live attenuated influenza virus vaccine; LAIV (FluMist, FluMist Quadrivalent)
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Introduction
Influenza vaccine given as nasal spray. (FDA approved 2003)
Indications
- prophylaxis for influenza, healthy people age 2-49 years[6]
- 1st line for healthy children 2-8 years of age[12]
- no longer recommended over inactivated vaccine, because observational studies failed to support superiority of live-attenuated vaccine seen in randomized trials[14]
- not recommended for 2016-17 flu season[17]
- as effective as inactivated influenza virus vaccine over 3 flu seasons in Canadian children[18]
- low effectiveness against influenza A H1N1 pdm09[19]
- may be reintroduced in 2018-2019 flu season[20]
Contraindications
- immunosuppressed patients
- immunosuppressed household contacts[7]
- caregivers & health care workers who care for immunosuppessed patients
- children or adolescents on aspirin therapy
- egg allergy
- history of Guillain-Barre syndrome
- asthma or reactive airway disease, COPD
- diabetes mellitus
- renal dysfunction
- hemoglobinopathy
Dosage
- single dose nasal spray 0.5 mL
- previously unvaccinated children 5-8 years of age receive 2 doses 60 days apart
Avoid antiviral agents for 2 weeks after administration[4]
Store at -15 degrees C* (use frost-free freezer[3])
May be thawed in refrigerator 24 hours before use
Shelf life: 18 weeks (2014)[13]
* 2007 formulation may be refrigerated[6]
* good for 8 hours at room temperature
Adverse effects
- nasal congestion
- rhinitis
- headache
- sore throat
- cough
- live virus is shed in nasal secretions & may be spread to unvaccinated contacts for at least 7 days[5]
- 20% of adverse events associated with use of expired vaccine[13]
Mechanism of action
- live virus vaccine containing 2 type A & 1 type B strains of influenza virus[2]
- quadrivalent live virus vaccine containing 2 type A & 2 type B strains of influenza virus FDA-approved in Feb 2012[10]
- induces IgA, IgG & cellular immunity[2]
- viruses attenuated by
- multiple passages through eggs
- recombination with influenza mutants
- enhanced growth in cool nasal passages
- systemic replication is inhibited
- estimates of protection vary
- 20-23% reduction in symptomatic influenza in adults[2]
- protection for single dose 56-89%[11]
- in 3 studies, live attenuated influenza virus vaccine more more effective than inactivated influenza virus vaccine in reducing culture-confirmed influenza caused by matched strains by 35-53%[11]
- also more effective than inactivated influenza virus vaccine in reducing influenza-associated otitis media by 51%[11]
- effectiveness of LAIV against influenza A(H3N2 improved by prior vaccination[21]
Notes
* Cost (2003) about $46, about $20 2007[6]
More general terms
References
- ↑ Prescriber's Letter 10(7):37 2003
- ↑ 2.0 2.1 2.2 2.3 Journal Watch 23(18):147, 2003 http://www.fda.gov/cber/label/infimed061703lb.pdf http://www.fda.gov/bbs/topic/NEWS/2003/NEW00913.html
- ↑ 3.0 3.1 Prescriber's Letter 10(10):56 2003
- ↑ 4.0 4.1 Prescriber's Letter 11(1):1 2004
- ↑ 5.0 5.1 Prescriber's Letter 11(9): 2004
- ↑ 6.0 6.1 6.2 6.3 Prescriber's Letter 14(9): 2007 Immunization Update 2007 Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230923&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 7.0 7.1 Prescriber's Letter 14(10): 2007 Selected Issues in the Effective and Safe Use of Live Virus Vaccines. Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=231009&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ US Food and Drug Administration (FDA). FDA News. FDA approves nasal influenza vaccine for use in younger children. 2007, Sept 19 http://www.fda.gov/bbs/topics/NEWS/2007/NEW01705.html
- ↑ Prescriber's Letter 15(10): 2008 CHART: Stability of Refrigerated and Frozen Drugs TECHNICIAN TRAINING TUTORIAL: Handling Refrigerated Drugs and Vaccines Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=241001&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 10.0 10.1 FDA News Release: Feb. 29, 2012 FDA approves first quadrivalent vaccine to prevent seasonal influenza http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm294057.htm
- ↑ 11.0 11.1 11.2 11.3 Ambrose CS et al Current Status of Live Attenuated Influenza Vaccine in the United States for Seasonal and Pandemic Influenza. Influenza Resp Viruses. 2008;2(6):193-202. on Medscape http://www.medscape.com/viewarticle/588302_2
- ↑ 12.0 12.1 Kelley KJ. Sofair A and Chavey WE (editors) CDC Panel Recommends Nasal Flu Vaccine Over Shot for Kids Physician's First Watch, June 27 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
- ↑ 13.0 13.1 13.2 Haber P et al. Centers for Disease Control and Prevention (CDC) Notes from the Field: Reports of Expired Live Attenuated Influenza Vaccine Being Administered - United States, 2007- 2014. MMWR. Weekly. September 5, 2014 / 63(35);773-773 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6335a3.htm
- ↑ 14.0 14.1 Grohskopf LA et al Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 Influenza Season. MMWR. August 7, 2015 / 64(30);818-825 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
- ↑ 15.0 15.1 Turner PJ et al Safety of live attenuated influenza vaccine in young people with egg allergy: multicentre prospective cohort study. BMJ 2015;351:h6291 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26645895 <Internet> http://www.bmj.com/content/351/bmj.h6291
Greenhawt M. Live attenuated influenza vaccine for children with egg allergy. BMJ 2015 Dec 9; 351:h6656. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26657778 <Internet> http://www.bmj.com/content/351/bmj.h6656 - ↑ 16.0 16.1 Centers for Disease Control and Prevention (CDC) VACCINE INFORMATION STATEMENT. Influenza (Flu) Vaccine (Live, Intranasal): What You Need to Know. Information Fact Sheet. Feb. 2016 http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flulive.pdf
- ↑ 17.0 17.1 Centers for Disease Control and Prevention (CDC) ACIP votes down use of LAIV for 2016-2017 flu season. http://www.cdc.gov/media/releases/2016/s0622-laiv-flu.html
American Academy of Pediatrics AAP Supports ACIP Recommendation for Use of Inactivated Flu Vaccine. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Supports-ACIP-Recommendation-for-Use-of-Inactivated-Flu-Vaccine.aspx
COMMITTEE ON INFECTIOUS DISEASES Recommendations for Prevention and Control of Influenza in Children, 2016-2017 Pediatrics Sep 2016, e20162527 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27600320 - ↑ 18.0 18.1 Loeb M, Russell ML, Manning V Live Attenuated Versus Inactivated Influenza Vaccine in Hutterite Children: A Cluster Randomized Blinded Trial. Ann Intern Med. Published online 16 August 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27538259 <Internet> http://annals.org/article.aspx?articleid=2543271
- ↑ 19.0 19.1 Kim DK, Riley LE, Harrima KH et al Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017. Ann Intern Med. 2017;166(3):209-219 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28166560 <Internet> http://annals.org/aim/article/2601209/recommended-immunization-schedule-adults-aged-19-years-older-united-states
- ↑ 20.0 20.1 NEJM JWatch Editors Live Attenuated Flu Vaccine Coming Back in 2018-19. Physician's First Watch, Feb 22, 2018 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Fox M FluMist nasal flu vaccine can come back, vaccine advisers say. NBC News. Feb 22, 2018 https://www.nbcnews.com/health/health-news/flumist-nasal-flu-vaccine-can-come-back-vaccine-advisers-say-n849986
Walker M ACIP Reinstates FluMist for 2018-2019 Flu Season Committee persuaded by new efficacy analyses. MedPage Today. February 21, 2018 https://www.medpagetoday.com/meetingcoverage/acip/71298 - ↑ 21.0 21.1 McLean HQ, Caspard H, Griffin MR et al Association of Prior Vaccination With Influenza Vaccine Effectiveness in Children Receiving Live Attenuated or Inactivated Vaccine. JAMA Netw Open. 2018;1(6):e183742 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2709714
Cobey S Repeated Vaccination May Protect Children From Influenza Infection. JAMA Netw Open. 2018;1(6):e183730 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2709711