ACIP issues recommendations on flu vaccine, third dose of MMR

Despite the absence of an intranasal option, it appears that influenza vaccine administration rates in children were virtually unchanged last year when compared with the prior year, according to a new report summarizing the Advisory Committee for Immunization Practices’ (ACIP) June meeting.

The meeting summary, published in the September issue of the Journal of the Pediatric Infectious Diseases Society, included a number of recommendations from the ACIP, which meets 3 times each year to review vaccine recommendations for both children and adults.

“Probably the part that is most interesting to pediatricians would be regarding influenza vaccination,” says Sean T. O’Leary, MD, associate professor of Pediatrics-Infectious Diseases at the University of Colorado School of Medicine, Aurora, Colorado, and a member of the ACIP and coauthor of the report. “There was concern that vaccination rates in children would go down because live attenuated influenza vaccine (LAIV) was not recommended for use for the 2016-2017 season because of a lack of effectiveness in the prior 3 seasons, and it was thought that because of this many children would not get immunized,” he says. “As it turns out, the rates among all children aged 6 months to 17 years were essentially identical at 59% in the 2015-2016 season and 58.2% in 2016-2017.”

In the ACIP’s review of influenza activity for the 2016-2017 season, it found that overall the season was moderate with peak activity in February. The primary circulating viruses were influenza A (70%) and H3N2 (97%), but influenza B viruses were most prominent in the late flu season after March. The vaccine was deemed to be about 42% effective overall-61% effective in children aged 6 months to 8 years and 35% effective in children aged 9 to 17 years. The vaccine was more effective against influenza B viruses than A/H3N2 viruses, according to the report.

For the coming flu season, the ACIP again is recommending that flu vaccines be administered to all individuals aged 6 months and older with no contraindications. The 2017-2018 trivalent vaccine will include an A/Michigan/45/2018 (H1N1)pdm09-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus. The quadrivalent vaccines will also include a B/Phuket/3073/2013-like virus. The ACIP also confirmed that live attenuated vaccines would not be recommended this season, and that all pregnant women should be vaccinated at any time during pregnancy.

O’Leary says pediatricians should also note the update on current mumps outbreaks.

Mumps cases have reached the highest rate in the last decade, at 6353 in 2016 and 3299 already for 2017, with the highest concentration of cases in Arkansas in the 18- to 22-year-old population, according to the report.

“For a number of reasons there have been increasing numbers of cases of mumps and outbreaks in the United States, primarily among young adults aged 18 to 22 years. At the time of the report there were at least 40 ongoing outbreaks in the United States, 19 of which were at universities,” O’Leary says. “Factors contributing to the outbreaks include waning immunity, less than optimal vaccine effectiveness at about 80%, force of infection, and possibly antigenic differences in the circulating and vaccine streams.”

The ACIP discussed the possibility of adding a third dose of measles/mumps/rubella (MMR) vaccine in the case of outbreaks, but this was tabled at the June meeting and is not included in the published recommendations. However, O’Leary says, in late October, the ACIP reviewed the issue and has now decided that a third dose of MMR vaccine is warranted in individuals identified as high risk for infection by public health during an outbreak of mumps. The recommendation will be officially published in the future.

Hepatitis A vaccines also were addressed at the June meeting. Since the vaccine was first recommended in 1996, infection rates have steadily declined. However, the vaccine has the lowest rate of uptake of all early childhood vaccines, according to the report. Roughly 86% of children aged 19 to 35 months received 1 or more doses in 2015, and 60% received 2 or more doses-far below the Healthy People 2020 goal of 80% receiving 2 or more doses.

To help meet this goal, the ACIP is considering expanding childhood recommendations to include catch-up vaccination. The catch-up vaccine was deemed not to be optimally cost effective and benefits would not be realized for several decades, but the ACIP’s Hepatitis Work Group still recommends updating current catch-up language to include a routine catch-up recommendation for children aged 2 to 18 years. The work group’s recommendation was met with some skepticism from other ACIP members, and the recommendation was not finalized at the June meeting. Consideration of this recommendation is expected to continue at future meetings.

Varicella vaccination was also discussed at the June meeting, with concerns about the role of the vaccine in the rise of herpes zoster cases considered. According to the report, concerns about increasing incidence of herpes zoster in older adults resulting from boosting varicella immunity and decreasing exposure were raised when varicella vaccination was first proposed in the 1990s. However, current research has shown no evidence of a correlation between increasing incidence of herpes zoster cases since the introduction of routine varicella vaccination-in fact, 5 of the 7 studies reviewed showed a deceleration in herpes zoster cases since varicella vaccination was introduced.

Members of the ACIP also reviewed meningococcal disease and vaccine response in patients who receive eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Eculizumab recipients should receive both serogroup ACWY (MenACWY) and serogroup B (MenB) meningococcal vaccines, according to the report, with the administration at least 2 weeks before starting eculizumab and antibiotic prophylaxis to be kept at the patient’s home after administration in case of fever.

The committee also continues to work on dengue vaccine development, but recommendations are not expected until sometime in 2018. An update was also given on yellow fever vaccine, which has faced supply shortages since late 2015. Work is under way to address manufacturing concerns, according to the ACIP, and there are several plans in place to ensure adequate access to the remaining supply of the vaccine.

There was also information presented by the Centers for Disease Control and Prevention (CDC) on updates to the Vaccine Adverse Event Reporting System (VAERS), O’Leary says. There are now 2 options for reporting available-an updated online reporting tool and a writable PDF form combined with electronic document-upload capability. Transition to the new forms began in June 2017 and a full transition is expected by December of this year.