By Dr. Geoffrey Modest
MMWR just published the influenza vaccine recommendations for 2015-16 (See http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm ). In brief:
- As per usual, vaccine is recommended for all >6 months old who do not have contraindications, and should be offered starting in October, before flu cases start. They also recommend vaccinating early even if the ideal vaccine preparation is not available, in order to avoid missed opportunities [eg, for the elderly, I would wait for the high-dose vaccine only if it will be available prior to the onset of flu season and it is clear that the patient will get the vaccine].
- Children 6 months til 8 years still need 2 doses (second dose >4 weeks later) if they have not had prior flu vaccines (at least 2 doses before 7/1/15). Unlike last year, there is no special consideration of influenza A (H1N1).
- The vaccine this year will contain A/California/7/2009 (H1N1), A/Switzerland/9715293/2013 (H3N2), and B/Phuket/3073/2013 (Yamagata lineage). The influenza A H3N2 and influenza B components are new this year. There will also be a quadrivalent vaccine, which includes these three plus B/Brisbane/60/2008 (Victoria lineage), as was included in the quadrivalent vaccine the last 2 years [CDC does not prefer either the trivalent or quadrivalent vaccine at this time, though this could change after the flu season begins.]
- The live-attenuated vaccine (LAIV), previously recommended as the preferred vaccine in kids aged 2-8, is no longer recommended over the inactivated vaccine injection, since there have been inconsistent findings more recently about the LAIV efficacy (in fact the LAIV4 vaccine in 2013-14 had poor efficacy against the predominant H1N1 flu virus that year). As before, LAIV can be used from age 2-49 yo unless there are contraindications, such as: children 2-4 yo who have asthma or wheezing episode in the last 12 months; LAIV is listed as a precaution in older kids and adults with asthma who “may be at increased risk for wheezing after administration of LAIV” and in those with chronic lung, heart, renal, liver, neuro, heme or metabolic disorders (ie, safety of LAIV is not clearly established in those with these underlying medical conditions) — I would add here that I do have a couple of older kids/adolescents who are quite large, very unwilling to have an injection, and pose a risk to themselves and the injectors, and I have given LAIV, with parental consent, in these cases even if there is mild asthma (ie, protection from flu, I felt, trumped the potential of some increased risk of wheezing). LAIV should still not be given to those with documented egg allergy (not enough data), those taking aspirin, or those immunocompromised or taking care of severely immunosuppressed persons (or should avoid contact with them for at least 7 days after LAIV, given the theoretical risk of transmission).
- For those with egg allergy, best to use an egg-free preparation (only indicated in those at least 18 yo), though they note that “severe allergic reactions to egg-based influenza vaccines are unlikely” based on a study of 4172 egg-allergic patients who had no episodes of anaphylaxis after the regular vaccine, though the VAERS (Vaccine Adverse Event Reporting System) does have a few reported cases. Small studies (up to 282 kids aged 2-17, of which 115 had anaphylaxis to eggs in the past) reported no cases of severe allergic reaction to LAIV. Given that these are small studies, they recommend using inactivated vaccine if the recombinant non-egg produced vaccine is not available, and that it should be given by a “physician with experience in the recognition and management of severe allergic conditions”
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