This post originally appeared on The PediaBlog on October 26, 2015.
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A mother emails:
My son had a liver transplant, and is now immune-suppressed by his anti-rejection medication. He has been instructed to only receive the flu injection and never receive the nasal FluMist vaccine. He has also been advised by his infection-control doctor at Children’s Hospital that he should avoid the nasal droplets from someone who has received the nasal flu vaccine for at least five days. I was wondering if it is safe for him (and those in a similar situation) to participate in one of your flu clinics, as children that he is coming face-to-face with have, just seconds prior, received the live nasal FluMist vaccine. The flu clinic offers very tight quarters and despite our best effort, he is still breathing recycled air from those freshly vaccinated kiddos.
Live attenuated influenza vaccine (LAIV), also known as the squirt-up-the-nose “FluMist,” is a live vaccine that has been changed (attenuated) to be of very low virulence to recipients and to those around them. The risk of an otherwise healthy child or adult having symptoms of influenza (severe congestion, cough, sore throat, high fever, headache, body ache, fatigue, etc.) after receiving LAIV is very low, but it can happen. In my own personal experience (once for me, and in a handful of children over the more than 20 years the vaccine has been available), a scratchy throat and stuffy nose one or two days after the vaccine can occur. A day or so later, it’s gone. (It’s more like the feeling you get when you first feel a cold coming on — not more severe than that, and it’s gone in a day.)
The standard influenza vaccine injection is an inactivated vaccine made from influenza viral proteins; it does not contain live viruses. As long as you have no contraindications to receiving it (like an allergy to flu vaccines, which are extraordinarily rare), there is nothing in a flu shot that can get you sick.
It must be said (and cannot be overstated) that flu vaccines, both live intranasal vaccines and inactivated shots, are given in the fall and winter — the “cold and flu season” — so it’s not uncommon for kids and adults to come down with cold or flu symptoms soon after a flu vaccine. Temporally, it’s natural to conclude that the flu vaccine made you sick, but that’s simply not the case. So when you hear, as I often do, adults say that they got a flu vaccine once and then they got really sick with the flu right after it (an excuse in their mind for not getting another one for themselves, or one for their kids), they are mistaken!
LAIV is approved for people between the ages of 2-49. (There are no studies that prove safety and efficacy in people over 50 years old, so no approval — though there is no reason to believe the vaccine wouldn’t be appropriate for them also.) The CDC lists 8 other situations where the LAIV intranasal spray shouldn’t be given:
- People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine.
- People who are allergic to eggs.*
- Children 2 years through 17 years of age who are receiving aspirin therapy or aspirin-containing therapy.
- Pregnant women.
- People with weakened immune systems (immunosuppression).
- Children 2 years through 4 years who have asthma or who have had a history of wheezing in the past 12 months.
- People who have taken influenza antiviral drugs within the previous 48 hours.
- People who care for severely immunocompromised persons who require a protective environment (or otherwise avoid contact with those persons for 7 days after getting the nasal spray vaccine).
That last point gets to the crux of our reader’s question. Her child has a weakened immune system (immunosuppression) because he takes anti-rejection medications. While he can get vaccines that are not “live” vaccines (he can get the regular flu shot, but he cannot get LAIV, rotavirus vaccine, MMR or chickenpox vaccines — all of which are “live”), his compromised immune system may not respond efficiently to a flu shot and other vaccines. Her child depends on everyone else being immunized against influenza and every other vaccine-preventable illness in order to be protected.
While the risk is low, it is recommended that an immunosuppressed child or adult avoid contact with anyone receiving live vaccines, including LAIV. Still, the answer to the reader’s question is a bit complicated. Her child needs a flu shot. He can come into the office during regular office hours to receive one. Or, he can come to one of our after-hours flu clinics where you sign in, give consent, line up, get a shot, and you’re out the door — usually in as little as five minutes. Since you have to be healthy — no colds or coughs — to receive a flu mist (and most parents elect to give their kids flu shots when they are healthy), practically everyone passing through a flu clinic is going to be healthy. During regular office hours, however, all bets on good health are off. Our reader’s child has the same low risk of being exposed to recipients of the live intranasal vaccine during regular hours, but a much higher risk of being exposed to all the other viruses and bacteria present in the office at those times. (I’m just being honest here.)
There is, of course, a third option for families with immunosuppressed children or those with other special health care needs. Call the office and we will make arrangements for your child to come in at non-peak hours — maybe first thing in the morning, right after lunch, or at the very end of the day. We will work together to limit exposure to your child.
*Editor’s note: In 2016, the CDC’s Advisory Committee on Immunization Practices eased restrictions on influenza vaccine for egg-allergic individuals. A history of egg allergy is no longer a contraindication to receiving a flu vaccine. Read more about the recommendations regarding egg allergy and flu vaccine here and here.
***Do you have a non-urgent, clinical or otherwise (but nothing personal!) question for your Pediatric Alliance doctor or provider? Send an email with your questions to firstname.lastname@example.org and we’ll do our best to answer them and post them on The PediaBlog. You don’t have to include your child’s name, but an idea of their age is helpful. Also, please include the name of the division you go to and your doctor’s or provider’s name.
Ask us anything! (But, please, no urgent or semi-urgent questions — we may not get to your question right away. If your child is sick, or you have acute concerns, please call our offices and speak with our triage staff.)
(Dr. Kathy Walczak and Dr. Sarah Kohl from the Chartiers/McMurray Division got their flu shots. Now it’s your turn!)