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2007-08 INFLUENZA PREVENTION & CONTROL RECOMMENDATIONS
Vaccination of Specific Populations
NOTE: For 2008-09 Influenza Prevention and Control Recommendations see Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2008. MMWR 2008 Jul 17; Early Release:1-60. (Also available as PDF, 586K).NOTE: The text below is taken directly from Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007 Jul 13;56(RR06):1-54. Also available as PDF (720K).
On this page:
- Children
- Persons Aged 50-64 Years
- Health-Care Personnel and Others Who Can Transmit Influenza to Those at High Risk
- Close Contacts of Immunocompromised Persons
- Pregnant Women
- Breastfeeding Mothers
- Travelers
- General Population
- Vaccines for Different Age Groups
Children
Any child aged 6 months or older may be vaccinated. However, vaccination is specifically recommended for certain children, including all children aged 6–59 months, children with certain medical conditions, and children who are contacts of persons at higher risk for influenza complications. The American Academy of Pediatrics (AAP) has developed an algorithm for determining specific recommendations for pediatric patients according to age, contact or health status has been provided (Figure).
Because children aged 6–23 months are at substantially increased risk for influenza-related hospitalizations, and children aged 24–59 months (i.e., 2–4 years) are at increased risk for influenza-related clinic and emergency department visits, ACIP recommends that all children aged 6 months– 4 years receive TIV. Influenza vaccines are not approved by FDA for use among children aged <6 months.
All children aged 6 months–8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first year they are vaccinated. Children aged 5–8 years who receive TIV should have a booster dose of TIV administered 1 month or later after the initial dose, if possible before the onset of influenza season. LAIV is not currently licensed for children aged <5 years. Children aged 5–8 years who receive LAIV should have a second dose of LAIV 6 or more weeks after the initial dose. If possible, both doses should be administered before onset of influenza season. However, vaccination, including the second dose, is recommended even after influenza virus begins to circulate in a community.
Although data are limited, recently published studies indicate that when young children receive only 1 dose of TIV in each of their first two seasons of being vaccinated, they have lower antibody levels, are less likely to have protective antibody titers, and have reduced protection against ILI compared with children who receive their first 2 doses of vaccine in the same season. ACIP recommends 2 vaccine doses for children aged 6 months–8 years who received an influenza vaccine (either TIV or LAIV) for the first time in the previous season but who did not receive the recommended second dose of vaccine within the same season. ACIP recommendations are now harmonized with regard to this issue with those of AAP. This recommendation represents a change from the 2006 recommendations, in which children aged 6 months–8 years who received only 1 dose of vaccine in their first year of vaccination were recommended to receive only a single dose in the following season. ACIP does not recommend that a child receive influenza vaccine for the first time in the spring with the intent of providing a priming dose for the following season. Children recommended for vaccination who are in their third or more year of being vaccinated and who received only 1 dose in each of their first 2 years of being vaccinated should continue receiving a single annual dose.
Persons Aged 50-64 Years
Vaccination is recommended for all persons aged 50–64 years because persons in this age group have an increased prevalence of high-risk conditions and low vaccination rates. In 2002, approximately 43.6 million persons in the United States were aged 50–64 years, of whom 13.5 million (34%) had one or more high-risk medical conditions. Persons aged 50–64 years without high-risk conditions also benefit from vaccination in the form of decreased rates of influenza illness, work absenteeism, and need for medical visits and medications, including antibiotics. In addition, other preventive services and routine assessment of vaccination and other preventive services has been recommended for all persons aged 50 years and older.
Healthcare Personnel (HCP) and Others Who Can Transmit Influenza to Those at High Risk
Healthy persons who are clinically or asymptomatically infected can transmit influenza virus to persons at higher risk for complications from influenza. In addition to HCP, groups that can transmit influenza to high-risk persons and that should be vaccinated include
- employees of assisted living and other residences for persons in groups at high risk;
- persons who provide home care to persons in groups at high risk; and
- household contacts (including children) of persons in groups at high risk.
In addition, because children aged <5 years are at increased risk for influenza-related hospitalization compared with older children, vaccination is recommended for their household contacts and out-of-home caregivers. Because influenza vaccines have not been approved by FDA for use among children aged <6 months, emphasis should be placed on vaccinating contacts of children aged <6 months. When vaccine supply is limited, priority for vaccination should be given to contacts of children aged <6 months.
Healthy persons aged 5–49 years in these groups who are not contacts of severely immunosuppressed persons (see Vaccination of Close Contacts of Immunocompromised Persons) may receive either LAIV or TIV. All other persons should receive TIV.
All HCP, as well as those in training for health-care professions, should be vaccinated annually against influenza. Persons working in health-care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient-care settings, medical emergency-response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and chronic-care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.
Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. Health-care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and obtain signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications (309). Influenza vaccination rates among HCP within facilities should be regularly measured and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration. Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and using strategies that increase vaccine acceptance.
Efforts to increase vaccination coverage among HCP are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission on Accreditation of Health-Care Organizations has approved an infection control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with close patient contact. The standard became an accreditation requirement beginning January 1, 2007. In addition, the Infectious Diseases Society of America recently recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons. Fifteen states have regulations regarding vaccination of HCP in long-term–care facilities, three states require that health-care facilities offer influenza vaccination to HCP, and three states require that HCP either receive influenza vaccination or indicate a religious, medical, or philosophical reason for not being vaccinated.
Close Contacts of Immunocompromised Persons
Immunocompromised persons are at risk for influenza complications but might have insufficient responses to vaccination. Close contacts of immunocompromised persons, including HCP, should be vaccinated to reduce the risk for influenza transmission. TIV is preferred for vaccinating household members, HCP, and others who have close contact with severely immunosuppressed persons (e.g., patients with hematopoietic stem cell transplants) during those periods in which the immunosuppressed person requires care in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes).
LAIV transmission from a recently vaccinated person causing clinically important illness in an immunocompromised contact has not been reported. The rationale for avoiding use of LAIV among HCP caring for such patients is the theoretic risk that a live, attenuated vaccine virus could be transmitted to the severely immunosuppressed person. As a precautionary measure, HCP who receive LAIV should avoid providing care for severely immunosuppressed patients for 7 days after vaccination. Hospital visitors who have received LAIV should avoid contact with severely immunosuppressed persons for 7 days after vaccination but should not be restricted from visiting less severely immunosuppressed patients.
No preference is indicated for TIV use by persons who have close contact with persons with lesser degrees of immunosuppression (e.g., persons with diabetes, persons with asthma who take corticosteroids, those who might have been cared for previously in a protective environment but who are no longer in that protective environment, or persons infected with HIV) or for TIV use by HCP or other healthy persons aged 5–49 years in close contact with persons in all other groups at high risk.
Pregnant Women
Pregnant women are at risk for influenza complications, and all women who are pregnant or will be pregnant during influenza season should be vaccinated. FDA has classified TIV as a “Pregnancy Category C” medication, indicating that animal reproduction studies have not been conducted. Whether influenza vaccine can cause fetal harm when administered to a pregnant woman or affect reproductive capacity is not known. However, one study of approximately 2,000 pregnant women who received TIV during pregnancy demonstrated no adverse fetal effects and no adverse effects during infancy or early childhood. A matched case-control study of 252 pregnant women who received TIV within the 6 months before delivery determined no adverse events after vaccination among pregnant women and no difference in pregnancy outcomes compared with 826 pregnant women who were not vaccinated. During 2000–2003, an estimated 2 million pregnant women were vaccinated, and only 20 adverse events among women who received TIV were reported to VAERS during this time, including nine injection-site reactions and eight systemic reactions (e.g., fever, headache, and myalgias). In addition, three miscarriages were reported, but these were not known to be causally related to vaccination. Similar results have been reported in several smaller studies. The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians also have recommended routine vaccination of all pregnant women. No preference is indicated for use of TIV that does not contain thimerosal as a preservative (see Vaccine Preservative [Thimerosal] in Multidose Vials of TIV) for any group recommended for vaccination, including pregnant women. LAIV is not licensed for use in pregnant women. However, pregnant women do not need to avoid contact with persons recently vaccinated with LAIV.
Breastfeeding Mothers
Vaccination is recommended for all persons, including breastfeeding women, who are contacts of infants or children aged 59 months or less (i.e., less than 5 years), because infants and young children are at higher risk for influenza complications and are more likely to require medical care or hospitalization if infected. Breastfeeding does not affect the immune response adversely and is not a contraindication for vaccination. Women who are breastfeeding may receive either TIV or LAIV unless contraindicated because of other medical conditions.
Travelers
The risk for exposure to influenza during travel depends on the time of year and destination. In the temperate regions of the Southern Hemisphere, influenza activity occurs typically during April–September. In temperate climate zones of the Northern and Southern Hemispheres, travelers also can be exposed to influenza during the summer, especially when traveling as part of large tourist groups (e.g., on cruise ships) that include persons from areas of the world in which influenza viruses are circulating. In the tropics, influenza occurs throughout the year. In one recent study among Swiss travelers to tropical and subtropical countries, influenza was the most frequently acquired vaccine-preventable disease.
Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, persons at high risk for complications of influenza and who were not vaccinated with influenza vaccine during the preceding fall or winter should consider receiving influenza vaccine before travel if they plan to
- travel to the tropics,
- travel with organized tourist groups at any time of year, or
- travel to the Southern Hemisphere during April–September.
No information is available regarding the benefits of revaccinating persons before summer travel who already were vaccinated in the preceding fall. Persons at high risk who receive the previous season’s vaccine before travel should be revaccinated with the current vaccine the following fall or winter. Persons at higher risk for influenza complications should consult with their health-care practitioner to discuss the risk for influenza or other travel-related diseases before embarking on travel during the summer.
General Population
Vaccination is recommended for any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected. Healthy, nonpregnant persons aged 5–49 years may choose to receive either TIV or LAIV. All other persons aged 6 months and older should receive TIV. Persons who provide essential community services should be considered for vaccination to minimize disruption of essential activities during influenza outbreaks. Students or other persons in institutional settings (e.g., those who reside in dormitories or correctional facilities) should be encouraged to receive vaccine to minimize morbidity and the disruption of routine activities during epidemics.
Vaccines for Different Age Groups
When vaccinating children aged 6–35 months, health-care providers should use TIV that has been approved by FDA for this age group. TIV from Sanofi Pasteur (FluZone split-virus) is approved for use among persons aged 6 months and older. TIV from Novartis (Fluvirin) is FDA-approved in the United States for use among persons aged 4 years and older. TIV from GlaxoSmithKline (Fluarix and FluLaval) is labeled for use in persons aged 18 years and older, because data to demonstrate efficacy among younger persons have not been provided to FDA. LAIV from MedImmune (FluMist) is currently approved for use by healthy nonpregnant persons aged 5–49 years (See Approved Influenza Vaccines for Different Age Groups: Table 4). Expanded age and risk group indications for currently licensed vaccines are likely over the next several years, and immunization providers should be alert to these changes. In addition, several new vaccine formulations are being evaluated in immunogenicity and efficacy trials; when licensed, these new products will increase the influenza vaccine supply and provide additional vaccine choices for practitioners and their patients.
- Page last updated October 26, 2007
- Content Source: Coordinating Center for Infectious Diseases (CCID)
- National Center for Immunization and Respiratory Diseases (NCIRD)
