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1Vol. 57 / RR-7 Recommendations and Reports
Prevention and Control of Influenza
Recommendations of the Advisory Committeeon Immunization Practices (ACIP), 2008
Prepared by Anthony E. Fiore, MD
1
David K. Shay, MD
1
Karen Broder, MD
2
 John K. Iskander, MD
2
Timothy M. Uyeki, MD
1
Gina Mootrey, DO
3
 Joseph S. Bresee, MD
1
Nancy J. Cox, PhD
1
1
Influenza Division, National Center for Immunization and Respiratory Diseases 
 2 
Immunization Safety Office, Office of the Chief Science Officer, Office of the Director 
 3
Immunization Services Division, National Center for Immunization and Respiratory Diseases 
 Summary 
 
This report updates the 2007 recommendations by CDC’s Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine and antiviral agents (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2007;56[No. RR6]). The 2008 recommendations include new and updated information. Principal updates and changes include 1) a new recommendation that annual vaccination be adminis-tered to all children aged 5–18 years, beginning in the 2008–09 influenza season, if feasible, but no later than the 2009–10 influenza season; 2) a recommendation that annual vaccination of all children aged 6 months through 4 years (59 months)continue to be a primary focus of vaccination efforts because these children are at higher risk for influenza complications com- pared with older children; 3) a new recommendation that either trivalent inactivated influenza vaccine or live, attenuated influenza vaccine (LAIV) be used when vaccinating healthy persons aged 2 through 49 years (the previous recommendation was to administer LAIV to person aged 5–49 years); 4) a recommendation that vaccines containing the 2008–09 trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)like, A/Brisbane/10/2007 (H3N2)like, and B/Florida/4/2006like antigens be used;and, 5) new information on antiviral resistance among influenza viruses in the United States. Persons for whom vaccination is recommended are listed in boxes 1 and 2. These recommendations also include a summary of safety data for U.S. licensed influenza vaccines. This report and other information are available at CDC’s influenza website (http://www.cdc.gov/flu),including any updates or supplements to these recommendations that might be required during the 2008–09 influenza season.Vaccination and healthcare providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.
group, but rates of infection are highest among children
Introduction
(
1–3
). Rates of serious illness and death are highest amongIn the United States, annual epidemics of influenza occurpersons aged >65 years, children aged <2 years, and personstypically during the late fall through early spring seasons.of any age who have medical conditions that place them atInfluenza viruses can cause disease among persons in any ageincreased risk for complications from influenza (
1,4,5 
). Anannual average of approximately 36,000 deaths during 1990–1999 and 226,000 hospitalizations during 1979–2001 have
The material in this report originated in the National Center for
been associated with influenza epidemics (
6,7 
).
Immunization and Respiratory Diseases, Anne Schuchat, MD, Director;the Influenza Division, Nancy Cox, PhD, Director; the Office of the
 Annual influenza vaccination is the most effective method
Chief Science Officer, Tanja Popovic, MD, Chief Science Officer; the
for preventing influenza virus infection and its complications.
Immunization Safety Office, John Iskander, MD, Acting Director, and
Influenza vaccine can be administered to any person aged
the Immunization Services Division, Lance Rodewald, MD, Director.
Corresponding preparer:
Anthony Fiore, MD, Influenza Division,
>6 months (who does not have contraindications to vaccina-
National Center for Immunization and Respiratory Diseases, CDC,
tion) to reduce the likelihood of becoming ill with influenza
1600 Clifton Road, NE, MS A-20, Atlanta, GA 30333. Telephone:
or of transmitting influenza to others. Trivalent inactivated
404-639-3747; Fax: 404-639-3866; E-mail: afiore@cdc.gov.
influenza vaccine (TIV) can be used for any person aged
 
2 MMWR August 8, 2008
>6 months, including those with high-risk conditions (Boxes1 and 2). Live, attenuated influenza vaccine (LAIV) may beused for healthy, nonpregnant persons aged 2–49 years. If vaccine supply is limited, priority for vaccination is typically assigned to persons in specific groups and of specific ages whoare, or are contacts of, persons at higher risk for influenzacomplications. Because the safety or effectiveness of LAIV hasnot been established in persons with underlying medical conditions that confer a higher risk for influenza complications,these persons should only be vaccinated with TIV. Influenzaviruses undergo frequent antigenic change (i.e., antigenic drift),and persons recommended for vaccination must receive anannual vaccination against the influenza viruses forecasted tobe in circulation. Although vaccination coverage has increased
BOX 1. Summary of influenza vaccination recommendations,2008: children and adolescents aged 6 months–18 years
Vaccination of all children aged 6 months–18 yearsshould begin before or during the 2008–09 influenzaseason if feasible, but no later than during the 2009–10influenza season. Vaccination of all children aged 5–18years is a new ACIP recommendation.Children and adolescents at high risk for influenzacomplications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents.Recommendations for these children have not changed.Children and adolescents at higher risk for influenzacomplication are those:aged 6 months–4 years;• who have chronic pulmonary (including asthma),cardiovascular (except hypertension), renal, hepatic,hematological or metabolic disorders (includingdiabetes mellitus);• who are immunosuppressed (including immunosuppression caused by medications or by humanimmunodeficiency virus);• who have any condition (e.g., cognitive dysfunction,spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or thatcan increase the risk for aspiration;who are receiving long-term aspirin therapy who therefore might be at risk for experiencing Reye syndromeafter influenza virus infection;who are residents of chronic-care facilities; and,who will be pregnant during the influenza season.
Note:
Children aged <6 months should not receive influenza vaccination.Household and other close contacts (e.g., daycare providers) of children aged<6 months, including older children and adolescents, should be vaccinated.
BOX 2. Summary of influenza vaccination recommendations,2008: adults
 Annual recommendations for adults have not changed. Annual vaccination against influenza is recommendedfor any adult who wants to reduce the risk for becomingill with influenza or of transmitting it to others. Vaccination also is recommended for all adults in the following groups, because these persons are either at high risk for influenza complications, or are close contacts of persons at higher risk:persons aged >50 years;• women who will be pregnant during the influenzaseason;• persons who have chronic pulmonary (includingasthma), cardiovascular (except hypertension), renal,hepatic, hematological or metabolic disorders (including diabetes mellitus);• persons who have immunosuppression (includingimmunosuppression caused by medications or by human immunodeficiency virus);• persons who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or otherneuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretionsor that can increase the risk for aspiration;• residents of nursing homes and other chronic-carefacilities;• health-care personnel;• household contacts and caregivers of children aged<5 years and adults aged >50 years, with particularemphasis on vaccinating contacts of children aged<6 months; and,household contacts and caregivers of persons with medical conditions that put them at high risk for severecomplications from influenza.in recent years for many groups targeted for routine vaccination, coverage remains low among most of these groups, andstrategies to improve vaccination coverage, including use of reminder/recall systems and standing orders programs, shouldbe implemented or expanded. Antiviral medications are an adjunct to vaccination and areeffective when administered as treatment and when used forchemoprophylaxis after an exposure to influenza virus.Oseltamivir and zanamivir are the only antiviral medicationsrecommended for use in the United States. Amantadine orrimantidine should not be used for the treatment or prevention of influenza in the United States until evidence of susceptibility to these antiviral medications has been reestablishedamong circulating influenza A viruses.
 
3Vol. 57 / RR-7 Recommendations and Reports
Methods
CDC’s Advisory Committee on Immunization Practices(ACIP) provides annual recommendations for the preventionand control of influenza. The ACIP Influenza Vaccine Working Group* meets monthly throughout the year to discussnewly published studies, review current guidelines, and consider potential revisions to the recommendations. As they review the annual recommendations for ACIP considerationof the full committee, members of the working group consider a variety of issues, including burden of influenza illness,vaccine effectiveness, safety and coverage in groups recommended for vaccination, feasibility, cost-effectiveness, andanticipated vaccine supply. Working group members alsorequest periodic updates on vaccine and antiviral production,supply, safety and efficacy from vaccinologists, epidemiologists, and manufacturers. State and local vaccination programrepresentatives are consulted. Influenza surveillance and antiviral resistance data were obtained from CDC’s InfluenzaDivision. The Vaccines and Related Biological Products Advisory Committee provides advice on vaccine strain selection to the Food and Drug Administration (FDA), whichselects the viral strains to be used in the annual trivalent influenza vaccines.Published, peer-reviewed studies are the primary source of data used by ACIP in making recommendations for the prevention and control of influenza, but unpublished data thatare relevant to issues under discussion also might be considered. Among studies discussed or cited, those of greatest scientific quality and those that measured influenza-specificoutcomes are the most influential. For example, population-based estimates that use outcomes associated with laboratory-confirmed influenza virus infection outcomes contribute themost specific data for estimates of influenza burden. The bestevidence for vaccine or antiviral efficacy and effectivenesscomes from randomized controlled trials that assess laboratory-confirmed influenza infections as an outcome measure andconsider factors such as timing and intensity of influenza circulation and degree of match between vaccine strains and wildcirculating strains (
8,9 
). Randomized, placebo-controlled trials cannot be performed ethically in populations for whichvaccination already is recommended, but observational studies that assess outcomes associated with laboratory-confirmedinfluenza infection can provide important vaccine or antiviraleffectiveness data. Randomized, placebo-controlled clinicaltrials are the best source of vaccine and antiviral safety datafor common adverse events; however, such studies do not havethe power to identify rare but potentially serious adverse events.
* A list of members appears on page 59 of this report.
The frequency of rare adverse events that might be associated with vaccination or antiviral treatment is best assessed by retrospective reviews of computerized medical records from largelinked clinical databases, and by reviewing medical charts of persons who are identified as having a potential adverse eventafter vaccination (
10,11
). Vaccine coverage data from anationally representative, randomly selected population thatincludes verification of vaccination through health-care recordreview is superior to coverage data derived from limited populations or without verification of vaccination but is rarely available for older children or adults (
12 
). Finally, studies that assessvaccination program practices that improve vaccination coverage are most influential in formulating recommendations if the study design includes a nonintervention comparison group.In cited studies that included statistical comparisons, a difference was considered to be statistically significant if the p-value was <0.05 or the 95% confidence interval (CI) around anestimate of effect allowed rejection of the null hypothesis (i.e.,no effect).These recommendations were presented to the full ACIPand approved in February 2008. Modifications were made tothe ACIP statement during the subsequent review process atCDC to update and clarify wording in the document. Datapresented in this report were current as of July 1, 2008. Further updates, if needed, will be posted at CDC’s influenza website (http://www.cdc.gov/flu).
Primary Changes and Updatesin the Recommendations
The 2008 recommendations include five principal changesor updates:Beginning with the 2008–09 influenza season, annual vaccination of all children aged 5–18 years is recommended. Annual vaccination of all children aged 5–18 years shouldbegin in September or as soon as vaccine is available for the2008–09 influenza season, if feasible, but annual vaccination of all children aged 5–18 years should begin no laterthan during the 2009–10 influenza season.Annual vaccination of all children aged 6 months–4 years(59 months) and older children with conditions that placethem at increased risk for complications from influenzashould continue. Children and adolescents at high risk for influenza complications should continue to be a focusof vaccination efforts as providers and programs transition to routinely vaccinating all children.Either TIV or LAIV can be used when vaccinating healthy persons aged 2–49 years. Children aged 6 months–8 yearsshould receive 2 doses of vaccine if they have not been
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