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2008-09 INFLUENZA PREVENTION & CONTROL RECOMMENDATIONS

Additional Information about Vaccination of Specific Populations

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Children

Beginning with the 2008--09 influenza season, all children aged 6 months--18 years should be vaccinated against influenza annually. The expansion of vaccination to include all children aged 5--18 years should begin in 2008 if feasible, but no later than the 2009--10 influenza season. In 2004, ACIP recommended routine vaccination for all children aged 6--23 months, and in 2006, ACIP expanded the recommendation to include all children aged 24--59 months. The committee's recommendation to expand routine influenza vaccination to include all school-age children and adolescents aged 5--18 years is based on 1) accumulated evidence that influenza vaccine is effective and safe for school-aged children (see "Influenza Vaccine Efficacy, Effectiveness, and Safety"), 2) increased evidence that influenza has substantial adverse impacts among school-aged children and their contacts (e.g., school absenteeism, increased antibiotic use, medical care visits, and parental work loss) (see "Health-Care Use, Hospitalizations, and Deaths Attributed to Influenza"), and, 3) an expectation that a simplified age-based influenza vaccine recommendation for all school-age children and adolescents will improve vaccine coverage levels among the approximately 50% of school-aged children who already had a risk- or contact-based indication for annual influenza vaccination.

Children typically have the highest attack rates during community outbreaks of influenza and serve as a major source of transmission within communities. If sufficient vaccination coverage among children can be achieved, evidence for additional benefits, such as the indirect effect of reducing influenza among persons who have close contact with children and reducing overall transmission within communities, might occur. Achieving and sustaining community-level reductions in influenza will require mobilization of community resources and development of sustainable annual vaccination campaigns to assist health-care providers and vaccination programs in providing influenza vaccination services to children of all ages. In many areas, innovative community-based efforts, which might include mass vaccination programs in school or other community settings, will be needed to supplement vaccination services provided in health-care providers' offices or public health clinics. In nonrandomized community-based controlled trials, reductions in ILI-related symptoms and medical visits among household contacts have been demonstrated in communities where vaccination programs among school-aged children were established, compared with communities without such vaccination programs. Rates of school absences associated with ILI also were significantly reduced in some studies. In addition, reducing influenza transmission among children through vaccination has reduced rates for self-reported ILI among household contacts and among unvaccinated children.

Reducing influenza-related illness among children who are at high risk for influenza complications should continue to be a primary focus of influenza-prevention efforts. Children who should be vaccinated because they are at high risk for influenza complications include all children aged 6--59 months, children with certain medical conditions, children who are contacts of children aged <-09 i5 years (60 months) or persons aged 50 years and older, and children who are contacts of persons at high risk for influenza complications because of medical conditions. Influenza vaccines are not licensed by FDA for use among children aged <6 months. Because these infants are at higher risk for influenza complications compared with other child age groups, prevention efforts that focus on vaccinating household contacts and out-of-home caregivers to reduce the risk for influenza in these infants is a high priority.

All children aged 6 months--8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first influenza season that they are vaccinated. The second dose should be administered 4 or more weeks after the initial dose. For example, children aged 6 months--8 years who were vaccinated for the first time during the 2007--08 influenza season but only received 1 dose during that season should receive 2 doses of the 2008--09 influenza vaccine. All other children aged 6 months--8 years who have previously received 1 or more doses of influenza vaccine at any time should receive 1 dose of the 2008-nfluenza vaccine. Children aged 6 months--8 years who only received a single vaccination during a season before 2007--08 should receive 1 dose of the 2008--09 influenza vaccine. If possible, both doses should be administered before onset of influenza season. However, vaccination, including the second dose, is recommended even after influenza virus begins to circulate in a community.

Health Care Personnel (HCP) and Others Who Can Transmit Influenza to Those at High Risk

Healthy persons who are infected with influenza virus, including those with subclinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. In addition to HCP, groups that can transmit influenza to high-risk persons and that should be vaccinated include

In addition, because children aged <5 years are at increased risk for influenza-related hospitalization compared with older children, vaccination is recommended for their household contacts and out-of-home caregivers. Because influenza vaccines have not been licensed by FDA for use among children aged <6 months, emphasis should be placed on vaccinating contacts of children aged <6 months. When vaccine supply is limited, priority for vaccination should be given to contacts of children aged <6 months.

Healthy HCP and persons aged 2--49 years who are contacts of persons in these groups and who are not contacts of severely immunosuppressed persons (see Close Contacts of Immunocompromised Persons) should receive either LAIV or TIV when indicated or requested. All other persons, including pregnant women, should receive TIV.

All HCP, as well as those in training for health-care professions, should be vaccinated annually against influenza. Persons working in health-care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient-care settings, medical emergency-response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and chronic-care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. Health-care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. Influenza vaccination rates among HCP within facilities should be regularly measured and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration. Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and by using strategies that increase vaccine acceptance.

Efforts to increase vaccination coverage among HCP are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission on Accreditation of Health-Care Organizations has approved an infection-control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with close patient contact. The standard became an accreditation requirement beginning January 1, 2007. In addition, the Infectious Diseases Society of America recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons. Fifteen states have regulations regarding vaccination of HCP in long-term--care facilities, six states require that health-care facilities offer influenza vaccination to HCP, and four states require that HCP either receive influenza vaccination or indicate a religious, medical, or philosophical reason for not being vaccinated.

Close Contacts of Immunocompromised Persons

Immunocompromised persons are at risk for influenza complications but might have insufficient responses to vaccination. Close contacts of immunocompromised persons, including HCP, should be vaccinated to reduce the risk for influenza transmission. TIV is preferred for vaccinating household members, HCP, and others who have close contact with severely immunosuppressed persons (e.g., patients with hematopoietic stem cell transplants) during those periods in which the immunosuppressed person requires care in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes).

LAIV transmission from a recently vaccinated person causing clinically important illness in an immunocompromised contact has not been reported. The rationale for avoiding use of LAIV among HCP or other close contacts of severely immunocompromised patients is the theoretical risk that a live, attenuated vaccine virus could be transmitted to the severely immunosuppressed person. As a precautionary measure, HCP who receive LAIV should avoid providing care for severely immunosuppressed patients for 7 days after vaccination. Hospital visitors who have received LAIV should avoid contact with severely immunosuppressed persons in protected environments for 7 days after vaccination but should not be restricted from visiting less severely immunosuppressed patients.

No preference is indicated for TIV use by persons who have close contact with persons with lesser degrees of immunosuppression (e.g., persons with diabetes, persons with asthma who take corticosteroids, persons who have recently received chemotherapy or radiation but who are not being cared for in a protective environment as defined above, or persons infected with HIV) or for TIV use by HCP or other healthy nonpregnant persons aged 2--49 years in close contact with persons in all other groups at high risk.

Pregnant Women

Pregnant women are at risk for influenza complications, and all women who are pregnant or will be pregnant during influenza season should be vaccinated. The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians also have recommended routine vaccination of all pregnant women. No preference is indicated for use of TIV that does not contain thimerosal as a preservative (see Vaccine Preservative [Thimerosal] in Multidose Vials of TIV) for any group recommended for vaccination, including pregnant women. LAIV is not licensed for use in pregnant women. However, pregnant women do not need to avoid contact with persons recently vaccinated with LAIV.

Breastfeeding Mothers

Vaccination is recommended for all persons, including breastfeeding women, who are contacts of infants or children aged 59 months and younger (i.e., <5 years), because infants and young children are at high risk for influenza complications and are more likely to require medical care or hospitalization if infected. Breastfeeding does not affect the immune response adversely and is not a contraindication for vaccination. Women who are breastfeeding can receive either TIV or LAIV unless contraindicated because of other medical conditions.

Travelers

The risk for exposure to influenza during travel depends on the time of year and destination. In the temperate regions of the Southern Hemisphere, influenza activity occurs typically during April--September. In temperate climate zones of the Northern and Southern Hemispheres, travelers also can be exposed to influenza during the summer, especially when traveling as part of large tourist groups (e.g., on cruise ships) that include persons from areas of the world in which influenza viruses are circulating. In the tropics, influenza occurs throughout the year. In a study among Swiss travelers to tropical and subtropical countries, influenza was the most frequently acquired vaccine-preventable disease.

Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, persons at high risk for complications of influenza and who were not vaccinated with influenza vaccine during the preceding fall or winter should consider receiving influenza vaccine before travel if they plan to

No information is available about the benefits of revaccinating persons before summer travel who already were vaccinated during the preceding fall. Persons at high risk who receive the previous season's vaccine before travel should be revaccinated with the current vaccine the following fall or winter. Persons at higher risk for influenza complications should consult with their health-care practitioner to discuss the risk for influenza or other travel-related diseases before embarking on travel during the summer.

General Population

Vaccination is recommended for any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected. Healthy, nonpregnant persons aged 2--49 years might choose to receive either TIV or LAIV. All other persons aged 6 months and older should receive TIV. Persons who provide essential community services should be considered for vaccination to minimize disruption of essential activities during influenza outbreaks. Students or other persons in institutional settings (e.g., those who reside in dormitories or correctional facilities) should be encouraged to receive vaccine to minimize morbidity and the disruption of routine activities during epidemics.

Vaccines for Different Age Groups

When vaccinating children aged 6--35 months with TIV, health-care providers should use TIV that has been licensed by the FDA for this age group (i.e., TIV manufactured by Sanofi Pasteur ([FluZone]). TIV from Novartis (Fluvirin) is FDA-approved in the United States for use among persons aged 4 years and older. TIV from GlaxoSmithKline (Fluarix and FluLaval) or CSL Biotherapies (Afluria) is labeled for use in persons aged 18 years and older because data to demonstrate efficacy among younger persons have not been provided to FDA. LAIV from MedImmune (FluMist) is licensed for use by healthy nonpregnant persons aged 2--49 years (Table 1). A vaccine dose does not need to be repeated if inadvertently administered to a person who does not have an age indication for the vaccine formulation given. Expanded age and risk group indications for licensed vaccines are likely over the next several years, and vaccination providers should be alert to these changes. In addition, several new vaccine formulations are being evaluated in immunogenicity and efficacy trials; when licensed, these new products will increase the influenza vaccine supply and provide additional vaccine choices for practitioners and their patients.

TABLE 1. Live, attenuated influenza vaccine (LAIV) compared with inactivated influenza vaccine (TIV) for seasonal influenza, United States formulations.
Factor LAIV TIV
Route of administration Intranasal spray Intramuscular injection
Type of vaccine Live-attenuated virus Killed virus
No. of included virus strains Three (two influenza A, one influenza B) Three (two influenza A, one influenza B)
Vaccine virus strains updated Annually Annually
Frequency of administration Annually* Annually*
Approved age Persons aged 2–49 yrs† Persons aged 6 months and older
Interval between 2 doses recommended for children aged 6 months and older–8 years who are receiving influenza vaccine for the first time 4 weeks 4 weeks
Can be administered to persons with medical risk factors for influenza-related complications† No Yes
Can be administered to children with asthma or children aged 2–4 years with wheezing during the preceding year§ No  Yes
Can be administered to family members or close contacts of immunosuppressed persons not  requiring a protected environment Yes  Yes
Can be administered to family members or close contacts of immunosuppressed persons requiring a protected environment (e.g., hematopoietic stem cell transplant recipient) No Yes
Can be administered to family members or close contacts of persons at high risk but not  severely immunosuppressed Yes Yes
Can be simultaneously administered with other vaccines Yes¶  Yes**
If not simultaneously administered, can be administered within 4 weeks of another live vaccine Prudent to space 4 weeks apart Yes
If not simultaneously administered, can be administered within 4 weeks of an inactivated vaccine Yes Yes

*Children aged 6 months–8 years who have never received influenza vaccine before should receive 2 doses. Those who only receive 1 dose in their first year of vaccination should receive 2 doses in the following year, spaced 4 weeks apart.

† Persons at high risk for complications of influenza infection because of underlying medical conditions should not receive LAIV. Persons at higher risk for complications of influenza infection because of underlying medical conditions include adults and children with chronic disorders of the pulmonary or cardiovascular systems; adults and children with chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunnosuppression; children and adolescents receiving long-term aspirin therapy (at risk for developing Reye syndrome after wild-type influenza infection); persons who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration; pregnant women; and residents of nursing homes and other chronic-care facilities that house persons with chronic medical conditions.

§ Clinicians and vaccination programs should screen for possible reactive airways diseases when considering use of LAIV for children aged 2–4 years, and should avoid use of this vaccine in children with asthma or a recent wheezing episode. Health-care providers should consult the medical record, when available, to identify children aged 2–4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2–4 years should be asked: “In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?” Children whose parents or caregivers answer “yes” to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months, should not receive FluMist.

¶ Live attenuated influenza vaccine coadministration has been evaluated systematically only among children aged 12–15 months who received measles, mumps and rubella vaccine or varicella vaccine.

** Inactivated influenza vaccine coadministration has been evaluated systematically only among adults who received pneumococcal polysaccharide or zoster vaccine..

NOTE: The text above is taken from Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2008. MMWR 2008 Jul 17; Early Release:1-60. (Also available as PDF, 586K).

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