Children Aged 6 Months—18 Years
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 (1,2). 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 (299—301). 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 (297,298).
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 <5 years (60 months) or persons aged >50 years, 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—09 influenza 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.
HCP and Other Persons 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
- employees of assisted living and other residences for persons in groups at high risk;
- persons who provide home care to persons in groups at high risk; and
- household contacts (including children) of persons in groups at high risk.
In addition, because children aged <5 years are at increased risk for influenza-related hospitalization (7,37,58,63,348) 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 (339,340,349).
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 (340). 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 (340). 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 (338,340,350).
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 (351). 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 (352). Fifteen states have regulations regarding vaccination of HCP in long-term—care facilities (353), 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 (354,355).
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) (340,356).
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 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 (357). 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.
Vaccination is recommended for all persons, including breastfeeding women, who are contacts of infants or children aged <59 months (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 (197). Women who are breastfeeding can receive either TIV or LAIV unless contraindicated because of other medical conditions.
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 (358,359). 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 (360).
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
- travel to the tropics,
- travel with organized tourist groups at any time of year, or
- travel to the Southern Hemisphere during April—September.
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.
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 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 (361,362).
Recommended 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. TIV from GlaxoSmithKline (Fluarix and FluLaval) or CSL Biotherapies (Afluria) is labeled for use in persons aged >18 years 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.
Influenza Vaccines and Use of Influenza Antiviral Medications
Administration of TIV and influenza antivirals during the same medical visit is acceptable. The effect on safety and effectiveness 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. Persons receiving antivirals within the period 2 days before to 14 days after vaccination with LAIV should be revaccinated at a later date (197,252).
Persons Who Should Not Be Vaccinated with TIV
TIV should not be administered to persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine. Prophylactic use of antiviral agents is an option for preventing influenza among such persons. Information about vaccine components is located in package inserts from each manufacturer. Persons with moderate to severe acute febrile illness usually should not be vaccinated until their symptoms have abated. However, minor illnesses with or without fever do not contraindicate use of influenza vaccine. GBS within 6 weeks following a previous dose of TIV is considered to be a precaution for use of TIV.
Considerations When Using LAIV
LAIV is an option for vaccination of healthy, nonpregnant persons aged 2—49 years, including HCP and other close contacts of high-risk persons (excepting severely immunocompromised persons who require care in a protected environment). No preference is indicated for LAIV or TIV when considering vaccination of healthy, nonpregnant persons aged 2—49 years. Use of the term “healthy” in this recommendation refers to persons who do not have any of the underlying medical conditions that confer high risk for severe complications (see Persons Who Should Not Be Vaccinated with LAIV). However, during periods when inactivated vaccine is in short supply, use of LAIV is encouraged when feasible for eligible persons (including HCP) because use of LAIV by these persons might increase availability of TIV for persons in groups targeted for vaccination, but who cannot receive LAIV. Possible advantages of LAIV include its potential to induce a broad mucosal and systemic immune response in children, its ease of administration, and the possibly increased acceptability of an intranasal rather than intramuscular route of administration.
If the vaccine recipient sneezes after administration, the dose should not be repeated. However, if 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, or TIV should be administered instead. No data exist about concomitant use of nasal corticosteroids or other intranasal medications (252).
Although FDA licensure of LAIV excludes children aged 2—4 years with a history of asthma or recurrent wheezing, the precise risk, if any, of wheezing caused by LAIV among these children is unknown because experience with LAIV among these young children is limited. Young children might not have a history of recurrent wheezing if their exposure to respiratory viruses has been limited because of their age. Certain children might have a history of wheezing with respiratory illnesses but have not had asthma diagnosed. The following screening recommendations should be used to assist persons who administer influenza vaccines in providing the appropriate vaccine for children aged 2—4 years.
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 LAIV. TIV is available for use in children with asthma or possible reactive airways diseases (363).
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 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.
Persons Who Should Not Be Vaccinated with LAIV
The effectiveness or safety of LAIV is not known for the following groups, and these persons should not be vaccinated with LAIV:
- persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs.
- persons aged <2 years or those aged >50 years;
- persons with any of the underlying medical conditions that serve as an indication for routine influenza vaccination, including asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems; other underlying medical conditions, including such metabolic diseases as diabetes, renal dysfunction, and hemoglobinopathies; or known or suspected immunodeficiency diseases or immunosuppressed states;
- children aged 2—4 years whose parents or caregivers report that a health-care provider has told them during the preceding 12 months that their child had wheezing or asthma, or whose medical record indicates a wheezing episode has occurred during the preceding 12 months;
- children or adolescents receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection);
- persons with a history of GBS after influenza vaccination; or
- pregnant women.
Personnel Who Can Administer LAIV
Low-level introduction of vaccine viruses into the environment probably is unavoidable when administering LAIV. The risk for acquiring vaccine viruses from the environment is unknown but is probably low. Severely immunosuppressed persons should not administer LAIV. However, other persons at higher risk for influenza complications can administer LAIV. These include persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged >50 years.
Concurrent Administration of Influenza Vaccine with Other Vaccines
Use of LAIV concurrently with measles, mumps, rubella (MMR) alone and MMR and varicella vaccine among children aged 12—15 months has been studied, and no interference with the immunogenicity to antigens in any of the vaccines was observed (252,364). Among adults aged >50 years, the safety and immunogenicity of zoster vaccine and TIV was similar whether administered simultaneously or spaced 4 weeks apart (365). In the absence of specific data indicating interference, following ACIP’s general recommendations for vaccination is prudent (197). Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. Inactivated or live vaccines can be administered simultaneously with LAIV. However, after administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered.
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