ACIP: Influenza Spray Tops Influenza Shot for Young Children

Yael Waknine

June 26, 2014

ATLANTA, Georgia — In a rare move, the Advisory Committee on Immunization Practices (ACIP) experts have unanimously endorsed AstraZeneca's FluMist Quadrivalent nasal spray over influenza shots for healthy children aged 2 to 8 years.

Until now, the panel had only issued general recommendations for ratification by the Centers for Disease Control and Prevention, such as annual immunization for everyone older than 6 months. Preferential use of the nasal spray vaccine is already endorsed by Canada, the United Kingdom, Germany, and Israel.

The vote reflected compelling data from 4 randomized controlled trials showing fewer cases of laboratory-confirmed influenza among young children receiving trivalent live attenuated vaccine (LAIV), rather than inactivated influenza vaccine. LAIV was also linked to a decreased risk for otitis media. There was no difference between vaccines with respect to hospitalization, medically attended respiratory illness, or influenza-like illness.

No comparative information is yet available for quadrivalent LAIV, which became available in 2013 and will be used this season.

In discussions before the vote, manufacturing and physician group representatives spoke out in opposition against the LAIV bias, noting that orders for inactivated influenza vaccine had been placed in February and that some families may be sensitive to the $10 price differential.

"You shouldn't place doctors and families in a situation where, if they don't receive the live vaccine, they feel they're getting an inferior product, because it may not be an inferior product," noted Michael Brody, MD, PhD, a family practitioner from Indianapolis, Indiana.

The ACIP emphasized that LAIV is only preferred "when available," and that vaccination should not be delayed to obtain LAIV.

"Both the live and attenuated vaccine are considered safe and effective.... [N]ot getting [LAIV] is not a major disadvantage," said Jeffery Duchin, MD, from the University of Washington School of Medicine in Seattle and chief of the Communicable Disease Epidemiology and Immunization Section of Seattle and King County Public Health Department.

Other members noted that studies suggest increased efficacy for inactivated influenza vaccine in adults that may extend to older children. LAIV is not indicated for individuals older than 49 years.

ACIP Postpones Vote on Yellow Fever Booster

Another issue discussed during yesterday's meeting was whether the ACIP should follow the World Health Organization's recent decision that a 10-year booster is no longer required for yellow fever vaccine, except in certain types of individuals.

Although available evidence suggests that 1 shot confers lifelong protection, panel members expressed concerns regarding data quality (level 4), particularly with respect to particular groups.

One of the issues raised was whether boosters should still be used among individuals originally vaccinated at younger than 1 year. Panel members cited the cutoff as "arbitrary" and suggested that an age of 5 years may be more appropriate to ensure vaccine response.

"We have incredible data that children younger than 3 years don't respond as well as older individuals," stated Janet Englund, MD, professor of pediatric infectious diseases at the University of Washington and Seattle Children's Hospital, noting that the proposed policy also did not account for older individuals returning to an endemic area after a long period of time. "When they come to be 40 or 50 years old, there is no vaccine we have that lasts that long," she said.

The original ACIP recommendation suggested a continued need for boosters among travelers who last received a vaccine 10 or more years ago and are planning long stays in endemic areas or travel to highly endemic areas such as West Africa; laboratory workers who routinely handle infectious yellow fever; and individuals who might have had a compromised immune response to the initial dose because of young age (younger than 1 year), pregnancy, or HIV infection.

The ACIP convened yesterday and today in Atlanta, Georgia, for 1 of the 3 meetings it holds each year.

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