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October 2009
Vol. 19 No. 10
Patient Care and Science
EIN: H1N1 and Seasonal Influenza Vaccination Questions

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds the EIN. The reader assumes all risks in using this information.

With the influenza season picking up steam, EIN members are discussing seasonal and H1N1 flu vaccination, including the use of inactivated and live attenuated influenza vaccine (LAIV). A member from Chicago started a recent discussion by asking if the intranasal form of the H1N1 vaccine and seasonal LAIV could be given simultaneously.

A respondent from Seattle posted an excerpt from a clinician question-and-answer guide from the Centers for Disease Control and Prevention (CDC), whose existing recommendations are that two inactivated vaccines—or an inactivated and a live vaccine—can be given any time before, after, or at the same visit as each other. CDC advises, “Live attenuated seasonal and live 2009 H1N1 vaccines should NOT be administered at the same visit until further studies are done. If a person is eligible and prefers the LAIV formulation of seasonal and 2009 H1N1 vaccine, these vaccines should be separated by a minimum of four weeks.”

A respondent from the CDC also referenced the agency’s recently posted Top 10 list of frequently asked questions—and answers—about the use of influenza vaccine, covering practical considerations for immunization programs and providers, including the use of both live and inactivated forms of seasonal and H1N1 vaccine.

Several EIN members also replied to a member in Arizona who asked about the vaccination of health care workers (HCWs) with the live form of the H1N1 vaccine at institutions with bone marrow transplant (BMT) units:

“We will not give LAIV to the nursing staff and other ‘regular’ BMT HCWs, but our BMT docs are concerned about other HCWs getting LAIV,” the member wrote. “Are you giving LAIV to other staff (e.g., EKG/X-ray/CT techs, phlebotomists, etc.) who go to different areas of the hospital, including the BMT unit? If so, should they (or the patient) wear a surgical mask during the encounter for a period of time after getting LAIV? Is it safe to take care of a BMT patient beyond seven days after receiving LAIV? From my reading, it does not seem like there’s viral shedding beyond seven days in healthy adults.”

A respondent in Florida wrote, “We do not allow any HCWs or employees to get live attenuated flu [vaccine] in our cancer hospital to prevent the rare possibility of transmission.”

A Tennessee member shared this response: “I am in charge of infection control at a children’s cancer hospital. We have been administering LAIV to health care workers here for five years without adverse effects.” Per guidelines from CDC’s Advisory Committee on Immunization Practices, the member continued, “we restrict vaccine from HCWs who will be taking care of inpatient bone marrow transplant patients in the seven days following receipt of vaccine but do not have any other exclusions related to [immunocompromised hosts].”

“In addition, we have conducted two clinical trials in the last three years administering LAIV to children with cancer, including leukemia, and have not seen any adverse events or prolonged shedding in recipients,” the member added. “We believe use of LAIV in hospitals is safe and is a useful adjunct vaccine to offer in the effort to improve HCW vaccination rates.”

Another EIN discussion involved timing. “Now that H1N1 LAIV is becoming available, say you have [an] otherwise healthy child in your office, and it is not recommended to give both seasonal and H1N1 LAIV at the same visit,” a Connecticut EIN member posted. “Which do you give first, knowing that you will have to wait one month between doses of live vaccine? Would you give H1N1 LAIV and wait a month for seasonal LAIV or vice versa?” Some practices have not gotten their allotment of inactivated seasonal influenza vaccine, the member added.

“If you were going to do both vaccines as live intranasal, I’d do the H1N1 first because it's circulating now, and seasonal flu (mostly H3N2) hasn’t arrived yet,” a Minnesota member replied. “Giving nasal H1N1 and [intramuscular] seasonal vaccine simultaneously seems a desirable approach as it only requires one visit, provided you’ve gotten supplies of both vaccines.” Several other respondents also suggested giving the LAIV form of the H1N1 vaccine first, if necessary, citing the current prevalence of H1N1.

CDC’s website and IDSA’s influenza webpage offer additional information for physicians and other health providers about the H1N1 and seasonal influenza vaccines, including vaccination information statements and the latest clinical guidance.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public-health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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