Immunization

Vaccination is the most effective way to prevent influenza illness and associated complications. For the 2011-12 Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011.

Annual influenza vaccination is associated with a reduction in influenza-related respiratory illness and physician visits. Hospitalizations and deaths among high risk persons are reduced by annual vaccination. Influenza vaccination has also proven effective in reducing otitis media in children and absenteeism in working adults.

Every year the CDC and the World Heath Organization select one influenza B and two influenza A strains that have the highest probability of causing a pandemic in the upcoming flu season. These three virus strains are then used by vaccine manufacturers to produce the annual vaccine. When this seasonal trivalent vaccine is well matched with the actual reassorted strains in circulation, a high inoculation rate can limit the spread of epidemics by inducing herd immunity.

There are currently two types of influenza vaccine used in the USA: TIV (trivalent inactivated influenza vaccine) and LAIV (live attenuated influenza vaccine):

• TIV is an inactivated virus (killed virus) incapable of replication. TIV is delivered via needle injection afterwhich the immune system responds by making antibodies to the viral H & N surface proteins. There are three different kinds of TIV on the market in the U.S. now.
  • The regular trivalent inactivated vaccine that given intramuscularly is approved for people 6 months of age and older, including healthy people, those with chronic medical conditions, and pregnant women.
  • A “high dose” trivalent inactivated vaccine also given intramuscularly containing 4 times the amount of antigen as the regular TIV. TIV "high dose" is approved for use in people 65 and older. It was introduced in 2009-2010.
  • An intradermal trivalent inactivated vaccine that is given into the dermal layer of the skin via a single-dose, prefilled microinjection syringe and that contains less antigen than the intramuscular TIV formulations. The intradermal vaccine was approved for use in people 18 through 64 years of age in 2011.
• LAIV is an attenuated virus (weakened virus) that has been genetically manipulated to replicate efficiently at 25 degrees C, but not above 39 degrees C. Therefore, LAIV only infects cells in the cooler nasopharynx. It is delivered by intranasal mist. The immune system responds to the limited nasopharyngeal infection by producing antibodies.

Dr. Taronna Maines of the CDC, inoculates a 10-day old embryonated hen's eggs with H5N1 within the biosafety Level 3-enhanced laboratory. Part of her personal protective equipment, is a powered air purifying respirator (PAPR), which is filtering the air that she breaths. Photo Credit: Greg Knobloch

TIV and LAIV are currently produced in embryonated chicken eggs. Reliance on chicken eggs reduces production capacity and introduces additional allergens. Hypersensitivity to eggs is a contraindication to using these vaccines. Recent vaccine shortages have stimulated increased research and development of manufacturing processes which use tissue culture technology. This should eventually alleviate shortages and eliminate the egg allergens.

• All persons 6 months and older (strictly adhere to manufacturer age group recommendations).
• Children 6 months through 8 years require 2 doses of influenza vaccine (administered a minimum of 4 weeks apart) during their first season of vaccination to optimize immune response.
• Children 6 months to 18 years of age on long-term salicylate therapy (Reye syndrome)
• Women who are pregnant
• Persons with chronic health problems including: heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), hematologic disorder
• Perons with certain muscle or nerve disorders (such as seizure disorders or cerebral palsy) that can lead to breathing or swallowing problems
• Residents of nursing homes and other chronic-care facilities.
• Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathy, or immunosuppression (including immunosuppression caused by radiation, medications or by human immunodeficiency virus [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
• Health-care workers
• Persons who provide essential community services

Who Will Benefit from the seasonal Intranasal Vaccine (LAIV)   

• Healthy nonpregnant persons from 2 to 49 years of age. This includes household contacts of most people at-risk for influenza complications
• Most health care workers

Immunizing Health Care Workers

• Getting vaccinated is the effective way to prevent influenza illness and its associated complications. It is the best way to protect your patients, your family and ultimately yourself.
• Inactivated influenza vaccine (killed virus) may be used to vaccinate all health care personnel who have no contraindications due to personal health conditions.
  • health-care personnel vaccinated with killed virus present no risk to the very young and severely immunosuppressed persons.
• Live attenuated vaccine (LAIV) may be given to health-care personnel ≤ 49 years of age who do not have contraindications to receiving the nasal vaccine.
• LAIV may be administered to health-care personnel who care for immunocompromised patients that do not require care in a protective environment.
• Health-care personnel who care for severely immunocompromised patients requiring protected environments, should not contact these patients for 7 days following LAIV immunization.

Dosage, Administration, and Storage*

TIV: Dosage, Administration, and Storage Manufacturer package inserts should be consulted for each product. TIV in multidose vials contain the vaccine preservative thimerosal. Preservative-free single dose preparations also are available. TIV should be stored at 35°F--46°F (2°C--8°C) and should not be frozen. TIV that has been frozen should be discarded. Dosage recommendations and schedules vary according to age group. Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season. The intramuscular route is recommended for TIV. Adults and older children should be vaccinated in the deltoid muscle. A needle length of 1 inch or greater (>25 mm) should be considered for persons in these age groups because needles of <1 inch might be of insufficient length to penetrate muscle tissue in certain adults and older children. When injecting into the deltoid muscle among children with adequate deltoid muscle mass, a needle length of 7/8--1.25 inches is recommended. Infants and young children should be vaccinated in the anterolateral aspect of the thigh. A needle length of 7/8--1 inch should be used for children aged <12 months A new jntradermal TIV was approved by the FDA in May 2011 The intradernal TIV is indicated for persons aged 18 through 64 years The vaccine is administered intradermally via a single-dose, prefilled microinjection syringe The preferred site for administration is over the deltoid muscle The most common adverse reactions include injection-site erythema, induration, swelling, pain, and pruritus Within the indicated age group there is no preferential recommendation for intradermal v.s. intramuscular delivery.

LAIV: Dosage, Administration, and Storage Manufacturer package inserts should be consulted for each product. LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal, or intravenous route. LAIV is not licensed for vaccination of children aged <2 years or adults aged >49 years. LAIV is supplied in a prefilled, single-use sprayer containing 0.2 mL of vaccine. Approximately 0.1 mL (i.e., half of the total sprayer contents) is sprayed into the first nostril while the recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. LAIV is shipped to end users at 35°F--46°F (2°C--8°C). LAIV should be stored at 35°F--46°F (2°C--8°C) on receipt and can remain at that temperature until the expiration date is reached. Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season.

 

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