Has your child gotten a flu vaccine yet? Which one?

Let’s see which vaccine kids are getting and why.

Hi all – it’s September, which is the unofficial start of flu vaccine season!

Since this year we have flu vaccine choices again (shot or nasal spray), and different recommendations from different organizations (i.e. CDC and AAP), I wanted to survey people to see what their docs recommend and what their child(ren) receive.  With FluMist (nasal spray influenza vaccine) back on the scene but no data on its effectiveness until December 2018 at the earliest, this will be an interesting flu season.

Please use the comments box below to let us know.  I will tally results every week or so and post here, so check back for updates.

Remember, it is very important to have your child vaccinated, whichever method you choose.  Earlier is better, so just do it!

Also, if you are pregnant, please get a flu vaccine ASAP (although I’m sure your obstetrician or nurse midwife is already on top of this).  Also any partners or others who will be spending significant time with your baby (i.e. grandparents) should receive one as well.

 

Breaking News: FluMist advised as a “last resort” by AAP but an “option” by the CDC for 2018-2019 season

close up injection instrument plastic
Photo by Pixabay on Pexels.com

In February 2018, the Advisory Committee on Immunization Practices (ACIP) of the CDC voted to once again recommend use of FluMist, the nasal spray flu vaccine, for the 2018-2019 influenza season.  Then, on May 21, 2018, the American Academy of Pediatrics came out with an official recommendation to use the injected form of the influenza vaccine over the newly resurrected nasal spray vaccine, and that the nasal spray should only be considered as a “last resort”.  This recommendation is due to a 3-year history of the nasal spray being of little value against influenza “A” strains in the last 3 seasons that it was used.  But really, “last resort”?  Given that this is going to be an approved vaccine, it’s hard to imagine a more negative ruling.  But the story gets better – read on…

This year, the maker of FluMist (MedImmune, a division of AstraZeneca) has changed the influenza A component to hopefully boost the response rate, but we will not know about the new vaccine’s effectiveness until several months after use begins in August.

Most people are thrilled to once again have the option of a nasal spray.  In general, children overwhelmingly prefer the nasal spray form as it does not cause pain nor does it involve using a needle.  Unfortunately, the AAP’s recommendation to use it only as a “last resort” puts many doctor’s offices in a bind, because decisions about which vaccine to order has to be made by May or June.  This is to ensure adequate supply and delivery in time to begin vaccination in late summer to early fall.  Ordering little or no nasal flu vaccine may backfire if patients are aware there is a choice and decide to wait until a nasal spray is available.  Alternatively, more patients may opt to receive the nasal spray vaccine at a Q-SHIP (quick-serve healthcare and immunization provider – my abbreviation!), such as CVS Minute Clinic.  This becomes a problem if such retail clinics also decide to under-order the spray, or if patients neglect to get this done once they have left the doctor’s office.  Historically, more children are vaccinated than adults, so the impact is greater on a pediatric office.  The disagreement between the CDC and the AAP is unusual, and this year will be interesting (to me) to see how the dissent pans out.

The nasal spray vaccine is approved for use in children 2 years and older, and for adults up to age 49.

Which would you choose????

Read the press release from the AAP here.

See a video by one of my vaccination heroes, Paul A. Offit, MD, from the Children’s Hospital of Philadelphia, here.

 

June 11, 2018: The Saga Continues…

Today the AAP released some amended recommendations on use of FluMist.  It acknowledged the differences in the recommendations between it and the CDC, and took a more moderate stance, stating that (italics added by me):

  • Annual influenza vaccination is recommended for everyone 6 months and older.
  • For the 2018-’19 season, the AAP recommends inactivated influenza vaccine (IIV3/4) as the primary choice for all children because the effectiveness of LAIV4:
  1. was inferior against A/H1N1 during past seasons; and
  2. is unknown against A/H1N1 for this upcoming season
  • LAIV4 may be offered for children who would not otherwise receive an influenza vaccine (and for whom it is appropriate by age and health status).
  • As always, families should receive counseling on these revised recommendations for the 2018-’19 season.

See the full press release here:

Note the “last resort” wording is conspicuously absent in this commentary.  This is what passes for intrigue in pediatrics!  Will be very interesting to see the effectiveness data when it starts to come out in the winter!!!!

But Wait, there’s more…

The CDC’s ACIP is also weighing in (again), with more detailed info on the new vaccine recommendations:

Recommendation of the ACIP:  For the 2018–19 U.S. influenza season, providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, recombinant influenza vaccine [RIV], or LAIV4). LAIV4 is an option for those for whom it is otherwise appropriate. No preference is expressed for any influenza vaccine product. ACIP will continue to review data concerning the effectiveness of LAIV4 as they become available. Providers should be aware that the effectiveness of the updated LAIV4 containing A/Slovenia/2903/2015 against currently circulating influenza A(H1N1)pdm09-like viruses is not yet known.

So now the CDC’s official position is that any of the age-appropriate flu vaccines are acceptable options, including FluMist (see here).  (Hooray from me!)  This difference of opinion between the AAP and the CDC is unusual (they almost always are in complete agreement) but both sides have valid points of view.   (For those who want the entire document, it’s posted here:)

July 2018: Now, even Canada is weighing in!  See the article from JAMA-Pediatrics here:

 

So I got my wish – everything is approved and everyone can have what they want.  Happy vaxxing!!


Usual Pediatric Schedule for influenza vaccine:

  • Every year for babies, children and adults 6 months and older; given from August to May; earlier is better
  • Children under age 9 years old receiving flu vaccine for the FIRST TIME get 2 doses, at least 1 month apart

Nasal spray flu vaccine (aka LAIV, or FluMist)

FluMist 5-pack     FluMist

Influenza prevention is getting more complicated, sort of. Until 15 years ago, the only way to prevent influenza was to get a flu shot in the fall and hope it would protect you from getting the flu.  The flu vaccine was grown in eggs and given annually.  Since then the options have expanded to include egg-free formulations, high-dose versions for older individuals, and a needle-free nasal spray.

In 2003 FluMist was approved for use  – a live attenuated influenza vaccine (LAIV) delivered as a spray into each nostril.  Intranasal administration made a lot of sense – this is the way that influenza virus enters the body and if we could create a barrier to entry, it would theoretically work better than waiting for the virus to enter the body before starting to fight it.  The big plus, of course, was that  it was not a shot.  This made it an immediate win with patients, especially kids.  For docs, it was faster to administer and easier to use – no needles, blood, bandages or sharps boxes.  Also, the back room management was easier, without need to draw fluid into a separate syringe.

However, although in some years the nasal spray vaccine worked well, there was a 2-year span when it seemed to work no better than a placebo.  Although there are differences of opinion as to why, with no evidence of protection, in 2016 the CDC had to pull its recommendation for use of this vaccine.  As a result, for the past 2 years, the only way to get vaccinated against influenza has been to get a shot.

For the influenza season starting in the fall (called the 2018-2019 flu season), FluMist is again on the list of possible vaccines for approval.  It will need to be approved based on data collected over the past 2 years, and although it’s not a sure thing, the CDC would certainly love to have a faster, painless product back in the office, and so would many patients.

Some basics about the nasal spray flu vaccine:

1. It is called FluMist (only 1 brand exists)

2. It is given as a tiny spray into each nostril

3. It is given in the same season that you would get any flu vaccine, August through May

4. It is approved for ages 2 years to 49 years (I’m too old for it now)

5. Many doctors are reluctant to use it in patients with asthma, as it makes an asthma exacerbation a little more likely in the few weeks after receiving it

6. It costs more than the cheapest injected flu vaccine but should be covered by insurance, including Medicaid, private insurance and government-provided insurance.


Usual Pediatric Schedule:

  • Can only be used in ages 2 years and older
  • Yearly dosing between August and May; earlier is better
  • Children receiving flu vaccine for first year ever get 2 doses, 1-2 months apart

Influenza – almost gone but back again soon

Flu shot poster

This is a piece on obtaining flu vaccines in pharmacies and other non-physician’s office locations.  As you can see, I’m in favor…

This year’s influenza season was a long and hard one. We had a longer season with more complications and more hospitalizations than usual. As we are just about finished with flu this time around, one looks back and wonders why. Doctors always complain that too few people get vaccinated and that too many patients call for antivirals (like Tamiflu) at the first sign of a respiratory infection. Patients are unhappy that it’s so hard to get to see their doctor on short notice, whether they are sick or trying to prevent an illness.
Some numbers: each year about 30,000 people in the U.S. die from influenza or its complications. These are usually the very old or the very young, and often those with heart, lung, or immune system conditions. Many more get sick and miss work or school. By early November 2017, less than 40% of U.S. infants, children and adults had received a flu vaccine, which was in line with recent years. Finally, in the past 10 years, the effectiveness of the influenza vaccine has ranged from 37 to 60% according to the CDC. As it is always hard to estimate this until a season is over or close to over, let’s agree on an average 50% vaccine effectiveness against “real” influenza (not against colds and stomach viruses). This means that for every 2 people who get the vaccine, one will not get the flu (and the other person will) if they are exposed. To get this 50% benefit, you have to: make an appointment with your doctor, likely miss some work, show up (although you may have to wait anyway), and get a shot, unless you qualify for a nasal spray. Or you could go to CVS, Walgreen or one of the many other places that offer flu vaccines. These are called retail clinics, or what I like to call quick-serve healthcare and immunization providers, or Q-SHIPs. Here, you still get your shot or spray, but it’s on your own time, and likely will still be covered by your health insurance. Some lucky employees may even have flu vaccine provided by their workplace.

Docs much prefer that patients get vaccinated. Why? First, it works on our schedules and we get paid (a little) to provide the service. Second, given the duration of illness of about a week, there is no question that preventing flu with a vaccine costs much less that treating it with medication or missing work, or both. Also, the flu vaccine is very good at preventing severe illness, and vaccinating people helps to prevent epidemic outbreaks in places where people congregate, such as at school, work, daycare, nursing homes, hospitals, etc.

On the other hand, patients often prefer the “I’ll take the risk” approach. Why? First, the patient decision-makers are usually adults, and they are often employed. This means that scheduling a visit to a doctor’s office usually involves missing work. So even if the vaccination is free, there is an opportunity cost associated with lost work or vacation time. Second, the effectiveness of about 50% leaves a lot of people underwhelmed. Also, many people who get vaccinated may later get a seasonal cold virus, which flu vaccine does NOT prevent. This may lead one to presume that the vaccine didn’t work for them. Also, many otherwise healthy adults feel that medication can be used instead, IF they get sick, and this can often be gotten over the phone, without the pain, time or expense of vaccination. Although the cost of a course of an antiviral for influenza may be hundreds of dollars, an insured patient’s much lower copay insulates them from this cost, so that medication costs are a tiny consideration for many. Of course, all those who got vaccinated and don’t get sick don’t really know if this was due to vaccination or just luck. Due to these issues, overall many patients feel that the value they get from a flu vaccine is low. When a busy doctor looks at it from the busy patient point of view, it makes sense.

So how to meet in the middle? A few simple suggestions to reduce the pain for everyone, both literally and figuratively:
1. Many pediatric offices offer flu vaccines on weekends. Offices serving adults should consider doing the same.
2. Medical offices should offer flu vaccines at ALL appointments to ALL patients during flu vaccination season (August through May). Vaccinating today means that your patient need not come through the office again for a vaccination visit this season.
3. Patients should accept this offer of vaccination if possible (and no, August is not too early).
4. Medical offices should use the nasal spray influenza vaccine when possible. This was not used for the past 2 years due to effectiveness issues, but it has been placed on the list of likely vaccines for the upcoming 2018-2019 season. It is approved for use in people from 2 to 49 years old.
5. Doctors should encourage patients to use Q-SHIPS, and should work to get documentation of their vaccination. Rather than worry about lost business, we should be HAPPY when a patient receives a vaccine at CVS or another pharmacy – it preserves office supply for others who will need it. Instead of worrying that business is going elsewhere, seek more of these partnerships and make sure that you have a system in place to document the vaccination. Remember, in the end the goal is more vaccinated patients and less influenza along with its complications.