Persons Who Should Not Be Vaccinated
Influenza Prevention and Control Recommendations
Published for the 2010-11 Influenza Season; Adapted for the 2012-13 Influenza Season
Persons with moderate to severe acute febrile illness usually should not be vaccinated until their symptoms have abated. Moderate or severe acute illness with or without fever is a precaution for trivalent inactivated influenza vaccine (TIV). Guillain-Barré syndrome (GBS) within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines.
Considerations and recommendations regarding vaccination of persons reporting allergy to eggs are available in the 2012-13 recommendations.
Live-attenuated influenza vaccine (LAIV) is an option for vaccination of healthy nonpregnant persons aged 2--49 years without contraindications, including health care personnel (HCP) and other close contacts of high-risk persons (excepting severely immunocompromised hospitalized persons who require care in a protected environment). The precaution regarding use of LAIV in protected environments is based upon a theoretic concern that the live attenuated vaccine virus could be transmitted to severely immunocompromised persons. However, no transmission of LAIV in health-care settings ever has been reported, and because these viruses are also cold-adapted (and cannot effectively replicate at normal body temperature) the risk for transmitting a vaccine virus to a severely immunocompromised person and causing severe infection appears to be extremely low. HCP working in environments such as neonatal intensive care, oncology, or labor and delivery units can receive LAIV without any restrictions.
No preference is indicated for LAIV or TIV when considering vaccination of healthy nonpregnant persons aged 2--49 years. Possible advantages of LAIV include its potential to induce a broad mucosal and systemic immune response in children, its ease of administration, and the possibly increased acceptability of an intranasal rather than intramuscular route of administration.
If the vaccine recipient sneezes immediately after administration, the dose should not be repeated. However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness, or TIV should be administered instead. No data exist about concomitant use of nasal corticosteroids or other intranasal medications.
Although Food and Drug Administration (FDA) licensure of LAIV excludes children aged 2--4 years with a history of asthma or recurrent wheezing, the precise risk, if any, of wheezing caused by LAIV among these children is unknown because experience with LAIV among these young children is limited. Young children might not have a history of recurrent wheezing if their exposure to respiratory viruses has been limited because of their age. Certain children might have a history of wheezing with respiratory illnesses but have not had asthma diagnosed.
Clinicians and vaccination programs should screen for asthma or wheezing illness (or history of wheezing illness) when considering use of LAIV for children aged 2--4 years, and should avoid use of this vaccine in children with asthma or a wheezing episode within the previous 12 months. Health-care providers should consult the medical record, when available, to identify children aged 2--4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2--4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive LAIV. TIV is available for use in children with asthma or wheezing. LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, use of TIV, or deferral of administration should be considered until resolution of the illness, is recommended. LAIV is approved for use in persons aged 2--49 years. However, the effectiveness or safety of LAIV is not known or is of potential concern for certain persons, and LAIV is not recommended for these persons.
Do not administer LAIV to the following groups:
- persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs;
- children aged younger than 2 years, because of an increased risk for hospitalization and wheezing observed in clinical trials;
- children aged 2--4 years whose parents or caregivers report that a health-care provider has told them during the preceding 12 months that their child had wheezing or asthma or whose medical record indicates a wheezing episode has occurred during the preceding 12 months;
- persons with asthma;
- persons aged 50 years and older;
- adults and children who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders;
- adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV);
- children or adolescents aged 6 months--18 years receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection); or
- pregnant women.
A moderate or severe illness with or without fever is a precaution for use of LAIV. Development of GBS within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines. LAIV should not be administered to close contacts of immunosuppressed persons who require a protected environment.
Low-level introduction of vaccine viruses into the environment probably is unavoidable when administering LAIV, but no instances have been reported of illness or attenuated vaccine virus infections among inadvertently exposed HCP or immunocompromised patients. The risk for acquiring vaccine viruses from the environment is unknown but is probably low; in addition, vaccine viruses are cold-adapted and attenuated, and unlikely to cause symptomatic influenza. Severely immunosuppressed persons should not administer LAIV. However, other persons at higher risk for influenza complications can administer LAIV. These include persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged 50 years and older.