supporting safety and effectiveness in this population.


AFLURIA QUADRIVALENT, Influenza Vaccine for intramuscular injection, is a sterile, clear, colorless to slightly opalescent suspension with some sediment that resuspends upon shaking to form a homogeneous suspension. AFLURIA QUADRIVALENT is prepared from influenza virus propagated in the allantoic fluid of embryonated chicken eggs. Following harvest, the virus is purified in a sucrose density gradient using continuous flow zonal centrifugation. The purified virus is inactivated with beta-propiolactone, and the virus particles are disrupted using sodium taurodeoxycholate to produce a “split virion”. The disrupted virus is further purified and suspended in a phosphate buffered isotonic solution.

AFLURIA QUADRIVALENT is standardized according to USPHS requirements for the 2019-2020 influenza season and is formulated to contain 60 mcg hemagglutinin (HA) per 0.5 mL dose in the recommended ratio of 15 mcg HA for each of the four influenza strains recommended for the 2019-2020 Northern Hemisphere influenza season:

A/Brisbane/02/2018 (IVR-190) (an A/Brisbane/02/2018 (H1N1)pdm09 – like virus), A/Kansas/14/2017 (X-327) (an A/Kansas/14/2017 (H3N2) – like virus), B/Maryland/15/2016 (a B/Colorado/06/2017 – like virus) and B/Phuket/3073/2013 BVR-1B (a B/Phuket/3073/2013 – like virus). A 0.25 mL dose contains 7.5 mcg HA of each of the same four influenza strains.

Thimerosal, a mercury derivative, is not used in the manufacturing process for the single dose presentation. This presentation does not contain preservative. The multi-dose presentation contains thimerosal added as a preservative; each 0.5 mL dose contains 24.5 mcg of mercury and each 0.25 mL dose contains 12.25 mcg of mercury.

A single 0.5 mL dose of AFLURIA QUADRIVALENT contains sodium chloride (4.1 mg), monobasic sodium phosphate (80 mcg), dibasic sodium phosphate (300 mcg), monobasic potassium phosphate (20 mcg), potassium chloride (20 mcg), and calcium chloride (0.5 mcg). From the manufacturing process, each 0.5 mL dose may also contain residual amounts of sodium taurodeoxycholate (≤ 10 ppm), ovalbumin (< 1 mcg), sucrose (< 10 mcg), neomycin sulfate (≤ 81.8 nanograms [ng]), polymyxin B (≤ 14 ng), beta-propiolactone (≤ 1.5 ng) and hydrocortisone (≤ 0.56 ng). A single 0.25 mL dose of AFLURIA QUADRIVALENT contains half of these quantities.

The rubber tip cap and plunger used for the preservative-free, single-dose syringes and the rubber stoppers used for the multi-dose vial were not made with natural rubber latex.


12.1 Mechanism of Action

Influenza illness and its complications follow infection with influenza viruses. Global surveillance of influenza identifies yearly antigenic variants. For example, since 1977 antigenic variants of influenza A (H1N1 and H3N2) and influenza B viruses have been in global circulation. Since 2001, two distinct lineages of influenza B (Victoria and Yamagata lineages) have co-circulated worldwide. Specific levels of hemagglutination inhibition (HI) antibody titers post-vaccination with inactivated influenza vaccine have not been correlated with protection from influenza virus. In some human studies, antibody titers of 1:40 or greater have been associated with protection from influenza illness in up to 50% of subjects.2,3

Antibody against one influenza virus type or subtype confers limited or no protection against another. Furthermore, antibody to one antigenic variant of influenza virus might not protect against a new antigenic variant of the same type or subtype. Frequent development of antigenic variants through antigenic drift is the virologic basis for seasonal epidemics and the reason for the usual change to one or more new strains in each year’s influenza vaccine. Therefore, inactivated influenza vaccines are standardized to contain the HA of four strains (i.e., typically two type A and two type B) representing the influenza viruses likely to be circulating in the U.S. during the upcoming winter.

Annual revaccination with the current vaccine is recommended because immunity declines during the year after vaccination and circulating strains of influenza virus change from year to year.1


13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

AFLURIA QUADRIVALENT has not been evaluated for carcinogenic or mutagenic potential, or male infertility in animals. A developmental toxicity study conducted in rats vaccinated with AFLURIA (trivalent formulation) revealed no impact on female fertility (see Pregnancy [8.1]).


14.1 Efficacy Against Laboratory-Confirmed Influenza

The efficacy of AFLURIA (trivalent formulation) is relevant to AFLURIA QUADRIVALENT because both vaccines are manufactured using the same process and have overlapping compositions (see Description [11]).

The efficacy of AFLURIA (trivalent formulation) was demonstrated in Study 5, a randomized, observer-blind, placebo-controlled study conducted in 15,044 subjects. Healthy subjects 18 through 64 years of age were randomized in a 2:1 ratio to receive a single dose of AFLURIA (trivalent formulation) (enrolled subjects: 10,033; evaluable subjects: 9,889) or placebo (enrolled subjects: 5,011; evaluable subjects: 4,960). The mean age of all randomized subjects was 35.5 years. 54.4% were female and 90.2% were White. Laboratory-confirmed influenza was assessed by active and passive surveillance of influenza-like illness (ILI) beginning 2 weeks post-vaccination until the end of the influenza season, approximately 6 months post-vaccination. ILI was defined as at least one respiratory symptom (e.g., cough, sore throat, nasal congestion) and at least one systemic symptom (e.g., oral temperature of 100.0ºF or higher, feverishness, chills, body aches). Nasal and throat swabs were collected from subjects who presented with an ILI for laboratory confirmation by viral culture and real-time reverse transcription polymerase chain reaction. Influenza virus strain was further characterized using gene sequencing and pyrosequencing.

Attack rates and vaccine efficacy, defined as the relative reduction in the influenza infection rate for AFLURIA (trivalent formulation) compared to placebo, were calculated using the per protocol population. Vaccine efficacy against laboratory-confirmed influenza infection due to influenza A or B virus strains contained in the vaccine was 60% with a lower limit of the 95% CI of 41% (Table 6).

Table 6: AFLURIA (trivalent formulation): Laboratory-Confirmed Influenza Infection Rate and Vaccine Efficacy in Adults 18 through 64 Years of Age (Study 5)a

Abbreviations: CI, confidence interval.

a NCT00562484

b The Per Protocol Population was identical to the Evaluable Population in this study.

c Vaccine efficacy = 1 minus the ratio of AFLURIA (trivalent formulation) /placebo infection rates. The objective of the study was to demonstrate that the lower limit of the CI for vaccine efficacy was greater than 40%.

Subjects b Laboratory-Confirmed Influenza Cases Influenza Infection Rate Vaccine Efficacy c
N N n/N % % Lower Limit of the 95% CI
Vaccine-matched Strains
AFLURIA 9889 58 0.59 60 41
Placebo 4960 73 1.47
Any Influenza Virus Strain
AFLURIA 9889 222 2.24 42 28
Placebo 4960 192 3.87 provides trustworthy package insert and label information about marketed drugs and vaccines as submitted by manufacturers to the U.S. Food and Drug Administration. Package information is not reviewed or updated separately by Every individual vaccine label and package insert entry contains a unique identifier which can be used to secure further details directly from the U.S. National Institutes of Health and/or the FDA.

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