1. LAIV Should we use it in India? Dr Gaurav Gupta Charak
Clinics, Chandigarh [email protected]
2. Conflict of Interest Received grants from various vaccine
manufacturers including - Sanofi Pasteur - GSK - Novartis - SII
(Manufacturers of different Influenza vaccines)
3. Overview Should we use the Flu vaccine at all? Latest
recommendations from CDC / NHS When to use LAIVs (Indications US
v/s UK) When NOT to use LAIVs (Contraindications/ precautions MMWR)
How does LAIV differ from TIV Talking about Nasovac & Nasovac S
FAQs
4. Should we use the Flu vaccine at all?
5. IAP recommendation 5 to 10% of ARI cases-caused by Influenza
in India Ref: Indian Pediatr. 2013 Sep;50(9):867-74.
6. http://www.who.int/influenza/vaccines/use/en/
7. SAGE Data- Protection against influenza Vaccine
effectiveness studies have found VE of 60-85% in children < 5
yrs age when vaccine strains match well with circulating strains
Limited data indicate additional protection of unvaccinated
household and community contacts by immunization of children Sage
working group: Background Paper on Influenza Vaccines and
Immunization. April 2012
8. Clinical Effectiveness of Influenza vaccine-1 Fully
vaccinated cohort (n=106) vs. Unvaccinated cohort (n=282)
Parameters Fully Vaccinate d cohort (%) Unvaccinat ed cohort (%)
Relative Risk VE % P-value Influenza like illness 0.9 35.5 0.0357
97 % 0.0009 Visits to Physician 2.8 38.7 0.0987 90 % 0.0001
Conclusion: Influenza vaccine is effective in reducing the ILI and
visits to physician for ARI in fully vaccinated Indian children as
compared to unvaccinated children.
9. Influenza Activity And Peaks
10. Ideal time of Influenza Vaccination in India: Summary Best
time to vaccinate against influenza in India is at least 1 month
before the monsoons with the latest available vaccine having
updated strains.1 However, any child that comes to the doctor later
in the year, post the monsoons with no history of influenza
vaccination in the past 1 year, should not be made to wait till
next year and should be vaccinated with the latest strains
available so as to protect from the winter peak. These children who
have been vaccinated late (NH) in the year should be shifted to
early (SH)vaccination next year and same cycle (SH) should be
continued every year. 1. Vashistha VM et al. Influenza Vaccination
in India: Position Paper of IAP, 2013. Indian Pediatrics
2013:50;867-74
11. What are the recommendations
12. Vaccine Recommendations Ideally, all individuals should
have the opportunity to be vaccinated against influenza. Priority
should be given to high risk population All those aged over 6
months in a clinical at-risk group Only in all high risk children
>6 months Universal Vaccination of all children from the age of
6 months. Special attention for children upto 60 months Routine
influenza vaccination is recommended for all persons aged 6 months
*CEVAG: Central European Advisory Group
http://www.who.int/docstore/wer/pdf/2002/wer7728.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr59e0729a1.htm?s_cid=rr59e0729a1_e
http://www.sehd.scot.nhs.uk/cmo/CMO(2010)14.pdf
http://www.biomedcentral.com/content/pdf/1471-2334-10-168.pdf
*
13. Prioritization of target groups as per IAP 1. Elderly
individuals (>65 years) and nursing-home residents (the elderly
or disabled) 2. Individuals with chronic medical conditions
including individuals with HIV/AIDS, and pregnant women (especially
to protect infants 0-6 months) 3. Other groups: health care workers
including professionals, individuals with asthma, and children from
ages 6 months to 2 years. 4. Children aged 2-5 years and 6-18
years, and healthy young adults. Amongst pediatric population,
apart from the children with chronic medical conditions (see
above), the children below 2 years * IAP of position age should
paper of be Influenza considered Indian a Pediatrics, target group
September for influenza 2013 immunization because of a high burden
of severe disease in this group. *
14. Center for Disease Control and prevention. Recommendations
, 201415 1. Routine annual influenza vaccination is recommended for
all persons aged 6 months who do not have contraindications 2. Live
attenuated influenza vaccine (LAIV) should be preferred for healthy
children aged 2 through 8 years, for the 201415 season
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
15. NHS recommendations 2014- 15 An annual nasal flu vaccine
for children is available on the NHS for all two, three and four
year olds. Over time, potentially all children between the ages of
two and 16 could be vaccinated each year against flu using the
nasal spray. Children aged two to 17 who are at extra risk from flu
because they have a long-term health condition, such as diabetes,
heart or lung disease, will have the annual flu nasal spray instead
of the annual flu jab Children with mild or moderate asthma are
able to have the flu nasal spray
16. What are the types of Influenza vaccines available?
17. Types of Influenza vaccines Egg Based Nomenclature changed
from TIV to IIV (Inactivated Influenza Vaccine) IIV3 was only
available in India previously. LAIV 3/4 Quadrivalent Influenza
Vaccine IIV4 Adjuvanted IIV3 Non egg based Cell culture based ccIIV
3 Recombinant RIV3
18. TIV Influenza Vaccination Schedule Age Vaccine Dose Initial
Vaccination Subsequent Vaccination 635 months 0.25 mL 2 doses 1
month apart Single annual dose as soon as new vaccine is released
38 years 0.5 mL 2 doses 1 month apart 9 years 0.5 mL 1 Dose
Individual vaccines. In: Yewale V, Choudhury P, Thacker N (eds).
IAP Guide Book on Immunization. IAP Committee on Immunization.
20092011. Mumbai, 2011, pp. 51144.
19. LAIV (Nasovac S) Schedule A single intranasal dose
recommended for people above the age of 2 years. This vaccination
is similar to what is being advised by NHS for routine immunization
of healthy kids as well.
20. Advantages of LAIV
21. LAIV Mimic natural infection and therefore it is expected
that LAIV induce a more rapid and broader immune response LAIV
induce IgA in natural tract which neutralize the virus at portal
entry Administered intranasal making it painless Used successfully
in Russian federation- Microgen Used successfully Medimmune
Vaccines is revised twice annually for prevalent strain of
virus
22. Advantages of LAIV Serum antibodies Adv. Nasal Specific
intranasal IgA Cell mediated immune Protection response against
drifted virus Herd immunity Painless Mimic natural route of inf
Ref: MMWR Morb Mortal Wkly Rep. 2014 Aug 15;63(32):691-7.
23. LAIV Precautions & Contraindications
24. CDC Contraindications Contraindications for LAIV 1. Persons
aged 49 years; 2. Children aged 2 through 17 years who are
receiving aspirin or aspirin-containing products; 3. Severe
allergic reaction to flu vaccine previously 4. Pregnant women *
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
25. CDC - Contraindications 4. Severely Immunosuppressed
persons 5. Persons with a history of egg allergy * 6. Children aged
2 through 4 years who have asthma or who have had a wheezing
episode noted in the medical record within the past 12 months 7.
Persons who have taken influenza antiviral medications within the
previous 48 hours
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
26. Precautions for LAIV - CDC Asthmatics might be at increased
risk for wheezing after administration of LAIV Theoretically,
Persons with other underlying medical conditions that might
predispose them to complications after wild-type influenza
infection (e.g., chronic pulmonary, cardiovascular [except isolated
hypertension], renal, hepatic, neurologic, hematologic, or
metabolic disorders [including diabetes mellitus] ) * These
conditions, in addition to asthma in persons aged 5 years, should
be considered precautions for the use of LAIV.
27. LAIV Vs TIV
28. Head to Head comparison of LAIV & IIV LAIV IIV Grows in
nasopharaynx Not grow Nasal spray Injection Grows in cooler areas
of nasal tract but stop growing in LRTI Not grow Mimic natural
infection and induce double layer immunity Serves only as a dose of
antigen to the immune system Induce local, systemic and cell
mediated immunity May not induce local immunity, good systemic
response Provide local immunity No local immunity More effective
Effectiveness less than LAIV Painless Painful Negligible side
effect Reported side effects Cost effective Comparatively expensive
Provide herd immunity Not possible Preferred in children Children
afraid of needles
29. LAIV Vs TIV in children In over 26,000 children aged 6
months to 17 years, LAIV demonstrated 44 48 % fewer cases of
culture positive influenza illness caused by similar strains and
all strains, respectively as compared to TIV! Overall efficacy of
LAIV was 83 % in first year & 87 % in second year. Ref:
Vaccine. 2012 Jan 20;30(5):886-92. doi:
10.1016/j.vaccine.2011.11.104. Epub 2011 Dec 7.
30. Live attenuated versus inactivated influenza vaccine in
infants and young children 54.9% fewer cases of cultured-confirmed
influenza in the group that received live attenuated vaccine than
in the group that received inactivated vaccine (153 vs. 338 cases,
P