Practice Guidelines

CDC Releases Guidelines on H1N1 Vaccination and Prevention of Seasonal Influenza



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2009 Oct 1;80(7):744-748.

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, July 31 and August 28, 2009 (published correction in Morbidity and Mortality Weekly Report, August 21, 2009)

Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5808a1.htm and http://cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm

Worldwide transmission of the novel influenza A (H1N1) virus has continued since June 2009, when the World Health Organization declared a global pandemic. Transmission is likely to persist and may increase in the Northern Hemisphere during the fall and winter of 2009–2010.

Influenza vaccination is the most effective method for preventing influenza and its complications. However, current seasonal influenza vaccines are not likely to provide protection against the H1N1 virus. For this reason, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) has published specific recommendations for vaccination against H1N1, in addition to its recommendations for seasonal influenza vaccination.

H1N1 Vaccination

Limited data indicate that seasonal influenza vaccines will not provide protection against the H1N1 virus. Vaccines specific for the H1N1 virus are being produced and are expected to be available in mid-October. Live, attenuated and monovalent inactivated H1N1 vaccine formulations will be available initially. Inactivated vaccines against seasonal and H1N1 viruses can be given simultaneously if different anatomic sites are used. However, simultaneous administration of live, attenuated vaccines is not recommended.

H1N1 vaccination efforts should focus on five target groups:

  • Pregnant women

  • Household contacts and child care providers for infants younger than six months

  • Emergency medical services personnel and other health care workers

  • Persons six months to 24 years of age

  • Persons 25 to 64 years of age with medical conditions that put them at higher risk of influenza-related complications.

Vaccination of persons in these groups should begin as soon as vaccine is available. If vaccine availability is insufficient to meet demands, the following subset of these groups should be prioritized:

  • Pregnant women

  • Household contacts and child care providers for infants younger than six months

  • Emergency medical services personnel and other health care workers who have direct contact with patients or infectious material

  • Children between six months and four years of age

  • Children and adolescents between five and 18 years of age with medical conditions that put them at higher risk of influenza-related complications.

Once vaccine demand has been met among persons in the target groups, vaccination should be offered to all persons 25 to 64 years of age. The risk of infection in persons 65 years and older is less than that in younger persons; therefore, vaccination of older adults is not recommended until vaccine demand among younger age groups is met.

Seasonal Influenza Vaccination

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

  • Vaccination of children six months to 18 years of age should begin as soon as vaccine is available. Vaccination efforts should focus on children six months to four years of age, and on older children with medical conditions that put them at risk of influenza-related complications.

  • Vaccines containing the trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens should be used during the 2009–2010 influenza season (Table 1).

Table 1

Approved Seasonal Influenza Vaccines for 2009–2010

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

0.5-mL prefilled syringe

< 1.0

≥ 4 years

1 or 2†

IM‡

5.0-mL multidose vial

25

≥ 4 years

1 or 2†

IM‡

TIV*

Fluarix

GlaxoSmithKline

0.5-mL prefilled syringe

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/Brisbane/60/2008-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 2009–2010 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Brisbane/60/2008.

‖— 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 seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 [published correction appears in Morb Mortal Wkly Rep. 2009;58(32):896–897]. MMWR Recomm Rep. 2009;58(RR-8):13.

Table 1   Approved Seasonal Influenza Vaccines for 2009–2010

View Table

Table 1

Approved Seasonal Influenza Vaccines for 2009–2010

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

0.5-mL prefilled syringe

< 1.0

≥ 4 years

1 or 2†

IM‡

5.0-mL multidose vial

25

≥ 4 years

1 or 2†

IM‡

TIV*

Fluarix

GlaxoSmithKline

0.5-mL prefilled syringe

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/Brisbane/60/2008-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 2009–2010 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Brisbane/60/2008.

‖— 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 seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 [published correction appears in Morb Mortal Wkly Rep. 2009;58(32):896–897]. MMWR Recomm Rep. 2009;58(RR-8):13.

Healthy, nonpregnant persons two to 49 years of age can choose to receive trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV; Table 2). 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 childrensix 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. Persons who live with or care for persons at high risk of influenza-related complications, including caregivers for children younger than six months, should receive influenza vaccine annually.

Table 2

Comparison of LAIV and TIV

Factor LAIV TIV

Route of administration

Intranasal spray

Intramuscular injection

Number of included virus strains

3

3

(2 influenza A, 1 influenza B)

(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.

‡— 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 seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 [published correction appears in Morb Mortal Wkly Rep. 2009;58(32):896–897]. MMWR Recomm Rep. 2009;58(RR-8):9.

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

3

(2 influenza A, 1 influenza B)

(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.

‡— 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 seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 [published correction appears in Morb Mortal Wkly Rep. 2009;58(32):896–897]. MMWR Recomm Rep. 2009;58(RR-8):9.

Antiviral Agents

Four influenza antiviral agents are licensed in the United States: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu). The CDC has published interim recommendations for antiviral treatment and chemoprophylaxis of influenza (http://www.cdc.gov/H1N1flu/recommendations.htm). Updates will likely be published as the influenza season progresses. The interim guidelines call for oseltamivir and zanamivir to be used as treatment for all persons with suspected or confirmed influenza who are likely to require hospitalization or are at higher risk for complications, or who present with warning signs of lower respiratory tract illness. All other patients with influenza generally do not require antiviral treatment.

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


Copyright © 2009 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

Navigate this Article