AAP urges flu shots over nasal spray for kids when possible

As fall approaches with new school year underway, the American Academy of Pediatrics (AAP) issued revised flu vaccination recommendations for the upcoming season, which say children ages 6 months and older should get the flu shot and that the live attenuated nasal spray vaccine (FluMist) should be used only as a last resort.

The group's recommendation regarding FluMist is slightly different than that of the US Centers for Disease Control and Prevention (CDC), which has no preferential recommendation between injectable vaccines and the inhaled formulation.

In May, a few months after CDC vaccine advisors cleared the use of FluMist after a 2-year absence from the US market, the AAP signaled that it would recommend families choose the inactivated vaccine (flu shot) for their children because of lingering uncertainties over how effective the spray will be.

However, both groups still recommend that everyone age 6 months and older be immunized against flu as soon as the vaccine is available. The AAP published its policy recommendations in the latest issue of Pediatrics.

Debate of studies after company's flu-strain swap

The AAP's updated recommendation comes on the heels of a 2017-18 flu season that was severe for all age-groups and led to 180 deaths in children, the highest for any year outside of the 2009 H1N1 pandemic since the CDC began recording kids' flu fatality numbers in 2004.

FluMist was first licensed in 2003, offering a needle-free, attractive option for children in a formulation that's easier to use in school-based flu vaccination campaigns.

However, in 2015 the CDC's Advisory Committee on Immunization Practices (ACIP) removed its recommendation for FluMist, based on disappointing performance against the 2009 H1N1 strain.

After intense study and debate, ACIP in February voted to include the vaccine in its recommended line-up for the 2018-19 flu season. The decision was reached after ACIP experts reviewed findings from AstraZeneca, the vaccine's maker, that suggested improved performance based on shedding and antibody response in children ages 2 to 4 years old following the company's switch to a different 2009 H1N1 type, from A/Bolivia to A/Slovenia.

Some members had reservations about whether the new data were strong enough evidence of protection and worried about how the new version of FluMist would perform, especially in a season potentially dominated by 2009 H1N1. Members raised concerns about how more problems might undercut vaccination coverage, while others said adding FluMist back into the mix might make it difficult to explain the changes to families.

However, several others said withholding ACIP recommendation for another year might reduce vaccine uptake, with some noting that flu vaccine effectiveness issues crop up with flu vaccines in general, not just FluMist.

Uncertainty about protection for season ahead

In its recommendations, the AAP said its Committee on Infectious Diseases and ACIP have reviewed and carefully considered all influenza vaccine data available and new information on FluMist's updated formulation for the 2018-19 flu season.

Given that FluMist protection against 2009 H1N1 was inferior during past flu seasons, however, the committee said it's effectiveness is unknown for the upcoming season.

It added, though that both AAP and the CDC support the use of FluMist for the upcoming flu season, with the goal of optimizing vaccine coverage and optimal protection for all ages. The AAP recommends inactivated trivalent (three-strain) or quadrivalent (four-strain) flu shots for all children, reserving FluMist for children who would otherwise not receive a flu vaccine, such as in cases of vaccine refusal, and for whom the vaccine is indicated—healthy children age 2 and older.

Vaccine makers expect to offer an adequate supply of quadrivalent vaccine, but AAP advised doctors to administer whichever formulation is available in their communities. The group's recommendations also cover when two doses are needed in children age 6 months through 8 years of age.

See also:

Sep 3 Pediatrics report

Sep 3 AAP News report

Feb 21 CIDRAP News story "CDC vaccine panel brings back FluMist for 2018-19 season"

May 22 CIDRAP News scan "AAP says FluMist can be used as a 'last resort' in kids"

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