Vaccinations for an Indian Vacation: Quiz Part II

January 20, 2016

A family of 4 will vacation in India. None has received a flu shot. Mom is pregnant; Dad takes Flovent; one son has acne. What do you tell them?

[[{"type":"media","view_mode":"media_crop","fid":"45097","attributes":{"alt":"","class":"media-image media-image-right","height":"212","id":"media_crop_3752843493677","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5112","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"© VoltCollection/Shutterstock.com ","typeof":"foaf:Image","width":"217"}}]]In Part 1 of our Vacation Vaccination Quiz, we met at a family of four in your office in May with plans to travel to India in August and will be visiting the Taj Mahal in northern India. No one in the family has ever received an influenza vaccine before. They are willing to do so today depending upon your recommendation. You haven't seen a case of flu in your office for about a month.

You tell them (more than one answer may be correct):

A. No flu vaccine is needed since the season is over.

B. The CDC recommends that flu vaccine be given until the vaccine expires in June.

C. Flu season usually peaks in northern India in July to September.

D. Flu often circulates year round in tropical climates.

Please click NEXT, below, for answer, discussion, and next question.

Answers: B, C, and D are correct

It is difficult to predict when the flu season ends in the US. Occasionally a different strain from the one that circulated earlier in the year will cause a surge in new cases late in the season. Thus, the CDC does recommend continuing vaccination through June. In the southern hemisphere, influenza does tend to peak in our summer months which are their winter months. Influenza often circulates year round in tropical areas, but still may show some seasonal increase during rainy seasons in some areas.

 

The parents agree to get everyone vaccinated against the flu. You tell them you have both the shot and nasal mist forms of the flu vaccine. The family members range in age from 2 to 49 years, the approved age range for Flumist. And, Mom is pregnant; Dad is on high-dose daily Flovent; the 12-year-old son is on daily tetracycline for his acne; and the 10-year-old has mild intermittent asthma. All four voice a preference for Flumist. Let's look at them in turn for your recommendation.

1. Mom is 16 weeks pregnant. You tell her:

A. She should not get Flumist due to her pregnancy. In addition, no one else in the family should get Flumist since persons vaccinated with Flumist will shed the live virus for perhaps a week and she should not be exposed.

B. Studies in pregnant rats showed no problems, but no studies in pregnant humans have been done.

C. Per the package insert, Flumist is contraindicated during pregnancy.

D. She should wait until the 3rd trimester to get her flu shot so the baby (due in October) will be born with some maternal antibodies against 4 flu strains in the vaccine.

  Please click NEXT, below, for answer, discussion, and next question.  Answer: B. Studies in pregnant rats showed no problems, but there have been no studies performed in pregnant humans.

Flumist can be given to persons who will come in contact with pregnant and immunocompromised persons, unless the immunocompromised individual is in a reverse isolation unit in the hospital. Since no data exist showing harm to a pregnant woman getting Flumist, a contraindication is not listed. Instead it falls in the “Precautions and Warnings" section of the prescribing information (PI). This means that if, in the opinion of the provider benefit outweighs risk and the individual provides consent, the live vaccine can be administered. A sample situation would be a pregnant woman who absolutely refuses the flu shot but will agree to the live vaccine. Since pregnancy is a high risk condition for influenza complications, I would consider giving Flumist to this individual. I would have her sign a written informed consent first. The shot is not only safe in pregnancy but is recommended for routine use in the third trimester if possible. I would suggest to the Mom about to travel to India that she return 2 weeks before her trip to receive the flu shot.

 

2. Dad is on high-dose Flovent for his asthma. You tell him:

A. Since taking Flovent does not put him into the immunocompromised category, he can receive the mist if he prefers.

B. Since he has asthma, Flumist is contraindicated.

C. Since he has persistent asthma, Flumist is contraindicated. If he had mild intermittent asthma, there is nothing in the Precautions and Warnings section of the PI about it, unlike for children.

D. Asthma is listed in the Precautions and Warnings section of the PI for individuals of all ages.

Please click NEXT, below, for answer, discussion, and next question.Answer: D. Asthma is listed in the Precautions and Warnings section of the PI for individuals of all ages.

Asthma is not listed as a contraindication for any age group. Anything listed in the contraindication section should be followed to the letter for medical liability reasons. I personally would not give FluMist to any individual with persistent asthma since very little data exist on its use in this population and the concern is that the Flumist might precipitate an asthma attack like a viral URI might. A number of open label studies have been done in children with mild intermittent asthma comparing rates of wheezing in those receiving Flumist as compared to the flu shot. I will talk about those results below.


Now, the 12-year-old who is on tetracycline for his acne. Earlier in the visit he was told that if he holds off on his antibiotics for about 2 weeks, he can receive the oral typhoid vaccine that he will need for the family vacation, rather than the injection, and he agreed.

3. Regarding flu vaccine for him, you tell the family:

A. He can get both the oral typhoid vaccine and the Flumist today even though he took his tetracycline today.

B. He can get Flumist today, but should not start the oral typhoid vaccine until he has been off  antibiotics for 3 days and he must put 4 weeks between the two live viral vaccines.

C. He can get Flumist today and start the live typhoid vaccine at any time as long as he has been off antibiotics for 3 days.

D. He can get Flumist today and start the live typhoid vaccine at any time as long as he has been off antibiotics for at least 24 hours.

Please click NEXT, below, for answer, discussion, and next question.

Answer: C. He can get Flumist today and start the live typhoid vaccine at any time as long as he has been off antibiotics for 3 days.

Oral vaccines against typhoid and rotavirus can be given at any time regardless of when a previous live vaccine was received or needs to be given. The 4-week rule of spacing between live vaccines not given on the same day applies to the other live vaccines:  MMR, varicella, yellow fever, zoster, and Flumist. Oral typhoid vaccine should not be given within 3 days of receipt of an antibiotic.

 

As for the 10-year-old son, he has mild intermittent asthma.

4. You tell the family:

A. He should not be given Flumist under any circumstances because of his asthma, per product labeling.

B. He should not be given Flumist under any circumstances because of his asthma, as recommended by the CDC.

C. If we were having this conversation in Canada we would just give him the Flumist since only individuals with severe asthma (on oral steroids or high dose inhaled steroids) are warned of an increased risk in that country's labeling.

D. A and B are both true

Please click NEXT, below, for answer and discussion.

Answer: C. In Canada, the child would receive the Flumist; individuals with mild intermittent asthma can be given Flumist without worry according to the Canadian equivalent to the FDA.

A history of asthma is in the Precautions and Warnings section of the Flumist PI, not the Contraindications section. A number of open label but randomized studies have been performed in children with mild intermittent asthma receiving either Flumist or the shot and most show no increased wheezing in recipients of the nasal spray versus the shot. I have routinely been giving Flumist to children with mild intermittent asthma in my pediatric practice for years without problem.

As an aside, I asked the science bureau at Medimmune (the maker of Flumist) why the difference between Canada and the US in regards to use of Flumist in children with mild asthma and was told that the US FDA would require at least 2 randomized, double dummy, double blinded studies in children with mild intermittent asthma before they would consider changing the label in the PI.