patient care perspectives

Special Considerations in the Influenza Vaccination of Pediatric Patients With Asthma

by Tina Q. Tan, MD, FAAP, FIDSA, FPIDS

Overview

Patients with asthma are at an increased risk for developing complications from influenza, which may include pneumonia and secondary bacterial infections. Our featured expert provides information on special considerations in the influenza vaccination of this population.

Expert Commentary

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS

Professor, Department of Pediatrics
Feinberg School of Medicine
Northwestern University
Attending Physician, Division of Infectious Diseases
Ann & Robert H. Lurie Children's Hospital of Chicago
Chicago, IL

“It is important to recognize that the only individuals in whom the LAIV could increase the risk of a severe asthma attack are those who already have severe asthma.”

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS

Virtually all patients with asthma should receive influenza vaccination annually, as these individuals are more likely to develop complications from influenza, such as viral pneumonia, bacterial superinfections, and airway reactivity, than those without asthma. According to the Centers for Disease Control and Prevention, asthma is the most common medical condition in pediatric patients who are hospitalized with influenza. Most children are eligible to receive the inactivated influenza vaccine when they reach 6 months of age. The live attenuated influenza vaccine (LAIV) is a nasal spray vaccine that is an option for healthy, nonpregnant individuals aged 2 to 49 years.

There is a precaution against the use of the LAIV in children between the ages of 2 and 4 years who have certain underlying medical conditions, including asthma or a history of wheezing within the previous 12 months, owing to an increased risk of wheezing with the LAIV. These precautions were formulated based on data from very early trials of the LAIV indicating an increase in asthma or reactive airway disease in a subset of children under 5 years of age. More recently, Duffy et al conducted a large, retrospective safety study that included 12,354 LAIV doses (75% in children; 93% in those with intermittent or mild persistent asthma). They concluded that LAIV use in individuals with asthma was mostly among those with intermittent or mild persistent asthma, and such use was not linked to an increased risk of medically attended respiratory adverse events. Thus, while most patients with severe asthma should probably not receive the LAIV, intermittent or mild persistent asthma is not a contraindication to the LAIV. Moreover, in countries where only the LAIV is used, there does not appear to be any increase in medically attended hospital visits or hospitalizations among patients with asthma. The Centers for Disease Control and Prevention has included asthma, along with certain other chronic medical conditions, among general precautions related to the LAIV, also referencing the contraindication for children aged 2 to 17 years who are receiving aspirin- or salicylate-containing medications.

The asthma/wheezing precaution for the LAIV is something to keep in mind. And, certainly, patients with uncontrolled asthma must be more careful than those with well-controlled asthma. However, it is also important to recognize that the only individuals in whom the LAIV could increase the risk of a severe asthma attack are those who already have severe asthma.

References

Baxtera R, Eaton A, Hansen J, Aukes L, Caspard H, Ambrose CS. Safety of quadrivalent live attenuated influenza vaccine in subjects aged 2-49 years [published correction appears in Vaccine. 2017;35(23):3152]. Vaccine. 2017;35(9):1254-1258.

Centers for Disease Control and Prevention. Flu and people with asthma. https://www.cdc.gov/flu/highrisk/asthma.htm. Accessed May 7, 2020.

Centers for Disease Control and Prevention. Live attenuated influenza vaccine [LAIV] (the nasal spray flu vaccine). https://www.cdc.gov/flu/prevent/nasalspray.htm. Accessed May 7, 2020.

Duffy J, Lewis M, Harrington T, et al. Live attenuated influenza vaccine use and safety in children and adults with asthma. Ann Allergy Asthma Immunol. 2017;118(4):439-444.

Harper SA, Fukuda K, Cox NJ, Bridges CB; Advisory Committee on Immunization Practices. Using live, attenuated influenza vaccine for prevention and control of influenza: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2003;52(RR-13):1-8.

Nakamura MM, Zaslavsky AM, Toomey SL, et al. Pediatric readmissions after hospitalizations for lower respiratory infections. Pediatrics. 2017;140(2). pii:e20160938.

Nordin JD, Vazquez-Benitez G, Olsen A, Kuckler LC, Gao AY, Kharbanda EO. Safety of guidelines recommending live attenuated influenza vaccine for routine use in children and adolescents with asthma. Vaccine. 2019;37(30):4055-4060.

Okamoto S, Nagase S. Pathogenic mechanisms of invasive group A Streptococcus infections by influenza virus-group A Streptococcus superinfection. Microbiol Immunol. 2018;62(3):141-149.

Turner PJ, Fleming L, Saglani S, Southern J, Andrews, NJ, Miller E; SNIFFLE-4 Study Investigators. Safety of live attenuated influenza vaccine (LAIV) in children with moderate to severe asthma. J Allergy Clin Immunol. 2020;145(4):1157‐1164.e6.

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