Guidance on Influenza Vaccine Prioritization

On October 5, 2004, the Centers for Disease Control and Prevention (CDC), in coordination with its Advisory Committee for Immunization Practices (ACIP), issued interim recommendations for influenza vaccination during the 2004–05 season. On October 19, 2004, the Washington State Vaccine Advisory Committee (VAC) published interim guidance to assist healthcare providers in interpreting and implementing the CDC guidelines. Any or all of this guidance may be superseded by subsequent recommendations from the CDC/ACIP or the VAC. The entire VAC guidance document can be found at: www.metrokc.gov/health/providers/epidemiology/flualert-041019.htm . The following is a summary of the guidance document.

The priority groups for vaccination with inactivated influenza vaccine this season are considered to be of equal importance and are:

• All children aged 6–23 months;
• Adults aged 65 years and older;
• Children and adolescents, aged 2 to18 years, on long-term aspirin therapy;
• Pregnant women;
• Residents of nursing homes and long-term care facilities;
• Healthcare workers involved in direct patient care;
• Out-of-home caregivers and household contacts of children aged <6 months;
• Persons aged 2–64 years with underlying chronic medical conditions, including:
  • Chronic cardiac and pulmonary diseases, including asthma
  • Adults and children who required regular medical follow-up or hospitalization during the past year because of:
    • Chronic metabolic diseases including diabetes mellitus
    • Renal dysfunction (kidney diseases)
    • Hemoglobinopathies (blood disorders such as sickle cell anemia)
    • Immunosuppression (including immuno-suppression caused by medication or by HIV)

The following conditions alone do not constitute a priority condition for vaccination in persons aged 2–64 years: hypertension; uncomplicated valvular heart disease or arrhythmia; hypercholesterolemia; gout; arthritis; diabetes managed by diet, without medications or regular medical follow-up; past or current cancer without current immune system suppression or compromise (i.e., not on chemo-therapy); uncomplicated mild asthma not requiring regular medication; history of pneumonia without chronic pulmonary disease; history of sinusitis; history of otitis media; urinary tract or kidney infections.

Use of inactivated influenza vaccine in household members of persons with severe immune system dysfunction

The VAC considers it acceptable to use inactivated influenza vaccine this season in household members of persons with severe immune system dysfunction (such that they would not be expected to respond to vaccination themselves, i.e. marrow and stem cell transplant recipients). Because of the severely limited supply of inactivated influenza vaccine, it should not be given to household contacts of less severely immunosuppressed patients who are more likely to respond to influenza immunization themselves (such as oncology patients undergoing standard chemotherapy).

Use of Live Attenuated Influenza Vaccine (LAIV, FluMist®)

The VAC suggests that, when possible, intranasally administered live, attenuated influenza vaccine (FluMist®, which is licensed for healthy, non-pregnant persons aged 5-49 years) should be used preferentially in persons who are in a CDC priority group for vaccination because they are healthcare workers, are out-of-home caregivers or household contacts of children <6 months of age, or are household contacts of persons in a priority group for vaccination because of chronic underlying medical conditions.

FluMist® is not recommended for:

• Health care providers, of severely immuno-compromised patients (e.g., those who work in specialized patient-care areas with a positive air flow relative to the corridor), or
• Household members of persons with severe immune system dysfunction, i.e. marrow and stem cell trasnplant recipients.

What is the definition of "direct patient care"?

The CDC defines "direct patient care" as direct, hands-on, or face-to-face contact with patients as part of routine daily activities. This includes doctors, nurses, other health care workers, paramedics, and triage receptionists who are physically located in places such as emergency rooms and clinics where they have frequent face-to-face contact with patients. It might also include police or other persons (e.g., volunteers) who are working routinely in healthcare settings and have hands-on or face-to-face contact with patients, but does not include staff working primarily in office settings where patients are not present, even if the office is located in a hospital or clinic. It is important to remember that the primary reason for vaccinating persons involved in "direct patient care" is to prevent transmission of influenza from such persons to those at high risk for complications from influenza.

The VAC suggests prioritizing for initial vaccination with influenza vaccine those healthcare workers who care primarily for patients at high-risk for severe influenza and who have frequent direct, hands-on, or face-to-face contact.