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Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

• November 13, 2006, Tamiflu (oseltamivir phosphate): Post-marketing reports of self-injury and delirium with the use of Tamiflu in patients with influenza.

Primary Changes and Updates in the Recommendations

The 2007 recommendations include six principal changes or updates:

• The Advisory Committee on Immunization Practices (ACIP) reemphasizes the importance of administering 2 doses of vaccine to all children aged 6 months to 8 years if they have not been vaccinated previously at any time with either live, attenuated influenza vaccine (LAIV) (doses separated by >6 weeks) or trivalent inactivated influenza vaccine (TIV) (doses separated by >4 weeks), on the basis of accumulating data indicating that 2 doses are required for protection in these children (see "Vaccine Efficacy, Effectiveness, and Safety" in the original guideline document).
• ACIP recommends that children aged 6 months to 8 years who received only 1 dose in their first year of vaccination receive 2 doses the following year (see "Vaccine Efficacy, Effectiveness, and Safety" in the original guideline document).
• ACIP reiterates a previous recommendation that all persons, including school-aged children, who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others should be vaccinated (see Box in the original guideline document and "Recommendations for Using TIV and LAIV During the 2007--08 Influenza Season," below).
• ACIP emphasizes that immunization providers should offer influenza vaccine and schedule immunization clinics throughout the influenza season (see "Timing of Vaccination," below).
• ACIP recommends that health-care administrators consider the level of vaccination coverage among health-care personnel (HCP) to be one measure of a patient safety quality program and implement policies to encourage HCP vaccination (e.g., obtaining signed statements from HCP who decline influenza vaccination) (see "Additional Information Regarding Vaccination of Specific Populations," below).
• The 2007--2008 trivalent vaccine strains are A/Solomon Islands/3/2006 (H1N1)-like (new for this season), A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like viruses. (see "Recommendations for Using TIV and LAIV During the 2007--08 Influenza Season," below).

Target Groups for Vaccination

All persons at risk for medical complications from influenza or more likely to require medical care and all persons who live with or care for persons at high risk for influenza-related complications should receive influenza vaccine annually. Approximately 73% of the United States population is included in one or more of these target groups; however, only an estimated one third of the United States population received an influenza vaccination in 2006--2007. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to these persons.

Persons at Risk for Medical Complications or More Likely to Require Medical Care

Vaccination with TIV is recommended for the following persons who are at increased risk for severe complications from influenza, or at a higher risk for influenza-associated clinic, emergency department, or hospital visits:

• All children aged 6 to 59 months (i.e., 6 months to 4 years)
• All persons aged >50 years
• Children and adolescents (aged 6 months to 18 years) who are receiving long-term aspirin therapy and who, therefore, might be at risk for experiencing Reye syndrome after influenza virus infection
• Women who will be pregnant during the influenza season
• Adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus)
• Adults and children who have immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV])
• Adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration
• Residents of nursing homes and other chronic-care facilities

Persons Who Live With or Care for Persons at High Risk for Influenza-Related Complications

To prevent transmission to persons identified above, vaccination with TIV or LAIV (unless contraindicated) is recommended for the following persons:

• HCP
• Healthy household contacts (including children) and caregivers of children aged <59 months and adults aged >50 years
• Healthy household contacts (including children) and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza

Recommendations for Using Antiviral Agents for Influenza

Although annual vaccination is the primary strategy for preventing complications of influenza virus infections, antiviral medications with activity against influenza viruses can be effective for the chemoprophylaxis and treatment of influenza. Four licensed influenza antiviral agents are available in the United States: amantadine, rimantadine, zanamivir, and oseltamivir. Influenza A virus resistance to amantadine and rimantadine can emerge rapidly during treatment. Because antiviral testing results indicated high levels of resistance, neither amantadine nor rimantadine should be used for the treatment or chemoprophylaxis of influenza in the United States during the 2007–08 influenza season. Surveillance demonstrating that susceptibility to these antiviral medications has been reestablished among circulating influenza A viruses will be needed before amantadine or rimantadine can be used for the treatment or chemoprophylaxis of influenza A. Oseltamivir or zanamivir can be prescribed if antiviral treatment of influenza is indicated. Oseltamivir is approved for treatment of persons aged >1 year, and zanamivir is approved for treatment of persons aged >7 years. Oseltamivir and zanamivir can be used for chemoprophylaxis of influenza; oseltamivir is licensed for use as chemoprophylaxis in persons aged >1 year, and zanamivir is licensed for use in persons aged >5 years.

Guideline Availability

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) website.

Other Resources

The Guide to Clinical Preventive Services includes U.S. Preventive Services Task Force (USPSTF) recommendations on screening, counseling, and preventive medication topics and includes clinical considerations for each topic. This new pocket guide provides general practitioners, internists, family practitioners, pediatricians, nurses, and nurse practitioners with an authoritative source for making decisions about preventive services.

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Now Available: The Electronic Preventive Services Selector (ePSS) is a quick hands-on tool designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. The ePSS is available both as a PDA application and a web-based tool. It is based on current recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors.

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