Practice Guidelines

CDC Updates Recommendations on Influenza Immunization for 2008–09 Season



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Am Fam Physician. 2008 Oct 15;78(8):996-999.

  Related Editorial

Guideline source: Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices

Literature search described? No

Evidence rating system used? No

Published source: MMWR Recommendations and Reports, August 8, 2008

Available at: http://cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm

In the United States, annual epidemics of influenza occur typically during the late fall through early spring. Rates of infection are highest among children, and rates of serious illness and death are highest among persons 65 years and older, children younger than two years, and persons with medical conditions that put them at increased risk of complications from influenza. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) has released updated recommendations for influenza control for the 2008–09 season.

Recommendations

The primary updates to this year's recommendations include the following:

  • Beginning this year, all children five to 18 years of age should be vaccinated annually. Vaccination should begin as soon as vaccine is available for the 2008–09 influenza season, but no later than during the 2009–10 season.

  • Annual vaccination of all children six months to four years of age should remain a focus of vaccination efforts because this group is at higher risk of complications.

  • Either trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV) should be used when vaccinating healthy persons two to 49 years of age (the previous recommendation was to administer LAIV to persons five to 49 years of age). Tables 1 and 2 list the available vaccines for the 2008–09 season and compare LAIV and TIV.

  • Vaccines containing the trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens should be used during the 2008–09 influenza season.

Healthy, nonpregnant persons two to 49 years of age can choose to receive TIV or LAIV. Some TIV formulations are licensed for use in children as young as six months; TIV also is licensed for use in persons with high-risk conditions. LAIV is licensed for use only in persons two to 49 years of age, and the safety of LAIV has not been established in persons with certain medical conditions. All children six months to eight years of age who have not previously been vaccinated with at least one dose of LAIV or TIV should receive two doses of vaccine in the same season, with a single dose during subsequent seasons.

Influenza vaccine should be provided to all persons who want to reduce their risk of infection or of transmitting influenza to others. However, an emphasis should be placed on vaccinating patients at higher risk of influenza infection or complications, including children six months to 18 years of age, persons 50 years and older, and other adults at risk of medical complications from influenza or more likely to require medical care (Table 3). Persons who live with or care for persons at high risk of influenza-related complications, including health care professionals and caregivers for children younger than six months, should receive influenza vaccine annually.

Antiviral Agents

Four influenza antiviral agents are licensed in the United States: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu). Oseltamivir-resistant influenza A (H1N1) strains have been identified in the United States and some other countries. However, oseltamivir and zanamivir continue to be the recommended agents for treatment of influenza because other virus strains remain sensitive to zanamivir, and resistance levels to other antiviral agents remain high.

Oseltamivir is licensed for treatment and chemoprophylaxis of influenza in persons one year and older, and zanamivir is licensed for treatment of influenza in persons seven years and older and for chemoprophylaxis in persons five years and older (for complete dosing information, see the CDC recommendations at http://cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm). Antiviral treatment should be initiated within two days of illness onset; benefits are greater if treatment is started earlier. Although chemoprophylaxis is not a substitute for vaccination, it is a critical adjunct in preventing and controlling influenza. To be maximally effective as chemoprophylaxis, the drug must be taken each day for the duration of influenza activity in the community.

Table 1

Approved Influenza Vaccines for 2008–09

Vaccine Brand name Manufacturer Presentation Mercury content (mcg Hg per 0.5-mL dose) Approved ages Number of doses required Route of administration

TIV*

Fluzone

Sanofi Pasteur

0.25-mL prefilled syringe

0

6 to 35 months

1 or 2†

IM‡

0.5-mL prefilled syringe

0

≥ 36 months

1 or 2†

IM‡

0.5-mL vial

0

≥ 36 months

1 or 2†

IM‡

5.0-mL multidose vial

25

≥ 6 months

1 or 2†

IM‡

TIV*

Fluvirin

Novartis Vaccines

5.0-mL multidose vial

24.5

≥ 4 years

1 or 2†

IM‡

0.5-mL prefilled syringe

< 1.0

≥ 4 years

1 or 2†

IM‡

TIV*

Fluarix

GlaxoSmithKline

0.5-mL prefilled syringe

< 1.0

≥ 18 years

1

IM‡

TIV*

Flulaval

GlaxoSmithKline

5.0-mL multidose vial

25

≥ 18 years

1

IM‡

TIV*

Afluria

CSL Biotherapies

0.5-mL prefilled syringe

0

≥ 18 years

1

IM‡

5.0-mL multidose vial

25

≥ 18 years

1

IM‡

LAIV§

Flumist‖

Medimmune

0.2-mL sprayer

0

2 to 49 years

1 or 2¶

Intranasal


IM = intramuscular; LAIV = live, attenuated influenza vaccine; TIV = trivalent inactivated influenza vaccine.

*— A 0.5-mL dose of TIV contains 15 mcg each of A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens.

†— Two doses administered at least one month apart are recommended for children six months to eight years of age who are receiving TIV for the first time. Those who received only one dose in their first year of vaccination should receive two doses the following year.

‡— For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh.

§— A 0.2-mL dose of LAIV contains 106.5 to 107.5 fluorescent focal units of live, attenuated influenza virus reassortants of each of the three strains for the 2008–09 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Florida/4/2006.

‖— Flumist is shipped and stored refrigerated. The dose is 0.2 mL divided equally between each nostril. Health care professionals should consult the medical record, when available, to identify children two to four years of age with asthma or recurrent wheezing that might indicate asthma. To identify children who might be at greater risk of asthma and at increased risk of wheezing after receiving LAIV, parents should be asked: “In the past 12 months, has a health care professional ever told you that your child had wheezing or asthma?” Children whose parents 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.

¶— Two doses administered at least four weeks apart are recommended for children two to eight years of age who are receiving LAIV for the first time. Those who received only one dose in their first year of vaccination should receive two doses the following year.

Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):13.

Table 1   Approved Influenza Vaccines for 2008–09

View Table

Table 1

Approved Influenza Vaccines for 2008–09

Vaccine Brand name Manufacturer Presentation Mercury content (mcg Hg per 0.5-mL dose) Approved ages Number of doses required Route of administration

TIV*

Fluzone

Sanofi Pasteur

0.25-mL prefilled syringe

0

6 to 35 months

1 or 2†

IM‡

0.5-mL prefilled syringe

0

≥ 36 months

1 or 2†

IM‡

0.5-mL vial

0

≥ 36 months

1 or 2†

IM‡

5.0-mL multidose vial

25

≥ 6 months

1 or 2†

IM‡

TIV*

Fluvirin

Novartis Vaccines

5.0-mL multidose vial

24.5

≥ 4 years

1 or 2†

IM‡

0.5-mL prefilled syringe

< 1.0

≥ 4 years

1 or 2†

IM‡

TIV*

Fluarix

GlaxoSmithKline

0.5-mL prefilled syringe

< 1.0

≥ 18 years

1

IM‡

TIV*

Flulaval

GlaxoSmithKline

5.0-mL multidose vial

25

≥ 18 years

1

IM‡

TIV*

Afluria

CSL Biotherapies

0.5-mL prefilled syringe

0

≥ 18 years

1

IM‡

5.0-mL multidose vial

25

≥ 18 years

1

IM‡

LAIV§

Flumist‖

Medimmune

0.2-mL sprayer

0

2 to 49 years

1 or 2¶

Intranasal


IM = intramuscular; LAIV = live, attenuated influenza vaccine; TIV = trivalent inactivated influenza vaccine.

*— A 0.5-mL dose of TIV contains 15 mcg each of A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens.

†— Two doses administered at least one month apart are recommended for children six months to eight years of age who are receiving TIV for the first time. Those who received only one dose in their first year of vaccination should receive two doses the following year.

‡— For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh.

§— A 0.2-mL dose of LAIV contains 106.5 to 107.5 fluorescent focal units of live, attenuated influenza virus reassortants of each of the three strains for the 2008–09 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Florida/4/2006.

‖— Flumist is shipped and stored refrigerated. The dose is 0.2 mL divided equally between each nostril. Health care professionals should consult the medical record, when available, to identify children two to four years of age with asthma or recurrent wheezing that might indicate asthma. To identify children who might be at greater risk of asthma and at increased risk of wheezing after receiving LAIV, parents should be asked: “In the past 12 months, has a health care professional ever told you that your child had wheezing or asthma?” Children whose parents 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.

¶— Two doses administered at least four weeks apart are recommended for children two to eight years of age who are receiving LAIV for the first time. Those who received only one dose in their first year of vaccination should receive two doses the following year.

Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):13.

Table 2

Comparison of LAIV and TIV

Factor LAIV TIV

Route of administration

Intranasal spray

Intramuscular injection

Number of included virus strains

3 (2 influenza A, 1 influenza B)

3 (2 influenza A, 1 influenza B)

Frequency of updates to vaccine virus strains

Annually

Annually

Frequency of administration

Annually*

Annually*

Approved ages

2 to 49 years †

6 months and older

Interval between doses for children 6 months to 8 years of age who are receiving vaccine for the first time

4 weeks

4 weeks

Can be administered to persons at risk of influenza-related complications†

No

Yes

Can be administered to children with asthma or children 2 to 4 years of age with a history of wheezing during the preceding year‡

No

Yes

Can be administered to close contacts of immunosuppressed persons who do not require a protective environment

Yes

Yes

Can be administered to close contacts of immunosuppressed persons who require a protective environment (e.g., hematopoietic stem cell transplant recipients)

No

Yes

Can be administered to close contacts of persons at high risk, but who are 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


LAIV = live, attenuated influenza vaccine; TIV = trivalent inactivated influenza vaccine.

*— Children six months to eight years of age who have never received influenza vaccine should receive two doses. Those who receive only one dose in their first year of vaccination should receive two doses in the following year, spaced four weeks apart.

†— Persons at high risk of complications of influenza because of underlying medical conditions should not receive LAIV (see Table 3).

‡— Physicians should screen for possible reactive airway diseases when considering use of LAIV for children two to four years of age, and should avoid use of this vaccine in children with asthma or a recent wheezing episode.

§— LAIV coadministration has been evaluated systematically only in children 12 to 15 months of age who received measles, mumps, and rubella vaccine or varicella vaccine.

‖— TIV coadministration has been evaluated systematically only in adults who received pneumococcal polysaccharide or zoster vaccine.

Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):10.

Table 2   Comparison of LAIV and TIV

View Table

Table 2

Comparison of LAIV and TIV

Factor LAIV TIV

Route of administration

Intranasal spray

Intramuscular injection

Number of included virus strains

3 (2 influenza A, 1 influenza B)

3 (2 influenza A, 1 influenza B)

Frequency of updates to vaccine virus strains

Annually

Annually

Frequency of administration

Annually*

Annually*

Approved ages

2 to 49 years †

6 months and older

Interval between doses for children 6 months to 8 years of age who are receiving vaccine for the first time

4 weeks

4 weeks

Can be administered to persons at risk of influenza-related complications†

No

Yes

Can be administered to children with asthma or children 2 to 4 years of age with a history of wheezing during the preceding year‡

No

Yes

Can be administered to close contacts of immunosuppressed persons who do not require a protective environment

Yes

Yes

Can be administered to close contacts of immunosuppressed persons who require a protective environment (e.g., hematopoietic stem cell transplant recipients)

No

Yes

Can be administered to close contacts of persons at high risk, but who are 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


LAIV = live, attenuated influenza vaccine; TIV = trivalent inactivated influenza vaccine.

*— Children six months to eight years of age who have never received influenza vaccine should receive two doses. Those who receive only one dose in their first year of vaccination should receive two doses in the following year, spaced four weeks apart.

†— Persons at high risk of complications of influenza because of underlying medical conditions should not receive LAIV (see Table 3).

‡— Physicians should screen for possible reactive airway diseases when considering use of LAIV for children two to four years of age, and should avoid use of this vaccine in children with asthma or a recent wheezing episode.

§— LAIV coadministration has been evaluated systematically only in children 12 to 15 months of age who received measles, mumps, and rubella vaccine or varicella vaccine.

‖— TIV coadministration has been evaluated systematically only in adults who received pneumococcal polysaccharide or zoster vaccine.

Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):10.

Data are limited about the effectiveness of zanamivir and oseltamivir in preventing serious influenza-related complications (e.g., bacterial or viral pneumonia, exacerbation of chronic disease), or for preventing influenza in persons at high risk of serious complications from the disease.

Table 3

High-Priority Groups for Influenza Vaccination, 2008–09

Children and adolescents

Children six months to four years of age

Children who are receiving long-term aspirin therapy (increases the risk of Reye syndrome after influenza infection)

Adults

Adults 50 years and older

Health care professionals

Any age

Household contacts and caregivers for persons with medical conditions that put them at higher risk of complications from influenza

Household contacts and caregivers for children younger than five years (especially for those younger than six months), and for adults 50 years and older

Persons with any condition that may compromise respiratory function or increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders)

Persons with chronic pulmonary disorders (including asthma), or renal, hepatic, hematologic, or metabolic disorders (including diabetes mellitus)

Persons with immunosuppression (including immunosuppression caused by medications or human immunodeficiency virus)

Residents of nursing homes or chronic-care Facilities

Persons who are pregnant during influenza season


Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008; 57(RR-7):2.

Table 3   High-Priority Groups for Influenza Vaccination, 2008–09

View Table

Table 3

High-Priority Groups for Influenza Vaccination, 2008–09

Children and adolescents

Children six months to four years of age

Children who are receiving long-term aspirin therapy (increases the risk of Reye syndrome after influenza infection)

Adults

Adults 50 years and older

Health care professionals

Any age

Household contacts and caregivers for persons with medical conditions that put them at higher risk of complications from influenza

Household contacts and caregivers for children younger than five years (especially for those younger than six months), and for adults 50 years and older

Persons with any condition that may compromise respiratory function or increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders)

Persons with chronic pulmonary disorders (including asthma), or renal, hepatic, hematologic, or metabolic disorders (including diabetes mellitus)

Persons with immunosuppression (including immunosuppression caused by medications or human immunodeficiency virus)

Residents of nursing homes or chronic-care Facilities

Persons who are pregnant during influenza season


Adapted from Fiore AE, Shay DK, Broder K, et al., for the Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008; 57(RR-7):2.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.



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