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.
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.
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:
was inferior against A/H1N1 during past seasons; and
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.
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.
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