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.

 

HPV Vaccine (updated 10-9-2018)

Gardasil

Today is HPV vaccine day!!  (I just decided it.)

I’m hoping to get to most of the vaccines commonly used in Pediatrics over time, but HPV vaccine is both an important and timely place to start.

Human papilloma virus is a scourge.  Previously felt to be only the cause of genital warts, it is now known to also cause the majority of cases of cervical cancer, most anal and penile cancers, and a large number of head and neck cancers.

Although treatments for HPV infection are only fairly effective, since 2006 we have had a licensed vaccine to prevent the most dangerous strains of HPV.  Initially, the vaccine covered either 2 or 4 strains of HPV.  In the past few years the vaccine has been improved and now prevents the 9 most commonly cancer-causing strains of HPV.

The basics:

-HPV vaccine, called Gardasil, which stands for “guard against squamous intraepithelial lesion”, the official designation of cervical precancer (yes, I know, terrible name – all drugmakers seem to have no talent for naming their products) is approved to use from ages 9-45 years old.

-Most doctors start giving it at age 11.

-If started at age 14 years or younger, a patient needs only 2 doses, at least 6 months apart.

-If started at age 15 or older one needs 3 doses, with at least 1 months  between the first 2 doses and with #3 given at least 6 months after #1.

-The vaccine is very safe and very effective.

-There is no link between getting HPV vaccine and initiating sexual activity, just like there is no link between getting a tetanus shot and playing with rusty nails.

Bottom line (literally): HPV vaccine is cancer prevention.

HPV vaccine has probably caused more discussion and controversy than any other vaccine after the MMR vaccine.  It seems to be inextricably tied up in an emotional battleground, with a lot of people scared both of the vaccine and of what its use means to them – the fact that their child will likely be intimate with other people in the future.  Whether parents who resist this vaccine do it on the basis of what they have read on the scaremonger websites, or whether they feel it goes against their religious beliefs to use it, or whether they just plain don’t want to think about this, our results in protecting our children from HPV are pretty dismal: only about 55% of boys and 65% of girls from 13-17 years old had received even a single dose.  This is FAR below every other routine pediatric vaccination used in the U.S.

The really painful part of this awful statistic is that HPV it not a disease of the young and  promiscuous; it takes women when they are in their 40s and 50s; when they may be wives, mothers, or grandmothers.  For those unlucky enough to develop cancers of the head and neck, many people need disfiguring surgery or worse.

Hepatitis B, which is also mainly spread by intimate contact, is also prevented by a highly effective vaccine.  This vaccine is given during infancy and has much better vaccination rates, with very little argument over its importance.  This is due in large part to the “Hep B message” being about preventing chronic liver disease and liver cancer, while the “HPV message” seems stuck on sex.


For my own patients and their parents: this is the part I told you about!!

In discussions in my office, I find that a lot of parents fall into 2 categories: those that know a lot about the HPV vaccine and want their child to get it, and those who are sure they do not want their child to get it before I even mention it.  Many of the second group are already dug in, but I’m wondering if we would have a different conversation if their child was not present, or if we had emailed about the issue prior to the appointment.  I say this because it seems that what many of these parents really don’t want is to be talking about their child and sex, especially in front of their 10- or 11-year old child.  I’m thinking that if this conversation came up in a coffee shop, not when we are all painfully pressed for time, the discussion might go a different way.   In the end, I think getting the HPV vaccine is REALLY important for your kids, of BOTH genders, and at the right age, not just “maybe next year”.  I don’t get anything out of your child’s vaccination except knowing that he or she is protected against a cancer that can be debilitating or worse.  Doctors do not get paid for giving vaccines, and we don’t collude with vaccine manufacturers to make sure they sell a lot of their products.

Now, I’m not suggesting that we all need to do a pre-physical-exam prep session at Starbucks, but in the end what a lot of people need most is information, delivered in a low-stress setting, with plenty of time for give and take.  I also happen to be a big fan of Starbucks and would love to have a session with a group of parents outside the office some time.  Any takers????


June 18, 2018: for more perspective on the marketing of vaccines, see this article from the medical/science/tech site STAT on the new, hipper approach that Gardasil’s maker (Merck) is using in its direct to consumer ads:

August 2018: a new CDC report indicates that by age 13-15 years, only half of U.S. teens have received the full series of HPV vaccines (either 2 or 3 doses, depending on age and immune system status).  Again, this is a vaccine, uniformly recommended and covered by insurance (as well as for the uninsured), without side effects on fertility, immune system function, or sexual activity/habits, that prevents multiple cancers (many of which have few or no symptoms until they spread), which are caused by a virus that most people WILL be exposed to in their lifetimes.  How does this add up???

October 9, 2018: Gardasil 9 now approved for men and women up to 45 years old!  The FDA announced on October 5 that it has approved an amendment to the labeling for Gardasil 9 to include older men and women, and now the vaccine can be given up until age 45.  This is a big deal because although we presume that most or all people are sexually active (and thus exposed to HPV) by their early 20s, this will allow uninfected people (who may be abstinent or not very sexually active) to receive protection until a much higher age.  Here’s the link:


Usual Pediatric Schedule:

  • 1st dose between 9 and 11 years old
  • 2nd dose 6-12 months later
  • If for some reason the series has not been started before age 15, a total of 3 doses are needed over a 6-12 month period)

Shingles Vaccine (This one’s for Parents and Grandparents; updated 8/2018)

Shingrix

Most of my posts will be about vaccines used in childhood, but there is an important one for many parents to be aware of that I’ve just become eligible for and many people are not yet clued into.  This is the newer version of the shingles vaccine.

What is it?

Shingles (i.e. zoster virus infection) is caused by the same virus that causes chickenpox in children, although we see a lot less of it now that there is an effective vaccine, available since the 1980s.

About varicella:

For most children, varicella is a mild but uncomfortable illness, causing fever, fatigue and blistering rash for most who still get it.  A small number of children are hospitalized for dehydration and a tiny number (about 1 in 10,000 of those infected) have a fatal complication.  Most of these fatal cases already have immune system problems before the infection develops.  Luckily, there is a very effective vaccine that almost all children get at 12-18 months old and again at 4-6 years old.  Receiving both doses of the vaccination is 88-98% effective in preventing any form of chickenpox and about 100% effective in preventing severe chickenpox.  It is routinely recommended and required for licensed daycare and school attendance, among other activities.

About shingles (hint: same virus but different symptoms in adults):

Once you get chickenpox, as most adults over 40 did as a child, the virus stays in your body but is kept dormant by your immune system.  As we age, our immune system slowly weakens and infectious conditions start to occur more easily.  Shingles is the condition that develops as the varicella-zoster (i.e. chickenpox) virus reactivates.  Initially one may have only severe pain, often in the abdominal region, chest or back.  Sometimes the pain may be so severe it is confused with appendicitis or a heart attack.  After several days, the pain improves but a rash develops in a particular pattern – it develops along the path of the sensory nerve that was harboring the virus for all those years.  The rash is most commonly red bumps and blisters, on only one side of the body, which can be painful, itchy or both.  The rash fades over time but the pain can be intense enough to need opiates.  After recovery, many people afterwards develop persistent pain, called post-herpetic neuralgia for months or years.  A family friend had this about 2 years ago and she still has fairly severe pain at times.

The older vaccine for adults (called Zostavax) was the same vaccine as we use to prevent chickenpox in children, only about 14 times stronger.  It was fairly effective and usually recommended for adults over 60.  For this reason, many people think of the shingles (or more properly the zoster) vaccine as a vaccine for the elderly.  Not true!!  The previous version was indeed generally recommended for those 60 and over but there is a newer, more effective version that is now recommended for adults age 50 and over (like my wife and me).  In fact, when given earlier, one has a more robust immune response, which means it works better when you receive it at a younger age.  The new vaccine is called “Shingrix” (ok, so no points for the name).  This is a new recommendation, so when calling your doctor’s office you may have to gently remind them that this is the new vaccine which is now given at a younger age (you can even send them the link below).  I strongly recommend this vaccine for all adults who are 50 and over.  It is safe and effective and should be covered by everyone’s medical insurance if they are over 50, even if they have already received Zostavax (the older version) in the past.

**Be aware, many doctors’ offices and retail pharmacies STILL do not have this in stock, even a year after its licensure.  I’m sure GSK (GlaxoSmithKlineBeecham) is doing everything in its power to increase their output, so hopefully it will not be long, but it would make sense to make a call to your doctor now, just to get onto a waiting list if possible.

See below for the excerpt from the CDC website at https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html

Here’s a post from the excellent blog Shotofprevention.com about needing this vaccine and how few adults are aware of it.

Summary of Recommendations

Routine Vaccination of People 50 Years Old and Older

CDC recommends Shingrix® (recombinant zoster vaccine) as preferred over Zostavax® (zoster vaccine live) for the prevention of herpes zoster (shingles) and related complications. CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older:

CDC Expert Commentary with Medscape

Medscape video; Dr. Kathleen Dooling

Everything You Need to Know About Shingrix
[3:58 mins]
Dr. Kathleen Dooling discusses storage, administration, and patient counseling for the new shingles vaccine
Released: 4/30/18

  • Whether or not they report a prior episode of herpes zoster
  • Whether or not they report a prior dose of Zostavax
  • Who have chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless a contraindication or precaution exists. Similar to Zostavax, Shingrix may be used for adults who are
    • are taking low-dose immunosuppressive therapy
    • are anticipating immunosuppression
    • have recovered from an immunocompromising illness
  • Who are getting other adult vaccines in the same doctor’s visit, including those routinely recommended for adults age 50 years and older, such as influenza and pneumococcal vaccines. The safety and efficacy of concomitant administration of two adjuvanted vaccines, such as Shingrix and Fluad, have not been evaluated.
  • It is not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection.

 

See this nice table from the CDC Website!

TABLE. Recommended storage, use, and administration of currently licensed herpes zoster (shingles) vaccines — United States, 2018Return to your place in the text
Characteristic Brand name (manufacturer)
Shingrix (GSK) Zostavax (Merck)
Vaccine type Recombinant adjuvanted (RZV, licensed 2017)* Live attenuated virus (ZVL, licensed 2006)
Packaging Supplied as 2 components: 1) single-dose vial of lyophilized varicella zoster virus glycoprotein E antigen and 2) a single-dose vial of AS01B adjuvant suspension Single-dose vial of lyophilized vaccine and a vial of sterile water diluent
Storage Antigen and adjuvant should be stored refrigerated between 2°C and 8°C (36°F and 46°F); discard antigen or adjuvant components if frozen; discard reconstituted vaccine if frozen Vaccine should be stored frozen between -50°C and -15°C (-58°F and +5°F),§ diluent should be stored separately at room temperature or refrigerated between 2° and 8°C (36°F and 46°F); do not freeze reconstituted vaccine
Reconstitution Reconstitute the lyophilized varicella zoster virus glycoprotein E antigen component with the accompanying AS01B adjuvant suspension component (single reconstituted dose is 0.5 mL) Reconstitute lyophilized vaccine with the supplied diluent (single reconstituted dose is 0.65 mL)
Use Administer immediately after reconstitution or refrigerate and use within 6 hours; discard reconstituted vaccine if not used within 6 hours Reconstitute immediately upon removal of vaccine from the freezer and administer immediately after reconstitution; discard reconstituted vaccine if not used within 30 minutes
Route Intramuscular (IM) injection Subcutaneous (SQ) injection
Dose/Schedule 2 doses; second dose 2–6 months after the first dose 1 dose
Indication Prevention of herpes zoster in adults aged ≥50 years Prevention of herpes zoster in adults aged ≥50 years
ACIP recommendation Immunocompetent adults aged ≥50 years, including those who previously received ZVL, RZV is preferred over ZVL for the prevention of herpes zoster and related complications Immunocompetent adults aged ≥60 years**

Abbreviations: ACIP = Advisory Committee on Immunization Practices, GSK = GlaxoSmithKline; RZV = recombinant zoster vaccine; ZVL = zoster vaccine live.

Ebola is back, and we should be very scared

Ebola Vaccine

Ebola has resurfaced in the Democratic Republic of Congo.  For the past month, the World Health Organization has been monitoring multiple cases of hemorrhagic fever which were suspected of being caused by Ebola or a similar virus, but Ebola has now been confirmed in multiple patients.  The first cases were in isolated regions in the country’s interior but unfortunately, several of the most recent cases have been found in Mbandaka, a port city of over 1 million people, which makes spread outside of the DRC far more likely.  The WHO has supplied the region with several thousand doses of an experimental Ebola vaccine (made by Merck) which are being administered, but the vaccine is new and not yet licensed, although it performed well in trials in Europe and Africa last year.  The mainstay right now is attempting containment and isolation of patients and their contacts.  Until more doses of the vaccine are available, the vaccine will be used for healthcare workers, contacts of known patients and contacts of those contacts, in a strategy known as “ring vaccination”.  WHO considers the risk of spread outside the DRC “very serious” at this time.

During a prior outbreak of Ebola in Africa several years ago, over 11,000 people died and there was a worldwide effort at containment which proved to be extremely expensive but effective.  Hopes are that the experimental vaccine will work well and that as Merck increases vaccine supply, extensive vaccinations can help to contain the outbreak before it spreads outside of the DRC.

Read or listen to the story on NPR here:

The world is full of life-threatening viruses; we tend to forget about most of them quickly unless they are local or unless we get reminders.  Currently there are several cases of Nipah Virus in India, which is spread to people from bats and pigs, and is even more scary than Ebola, with up to a 75% fatality rate.  Mark my words, unless it spreads outside India, you’ll probably forget about it by next week.  As Americans we are inundated with news and very little stays with us – we tend to care about a lot of things but only for a moment.

 

Update 10/9/2018: Ebola Likely to Spread From Congo to Uganda

The New York Times recently reported that the Ebola outbreak in Congo is now “very likely” to spread to Uganda.  Spread outside of Congo was predicted by many, as containment efforts are hampered by civil war, poverty and decentralized healthcare provision.  Uganda has better tools to deal with Ebola but to to the speed with which the virus can spread this is a very serious development.  Here’s the link:

Tdap vaccine for adolescents and adults (especially pregnant women)

Boostrix               Adacel

The Tdap vaccine, normally given to preteens, teens and adults, is different from the DTaP vaccine that we use in infancy and young childhood.  It protects against the same diseases (tetanus, diphtheria and pertussis), but the relative amount of each component is different.  We get asked about this a lot because it is given routinely to pregnant women during their third trimester and many times the rationale is not fully explained.

Some basics:  The vaccine protects against tetanus, diphtheria and pertussis.

-Tetanus is a bacterial infection commonly acquired through a contaminated wound. The bacteria often lives in dirt and in humans can produce a toxin that can cause severe muscle contractions.  The old term for tetanus was “lockjaw,” named for the severe clenching of the mouth that some patients developed.  Most people have never seen a person with tetanus, partially because the vaccine is so effective.  It advised to get a routine tetanus vaccine every 10 years, or after 5+ years if you get a dirty wound.

-Diphtheria is a bacterial infection that causes respiratory symptoms including cough and fever.  It can be severe, especially in the very young and old.  We see very little diphtheria in the U.S. today, but some countries that cut back on immunizing against it have seen a resurgence.

-Pertussis is also known as “whooping cough,” named after the sound that some people make when they have this infection.  Pertussis in most people causes a pronged coughing illness which can be quite contagious to their close contacts.  Some people with pertussis also develop fever, wheezing, and pneumonia.  Often it is not diagnosed because a doctor or nurse does not think of testing for it, as other causes of cough are more common.  Diagnosis requires a special test which takes a long time to get results.  It is treated with an antibiotic.  The biggest problem with pertussis is that it can be fatal for the elderly and for newborns.

 

Tdap vaccine is normally given only once to most people.  Preteens get it somewhere between 10 and 12 years old.  After that most people continue to get a “Td” vaccine, also just called a tetanus shot, every 10 years.  However, about 5 years ago, some obstetricians began giving Tdap vaccine to pregnant women.  The rationale for this was that the pertussis antibodies would pass through the placenta to the fetus and the baby would be born with some immunity (called passive immunity) from the mother’s vaccination.  Normally a baby is not given their first pertussis vaccine until 2 months old, so immunizing mothers during pregnancy gives the baby some protection until then.  This elegant strategy works very well, so now it is standard to immunize all pregnant women with Tdap with each pregnancy.  For those who never received a Tdap, having a newborn is a great excuse to push grandparents, aunts, uncles and fathers to get the shot they should have anyway, as well as anyone else who will have frequent contact with the newborn.  This would also apply to daycare workers, nannies, etc.

In the near future, we are likely to have an improved version of Tdap, and when we do it may replace Td for all adult doses. Stay tuned!!

Here’s a story from NPR regarding Tdap vaccine during pregnancy:


Usual Pediatric Schedule:

  • One dose only, at age 11-12 years
  • Pregnant women get a dose with EACH pregnancy, in 3rd trimester

Vaccine Side Effects

It has been said that pro-vaxers (i.e. docs, especially pediatricians), always talk about vaccine benefits and rarely about side effects.  I agree!  So today I want to talk about some of the side effects most commonly encountered with the routine vaccines we give to children.

Overall I think the reason that we accentuate the positive with vaccines is for 2 reasons: time and odds.  Time is the biggest reason, at least for me.  In my usual 15 minutes for a well visit, I need to take a history, discuss concerns, examine my patient, show parents growth charts, discuss any abnormal findings, AND then talk about labs and vaccines that are due.  As we already give out a Vaccine Information Statement (aka VIS) that lists individual vaccine side effects with each vaccine, most docs, me included, are a little fast and loose with discussing vaccine side effects in detail unless a parent has specific questions.

Odds are a different story.  Doctors are trained in thinking about risk:benefit ratios, making choices that serve the greatest good, and taking a global perspective of a patient’s health.  This means (I hope) that we presume that a parent will share our perspective of, say, the value of receiving a measles, mumps and rubella vaccine despite the pain of vaccination, the chance of rash and fever, and the small possibility of more severe side effects such as a febrile seizure.

Some side effects of vaccination are common to almost all vaccines given, while some are particular to a certain vaccine or when certain vaccines are given together.  Also, due to how side effects are monitored, almost any symptom might occur after a vaccine, whether it was an actual side effect or just a coincidence.  Some definite side effects are very serious but also very rare, which makes the vaccine “worth” giving to people in general although horrible for those who experience the severe side effect (see “odds” above).

So in no particular order, here is my take on some vaccine side effects.

Side effects of most most or all vaccines:

Pain: ok, I know this is obvious, but it’s also by far the biggest factor for all young children and lots of older ones as well.  Any injection is likely to cause pain although some kids seem not to care very much, even after the shot has been given.  Pain is most commonly present for up to a day or two after vaccination, at the site of the injection.  Pain meds like acetaminophen and/or ibuprofen work well.  If one is averse to medication, an ice pack can help.

Fever: also a biggie; timing varies by vaccine but commonly one should expect a fever in the 1-3 days following most vaccines.  The big exception is the measles vaccine (either MMR or MMRV), which can cause fever starting anywhere from 5-12 days after vaccination and can last several days from then.  Just like with pain, normally the best treatment for this is acetaminophen and/or ibuprofen.  Also you can consider cool cloths draped onto your child.  Do not try to put a child with a fever into a cold bath, because if he/she does have a febrile seizure (see below) that is the last place you want him or her to be, at risk for hitting the head or inhaling  bath water or both.

Fussiness: many children are more fussy in the day or two after a vaccine; often it is hard to tell if this is due to fever or pain or the vaccine itself

Rash: common after MMR and varicella (aka chickenpox) vaccines or the two combined as MMRV, rash usually happens in a similar time period as fever. There’s not much to do about it unless it itches, in which case a topical anti-itch medicine or moisturizing lotion may help.

 

 

More uncommon side effects:

Febrile seizure: this is an uncommon side effect but one that can occur after vaccination.  Febrile seizures usually occur as a child’s temperature is rising, and the is usually not any warning beforehand.  They are most common in children from 6 months to 5 or 6 years old, which is also an age range when lots of vaccines are given.  Thankfully, febrile seizures are usually very brief (under a minute) and almost always stop on their own.  If this occurs, after making sure the child is in a safe place (safe from falls, sharp objects and other dangers) you should call you child’s doctor but there is usually not much to do as the seizure is usually over before you reach anyone.  Of course, a prolonged seizure should prompt a call for an ambulance.  See below for a reference about this.  *It has been found that in 12-15 month olds, febrile seizures are more common when the MMR and varicella vaccines are given at the same time, so many doctors give them at different visits, say one at 12 months and the other at 15 months old.

 

Fainting: fainting, if it occurs, is most common in the 10-30 minutes right after a vaccination.  It seems to happen much more commonly with teens than with younger children.  The biggest worries are getting injured during a fall, especially head injuries.  Some people are prone to faint after vaccines, so with them a period of waiting while sitting down for 15 or 20 minutes after being vaccinated is advised.

 

A rare one but a big deal:

Guilian-Barre Syndrome: this is a rare but serious condition that usually occurs after infections but can also rarely occur after influenza vaccination.  It is a rapidly worsening tingling of nerves and weakness of muscles and can be life-threatening for some.  Again, rare but very serious.  People with a history of GBS are not given flu vaccine.

 

Whew!  That is a quick summary of some more common vaccine side effects.  There are many more as well, feel free to comment if you like.

 

 

This reference on measles-contains vaccines is from the CDC; it’s long but pretty comprehensive; with an excerpt below:

https://www.cdc.gov/mmwr/preview/mmwrhtml/00046738.htm

The following recommendations concerning adverse events associated with measles vaccination update those applicable sections in “Measles Prevention: Recommendations of the Immunization Practices Advisory Committee” (MMWR 1989; 38{No. S-9}), and they apply regardless of whether the vaccine is administered as a single antigen or as a component of measles-rubella (MR) or measles-mumps-rubella (MMR) vaccine. Information concerning adverse events associated with the mumps component of MMR vaccine is reviewed later in this document (see Mumps Prevention), and information concerning the rubella component is located in the previously published ACIP statement for rubella (18).

Side Effects and Adverse Reactions

More than 240 million doses of measles vaccine were distributed in the United States from 1963 through 1993. The vaccine has an excellent record of safety. From 5% to 15% of vaccinees may develop a temperature of greater than or equal to 103 F ( greater than or equal to 39.4 C) beginning 5-12 days after vaccination and usually lasting several days (19). Most persons with fever are otherwise asymptomatic. Transient rashes have been reported for approximately 5% of vaccinees. Central nervous system (CNS) conditions, including encephalitis and encephalopathy, have been reported with a frequency of less than one per million doses administered. The incidence of encephalitis or encephalopathy after measles vaccination of healthy children is lower than the observed incidence of encephalitis of unknown etiology. This finding suggests that the reported severe neurologic disorders temporally associated with measles vaccination were not caused by the vaccine. These adverse events should be anticipated only in susceptible vaccinees and do not appear to be age-related. After revaccination, most reactions should be expected to occur only among the small proportion of persons who failed to respond to the first dose. Personal and Family History of Convulsions

As with the administration of any agent that can produce fever, some children may have a febrile seizure. Although children with a personal or family history of seizures are at increased risk for developing idiopathic epilepsy, febrile seizures following vaccinations do not in themselves increase the probability of subsequent epilepsy or other neurologic disorders. Most convulsions following measles vaccination are simple febrile seizures, and they affect children without known risk factors.

An increased risk of these convulsions may occur among children with a prior history of convulsions or those with a history of convulsions in first-degree family members (i.e., siblings or parents) (20). Although the precise risk cannot be determined, it appears to be low.

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