Safety of AS03-adjuvanted influenza vaccines: A review of the evidence

Vaccine. 2019 May 21;37(23):3006-3021. doi: 10.1016/j.vaccine.2019.04.048. Epub 2019 Apr 25.


Clinical and post-licensure data have demonstrated that AS03-adjuvanted inactivated split virion vaccines, many with reduced antigen content, are effective against influenza infection. The objective of this review is to provide a comprehensive assessment of the safety of trivalent seasonal, monovalent pre-pandemic and pandemic AS03-adjuvanted influenza vaccines, based on non-clinical, clinical and post-licensure data in various populations. Non-clinical studies on local tolerance, toxicology and safety pharmacology did not raise any safety concerns with AS03 administered alone or combined with various influenza antigens. Data from clinical trials with over 55,000 vaccinated subjects showed that AS03-adjuvanted influenza vaccines were generally well tolerated and displayed an acceptable safety profile, although the power to detect rare events was limited. Approximately 90 million doses of A/H1N1pdm09 pandemic influenza vaccines (Pandemrix and Arepanrix H1N1) were administered worldwide, which contributed post-licensure data to the collective safety data for AS03-adjuvanted influenza vaccines. An association between Pandemrix and narcolepsy was observed during the A/H1N1pdm09 pandemic, for which a role of a CD4 T cell mimicry sequence in the haemagglutinin protein of A/H1N1pdm09 cannot be excluded. Provided that future AS03-adjuvanted influenza vaccines do not contain this putative mimicry sequence, this extensive safety experience supports the further development and use of AS03-adjuvanted inactivated split virion candidate vaccines against seasonal and pandemic influenza infections.

Keywords: Adjuvant system; Influenza; Pharmacovigilance; Reactogenicity; Safety; Vaccine.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Adjuvants, Immunologic / administration & dosage
  • Adjuvants, Immunologic / adverse effects
  • Animals
  • Antibodies, Viral / blood
  • Clinical Trials as Topic
  • Drug Combinations
  • Hemagglutination Inhibition Tests
  • Humans
  • Influenza A Virus, H1N1 Subtype
  • Influenza Vaccines / administration & dosage
  • Influenza Vaccines / adverse effects*
  • Narcolepsy / etiology
  • Pharmacovigilance
  • Polysorbates / administration & dosage
  • Polysorbates / adverse effects*
  • Squalene / administration & dosage
  • Squalene / adverse effects*
  • Vaccination / adverse effects*
  • Vaccines, Inactivated / administration & dosage
  • Vaccines, Inactivated / adverse effects
  • alpha-Tocopherol / administration & dosage
  • alpha-Tocopherol / adverse effects*


  • ASO3B adjuvant
  • Adjuvants, Immunologic
  • Antibodies, Viral
  • Drug Combinations
  • Influenza Vaccines
  • Polysorbates
  • Vaccines, Inactivated
  • arepanrix
  • pandemrix
  • Squalene
  • alpha-Tocopherol