RECOMMENDATIONS ON THE USE OF THE FLUMIST & RESPIRATORY SYNCYTIAL VIRUS VACCINES FOR NEUROMUSCULAR DISEASE PATIENTS
General considerations for neuromuscular disease patients
Neuromuscular disease (NMD) patients are considered to have compromised immune systems and this comes with both a greater risk for influenza infection alongside a greater risk for side effects and complications from influenza vaccination. Adults over the age of 65 and aboriginals are also considered to be at increased risk for influenza infection even if they are otherwise healthy. The most important thing a family can do to prevent influenza from entering their home and infecting a person with a neuromuscular disease is to get immunized against influenza virus. The entire family and all caregivers are strongly recommended to get influenza vaccine as soon as it is available.
What is the FluMist® vaccine?
Perhaps you have already come across this conversation in your respective practice this flu season. In any case, one of the issues we will be discussing in this edition of NeuromuscularNow is whether or not it is safe for your neuromuscular (NM) patients to take the live attenuated influenza vaccine (LAIV), also referred to as FluMist. FluMist is to be administered through the nose (intranasal administration). The 2015-2016 LAIV contains protective agents against all four flu viruses: an influenza A (H1N1) virus, an influenza A (H3N2) virus and two influenza B viruses. The LAIV vaccines are made from actual disease pathogens, which are weakened in the laboratory setting.
Recommendations for your neuromuscular disease patients
The statement on seasonal influenza vaccine 2015-2016 released by the Public Health Agency of Canada (PHAC) provides some recommendations on the use of the FluMist vaccine(1). Although LAIV is the recommended preferential vaccine for healthy children and adolescents 2 to 17 years of age, PHAC does not recommend its use for children, adolescents and adults (2-59 years of age) with immune compromising conditions.
Specific contraindications for the LAIV vaccine include:
PHAC also recommends that LAIV recipients avoid close contact with persons with severe immune compromising conditions for at least two weeks following vaccination, because of the risk for transmitting a vaccine virus and causing infection. Individuals caring for people with compromised immune systems and family members residing in the home should be vaccinated with inactivated vaccine.
The information above is taken from the Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2015-2016 published by the Public Health Agency of Canada and is available at: http://www.phac-aspc.gc.ca/naci-ccni/flu-2015-grippe-eng.php
Administration of RSV vaccine for children with muscle disease: Not to be given to ANYONE outside of the first year of life
Another vaccine being discussed in this edition of NeuromusclarNow for your NM patients with a disease of the muscle is palivizumab (RSVAb). RSVAb is a humanized murine monoclonal immunoglobulin anti-respiratory syncytial virus antibody used to prevent respiratory syncytial virus (RSV) (2). This vaccine is produced by DNA technology and is made up of 95% human and 5% murine amino acid sequences (2,5).
RSV is the most common virus that can affect lungs and breathing tubes, and cause lower respiratory tract infection (LRTI) in infants and children (2,3,4). Severe RSV has an increased prevalence among infants with a neuromuscular condition due to risk factors such as an impaired ability to clear airway secretions, respiratory muscle weakness, a high prevalence of gastro-esophageal reflux and swallowing dysfunction leading to aspiration(2).
The Canadian RSV season usually begins in November or December, lasting for about four to five months (3). In addition to many other indications, the Canadian Immunization Guide published by PHAC recommends that children at risk for severe RSV receive RSVAb (5). It is under this category that you can request RSVAb prophylaxis for your NM patients. Children residing in Ontario may be eligible for reimbursement of vaccination costs for RSV prophylaxis (6).
The Canadian Paediatric Society (CPS) has recently conducted an analysis on the efficacy and cost effectiveness of palivizumab for preventing RSV(2). Randomized controlled trials have demonstrated a 40% efficacy of the vaccine in children with chronic lung disease (CLD) and 45% in those with congenital heart defect (CHD). In terms of cost effectiveness analysis, it was concluded that it is unlikely that palivizumab is cost-effective in reducing cost of hospitalizations for children with CLD or CHD and palivizumab’s cost effectiveness can only be evident in settings where RSV hospitalizations are exceedingly common and very expensive(5).
Health care providers must note that because the RSV infection does not confer protective immunity, for children who get infected with RSV while taking the RSVAb prophylaxis, the scheduled monthly dosage should be given throughout the RSV season.
For specific guidelines, please visit the references enclosed. We look forward to receiving your thoughts and comments in the discussion section below.
(1)Public Health Agency of Canada (2015). An Advisory Committee Statement (ACS) – National Advisory Committee on Immunization (NACI). Retrieved from http://www.phac-aspc.gc.ca/naci-ccni/flu-2015-grippe-eng.php
(2)Robinson,J. L., Le Saux, N. (2015). Canadian Paediatic Soceity, Infectious Diseases and Immunization Committee. Preventing hospitalizations for respiratory syncytial virus infection. Paediatric Child Health, 20(6), 321-326.
(3)Resch, B., Manzoni, P., Lanari, M. (2009). Sever respiratory syncytial virus (RSV) infection in infants with neuromuscular diseases and immune deficiency syndromes. Paediatric Respirartory Reviews, 10(3), 148-153. doi:10.1016/j.prrv.2009.06.003.
(4)Welliver, T. P., Garofalo, R. P., Hosakote, Y., Hintz, K. H., Avendano, L., Sanchez, K., Velozo, L., et al. (2007). Severe human lower respiratory tract illness caused by respiratory syncytial virus and influenza virus is characterized by the absence of pulmonary cytotoxic lymphocyte responses. Journal of Infectious Diseases, 2007(195), 1126-1136. doi: 10.1086/512615
(5)Public Health Agency of Canada. (2013). Canadian Immunization Guide. Part 5: Passive Immunizing Agents. Retrieved from http://www.phac-aspc.gc.ca/publicat/cig-gci/p05-01-eng.php#pass
(6)Government of Ontario: Ministry of Health and Long-Term Care. (2015). Re: 2015-2016 Season for Respiratory Syncytial Virus Prophylaxis for High Risk Infants. Retrieved from http://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/pdf/rsv_info.pdf