Flu Shot Recommendations

[Guest guest]

As a reminder about the flu shot indications....

I hadn't remembered the new recommendation is to vaccinate all kids -- 6 months to 18 years.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm

Primary Changes and Updates in the Recommendations

The 2008 recommendations include five principal changes or updates:

Beginning with the 2008--09 influenza season, annual vaccination of all children aged 5--18 years is recommended. Annual vaccination of all children aged 5--18 years should begin in September or as soon as vaccine is available for the 2008--09 influenza season, if feasible, but annual vaccination of all children aged 5--18 years should begin no later than during the 2009--10 influenza season.

Annual vaccination of all children aged 6 months--4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children.

Either TIV or LAIV can be used when vaccinating healthy persons aged 2--49 years. Children aged 6 months--8 years should receive 2 doses of vaccine if they have not been vaccinated previously at any time with either LAIV or TIV (doses separated by >4 weeks); 2 doses are required for protection in these children. Children aged 6 months--8 years who received only 1 dose in their first year of vaccination should receive 2 doses the following year. LAIV should not be administered to children aged <5 years with possible reactive airways disease, such as those who have had recurrent wheezing or a recent wheezing episode. Children with possible reactive airways disease, persons at higher risk for influenza complications because of underlying medical conditions, children aged 6--23 months, and persons aged >49 years should receive TIV.

The 2008--09 trivalent vaccine virus strains are A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens.

Oseltamivir-resistant influenza A (H1N1) strains have been identified in the United States and some other countries. However, oseltamivir or zanamivir continue to be the recommended antivirals for treatment of influenza because other influenza virus strains remain sensitive to oseltamivir, and resistance levels to other antiviral medications remain high.

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Recommendations for Using TIV and LAIV During the 2008--09 Influenza Season

Target Groups for Vaccination

Influenza vaccine should be provided to all persons who want to reduce the risk of becoming ill with influenza or of transmitting it to others. However, emphasis on providing routine vaccination annually to certain groups at higher risk for influenza infection or complications is advised, including all children aged 6 months--18 years, all persons aged >50 years, and other adults at risk for medical complications from influenza or more likely to require medical care should receive influenza vaccine annually. In addition, all persons who live with or care for persons at high risk for influenza-related complications, including contacts of children aged <6 months, should receive influenza vaccine annually (Boxes 1 and 2). Approximately 83% of the United States population is included in one or more of these target groups; however, <40% of the U.S. population received an influenza vaccination during 2007--2008.

Children Aged 6 Months--18 Years

Beginning with the 2008--09 influenza season, annual vaccination for all children aged 6 months--18 years is recommended. Annual vaccination of all children aged 6 months--4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children. Annual vaccination of all children aged 5--18 years should begin in September 2008 or as soon as vaccine is available for the 2008--09 influenza season, if feasible. Annual vaccination of all children aged 5--18 years should begin no later than during the 2009--10 influenza season.

Healthy children aged 2--18 years can receive either LAIV or TIV. Children aged 6--23 months, those aged 2--4 years who have evidence of possible reactive airways disease (see Considerations When Using LAIV) or who have medical conditions that put them at higher risk for influenza complications should receive TIV. All children aged 6 months--8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first year they are vaccinated.

Persons at Risk for Medical Complications

Vaccination to prevent influenza is particularly important for the following persons who are at increased risk for severe complications from influenza, or at higher risk for influenza-associated clinic, emergency department, or hospital visits. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to these persons:

all children aged 6 months--4 years (59 months); all persons aged >50 years; children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection; women who will be pregnant during the influenza season; adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus); adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV); adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration; and residents of nursing homes and other chronic-care facilities.

Persons Who Live With or Care for Persons at High Risk for Influenza-Related Complications

To prevent transmission to persons identified above, vaccination with TIV or LAIV (unless contraindicated) also is recommended for the following persons. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to these persons:

HCP; healthy household contacts (including children) and caregivers of children aged <59 months (i.e., aged <5 years) and adults aged >50 years; and healthy household contacts (including children) and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza.

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Timing of Vaccination

Vaccination efforts should be structured to ensure the vaccination of as many persons as possible over the course of several months, with emphasis on vaccinating before influenza activity in the community begins. Even if vaccine distribution begins before October, distribution probably will not be completed until December or January. The following recommendations reflect this phased distribution of vaccine.

In any given year, the optimal time to vaccinate patients cannot be precisely determined because influenza seasons vary in their timing and duration, and more than one outbreak might occur in a single community in a single year. In the United States, localized outbreaks that indicate the start of seasonal influenza activity can occur as early as October. However, in >80% of influenza seasons since 1976, peak influenza activity (which is often close to the midpoint of influenza activity for the season) has not occurred until January or later, and in >60% of seasons, the peak was in February or later (Figure 1). In general, health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health-care visits or during hospitalizations whenever vaccine is available.

Vaccination efforts should continue throughout the season, because the duration of the influenza season varies, and influenza might not appear in certain communities until February or March. Providers should offer influenza vaccine routinely, and organized vaccination campaigns should continue throughout the influenza season, including after influenza activity has begun in the community. Vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons. The majority of adults have antibody protection against influenza virus infection within 2 weeks after vaccination (368,369).

All children aged 6 months--8 years who have not received vaccination against influenza previously should receive their first dose as soon after vaccine becomes available as is feasible. This practice increases the opportunity for both doses to be administered before or shortly after the onset of influenza activity.

Persons and institutions planning substantial organized vaccination campaigns (e.g., health departments, occupational health clinics, and community vaccinators) should consider scheduling these events after at least mid-October because the availability of vaccine in any location cannot be ensured consistently in early fall. Scheduling campaigns after mid-October will minimize the need for cancellations because vaccine is unavailable. These vaccination clinics should be scheduled through December, and later if feasible, with attention to settings that serve children aged 6--59 months, pregnant women, other persons aged <50 years at increased risk for influenza-related complications, persons aged >50 years, HCP, and persons who are household contacts of children aged <59 months or other persons at high risk. Planners are encouraged to develop the capacity and flexibility to schedule at least one vaccination clinic in December. Guidelines for planning large-scale vaccination clinics are available at http://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm.

During a vaccine shortage or delay, substantial proportions of TIV doses may not be released and distributed until November and December or later. When the vaccine is substantially delayed or disease activity has not subsided, providers should consider offering vaccination clinics into January and beyond as long as vaccine supplies are available. Campaigns using LAIV also can extend into January and beyond.

Locke, MD