Ask the Experts
As appeared in the September 2009 issue of Vaccinate Adults
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Seasonal & H1N1 influenza
Q:
In anticipation of H1N1 monovalent vaccine arriving later this fall, CDC recommends that we begin vaccinating with seasonal influenza vaccine now. Does protection from seasonal influenza vaccine decline or wane within 3 or 4 months of vaccination? Should I wait until October or November to vaccinate my elderly or medically frail patients?
A:   CDC recommends that seasonal influenza vaccine be administered to all age groups as soon as it becomes available. Antibody to seasonal inactivated influenza vaccine declines in the months following vaccination. However, antibody level at a point several months after vaccination does not necessarily correlate with clinical vaccine effectiveness. There are no studies that compare vaccine effectiveness according to the month when the vaccination was given. The authors of a recent review on antibody declines among the elderly after vaccination reported, “In conclusion, we found no compelling evidence for more rapid decline of the influenza vaccine-induced antibody response in the elderly, compared with young adults, or evidence that seroprotection is lost at 4 months if it has been initially achieved after immunization.” (See Skowronski, et al., Rapid Decline of Influenza Vaccine-Induced Antibody in the Elderly: Is it Real, or Is It Relevant? Journal of Infectious Diseases 2008;197:490-502). In addition, there is a lack of evidence for late-season outbreaks among vaccinated persons that can be attributed to waning immunity.
 
Q:
Will we be able to administer both the seasonal and H1N1 influenza vaccines at the same visit?
A:  
You can in most cases. See the points below.
•
You can administer both the inactivated seasonal and the inactivated H1N1 influenza vaccines at the same visit (using separate syringes and sites) or at any time before or after each other.
•
You can administer the inactivated seasonal and live H1N1 influenza vaccines together or at any time before or after each other.
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You can administer the live seasonal and inactivated H1N1 influenza vaccines together or at any time before or after each other.
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Administering both the live attenuated seasonal and the live attenuated H1N1 influenza vaccines at the same visit is NOT recommended because of concerns about competition between the 2 vaccine viruses. If you have only live vaccines for both seasonal and H1N1 influenza available, you should separate the doses of the live vaccines by at least 4 weeks.
 
Q:
When will vaccine for the 2009 H1N1 influenza virus be available?
A:   In late August, CDC announced that approximately 45 million doses of H1N1 influenza vaccine would be available in mid-October with approximately 20 million additional doses released in each subsequent week. On September 15, the FDA licensed three new injectable influenza A (H1N1) 2009 vaccines (CSL, Novartis, and sanofi pasteur) and one new intranasal influenza A (H1N1) vaccine (MedImmune). Package inserts are available at www.immunize.org/packageinserts/pi_h1n1.asp. Once H1N1 influenza vaccine is made available, vaccination efforts should begin immediately.
 
Q:
Is the 2009 H1N1 influenza vaccine experimental?
A:  
No. The 2009 H1N1 influenza vaccines are made employing the same methods and facilities used annually to produce seasonal influenza vaccine. H1N1 influenza vaccine will be available in an inactivated, injectable formulation and a nasal-spray, live attenuated formulation. These vaccines have been undergoing clinical trials to determine the size of the dose and the number of doses needed.
 
Q:
Once a 2009 H1N1 influenza vaccine becomes available, who will be targeted to receive the vaccine?
A:   On Aug. 28, 2009, CDC issued recommendations for the use of the 2009 H1N1 influenza vaccine. The recommendations identify 5 initial target groups for H1N1 influenza vaccination. They are (1) pregnant women; (2) people who live with or provide care for infants younger than age 6 months (e.g., parents, siblings, day care providers); (3) healthcare and emergency medical services personnel; (4) children and young adults ages 6 months through 24 years; and (5) people ages 25 through 64 years who have medical conditions that put them at higher risk for influenza-related complications. You can access the complete recommendations at www.cdc.gov/mmwr/pdf/rr/rr5810.pdf.
 
Q:
Are healthcare personnel among the initial target groups for monovalent H1N1 vaccine?
A:  
Emphatically yes. Healthcare personnel are among the highest priority groups for both monovalent H1N1 AND seasonal influenza vaccine. HCP of all ages should be vaccinated as soon as the vaccines become available.
 
Q:
Why are pregnant women prioritized for vaccination?
A:   Data from early 2009 H1N1 influenza cases in the United States show that pregnant women account for a disproportionate number of deaths, making them a high-priority group for vaccination (see www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/abstract). Also, guidance has been issued for clinicians to promptly treat pregnant women who become infected with the 2009 H1N1 virus with antiviral drugs (see www.cdc.gov/h1n1flu/clinician_pregnant.htm).
 
Q:
Why aren’t adults age 65 years and older included as a priority group for the 2009 H1N1 vaccination as they are for seasonal influenza, where they are included as part of the age-50-and-older priority group?
A:   People age 65 years and older are included as a priority group if they live with or care for infants younger than age 6 months or are a healthcare or emergency services provider. Current studies indicate that the risk of infection, hospitalization, and death from the 2009 H1N1 influenza virus among persons age 65 years and older is less than is the risk for younger age groups. Studies suggest that there is some degree of preexisting immunity to the 2009 H1N1 strains, especially among adults older than age 60 years. One possible explanation is that some adults in this age group have had previous exposure, either through infection or vaccination, to an influenza A (H1N1) virus.
 
Q:
Will H1N1 influenza vaccine be available for healthy people age 25 years and older (who are not in targeted groups)?
A:   Once public health authorities at the local level determine that the H1N1 influenza vaccine demand for the 5 target groups has been met, providers will be notified that they can administer the vaccine to healthy people ages 25 through 64 years. Once demand for H1N1 influenza vaccine among younger age groups is met, vaccination should be expanded to all people age 65 and older.
 
Q:
Once H1N1 influenza vaccine becomes available, should we stop administering seasonal influenza vaccine?
A:
No. Providers should start administering seasonal influenza vaccine as soon as it is available and continue to administer it throughout influenza season, including during the winter and spring months.
 
Q:
If a patient has received the seasonal influenza vaccine, do they need to receive the H1N1 influenza vaccine?
A:
If a patient is in a risk group to receive H1N1 influenza vaccine, they should be vaccinated. Studies suggest that vaccination with seasonal influenza vaccine will not provide protection against the 2009 H1N1 influenza virus and vice versa.
 
Q:
Will there be a new Vaccine Information Statement (VIS) for the 2009 H1N1 influenza vaccine or can we use the same influenza VISs that have been issued from CDC for seasonal influenza vaccine?
A:
A new VIS will be developed that pertains only to the 2009 H1N1 vaccine. You will find it posted at www.immunize.org/vis when it is available.
 
Q:
We have begun a more aggressive approach to vaccinating our high-risk patients against pneumococcal disease in light of the 2009 H1N1 influenza pandemic. Do you have any suggestions on how we can improve our system?
A:
Congratulations on your efforts to increase your clinic’s vaccination rates against this serious and deadly disease. Health experts have found that influenza predisposes individuals to bacterial community-acquired pneumonia, and studies have shown that this is heightened during influenza pandemics.
In June 2009, CDC issued interim guidance for use of 23-valent pneumococcal polysaccharide vaccine (PPSV) in preparation for the upcoming influenza season. Though the interim guidance does not change the groups indicated for PPSV vaccination, it does remind providers that many at-risk people younger than age 65 years and many people who are age 65 and older have not yet been vaccinated—and they need to be. You can find the interim guidance statement at www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm.
For more information on PPSV vaccination, including a listing of the high-risk people recommended
to be vaccinated, read IAC’s professional education sheet “Pneumococcal polysaccharide vaccine (PPSV): CDC answers your questions” (see page 6 of this issue of Vaccinate Adults or go to www.immunize.org/catg.d/p2015.pdf).
Other Vaccine Questions
Q:
We’ve heard there is a new recommendation for giving hepatitis A vaccine to people who will be in contact with recently adopted children. Would you give us the details?
A:
Yes. ACIP voted in February 2009 to recommend vaccination against hepatitis A for all previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee’s arrival in the U.S. In addition to the adoptee’s new parents and siblings, this group could include grandparents grandparents and other members of the extended family, caregivers, and healthcare providers. Ideally, the first dose of hepatitis A vaccine should be given to close contacts as soon as adoption is planned but no later than 2 weeks prior to the arrival of the adoptee. A second dose should be given no sooner than 6 months after the first dose.
 
Q:
Who is recommended to receive hepatitis A vaccine?
A:
According to CDC, people recommended for vaccination include:
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All children at age 1 year (12–23 months)
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People age 12 months or older who are traveling to or working in an area of the world except the United States, Canada, Western Europe, Japan, New Zealand, and Australia
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Men who have sex with men
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Users of illicit drugs, injectable or noninjectable
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Previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee’s arrival in the U.S.
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People who have blood clotting disorders
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People who work with HAV-infected primates or with HAV in a research laboratory setting (no other groups have been shown to be at increased risk for HAV infection because of occupational exposure)
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People with chronic liver disease
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Any person who wishes to be immune to hepatitis A
Hepatitis A vaccine is not routinely recommended for healthcare workers, sewage workers, or day care providers. Children who are not vaccinated by age 2 years should be vaccinated as soon as feasible.
 
Q:
If an adult has had zoster with herpetic neuralgia ophthalmic complications, when can they receive the zoster vaccine?
A:
Once they are no longer acutely ill, they can be vaccinated with zoster vaccine. There is no evidence that the vaccine will have therapeutic effect for a person with existing postherpetic neuralgia.
 
Q:
I understand that ACIP now recommends fewer doses of rabies vaccine be given in certain post-exposure situations. Can you tell me more?
A:
In June 2009, ACIP voted to eliminate the fifth dose of vaccine given as post-exposure prophylaxis to previously unvaccinated persons who are not immunosuppressed. This decision was based on evidence that the elimination of the fifth dose will not compromise immunity. The implications of this change are that it will conserve the supply of rabies vaccine, protect the patient, and reduce the number of office visits. To view the provisional recommendations,
go to www.cdc.gov/vaccines/recs/provisional/downloads/rabies-July2009-508.pdf.
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