Breaking News: FluMist advised as a “last resort” by AAP but an “option” by the CDC for 2018-2019 season

In February 2018, the Advisory Committee on Immunization Practices (ACIP) of the CDC voted to once again recommend use of FluMist, the nasal spray flu vaccine, for the 2018-2019 influenza season. Then, on May 21, 2018, the American Academy of Pediatrics came out with an official recommendation to use the injected form of the influenza vaccine over the newly resurrected nasal spray vaccine, and that the nasal spray should only be considered as a "last resort". This recommendation is due to a 3-year history of the nasal spray being of little value against influenza "A" strains in the last 3 seasons that it was used. But really, "last resort"? Given that this is going to be an approved vaccine, it’s hard to imagine a more negative ruling. But the story gets better – read on…

This year, the maker of FluMist (MedImmune, a division of AstraZeneca) has changed the influenza A component to hopefully boost the response rate, but we will not know about the new vaccine’s effectiveness until several months after use begins in August.

Most people are thrilled to once again have the option of a nasal spray. In general, children overwhelmingly prefer the nasal spray form as it does not cause pain nor does it involve using a needle. Unfortunately, the AAP’s recommendation to use it only as a "last resort" puts many doctor’s offices in a bind, because decisions about which vaccine to order has to be made by May or June. This is to ensure adequate supply and delivery in time to begin vaccination in late summer to early fall. Ordering little or no nasal flu vaccine may backfire if patients are aware there is a choice and decide to wait until a nasal spray is available. Alternatively, more patients may opt to receive the nasal spray vaccine at a Q-SHIP (quick-serve healthcare and immunization provider – my abbreviation!), such as CVS Minute Clinic. This becomes a problem if such retail clinics also decide to under-order the spray, or if patients neglect to get this done once they have left the doctor’s office. Historically, more children are vaccinated than adults, so the impact is greater on a pediatric office. The disagreement between the CDC and the AAP is unusual, and this year will be interesting (to me) to see how the dissent pans out.

The nasal spray vaccine is approved for use in children 2 years and older, and for adults up to age 49.

Which would you choose????

Read the press release from the AAP here.

See a video by one of my vaccination heroes, Paul A. Offit, MD, from the Children’s Hospital of Philadelphia, here.

June 11, 2018: The Saga Continues…

Today the AAP released some amended recommendations on use of FluMist. It acknowledged the differences in the recommendations between it and the CDC, and took a more moderate stance, stating that (italics added by me):

• Annual influenza vaccination is recommended for everyone 6 months and older.
• For the 2018-’19 season, the AAP recommends inactivated influenza vaccine (IIV3/4) as the primary choice for all children because the effectiveness of LAIV4.

1. was inferior against A/H1N1 during past seasons; and
2. is unknown against A/H1N1 for this upcoming season

• LAIV4 may be offered for children who would not otherwise receive an influenza vaccine (and for whom it is appropriate by age and health status).
• As always, families should receive counseling on these revised recommendations for the 2018-’19 season.

See the full press release here.

Note the "last resort" wording is conspicuously absent in this commentary. This is what passes for intrigue in pediatrics! Will be very interesting to see the effectiveness data when it starts to come out in the winter!!!!

But Wait, there’s more…

The CDC’s ACIP is also weighing in (again), with more detailed info on the new vaccine recommendations:

• Recommendation of the ACIP: For the 2018–19 U.S. influenza season, providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, recombinant influenza vaccine [RIV], or LAIV4). LAIV4 is an option for those for whom it is otherwise appropriate. No preference is expressed for any influenza vaccine product. ACIP will continue to review data concerning the effectiveness of LAIV4 as they become available. Providers should be aware that the effectiveness of the updated LAIV4 containing A/Slovenia/2903/2015 against currently circulating influenza A(H1N1)pdm09-like viruses is not yet known.

So now the CDC’s official position is that any of the age-appropriate flu vaccines are acceptable options, including FluMist (see here). (Hooray from me!) This difference of opinion between the AAP and the CDC is unusual (they almost always are in complete agreement) but both sides have valid points of view. (For those who want the entire document, it’s posted here.)

July 2018: Now, even Canada is weighing in! See the article from JAMA-Pediatrics here.

So I got my wish – everything is approved and everyone can have what they want. Happy vaxxing!!

USUAL PEDIATRIC SCHEDULE FOR INFLUENZA VACCINE:

• Every year for babies, children and adults 6 months and older; given from August to May; earlier is better
• Children under age 9 years old receiving flu vaccine for the FIRST TIME get 2 doses, at least 1 month apart