Flu Vaccine Season 2018-2019

Every year the flu vaccine season throws us something new and challenging. The buzz this year is pediatricians questioning what to recommend with the new version of FluMist.  So what’s new with the flu vaccine season 2018-2019?

If you tried to get a FluMist vaccine for the past couple of years, you know that it wasn’t available. It did not seem to be effective, so it was removed from use. It has been reconfigured to improve the efficacy. The CDC’s Advisory Committee on Immunization Practices (ACIP) is allowing it to be re-released for the 2018-2019 season.

There are many versions of the flu shot. Some contain 3 strains of flu protection, others have 4 strains. Use of each is dependent on age and other factors. There is only one version of nasal spray flu vaccine, the FluMist.

Flu Vaccine Season 2018- 2019 ACIP Recommendations:

    • Everyone over 6 months of age who does not have a contraindication to vaccination should get a flu vaccine.
    • No preference is given for one vaccine product over another, as long as it is age appropriate and there are no contraindications. (See Controversy for details on this.)
    • Children under 10 years of age who have never had a flu vaccine should get two doses this year.
    • If vaccine supply is limited, high risk people should get priority. This includes:
    •      children 6-59 months
    •      adults over 50 years
    •      those with chronic diseases
    •      immunocompromised persons
    •      pregnant women
    •      American Indians and Alaska Natives
    •      morbidly obese people
  •      residents of long term care facilities

For the full report of recommendations, see MMWR: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season.

The big questions that may be on your mind:

1. When’s the best time to get a flu vaccine?

The CDC recommends starting to vaccinate as soon as it’s available (usually August or September) and to have the vaccine given by Halloween.

It’s not hard to see the logistical problems of vaccinating essentially everyone in the two months of September and October.

Some of the problems getting masses vaccinated:
  • Getting the vaccine itself. Recently flu shots have started to be delivered around the country. They seemed to show up first at big chain pharmacies before doctor’s offices. There aren’t any shortages this year so far, but not everyone can get all their vaccine orders at once.
  • The FluMist hasn’t been approved for shipping yet, so no one has that at this time. If you’re hoping to get it, you’ll have to wait. No approval date has been announced as far as I know.
  • I’ve heard that some Vaccine For Children (VFC) programs haven’t even opened up their ordering for the year. (Most flu vaccines are ordered in January or February for the next vaccine season, but VFC programs are state run and vary in rules.) If your child will require a VFC vaccine, you will likely have to wait until your clinic has them in stock, even if they have other flu vaccines.
  • Many years there are shortages. Those are hard to anticipate, but are another reason not to turn down a vaccine if it’s offered.
  • Having extra personnel skilled in giving flu vaccines available is difficult when they’re needed to perform typical work. Giving vaccines takes time. There’s a lot behind the scenes that needs to be done and documented in addition to the time of getting people prepared for the shot itself. And we all have seen the kids who put up a good fight, which means the nurse can’t quickly give the shot.
  • There are always time conflicts getting to a place that offers flu shots.  Work, school and activity schedules are busy. It can be hard getting everyone in the family to a place that has the right vaccine for each person at a time that you’re not busy.
What if you aren’t vaccinated by Halloween?

There will be many who continue to be vaccinated in November and beyond. It is recommended to continue vaccinating until the vaccine supply is gone or the season ends. The flu season can possibly last through May in the Northern Hemisphere.

Will an early flu vaccine last long enough?

I’m asked this question often. I’ve been told by several parents that they want to wait to get the shot for their family until October to optimize the protection during flu season.

While this sounds good in theory, I’m afraid that some of these people may miss the opportunity to be vaccinated before the flu hits.

Although we say that it tends to hit in January in my area, it can hit at any time. I’ve already heard of one case of Flu A in another local pediatric practice.

All vaccines take time to become effective, so waiting until you hear that it’s in the community is already too late in some respects. We often have more than one peak of flu activity each year, so still get the vaccine!

The effectiveness of the flu vaccine does decrease over time, but it’s estimated to last about 6 months. Unfortunately our season can last up to 8 months, so there is no perfect time.

What if we got our flu shot later in the season last year? Is it still good?

Each year the strains in the flu vaccines are updated to reflect the anticipated strains of influenza that will circulate. It’s important to get a new flu vaccine each season. Even if your child got a flu shot in May 2018, he should get another this Fall or Winter.

Who needs a second vaccine?

It is not recommended to get a second flu shot later in the season for most people.

Children under 9 years of age getting vaccinated for the first time need their primer dose and a booster dose at least 4 weeks later. Children who have previously received ≥2 total doses of influenza vaccine at least 4 weeks apart before July 1, 2018, require only one dose for 2018–19. The 2 doses of influenza vaccine do not have to have been administered in the same season or consecutive seasons. If they had only 1 flu vaccine before July 1, 2018, they need 2 doses this season.

number of flu vaccines needed
Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season. MMWR Recomm Rep 2018;67(No. RR-3):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6703a1

2. Will FluMist work?

Unfortunately, we won’t really know until the season is well underway. Every year we must wait to learn if the flu vaccine is effective. The effectiveness varies from year to year.

FluMist History

The FluMist was first approved in 2003. It was a welcome addition to the flu vaccine lineup because there are no needles needed. It seemed to be very effective initially. In 2014, the CDC’s Advisory Committee on Immunization Practices (ACIP) even gave it preferential status because it seemed to be more effective than the flu shot version.

The very next year ACIP reversed its decision due to very poor performance of the H1N1 strain in the FluMist in the United States. (This didn’t seem to be a problem everywhere.) FluMist was removed from the market for two years as scientists tried to figure out why it didn’t work well so they could remedy the problem.

This Year’s FluMist

Testing of the new version shows that the new H1N1 LAIV strain (A/Slovenia) performed significantly better than the 2015-16 strain (A/Bolivia).  Does this mean that it will perform better this season? We really don’t know, but in February 2018, ACIP voted to bring back the newly formulated FluMist for the 2018-2019 season.

In years past it was recommended for anyone who had received the FluMist to avoid contact with immunocompromised people for 7 days. It is no longer considered to be a risk to most immunocompromised people to be around a recently vaccinated person. If the immunocompromised state is severe enough to require a protected environment, avoidance for 7 days after FluMist continues to be recommended.

Controversy

While most of the experts on the ACIP panel voted in favor to bring the FluMist back based on the study results, some members were not in agreement. They still worry that the FluMist may not perform well during the flu season.

The CDC official position states no preference between the FluMist and the shot version, as long as the vaccine is age appropriate and there are no contraindications, such as allergy or chronic disease. The shot is available for all ages over 6 months old, but the FluMist is only for 2 – 49 year olds.

The AAP (American Academy of Pediatrics) stance on the FluMist is that it should only be used when the shot version is refused or unavailable. They will continually monitor the flu vaccine effectiveness patterns and may change their recommendation. If your child is worried about giving the shot, check out ways to make shots less scary.

Interestingly, Dr. Paul Offit, one of our country’s leading vaccine experts, disagrees with the AAP.

So I think the AAP was wrong, frankly, to say that FluMist should only be used as a last-resort vaccine for influenza. Rather, they should have gone along with what the ACIP said, which was that these vaccines can now be used interchangeably for persons aged 2-49 years. ~ Dr. Paul Offit

3. What about egg allergy?

For several years now egg allergy is not considered a contraindication to flu vaccines. Despite this, people still think they cannot be vaccinated due to an allergy.

Severe allergic reactions to vaccines, although rare, can occur at any time, even in without a history of previous allergic reaction. The person giving flu vaccines should be able to identify and equipped to handle any allergic reaction.

Different influenza vaccines contain different amounts of egg components, so it is important to discuss the history of egg allergy with the person who will give the flu vaccine.

Recommendations for those with egg allergy:
  • People with a history of egg allergy who have only had hives after exposure to egg should receive influenza vaccine. Any version that is age appropriate can be used.
  • People who have required epinephrine after eating egg or who have had angioedema, respiratory distress, lightheadedness, or recurrent vomiting are considered higher risk with influenza vaccination. They still may receive an age appropriate influenza vaccine, but it should be done in a health care setting, such as a medical clinic or hospital. They should not get the vaccine at a community drive, such as in a school or church setting. Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic reactions.
  • A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to vaccinating with that vaccine in the future. This does not include the typical reactions of redness at the injection site, fever, or muscle aches.
  • No observation period is recommended specifically for egg-allergic people. If there is concern, a 15 minute observation period after any vaccine can be done. This is commonly done in the adolescent age group due to their high risk for passing out after any needle – shots or blood draws.

4. What if you’re traveling internationally?

Influenza season varies by location. In the US, we tend to think of it as a winter thing, but it can happen during our summer months elsewhere. Flu is seen in the fall and spring in addition to the winter months in Kansas.

In the Northern Hemisphere it tends to hit between October and May. The Southern Hemisphere’s season tends to be April through September.

Even the types of influenza that circulates can vary by location. These types affect the type of vaccine that is used in that location.

It’s recommended to be vaccinated against influenza at least 2 weeks before traveling to any location during their flu season. This can be difficult if there is not any flu vaccine in your area. It can also be difficult to find the correct strains of flu vaccine in your location.

Talk to your physician or a travel clinic to see what is needed and available.

5. Doesn’t the flu shot cause the flu?

No. No it doesn’t.

Flu is a very dangerous illness that results in many people requiring hospitalization. Each year previously healthy children and adults die from influenza.

The symptoms people get after flu shots often could be explained by many viruses. They are not the flu. If they really are flu symptoms, it is because the vaccine didn’t have time to take effect or it was a strain not included in the vaccine.

There is no plausible way that the injectable flu vaccine can cause the flu. There is no live virus in the injectable vaccine that can lead to flu disease. Injectable flu vaccines are made in two ways. Either the vaccine is made with flu vaccine viruses that have been ‘inactivated’ and are not infectious or with no flu vaccine viruses at all.

The most common side effects from the influenza shot are soreness, redness, tenderness or swelling where the shot was given. Low-grade fever, headache and muscle aches also may occur, but interestingly these same symptoms occur with placebo shots too.

How do we know it doesn’t cause illness?

Studies like this one in adults have compared side effects of a flu shot to side effects of a placebo with saline (salt water). The only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. These all can occur during the time frame that the flu vaccine is typically recommended. It’s just a coincidence if you “get sick” after getting the vaccine.

Studies in children are lacking. Ethically it is difficult to study this, since it would require not giving some children a potentially life saving vaccine if they receive the placebo.

What about the FluMist?

The FluMist is a live virus. It can cause congestion and symptoms like a very mild case of the flu.

FluMist can cause mild illness, but it prevents (or hopefully will prevent) significant flu disease symptoms.

6. What if you get the flu?

I’ll write separately about how to treat the flu and flu-like symptoms.

You can guess what it will say based on what I’ve written previously about fever being scary, how to treat coughs, and Tamiflu.

7. Why bother, since the flu shot isn’t effective.

The effectiveness of the flu vaccine is never perfect, but it’s better than nothing. For more on this, see The flu shot doesn’t work.

What's new for the flu vaccine season 2018-2019? Should we use the shot or nosespray?
This Flat Stanley spent time in our office one flu vaccine season. Given the paucity of good stock photos of people getting vaccines, I chose this one to highlight the point of few photo choices. And I think it’s fun.

Flu Season Fears: What should you do?

Headlines are making everyone nervous about this year’s flu season. Schools are closing due to high flu numbers. Parents are worried that their child will be the next that dies.

Yes, the risk is real.

But there are things to do.

First: Prevent

Vaccinate

Vaccines are the one of the best inventions to prolong our lives. They really can help. I know the flu vaccine (or any vaccine) isn’t 100% effective, but it does help. Everyone over 6 months of age should get a flu shot.

I’ve heard from many pediatricians taking care of kids hospitalized with influenza, and none of the dying kids were vaccinated.

Kids who were vaccinated this season might get flu symptoms, but generally not as severe.

It does take 2 weeks for the vaccine to be effective, so get it ASAP. Kids under 9 years old who haven’t been vaccinated for flu previously will need 2 doses a month apart. Call around to see where you can get it.

If your kids (or you) are scared of shots, check out these tips.

Not convinced? Check out these 10 Reasons to Get the Flu Vaccine.

Wash hands

Wash hands often. This goes without saying. Whatever you touch stays on your hands. When you bring your hands to your face, the germs get into your body. Teach kids to wash hands well too!

Cover!
cough, cold, urgent care, primary care, medical home
Cover your cough!

Teach kids to cover their cough (and sneeze) with their elbow. This collects most of the germs in the elbow. Hands touch other things, so if you cover with your hands, you need to wash them before touching anything.

The only time I don’t recommend the elbow trick is if you’re holding a baby. Their head is in your elbow, so you should use your hands to cover and wash often!

You can get masks at the pharmacy to cover your nose and mouth to protect yourself from catching something and to prevent spreading an illness you have. We have masks available for anyone who comes to our office. We ask those who are sick to wear them, but those who are well can also put them on to prevent catching something!

In my office you’ll see that most of our nurses and clinicians have opted to wear masks when seeing sick kids even though we all have had our flu vaccine!

Avoid the T-zone

Avoid touching your face. It’s a horrible habit that most of us have. Be conscious of how often you wipe your mouth, eyes, or nose. Those are the portals to our body. Avoid touching them unless you can wash your hands before and after. Show kids how the eyes, nose and mouth make a “T” and teach them to not touch their T-zone.

Stay home when sick.

I’ve heard many angry complaints from parents about exposures. One mother was sick because she was exposed at work and then her illness spread to her family. She was especially upset because the exposure was from a child of a co-worker who brought the child to work because the child was sick and couldn’t go to school.

Keep sick kids home. If you’re sick: stay home.

If you’re sick with a flu-like illnesss, don’t
  • run to the store.
  • send your child to school with ibuprofen.
  • go to work.
  • go to your child’s game.

Stay home unless you need to seek medical attention.

Tamiflu and other anti-virals

My office is getting inundated with phone calls requesting us to call out Tamiflu. In some instances it’s appropriate for us to prescribe it for prophylaxis, but often we want to see your child first. If your child has flu-like symptoms, I do not want to prescribe a treatment without first evaluating your child. I don’t want to miss a more serious case that needs to be hospitalized. I don’t want to treat bronchiolitis or another condition as flu and miss the proper treatment. More on treatment with Tamiflu below.

Prophylactic uses

Tamiflu can be used for prophylaxis after exposure, but don’t rely on it. (If you follow my blog, you know I’m not a Tamiflu fan.)

Newborns

Some of the calls we are getting are from mothers with influenza who have newborns and their OB’s have recommended prophylaxis for the baby. If the baby is under 3 months of age, Tamiflu is not approved for prophylaxis. (See the chart and corresponding footnotes from the CDC below.) If you are sick, try these tips to prevent spreading illness to your kids.

Community exposures

Many calls are from parents worried about a classroom (or other) exposure in a child who is not high risk. Unfortunately we cannot and should not use Tamiflu for routine exposures. Tamiflu itself is not without risk and if overused it will not be available for people who might really need it.

Big event coming soon!

A big birthday party, a big test, a planned vacation, etc do not make your child high risk. We really shouldn’t use Tamiflu inappropriately just because flu will make life inconvenient. Remember that all treatments have potential side effects and if we use them indiscriminately they will not be available when really needed.

Tamiflu prophylaxis is recommended for high risk people who have known exposure.

High risk includes:

  • children under 2 years of age
  • adults over 65 years of age
  • persons with chronic lung (including asthma), heart (except hypertension alone), kidney, liver, hematologic (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury)
  • persons with immunosuppression, including that caused by medications or by HIV infection
  • women who are pregnant or postpartum (within 2 weeks after delivery)
  • under 19 years of age receiving long-term aspirin therapy
  • American Indians/Alaska Natives
  • persons who are morbidly obese
  • residents of nursing homes and other chronic care facilities

Prophylactic and treatment options are summarized in this table from the CDC:

Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza
Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza

Finding Tamiflu

Right now it’s hard to find Tamiflu in many parts of the country, so you might not be able to get it after you’re exposed (or even if you’re sick with flu).

What’s better than Tamiflu?

Flu season can last through April, so taking it for 10 days now won’t help in 2 weeks when you’re exposed again. The flu vaccine protects more effectively and for a longer duration!

If sick: Treat

Most flu symptoms can be treated at home.
Fever and pain reducers

Use age and weight appropriate pain and fever reducers, such as acetaminophen and ibuprofen to keep kids comfortable. It is not necessary to bring the temperature to normal – the goal is to keep them comfortable. Don’t fear the fever – it is the immune system hard at work!

Offer plenty of fluids

Infants should continue their breastmilk or formula as tolerated. Older kids can drink water and it’s okay for them to eat. There is no need to avoid foods if a child wants to eat – I don’t know where the “feed a fever starve a cold” or other common myths started. Of course, appetite is usually down during illness, so don’t push foods. Push fluids.

Saline and suction

Saline and suction can go a long way to help relieve nasal congestion. Noisy breathing isn’t necessarily bad, but if the breathing is labored that’s another story. Check out the Sounds of Coughing to learn how to identify various breathing problems.

Cough medicine?

Pediatricians don’t recommend cough medicines due to high risk of side effects. Kids over a year of age can use honey. Some kids can get relief from menthol products. I’ve previously written all about cough medicines if you want to read more.

Natural treatments?

A lot of parents want to do natural treatments. Learn which have been shown to work and which haven’t.

For more…

For more on treating symptoms, visit my office website’s tips.

when not to go to the doctor

Not every person with influenza needs to be seen by a medical provider. I know we’re all scared, but in most cases there isn’t much doctors and other healthcare professionals can do to help.

Medical offices, urgent care clinics and ERs are overwhelmed with mildly sick people, which makes it harder for those who are really sick to be seen.

If your child is low risk (anyone who doesn’t meet the high risk criteria above) and is drinking well, overall comfortable with support measures, and doesn’t have any breathing distress, you can manage at home. Certainly if the situation changes, bring him in, but coming in before any signs of distress will not “ward off” the development of those symptoms.

When you should bring your child to be evaluated

If you think your child might have another illness, such as Strep throat, ear infection or wheezing, bring him in for evaluation and treatment.

When any signs of distress are noticed in your child: bring him in.

If your child is high risk (as described above) and has sick symptoms, he should be seen to determine if Tamiflu is appropriate. I do not recommend getting Tamiflu called in if a child is symptomatic. A child should have an exam to be sure there aren’t complications before just starting Tamiflu. I’ve seen several kids whose parents thought they had flu, but their exam and labs showed otherwise. They could be properly treated for Strep throat, ear infections, or pneumonias instead of taking Tamiflu inappropriately after an evaluation.

How can you tell if it’s the flu or another upper respiratory tract infection?

I have seen many kids who are brought in with a runny nose just to see if it’s early flu. No. No it’s not. Flu hits like a tsunami: fever/chills, cough, body aches, and fatigue. But the child was playing in the waiting room full of kids who do have flu, so you might recognize flu symptoms soon.

cold vs flu
From the CDC: How to tell if it’s a cold or the flu?

If your low-risk child had the flu vaccine, they may still get influenza disease. But if it’s mild, they can be treated at home. If symptoms worsen, they should be seen. Yes, there is a benefit to starting Tamiflu early, but we shouldn’t use it for low risk people who aren’t significantly sick. Even if you come in early, Tamiflu probably won’t be recommended if your child doesn’t meet criteria. Tamiflu has some significant side effects and is in short supply. We shouldn’t overuse it.

Flu testing

We currently have the ability to do a rapid flu test in the office, but there is a national shortage of the test supplies, so we might choose to not test your child if they don’t meet high risk criteria. I know at least one local hospital is out of rapid test kits and we probably won’t be able to get more this season if we run out.

Don’t come to the office or go to an urgent care or emergency room just to be tested.

Please don’t be upset if we do not test your child, especially if your child is not high risk and we wouldn’t recommend Tamiflu if they are positive.

If your child has classic flu symptoms, the guidelines don’t rely on test results for treatment, so if your child meets criteria for treatment, we can prescribe without a positive test.

Knowing test results doesn’t really help guide treatment when we have such high numbers of flu in the community. It does help early in the season to recognize when flu is coming to town, but we know it’s here. Pretty much everywhere in the US, it’s here.

Let’s work on stopping the spread.

Be healthy!


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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

flu shot ineffectiveHow do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

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