Issue Number 832
November 5, 2009
CONTENTS OF THIS ISSUE
1. Read "Ask the Experts" Q&As about 2009 H1N1 and seasonal
influenza vaccination
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ABBREVIATIONS: AAFP, American Academy of Family Physicians;
AAP, American Academy of Pediatrics; ACIP, Advisory
Committee on Immunization Practices; AMA, American Medical
Association; CDC, Centers for Disease Control and
Prevention; FDA, Food and Drug Administration; IAC,
Immunization Action Coalition; MMWR, Morbidity and Mortality
Weekly Report; NCIRD, National Center for Immunization and
Respiratory Diseases; NIVS, National Influenza Vaccine
Summit; VIS, Vaccine Information Statement; VPD, vaccine-
preventable disease; WHO, World Health Organization.
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November 5, 2009
READ "ASK THE EXPERTS" Q&As ABOUT 2009 H1N1 AND SEASONAL
INFLUENZA VACCINATION
Many readers of Needle Tips and Vaccinate Adults
consistently rank "Ask the Experts" as their favorite
feature in these publications. As a thank-you to our loyal
IAC Express readers, we have decided to periodically publish
Extra Editions of IAC Express with new "Ask the Experts"
Q&As answered by CDC experts.
IAC thanks William L. Atkinson, MD, MPH, and Andrew T.
Kroger, MD, MPH, medical epidemiologists, at the National
Center for Immunization and Respiratory Diseases, CDC, for
agreeing to answer the following questions.
The Q&As in this "Ask the Experts" edition provide
healthcare professionals with answers to some of the most
common questions related to H1N1 and seasonal influenza
vaccination.
CDC is currently finalizing rules for situations involving doses
of influenza vaccine given without the recommended spacing between
doses. When CDC publishes this information on its website,
IAC will provide a link to it in a future issue of IAC
Express.
We encourage you to reprint any of these Q&As in your own
newsletters. Please credit the Immunization Action Coalition
and the Centers for Disease Control and Prevention.
Information about IAC's preferred citation style can be
found at http://www.immunize.org/citeiac
You can access more "Ask the Experts" Q&As in our online
archive at http://www.immunize.org/askexperts
Editor's note: Information about submitting a question to
"Ask the Experts" is provided at the end of this Extra
Edition.
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Q: Should the 2009 H1N1 influenza vaccine be given to
someone who had an influenza-like illness between April and
now?
A: If an influenza-like illness (ILI) was confirmed as H1N1
by reverse transcriptase polymerase chain reaction (RT-PCR),
then vaccination with H1N1 monovalent vaccine is not
necessary for the 2009-2010 season. If the ILI was not
confirmed by RT-PCR, then the person should be vaccinated if
indicated. There is no harm in vaccinating a person who had
2009 H1N1 influenza in the past.
Q: Can we test patients who think they already had H1N1
influenza to see if their infection was caused by H1N1?
A: There is no test readily available that can show whether
a person had 2009 H1N1 influenza in the past. People for
whom the 2009 H1N1 influenza vaccine is recommended should
receive it, unless they can be certain they had 2009 H1N1
influenza based on a reverse transcriptase polymerase chain
reaction (RT-PCR) test.
Q: Can patients on influenza antiviral prophylaxis (e.g.,
Tamiflu) receive seasonal and/or H1N1 influenza vaccine?
A: Such patients can receive inactivated seasonal or inactivated
H1N1 influenza vaccine. A person taking an influenza antiviral
drug (including Tamiflu or Relenza) should not be given the
nasal-spray influenza vaccine until 48 hours after the last dose
of the influenza antiviral medication was given. If LAIV is
administered less than 48 hours after a dose of antiviral
medication, or if antivirals are administered less than 2 weeks
after LAIV is administered, then the LAIV dose should not be
counted as valid.
Q. Can a person with a runny nose receive nasal-spray
influenza vaccine?
A: Yes.
Q: According to ACIP, individuals aged 25-64 years with
medical conditions that put them at higher risk for
influenza-related complications should be among those
targeted to receive the first available H1N1 influenza
vaccine. What exactly are these high-risk conditions?
A: A footnote on page 5 of the ACIP recommendations for use
of H1N1 influenza vaccine
(http://www.cdc.gov/mmwr/PDF/rr/rr5810.pdf) defines these
medical conditions in a footnote, as follows: "Chronic
medical conditions that confer a higher risk for influenza-
related complications include chronic pulmonary (including
asthma), cardiovascular (except hypertension), renal,
hepatic, cognitive, neurologic/neuromuscular, hematologic,
or metabolic disorders (including diabetes mellitus) or
immunosuppression (including immunosuppression caused by
medications or by human immunodeficiency virus)."
Q: Can 2009 H1N1 vaccine be administered at the same visit
as other vaccines?
A: Inactivated 2009 H1N1 vaccine can be administered at the
same visit as any other vaccine, including pneumococcal
polysaccharide vaccine. Live (nasal-spray) 2009 H1N1 vaccine
can be administered at the same visit as any other live or
inactivated vaccine EXCEPT seasonal live attenuated
influenza vaccine.
Q: In the package inserts, the age for two doses in children
is different for seasonal (6 months through 8 years) and
2009 H1N1 monovalent vaccine (6 months through 9 years).
Does CDC recommend that clinicians follow the recommendation
in the package inserts?
A: Yes, CDC recommends that clinicians follow the guidance
in the manufacturer package inserts. For 2009 H1N1
monovalent vaccines, that means that clinicians should
administer two doses of 2009 H1N1 monovalent vaccine to
children ages 6 months through 9 years. Persons 10 years and
older should receive one dose.
Q: If a child needs two doses of either seasonal or H1N1
influenza vaccine, can you give the child one dose of
inactivated vaccine and one dose of live vaccine? This may
be an issue because of supply fluctuation.
A: Yes.
Q: If seasonal LAIV and 2009 H1N1 LAIV are given during the
same visit, do either or both doses need to be repeated,
and if so, when?
A: There are no data on the administration of seasonal and
2009 H1N1 LAIV during the same visit. ACIP recommends that
seasonal and 2009 H1N1 LAIV not be administered during the
same visit. However, if both types of LAIV are inadvertently
administered during the same visit, neither vaccine needs to
be repeated.
Q: Can the live nasal-spray influenza vaccines be given to
close contacts of pregnant women?
A: Yes. A pregnant woman can be in close contact with
someone who has gotten the nasal-spray (live) vaccine for
either H1N1 or seasonal influenza. A pregnant healthcare
worker can also administer nasal-spray influenza vaccines to
patients. Because the viruses in the nasal-spray vaccines
are attenuated or weakened, vaccine viruses are unlikely to
cause any illness symptoms, even if an unvaccinated person
inadvertently gets vaccine viruses in their nose. The nasal-
spray vaccine against seasonal influenza viruses has been
used in millions of school children and healthy adults since
it was licensed, and there have been no reports of pregnant
women becoming ill after exposure to their vaccinated
children or other family members.
Although the live nasal-spray influenza vaccines can be
given to contacts of pregnant women, they should not be
administered to pregnant women.
Q: Are there any contraindications to giving breastfeeding
mothers the 2009 H1N1 vaccine?
A: Breastfeeding mothers can get either live or inactivated
H1N1 influenza vaccine. They can also receive either live
or inactivated seasonal influenza vaccine. As noted elsewhere,
seasonal and H1N1 live (nasal-spray) vaccines should not
both be given at the same visit.
Q: What if seasonal or H1N1 LAIV is given 2 weeks after a
dose of varicella vaccine or MMR? Does the dose of LAIV need to
be repeated?
A: Yes. If two live virus vaccines are administered less
than 4 weeks apart and not on the same day (EXCEPTION: live
H1N1 and live seasonal influenza vaccines should not be
given on the same day), the vaccine given second should be
considered invalid and repeated. The repeat dose should be
administered at least 4 weeks after the invalid dose. If the
repeat dose is inactivated influenza vaccine it can be
administered immediately.
Q: What can I say to patients who think the H1N1 influenza
vaccines are "new" or experimental?
A: The 2009 H1N1 influenza vaccines are being produced by the
same companies using the same procedures used to produce
seasonal influenza vaccines. The 2009 H1N1 vaccines are exactly
the same as seasonal influenza vaccines except for the strain
of influenza virus they contain. One way to approach this
discussion is to emphasize that the 2009 H1N1 vaccine is not
a "new" vaccine but rather is a change in the strains (just
as is done in preparing new vaccine for each influenza
season). Each year, experts look at the strains that are
likely to be circulating during the next influenza season,
and put those into the upcoming year's influenza vaccine.
That's exactly what has been done in this case.
Most of the seasonal influenza vaccines distributed over the
last decade have included H1N1-like strains. If the timing
had been better, it is possible that the 2009 H1N1 strain
could have been included in the 2009-2010 seasonal influenza
vaccine.
Q: Do any of the H1N1 influenza vaccines include an
adjuvant?
A: None of the currently approved influenza A 2009 (H1N1)
monovalent vaccines or seasonal influenza vaccines contains
an adjuvant. (NOTE: An adjuvant is a substance that is
sometimes added to the vaccine to enhance the immune
response, so that smaller quantities of vaccine can be
given.)
Q: Do the H1N1 influenza vaccines use thimerosal as a
preservative?
A: All multidose vials of influenza vaccine (both seasonal
and H1N1) contain thimerosal as a preservative. There is no
evidence that thimerosal is harmful. CDC recommends that
pregnant women and children may receive influenza vaccine
with or without thimerosal. However, because some pregnant
women and parents are concerned about exposure to
thimerosal, manufacturers are producing some preservative-
free seasonal and 2009 H1N1 influenza vaccines in single-
dose syringes.
The live intranasal H1N1 influenza vaccine is packaged in
single doses so it does not use a preservative; however, it
cannot be used for pregnant women or children younger than
age 2 years.
Q: Can healthcare workers who cannot receive the nasal-spray
vaccine (e.g., pregnant women, older adults, persons with
chronic medical conditions) administer this vaccine to
others?
A: Yes. Healthcare workers who cannot get the nasal-spray
vaccine themselves can administer the vaccine to others.
Q: What personal protective equipment is recommended for
healthcare workers who are giving the 2009 H1N1 nasal-spray
vaccine?
A: Personal protective equipment (gloves and masks) are not
needed when administering nasal-spray vaccine, including the
2009 H1N1 nasal-spray vaccine.
Q: Do providers working at a large-scale influenza
vaccination event have to wash their hands between each
patient?
A: Hands should be washed thoroughly with soap and water or
cleansed with an alcohol-based waterless antiseptic between
patients. The Department of Health and Human Services has
provided the following guidance in its Pandemic Influenza
Plan:
*If hands are visibly soiled or contaminated with
respiratory secretions, wash hands with soap (either non-
antimicrobial or antimicrobial) and water.
*In the absence of visible soiling of hands, approved
alcohol-based products for hand disinfection are preferred
over antimicrobial soap and water or plain soap and water
because of their superior microbiocidal activity, reduced
drying of the skin, and convenience.
For more information, go to: http://www.cdc.gov/handhygiene
Q: Though I know it is not necessary to wear gloves when
providing injections, if a nurse chooses to wear gloves,
should the nurse change gloves after administering each
vaccination during a busy flu clinic?
A: Yes. Persons who administer vaccines should either wash
their hands with soap and water, use alcohol-based hand
sanitizer, or change their gloves between individual patient
encounters.
Q: Where can I find VISs for seasonal and H1N1 influenza
vaccines?
A: IAC posts the English-language VISs developed by CDC and
all available translations on its website as soon as they
become available. Please note that all VIS translations are
graciously donated, so IAC is unable to guarantee specific
delivery dates.
To access all available seasonal inactivated influenza VISs,
go to: http://www.immunize.org/vis/vis_fluinactive.asp
To access all available seasonal live influenza VISs, go to:
http://www.immunize.org/vis/vis_flulive.asp
To access all available H1N1 inactivated influenza VISs, go
to: http://www.immunize.org/vis/vis_h1n1inactive.asp
To access all available H1N1 live influenza VISs, go to:
http://www.immunize.org/vis/vis_h1n1live.asp
Q: What if our organization needs a VIS translation before it
is available from IAC's website, or needs VISs in a language
that is unlikely to be donated by others? Is it legal to
translate CDC's English-language VIS ourselves?
A: Permission is not required to translate a VIS. However,
providers should not change the text of a VIS or write their
own VISs. It is permissible to add a practice's name,
address, or phone number to an existing VIS.
If your organization decides to have some VISs translated,
consider sharing the translations with IAC for possible
posting to our website. You can access our guidelines for
translations at
http://www.immunize.org/printmaterials/print_translate.asp
Q: Do you have any other resources that would make this
difficult influenza season easier for those of us providing
vaccines?
A: IAC has developed standing orders for both seasonal and
H1N1 influenza vaccination and has revised its influenza
screening questionnaires to be suitable for both seasonal
and H1N1 influenza vaccines.
STANDING ORDERS
Standing Orders for Administering Seasonal Influenza
Vaccines to Children & Adolescents
http://www.immunize.org/catg.d/p3074a.pdf
Standing Orders for Administering Seasonal Influenza Vaccine
to Adults
http://www.immunize.org/catg.d/p3074.pdf
Standing Orders for Administering Influenza A (H1N1) 2009
Monovalent Vaccines
http://www.immunize.org/catg.d/p3074b.pdf
SCREENING QUESTIONNAIRES FOR VACCINE CONTRAINDICATIONS AND
PRECAUTIONS
Screening Questionnaire for Injectable Influenza
Vaccination--the same form may be used to screen for both
seasonal and H1N1 influenza vaccine
English: http://www.immunize.org/catg.d/p4066.pdf
Spanish: http://www.immunize.org/catg.d/p4066-01.pdf
Screening Questionnaire for Intranasal Influenza
Vaccination--the same form may be used to screen for both
seasonal and H1N1 influenza vaccines
English: http://www.immunize.org/catg.d/p4067.pdf
Spanish: http://www.immunize.org/catg.d/p4067-01.pdf
Note: CDC is finalizing rules for situations involving doses
of influenza vaccine given without the recommended spacing
between doses. Watch for information about this in a future
issue of IAC Express!
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HOW TO SUBMIT A QUESTION TO "ASK THE EXPERTS"
IAC works with CDC to compile new "Ask the Experts" Q&As for
our publications based on commonly asked questions. We also
consider the need to provide information about new vaccines
and recommendations. Most of the questions are thus a
composite of several inquiries.
You can email your question about vaccines or immunization
to IAC at admin@immunize.org As we receive hundreds of
emails each month, we cannot guarantee that we will print
your specific question in the "Ask the Experts" feature.
However, you will get an answer. To see if your question has
already been answered, you can first check the "Ask the
Experts" online archive at
http://www.immunize.org/askexperts
You can also email CDC's immunization experts directly at
nipinfo@cdc.gov There is no charge for this service.
If you have a question about IAC materials or services,
email admininfo@immunize.org