• Harper SA, Fukuda K, Cox NJ, Bridges CB. Using live, attenuated influenza vaccine for prevention and control of influenza: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2003 Sep 26;52(RR-13):1-8. [24 references] PubMed

Recommendations for inactivated influenza vaccination have targeted specific groups for annual immunization, including persons aged >6 months who are at high risk for complications from influenza because of age or presence of certain medical conditions, persons who are in close contact with those at high risk, persons aged 50 to 64 years, and close contacts of infants aged 0 to 6 months. Vaccination with inactivated influenza vaccine is also encouraged when feasible for children aged 6 to 23 months and their close contacts and caregivers. In addition, physicians should administer inactivated influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza. Recommendations for use of inactivated influenza vaccine are located at CDC Web site.

Recommendations for Using Live, Attenuated Influenza Vaccine (LAIV)

• Persons Who Should Not Be Vaccinated with LAIV

  The following populations should not be vaccinated with LAIV:

  • persons aged <5 years or those aged > 50 years^†
  • persons with asthma, reactive airways disease or other chronic disorders of the pulmonary or cardiovascular systems; persons with other underlying medical conditions, including such metabolic diseases as diabetes, renal dysfunction, and hemoglobinopathies; or persons with known or suspected immunodeficiency diseases or who are receiving immunosuppressive therapies^†
  • children or adolescents receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza infection)^†
  • persons with a history of Guillain-Barré syndrome
  • pregnant women^†
  • persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs

  ^† These persons should receive inactivated influenza vaccine.

• Close Contacts of Persons at High Risk for Complications from Influenza

  Close contacts of persons at high risk for complications from influenza should receive influenza vaccine to reduce transmission of wild-type influenza viruses to persons at high risk. No data are available assessing the risk for transmission of LAIV from vaccine recipients to immunosuppressed contacts. In the absence of such data, use of inactivated influenza vaccine is preferred for vaccinating household members, health-care workers, and others who have close contact with immunosuppressed persons because of the theoretical risk that a live, attenuated vaccine virus could be transmitted to the immunosuppressed person and cause disease. Otherwise, no preference is given to either inactivated influenza vaccine or LAIV for vaccination of healthy persons aged 5 to 49 years in close contact with all other groups at high risk.

• Timing of LAIV Administration

  Administration of LAIV is not subject to tiered timing recommendations because it is not approved for use among populations at high risk. The optimal time to vaccinate is usually in October and November, but providers can begin vaccinating with LAIV as soon as vaccine supplies are available. Children aged 5 to 8 years who have never received influenza vaccine should receive LAIV for the first time in October or earlier because they need a second dose 6 to 10 weeks after the initial dose.

• Dosage, Administration, and Storage

  LAIV Dosage

  LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal, or intravenous route. LAIV must be stored at –15°C or colder. LAIV should not be stored in a frost-free freezer (because the temperature might cycle above –15°C), unless a manufacturer-supplied freezer box is used. LAIV must be thawed before administration. This can be accomplished by holding an individual sprayer in the palm of the hand until thawed, with subsequent immediate administration. Alternatively, the vaccine can be thawed in a refrigerator and stored at 2°C to 8°C for <24 hours before use. Vaccine should not be refrozen after thawing. LAIV is supplied in a prefilled singleuse sprayer containing 0.5 mL of vaccine. Approximately 0.25 mL (i.e., half of the total sprayer contents) is sprayed into the first nostril while the recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. If the vaccine recipient sneezes after administration, the dose should not be repeated.

  LAIV should be administered annually according to the following schedule:

  • Children aged 5 to 8 years previously unvaccinated at any time with either LAIV or inactivated influenza vaccine should receive 2 doses of LAIV separated by 6 to 10 weeks (Note: one dose equals 0.5 mL, divided equally between each nostril).
  • Children aged 5 to 8 years previously vaccinated at any time with either LAIV or inactivated influenza vaccine should receive 1 dose of LAIV. They do not require a second dose.
  • Persons aged 9 to 49 years should receive 1 dose of LAIV.

  LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if clinical judgment indicates nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness.

  Whether concurrent administration of LAIV with other vaccines affects the safety or efficacy of either LAIV or the simultaneously administered vaccine is unknown. In the absence of specific data indicating interference, following the ACIP general recommendations for immunization is prudent (Centers for Disease Control [CDC], 2002). Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. An inactivated vaccine can be administered either simultaneously or at any time before or after LAIV. Two live vaccines not administered on the same day should be administered >4 weeks apart when possible.

  LAIV Administration and Use of Influenza Antiviral Medications

  The effect on safety and efficacy of LAIV coadministration with influenza antiviral medications has not been studied. However, because influenza antivirals reduce replication of influenza viruses, LAIV should not be administered until 48 hours after cessation of influenza antiviral therapy, and influenza antiviral medications should not be administered for 2 weeks after receipt of LAIV.

  LAIV Storage

  LAIV must be stored at –15°C or colder. LAIV should not be stored in a frost-free freezer because the temperature might cycle above –15°C, unless a manufacturer-supplied freezer box or other strategy is used. LAIV may be thawed in a refrigerator and stored at 2°C to 8°C for <24 hours before use. It should not be refrozen after thawing. Additional information is available at Wyeth Product Quality (1-800-411-0086) or at www.FluMist.com.

• Side Effects and Adverse Reactions

  Refer to the "Potential Harms" field for information on side effects and potential adverse reactions.

  Serious Adverse Events

  Serious adverse events among healthy children aged 5 to 17 years or healthy adults aged 18 to 49 years occurred at a rate of <1%. Surveillance should continue for adverse events that might not have been detected in previous studies.

• Harper SA, Fukuda K, Cox NJ, Bridges CB. Using live, attenuated influenza vaccine for prevention and control of influenza: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2003 Sep 26;52(RR-13):1-8. [24 references] PubMed

• HTML Format
• Portable Document Format (PDF)

Print copies: Available from the Centers for Disease and Control Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.