In the recent issue ( July 2016) of Assocations of Pysicians of India, through their supplement issue, A Muruganathan1, Santanu Guha, YP Munjal, SS Agarwal, KK Parikh, Vivekanand Jha, Anjani Kumar Jha, Ijanti Abeywicreme, Mangesh Tiwaskar, Milind Y Nadkar, Jyotirmoy Pal, Shohael Mahmud Arafat, Anupam Prakash, Jayant Panda, V Ramasubramanian, Sampath Kumari, Bibhuti Saha, Sekhar Chakraborty, Somusundaram, Jain, MK Ghosh, Parvaiz A Koul identified Recommendations for Vaccination Against Seasonal Influenza in Adult High Risk Groups: South Asian Recommendations.
These recommendations include
• Every one with diabetes over the age of six month are strongly advised to maintain good glycemic control and to take influenza vaccination yearly for minimizing infective episodes, except who are allergic to eggs.
• Influenza immunization is strongly recommended yearly in all people with diabetes with renal failure, immunocompromised state due to concomittant illness and comorbidities, chronic respiratory diseases like bronchial asthma and COPD, smokers, poor hygenic conditions (like slum dwellers) and those who frequently travel to high risk areas.
• In younger persons with diabetes (18-50 years) counseling should be done about influenza vaccination. People with diabetes with long duration of disease and poor control have greater susceptibility to infection by Influenza virus hence should be vaccinated.
• Elderly people with diabetes above 50 years of age and with co-morbidities should be strongly motivated for mandatory vaccination against influenza.
• All patients with chronic kidney disease (CKD) and all kidney transplant recipients should be advised to receive annual influenza vaccine.
• Household contacts and health care workers should also be vaccinated annually to decrease the transmission to highrisk CKD or post-transplant patients.
Special Considerations in Renal Disease
• Dialysis: No difference in the serological response to influenza vaccines was noted in peritoneal dialysis (PD) and hemodialysis (HD) patients, with response rate of 66–77.3% versus 66–78.7% in PD and HD patients, respectively. The present evidence suggests that both PD and HD patients should receive the standard annual dose of the vaccine.
• Kidney Transplant: Inactivated influenza vaccine may be given to transplant recipients despite intensive immunosuppression. It is best to wait until the first 3–6 months after kidney transplantation, the period of intense immunosuppression , before attempting vaccination. However, inactivated influenza vaccination can be administered as early as one month after kidney transplant to time it before onset of the flu season.
Concerns about influenza vaccine triggering an immune response and increase the risk of acute rejections have not been substantiated in large scale studies that demonstrated no increase in acute rejection episodes when influenza vaccine was used. In large registry data, influenza vaccine use in transplant recipients was associated with lower rates of allograft loss and death. Use of adjuvanted Influenza vaccines has been shown to cause a rise in anti HLA antibodies but not acute rejection episodes.
• All patients with chronic respiratory diseases including bronchial asthma, COPD, bronchiectasis, interstitial lung disease and chronic smoker should receive annual influenza vaccination.
• Smoking may increase the risk of hospitalization in smokers and ex-smokers when infected by the influenza virus. Current smokers in a recent Spanish study were found to be twice at risk of hospitalization than non-smokers.
• Influenza vaccination is recommended for patients with atherosclerotic heart disease, cardiomyopathy/chronic congestive heart failure, and congenital heart disease.
• Patients with valvular heart disease should also receive annual influenza vaccination.
• Influenza vaccination is recommended for patients with chronic liver disease with cirrhosis ( both compensated and decmpensated cirrhosis). Annual vaccination is also recommended for Chronic Hepatitis (especially Hepatitis B and C) and alcoholics.
• Influenza vaccine is recommended in patients above 50 years of age
• Currently in India the high dose vaccine is not available. Available trivalent inactivated vaccine may be given to elderly people.
• Influenza vaccination should be given to all pregnant women
• Influenza vaccine can be given in any trimester of pregnancy
• LAIV i s contraindicated i n pregnancy
• Influenza vaccine is recommended in all healthcare workers with direct or indirect interaction with patients or hospital staff. It should include hospital staff as well as office staff i.e. house keeping personnel, laundry personnel, receptionists etc
• Seniors in the hospital should act as role models to increase acceptance rate of vaccination
In case of inadequate vaccine supply, following prioritization is recommended.
- Those who are in close, prolonged contact and repeated contact with high risk patients should be vaccinated first.
- Close but not in prolonged or repeated contact with high risk patients, those work with high risk patients, perform the essential patient care functions and HCP who are in contact with patients not at risk should be given second priority and lastly.
- Other healthcare personnel should be vaccinated subsequently
Neurological Disorders, Obesity and Autoimmune Diseases
• Vaccination should b e recommended in all patients with chronic vascular disease
• Patients with history of stroke or transient ischemic attacks should receive an annual influenza vaccination
• Patients with diabetes mellitus or with a combination of risk factors that further increases risk of stroke should receive vaccination
• Obese patients should b e considered priority group for influenza vaccination
• Patients with rheumatoid arthritis, systemic lupus erythematosus and Sjogren’s syndrome should be considered for annual influenza vaccination
Immunocompromised, Cancers and Blood Disorders
• Annual vaccinationfor HIV infected individuals with inactivated vaccine is recommended.
• Seve rely impaired antibody responses are observed in HIVinfected individuals with CD4+ T lymphocyte counts <100 x 10 6/l. Annual vaccination of HIVinfected individuals with CD4+ T lymphocyte counts exceeding 100 x 106/l seems to be worthwhile, although it may not be expected to render the same level of protection against influenza as in non-infected individuals.
• Annual influenza vaccination is recommended in cancer and solid organ transplant (SOT) recipients.
• Donors and recipients of solid organ transplant should be updated regarding vaccination
• Post organ transplant, it is advisable to postpone influenza vaccination for the first two months, but in the event of an outbreak in the community, injectable vaccine can be given after one month of transplant. Live vaccines are not advised in this group of patients.
• Vaccine should be given prior to the immunosuppressive therapy if possible. Live vaccines if needed should be given at least four weeks before immunosuppression and should be avoided two weeks prior to immunosuppression. Inactivated vaccines can be given two weeks or more prior to immunosuppression
• Annual vaccine with inactivated influenza vaccine is recommended for all immuno compromized patients aged six months after the immune-suppressive therapy except those who are unlikely to respond (e.g. those receiving intensive chemotherapy or those who have received anti B cell antibody in last six months). Live influenza vaccine should not be given to these patients.
• Household members of immuno suppressed members should preferably given the inactivated vaccine, especially for hematopoietic stem cell transplant recipients within two months after transplant, or for those with subacute combined immunedeficiency.
• Patients aged six months and more with hematological malignancy or solid tumor except those receiving anti B cell antibodies or intensive chemotherapy for induction or consolidation of leukemia should receive influenza vaccine every year
• Acute leukemia patients o n chemotherapy should not receive the vaccine. Before chemotherapy, they can receive the vaccine.
• Hematopoietic stem cell transplantation (HSCT) donor should be advocated regarding vaccination whereas recipient if not already immunocompromized should be advocated vaccination more than four weeks before immunosuppression in case of live vaccine and more than two weeks in case of inactivated vaccine
• After HSCT, one dose should be given six months after the HSCT and if there is a community outbreak of influenza, it can be given four months after. In children, two doses should be given as per recommendations
• In patients of chronic inflammatory diseases on immunosuppressive therapy, inactivated vaccine should be administered while planning to give immunosuppressive therapy. A live attenuated vaccine should be avoided for these patients.
• Patients with asplenia and sickle cell disease should be given the annual injectable vaccine and not the live attenuated vaccine
Other High Risk Populations (Hajj, Kumbh Mela, Umrah, Military, Army, Air Force, Hostellers, Prisoners and Other High Risk Situations Conditions like Corporates, Manufacturing Units, Miners, Frequent Air Travelers, etc.)
• Any industry can host immunization camps in their organization to benefit their workers. Vaccination of workers /employees for Influenza substantially reduces influenza like illness and absenteeism in all types of industries. Thus annual influenza vaccination is beneficial in these settings.
• In case of epidemics, if travel is must, vaccination should be taken before traveling
• Military, paramilitary and emergency personnel are prone to outbreaks of respiratory illnesses including influenza for variety of reasons. They are at risk particularly in crowded places such as recruitment camps. Influenza is one of the few infectious diseases that is able to disrupt military operations quickly. Seasonal influenza varies from year to year and since its impact is dependent on antigenic evolution, it is largely unpredictable.
• Military land forces are typically most at risk of influenza when crowded into camps, particularly recruit camps.
• Air forces have been particularly concerned with influenza, not because they are more susceptible than other military groups, but because large numbers of flight personnel can suddenly become sick and unable to fly during an influenza outbreak within a short time. Flight personnel often undertake international travel extensively, thereby increasing the risk of early introduction of new influenza viruses into air force installations.
• Naval forces have to deal with the particular problem of ship board influenza epidemics given the crowded conditions on board most warships.
• The re f o re annual Influenza vaccination is recommended to the armed forces personnel from Army, Navy or Air-force. • Hos telle rs, boarding school and medical colleges: Mass immunization is very effective in increasing the uptake of vaccination and success rate . Hostellers comprise a large, susceptible segment of the population and regularly have a high attack rate. It is recommended to immunize the hostellers annually with Influenza vaccine.
• It is important t o immunize the prison staff rather than the residents.Staff with influenza like illness should stay home and remain home at least for seven days after symptoms subside
• In airline personnel In case ill, they should discontinue work as soon as possible without affecting flight safety and start working after 24 hours after the resolution of symptoms o Disinfection and cleaning of aircraft after the outbreak is important
• Hajj & Umrah Severe crowding, shared accommodation, reduced personal hygiene, and environmental pollution at Hajj& Umrah may collectively lead to increased transmission of respiratory viruses, notably influenza. The Centre for Disease Control and Saudi Government recommend that international pilgrims be vaccinated against seasonal influenza before arriving in the country. The group endorses this recommendation. It is strongly recommended that even in other large gatherings like Kumbh mela the pilgrims should get an Influenza vaccination prior to travelling to the religious shrines.
Other General Recommendation
• Importance o f hand washing and cough etiquette should be emphasized to all. Poor Influenza Vaccine Uptake in India Vaccine uptake in India is dismal even among the high risk population including healthcare workers, 8 COPD, 29diabetics, 74 and pregnant females57 in India is dismal. Recommendations for Improving the Implementation of Influenza Vaccination Following are general recommendations for improving access to influenza vaccination.
• Efforts should be made to create and maintain disease specific registries for systemic tracking and reminders for vaccination
• Periodic training o f the staff accompanied by on going assessment of immunization rate and workflow with close follow up is essential
• Quality assurance and standards of care should be maintained.
• Clinics using vaccination should try to maintain the records to assess the efficacy of vaccines and occurrence of complications.
• Awareness among patients as well as physicians should be improved for improving vaccination uptake rate.
• Along with the vaccine recommendation, the patients should also be educated about the risk of the illness and its complicatons which can be prevented by vaccination.
• Access to vaccination is key to minimize risk of pandemic influenza. Vaccine should be made available at any time especially in high risk areas.
• Multiple vaccines given in single visit, reduction of financial barriers and use of all possible means to create awareness are some of the useful measures to improve the uptake rates of influenza.
• Vaccination reminders through cellular companies as a part of corporate social responsibility can be considered
The orginal article contains number of indications and rationale for vaccinations for high risk patients. You can read the full recommendations below