A 3 year old F with h/o asthma and cochlear implant was recently diagnosed with Kawasaki Disease and was treated appropriately at her local pediatric hospital. The patient also received a dose of Tamiflu (Oseltamivir) yesterday. The parents are requesting the patient receive a live attenuated influenza vaccine, but you counsel them that she should avoid a live influenza vaccine. Which of the following is NOT a reason to avoid the live attenuated influenza vaccine in this patient?

A. History of asthma

B. Recent administration of Tamiflu (Oseltamivir)

C. Cochlear implant

D. Age

E. Receiving aspirin or salicylate-containing medications

 

The answer is D. The CDC recommends the live attenuated influenza vaccine (LAIV) may be given starting at age 2. However, the rest of the answer choices are contraindications to receiving the LAIV.

 

Recommendations of the Advisory Committee on Immunization Practices- United States, 2020-21 Influenza Season (Published August 21, 2020)

  • Contraindications to live attenuated influenza vaccination (LAIV4) are as follows:
  • History of severe allergic reaction to a previous dose of influenza vaccine or to any vaccine component (except egg)
  • Receiving aspirin or salicylate-containing medications (Risk of Reye Syndrome)
  • Age 2-4 years with history of asthma or wheezing
  • Immunocompromised due to any cause (including medications and HIV infection)
  • Anatomic or functional asplenia (including due to Sickle Cell Anemia)
  • Close contacts or caregivers of severely immunosuppressed persons who require a protected environment
  • Cerebrospinal fluid communication with oropharynx, nasopharynx, nose, ear, or any other cranial CSF leak
  • Cochlear implant (Potential for CSF leak)
  • Pregnancy
  • Received influenza antiviral medications within the previous 48 hours for Oseltamivir (Tamiflu) and Zanamivir (Relenza), 5 days for Peramivir (Rapivab), and 17 days for Baloxavir (Xofluza). This duration may be prolonged in patients with delayed medication clearance, such as renal insufficiency.

 

Precautions for use of LAIV4 include the following:

  • Moderate or severe acute illness with or without fever
  • History of GBS within 6 weeks of receiving any influenza vaccine
  • Asthma in patients aged 5 years or older
  • “Other underlying medical condition (other than contraindications) that might predispose to complications after wild-type influenza virus infection (i.e. chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus])”

 

Per 2013 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for Vaccination of the Immunocompromised Host (Published December 4, 2013)

Annual inactivate influenza vaccination is recommended for immunocompromised patients aged 6 months or older, except for patients who are very unlikely to respond (although unlikely to be harmed by IIV), such as those receiving intensive chemotherapy (induction or consolidation chemotherapy for acute leukemia) or those who have received anti–B-cell antibodies within 6 months.

 

References

1. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season. MMWR Recomm Rep 2020;69(No. RR-8):1–24. DOI: http://dx.doi.org/10.15585/mmwr.rr6908a1

2. Lorry G. Rubin, Myron J. Levin, Per Ljungman, E. Graham Davies, Robin Avery, Marcie Tomblyn, Athos Bousvaros, Shireesha Dhanireddy, Lillian Sung, Harry Keyserling, Insoo Kang, 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Volume 58, Issue 3, 1 February 2014, Pages e44–e100, https://doi.org/10.1093/cid/cit684

3. Robinson CL, Bernstein H, Poehling K, Romero JR, Szilagyi P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:130–132. DOI: http://dx.doi.org/10.15585/mmwr.mm6905a3

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