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October 29, 2009

The Double Flu Vaccine Season Is Here -- Now What Should You Do?

Sandra A. Fryhofer, MD
Welcome to the first issue of "Staying Well," which will focus on prevention. I know many of us have been bombarded with phone calls and questions about flu and flu vaccination. That's why influenza is my inaugural topic.
First, Take Your Own Medicine. Get Immunized -- It Protects You and Your Patients
The 2009 American College of Physician Adult Immunization Campaign reported a dismal influenza vaccination rate of only 36% for healthcare workers. These vaccination statistics are surprising, shocking, disappointing, and downright embarrassing. What's even worse? The American College of Physicians finds that 70% of sick healthcare workers go to work anyway. Follow the advice you give to your patients. If you do get sick, stay home. Don't pass your flu on to your patients and staff. Many health systems now require flu immunization for healthcare workers. To me, getting vaccinated is professional and being responsible to our patients and our families. The only contraindications to vaccination are egg allergy or history of Guillain-Barré syndrome with previous flu vaccine administration. And of course, this year, all healthcare workers need both seasonal flu and H1N1 flu vaccination.
This Season, Flu Treatments Come in Pairs
Here's what to choose from:
Two types of flu vaccinations: seasonal and H1N1;
Two types of vaccine to choose from: nasal mist and a shot; and
Two doses, 1 month apart, of H1N1 vaccine for kids younger than 10 years of age.
Trials of 2009 H1N1 live attenuated vaccines (LAIVs) nasal mist indicate that 28 days is the appropriate valid interval for the 2 doses. However, there is a little more leeway with the inactivated shot. Centers for Disease Control and Prevention (CDC) guidance says that administering the 2 doses of a 2009 H1N1 inactivated vaccine at least 21 days apart is safe.
Kids younger than 9 years of age receiving their first-ever seasonal flu vaccination also need those 2 doses given 1 month apart. Children younger than 6 months of age are too young for flu vaccination. That's why it is so important for all caregivers of infants to get vaccinated. Adults and children age 10 years and older need just 1 dose of H1N1 flu vaccination. Check the CDC Website[1] as the season progresses for any updated information on ages and intervals.
Nasal mist LAIV should only be given to healthy individuals age 2-49 years old and not to pregnant women. Pregnant women should only be given the flu shot made from inactivated virus.
Simultaneous Dosing of Seasonal and H1N1 Vaccination
Knowing the rules for mixing and matching different types of vaccine means learning the lingo.
LAIV: live attenuated influenza vaccine (nasal mist: 1 for seasonal flu, and 1 for H1N1);
TIV: trivalent inactivated influenza vaccine (the seasonal flu shot). The 2009-2010 seasonal flu vaccine contains:
A/Brisbane/59/2007 (H1N1)-like virus;
A/Brisbane/10/2007 (H3N2)-like virus; and
B/Brisbane/60/2008-like virus.
MIV: monovalent inactivated influenza vaccine (the novel H1N1 flu shot).
For administering inactivated TIV and H1N1 MIV, mixing and matching is not a problem and there are no restrictions. Shots for seasonal TIV and H1N1 MIV can be given on the same day, at the same time. Simultaneous dosing of LAIV at the same time as inactivated TIV or inactivated H1N1 MIV is also not a problem.
Using LAIVs for both vaccines is tricky, however. The CDC says don't give seasonal LAIV and H1N1 LAIV at the same time. Although there are no data on sequential administration of seasonal LAIV and H1N1 LAIV, experts are concerned that simultaneous administration could result in reduced immunogenicity for 1 of the vaccines. This means the vaccines may not work as well. Specific CDC guidance posted October 21, 2009 says doses of seasonal LAIV and 2009 H1N1 LAIV administration should be separated by at least 14 days.[2]
Separate injections and/or separate nasal mist must be used for administering seasonal and H1N1 vaccines. Different products should not be physically mixed before administration. A 2009 study suggested that the TIV might offer some protection against H1N1. At this time, the significance of this finding is unknown.[3]
What Mask Should You Wear?
Interim CDC recommendations for facemask and respirator use were issued on September 24, 2009, which say "no change has been made to guidance on the use of facemasks and respirators for healthcare settings." Current CDC recommendations designate wearing N95 masks (respirators) for healthcare workers with "direct medical care and support activities for patients with confirmed or suspected H1N1 flu."[4]
N95 respirator vs facemask. In choosing personal protective equipment, safety and protection are most important. N95 masks are expensive, and if all healthcare workers are required to wear them, there may not be enough to go around. Surgical masks are cheaper and more comfortable. Furthermore, a Canadian study in the Journal of the American Medical Association suggests that they may work just as well as N95 respirators in protecting healthcare workers from flu exposure in emergency departments and medical units.[5] Of course, when extra protection is needed in droplet exposure-laden settings, such as during intubation or when in a bronchoscopy laboratory, an N95 mask is probably better. Facemasks should be available for patients if they come into the office sick.
Note: At this time some facilities are currently experiencing shortages of respiratory protection equipment, including N95 respirators, and further shortages are expected. In such cases, if all reasonable methods fail to alleviate the shortage, the CDC recommends the use of facemasks. [6]
Flu Antiviral Drugs: Who Needs Them?
The CDC Health Advisory issued recommendations on October 19, 2009 to say that most healthy people who come down with flu will not need antiviral drugs, as long as they seem to be getting better.[7] On the other hand, those who have severe flu symptoms, including those requiring hospitalization, should be started on antiviral drugs as soon as possible. Don't wait for laboratory confirmation before instituting treatment. Antiviral drugs work best if started within 48 hours of onset of symptoms. Groups at increased risk for flu-related complications should also be treated. They include pregnant women, children younger than age 2, people age 65 and older, and patients with chronic medical conditions including immune system problems.
Which antiviral drug should be used? Base your choice on what virus is currently circulating. Virus susceptibility to antiviral drugs can change. At the time this article has been published, almost all circulating viruses are novel H1N1 influenza A, which, at least for now, tend to be sensitive to both oseltamivir and zanamivir. A few cases of oseltamivir resistance to H1N1 have been reported. Keep this in mind if your patient does not seem to be responding to therapy. You best bet is to check the CDC Website at least weekly and look and stay tuned for weekly flu updates.[8]
Antiviral drugs for treatment. For treatment, dosing is twice daily for 5 days. Treatment choices for adults include:
Oseltamivir: 75-mg capsule twice daily for 5 days; and
Zanamivir: 10 mg (two 5-mg inhalations) twice daily for 5 days.
Antiviral drugs for chemoprophylaxis. Chemoprophylaxis is not generally recommended due to concerns that it could exacerbate antiviral resistance. Use for healthcare workers is an exception. Postexposure antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for healthcare personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person's infectious period.[7] Note that viral shedding generally begins 1 day before and continues for 7 days after the onset of symptoms.
In using antiviral agents for chemoprophylaxis, dosing is half as much and they are taken for twice as long as in treatment -- once a day for 10 days. Chemoprophylaxis choices for adults include:
Oseltamivir: 75 mg capsule once a day for 10 days; and
Zanamivir: 10 mg (two 5-mg inhalations) once daily for 10 days.
Diagnosing H1N1: What About Quick Flu Tests?
Rapid flu tests may not be so helpful for diagnosing novel H1N1, because their sensitivity for 2009 H1N1 ranges from 10% to 70%. Use your best clinical judgment to make the diagnosis and to decide who needs treatment. Hospitalized patients should be tested using real-time reverse transcriptase-polymerase chain reaction.[9,10]
Don't Forget About the Pneumococcal Vaccination
Influenza of any type can kill. CDC stats report more than 200,000 hospitalizations and 36,000 deaths from flu and flu-related complications each year, on average. During the 20th century influenza pandemics, secondary bacterial pneumonia was an important cause of illness and death and Streptococcus pneumoniae (pneumococcus) was the most common etiology.[11]
The most recent Advisory Committee on Immunization Practices recommendations add smokers and asthmatics to the pneumococcal vaccination list, which also includes patients with chronic medical conditions and people age 65 and older.[12]
When to revaccinate has always been confusing. The Adult Immunization Schedule says revaccinate once after 5 years for chronic medical conditions (including patients with renal failure, immunocompromised patients, and after splenectomy). Also, people age 65 and older should receive a one-time additional pneumococcal vaccination if they were younger than 65 years of age when first vaccinated and it has been 5 years or more since last vaccination.[13]
Summary: Vaccinate!
I plan to get H1N1 vaccination when available, and I have encouraged my college-age twins to get vaccinated at school. I have already received my seasonal influenza vaccination. Please join me.

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