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

A 4 month-old full term female with history of eczema and egg allergy presents for her 4 month well child visit in October. Mother is requesting an influenza vaccine be given with her scheduled 4 month vaccines. When questioned about the egg allergy, mom states that she had hives and respiratory distress after eating eggs previously. Should this patient receive the influenza vaccine at this visit?

A. No, her severe egg allergy is a contraindication to giving the vaccine.

B. No, she is not old enough to receive the vaccine at this visit.

C. Yes, she can receive the vaccine if monitored closely in clinic for signs of anaphylaxis.

D. Yes, she can receive the vaccine without additional monitoring.

E. Yes, she can receive the vaccine, but she will need a second vaccine dose.

The correct answer is B. The CDC recommends annual influenza vaccines be given starting at age 6 months for Inactivated Influenza Vaccine (IIV), 2 years for Live Attenuated Influenza Vaccine (LAIV), and 18 months for recombinant influenza vaccine (RIV).

If the patient had been 6 months of age, answer choice C would have been correct. Severe egg allergy is NOT a contraindication to receiving the influenza vaccine. However, the patient should be closely monitored by a medical provider after administration for signs of severe allergic reaction.

If the patient is 6 months to 8 years of age, then you should ask if the child has received 2 doses or more TOTAL. If not, then give 2 doses of influenza vaccine, given 4 weeks apart as minimum interval. It is important to note that the 2 doses of influenza vaccine do not have to have been given in the same season or consecutive seasons to count. The 2 dose series should be based on age of first vaccination. In other words, if the first dose is given at age 8, and the child turns 9 during the same season, they should still receive the second dose of the influenza vaccine.

A systematic review and meta-analysis posted in Vaccine journal in March 2020 showed influenza “vaccination offered high protection against influenza hospitalization in children… Effectiveness was higher against H1N1 (74%) and Influenza B (51%) and moderate against H3N2 (41%)… and significantly higher in fully vs partially vaccinated children” (62% vs 34%, respectively).

References

1. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-flu

2. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Influenza-Implementation-Guidance/Pages/Annual-AAP-Influenza-Policy.aspx

3. https://www.sciencedirect.com/science/article/pii/S0264410X20302619

Influenza vaccine effectiveness against influenza-associated hospitalization in children: A systematic review and meta-analysis. Vaccine. Volume 38, Issue 14, 23 March 2020, Pages 2893-2903

A 12 year old previously healthy male presents to the ED after stepping barefoot on a broken bottle on the beach. He has a jagged, deep laceration to his Right foot approximately 4cm in length. His immunization history is unknown. What tetanus post-exposure prophylaxis should this patient receive?

A. Tdap AND Tetanus Immunoglobulin

B. Tdap ONLY

C. Td ONLY

D. Neither Tdap or Tetanus Immunoglobulin

E. Tetanus Immunoglobulin ONLY

The correct answer is A.

After a “tetanus-prone injury,” it is recommended to receive a tetanus toxoid-containing vaccine (Td, Tdap, TT) if the following conditions are met:

1. Any person with an uncertain or incomplete history of completing a three-dose primary series of tetanus toxoid-containing vaccine
2. If the most recent dose was given 10 or more years ago (for minor and clean wounds)
3. If the most recent dose was given 5 or more years ago (for puncture wounds or wounds contaminated with dirt)

In addition, it is recommended to add a single dose of tetanus immune globulin (except after minor and clean wounds) if it is unclear that the three-dose primary vaccination series has been completed.

Because the immunization history in this individual is unknown, he at least would need Tdap or Td. If the wound had been clean and minor, he would not have needed Tetanus Immunoglobulin. However, since this wound is not clean or minor, he would also need Tetanus Immunoglobulin. If the patient had received at least 3 doses of tetanus toxoid-containing vaccines, then he would not require Tdap, DTaP, or Td, or Tetanus Immunoglobulin. However, if the patient has received at least 3 tetanus-containing vaccines, then they would need a booster vaccine without immunoglobulin after 10 years for a clean and minor wound, or after 5 years with all other wounds.

References

1. Bader MS, McKinsey DS. Postexposure Prophylaxis for Common Infectious Diseases. Am Fam Physician. 2013 Jul 1;88(1):25-32. https://www.aafp.org/afp/2013/0701/p25.html
2. CDC Immunization Schedule 2020 https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-tdap