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Immunization Action Coalition
IAC Express 2009
Issue number 832: November 5, 2009
Please click here to subscribe to IAC Express as well as other FREE IAC periodicals.
Contents of this Issue
Select a title to jump to the article.
  1. Read "Ask the Experts" Q&As about 2009 H1N1 and seasonal influenza vaccination
 
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.
  
Issue 832: November 5, 2009
1.  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.


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_flu_inactive.asp

To access all available seasonal live influenza VISs, go to:
http://www.immunize.org/vis/vis_flu_live.asp

To access all available H1N1 inactivated influenza VISs, go to:
http://www.immunize.org/vis/vis_h1n1_inactive.asp

To access all available H1N1 live influenza VISs, go to:
http://www.immunize.org/vis/vis_h1n1_live.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!


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

Please forward these "Ask the Experts" Q&As to your co-workers and suggest they subscribe to IAC Express at http://www.immunize.org/subscribe

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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.