This report updates the 2008 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of seasonal influenza (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices . MMWR 2008;57). Information on vaccination issues related to the recently identified novel influenza A H1N1 virus will be published later in 2009. The 2009 seasonal influenza recommendations include new and updated information. Highlights of the 2009 recommendations include 1) a recommendation that annual vaccination be administered to all children aged 6 months-18 years for the 2009-10 influenza season; 2) a recommendation that vaccines containing the 2009-10 trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; and 3) a notice that recommendations for influenza diagnosis and antiviral use will be published before the start of the 2009-10 influenza season. Vaccination efforts should begin as soon as vaccine is available and continue through the influenza season. Approximately 83% of the United States population is specifically recommended for annual vaccination against seasonal influenza; however, <40% of the U.S. population received the 2008-09 influenza vaccine. These recommendations also include a summary of safety data for U.S. licensed influenza vaccines. These recommendations and other information are available at CDC's influenza website (/ flu); any updates or supplements that might be required during the 2009-10 influenza season also can be found at this website. Vaccination and health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.# Introduction
In the United States, annual epidemics of seasonal influenza occur typically during the late fall through early spring. Influenza viruses can cause disease among persons in any age group, but rates of infection are highest among children (1)(2)(3). Rates of serious illness and death are highest among persons aged >65 years, children aged <2 years, and persons of any age who have medical conditions that place them at increased risk for complications from influenza (1,4,5). An annual average of approximately 36,000 deaths during 1990-1999 and 226,000 hospitalizations during 1979-2001 have been associated with influenza epidemics (6,7).
Annual influenza vaccination is the most effective method for preventing influenza virus infection and its complications. Influenza vaccine can be administered to any person aged >6 months who does not have contraindications to vaccination to reduce the likelihood of becoming ill with influenza or of transmitting influenza to others. Trivalent inactivated influenza vaccine (TIV) can be used for any person aged >6 months, including those with high-risk conditions (Boxes 1 and 2). Live, attenuated influenza vaccine (LAIV) may be used for healthy, nonpregnant persons aged 2-49 years. No preference All children aged 6 months-18 years should be vaccinated annually.
Children and adolescents at higher risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents, including those who:
are aged 6 months-4 years ( - 59 months); have chronic pulmonary (including asthma), cardiovas-- cular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematological or metabolic disorders (including diabetes mellitus); are immunosuppressed (including immunosuppression - caused by medications or by human immunodeficiency virus); are receiving long-term aspirin therapy and therefore - might be at risk for experiencing Reye syndrome after influenza virus infection; are residents of long-term care facilities; and - will be pregnant during the influenza season. - Note: Children aged <6 months cannot 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. is indicated for LAIV or TIV when considering vaccination of healthy, nonpregnant persons aged 2-49 years. Because the safety or effectiveness of LAIV has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications, these persons should be vaccinated only with TIV. Influenza viruses undergo frequent antigenic change (i.e., antigenic drift); to gain immunity against viruses in circulation, patients must receive an annual vaccination against the influenza viruses that are predicted on the basis of viral surveillance data. . Although vaccination coverage has increased in recent years for many groups targeted for routine vaccination, coverage remains low among most of these groups, and strategies to improve vaccination coverage, including use of reminder/recall systems and standing orders programs, should be implemented or expanded.
Antiviral medications are an adjunct to vaccination and are effective when administered as treatment and when used for chemoprophylaxis after an exposure to influenza virus. However, the emergence since 2005 of resistance to one or more of the four licensed antiviral agents (oseltamivir, zanamivir, amantadine and rimantadine) among circulating strains Annual vaccination against influenza is recommended for any adult who wants to reduce the risk of becoming ill with influenza or of transmitting it to others. Vaccination is recommended for all adults without contraindications in the following groups, because these persons either are at higher risk for influenza complications, or are close contacts of persons at higher risk has complicated antiviral treatment and chemoprophylaxis recommendations. Updated antiviral treatment and chemoprophylaxis recommendations will be provided in a separate set of guidelines later in 2009. CDC has issued interim recommendations for antiviral treatment and chemoprophylaxis of influenza (8), and these guidelines should be consulted pending issuance of new recommendations.
In April 2009, a novel influenza A (H1N1) virus that is similar to influenza viruses previously identified in swine was determined to be the cause of an influenza respiratory illness that spread across North America and was identified in many areas of the world by May 2009. The symptoms of novel influenza A (H1N1) virus infection are similar to those of seasonal influenza, and specific diagnostic testing is required to distinguish novel influenza A (H1N1) virus infection from seasonal influenza (9). The epidemiology of this illness is still being studied and prevention issues related to this newly emerging influenza virus will be published separately.

# Methods
CDC's Advisory Committee on Immunization Practices (ACIP) provides annual recommendations for the prevention and control of influenza. The ACIP Influenza Vaccine Working Group- meets monthly throughout the year to discuss newly published studies, review current guidelines, and consider revisions to the recommendations. As they review the annual recommendations for ACIP consideration of the full committee, members of the working group consider a variety of issues, including burden of influenza illness, vaccine effectiveness, safety, and coverage in groups recommended for vaccination, feasibility, cost-effectiveness, and anticipated vaccine supply. Working group members also request periodic updates on vaccine and antiviral production, supply, safety and efficacy from vaccinologists, epidemiologists, and manufacturers. State and local vaccination program representatives are consulted. CDC's Influenza Division (available at / flu) provides influenza surveillance and antiviral resistance data. The Vaccines and Related Biological Products Advisory Committee provides advice on vaccine strain selection to the Food and Drug Administration (FDA), which selects the viral strains to be used in the annual trivalent influenza vaccines.
Published, peer-reviewed studies are the primary source of data used by ACIP in making recommendations for the prevention and control of influenza, but unpublished data that are relevant to issues under discussion also might be considered. Among studies discussed or cited, those of greatest scientific quality and those that measured influenza-specific outcomes are the most influential. For example, population-based estimates that use outcomes associated with laboratory-confirmed influenza virus infection outcomes contribute the most specific data for estimates of influenza burden. The best evidence for vaccine or antiviral efficacy and effectiveness comes from randomized controlled trials that assess laboratory-confirmed influenza infections as an outcome measure and consider factors such as timing and intensity of influenza circulation and degree of match between vaccine strains and wild circulating strains (10,11). Randomized, placebo-controlled trials cannot be performed ethically in populations for which vaccination already is recommended, but observational studies that assess outcomes associated with laboratory-confirmed influenza infection can provide important vaccine or antiviral effectiveness data. Randomized, placebo-controlled clinical trials are the best source of vaccine and antiviral safety data for common adverse events; however, such studies do not have the statistical power to identify rare but potentially serious adverse events. The frequency of rare adverse events that might be associated with vaccination is best assessed by reviewing computerized medical records from large linked clinical databases and medical charts of persons who are identified as having a potential adverse event after vaccination (12,13). Vaccine coverage data from a nationally representative, randomly selected population that includes verification of vaccination through health-care record review are superior to coverage data derived from limited populations or without verification of vaccination; however, these data rarely are available for older children or adults (14). Finally, studies that assess vaccination program practices that improve vaccination coverage are most influential in formulating recommendations if the study design includes a nonintervention comparison group. In cited studies that included statistical comparisons, a difference was considered to be statistically significant if the p-value was <0.05 or the 95% confidence interval (CI) around an estimate of effect allowed rejection of the null hypothesis (i.e., no effect).
These recommendations were presented to the full ACIP and approved in February 2009. Modifications were made to the ACIP statement during the subsequent review process at CDC to update and clarify wording in the document. Vaccine recommendations apply only to persons who do not have contraindications to vaccine use (see Contraindications and Precautions for use of TIV and Contraindications and Precautions for use of LAIV). Data presented in this report were current as of July 17, 2009. Further updates, if needed, will be posted at CDC's influenza website (. gov/flu).

# Primary Changes and Updates in the Recommendations
The 2009 recommendations include three principal changes or updates:
Annual vaccination of all children aged 6 months-18 - years should begin as soon as the 2009-10 influenza vaccine is available. Annual vaccination of all children aged 6 months-4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue to be a primary focus of vaccination efforts as providers and programs transition to routinely vaccinating all children. from the United States and other countries are now resistant to oseltamivir. Recommendations for influenza diagnosis and antiviral use will be published later in 2009. CDC issued interim recommendations for antiviral treatment and chemoprophylaxis of influenza in December 2008, and these should be consulted for guidance pending recommendations from the ACIP (8).

# Background and Epidemiology

# Biology of Influenza
Influenza A and B are the two types of influenza viruses that cause epidemic human disease. Influenza A viruses are categorized into subtypes on the basis of two surface antigens: hemagglutinin and neuraminidase. Since 1977, influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses have circulated globally. Influenza A (H1N2) viruses that probably emerged after genetic reassortment between human A (H3N2) and A (H1N1) viruses also have been identified in some influenza seasons. In April 2009, human infections with a novel influenza A (H1N1) virus were identified; as of June 2009, infections with the novel influenza A (H1N1) virus have been reported worldwide. This novel virus is derived partly from influenza A viruses that circulate in swine and is antigenically distinct from human influenza A (H1N1) viruses in circulation since 1977. Influenza A subtypes and B viruses are further separated into groups on the basis of antigenic similarities. New influenza virus variants result from frequent antigenic change (i.e., antigenic drift) resulting from point mutations and recombination events that occur during viral replication (15). Recent studies have begun to shed some light on the complex molecular evolution and epidemiologic dynamics of influenza A viruses (16)(17)(18).
Currently circulating influenza B viruses are separated into two distinct genetic lineages (Yamagata and Victoria) but are not categorized into subtypes. Influenza B viruses undergo antigenic drift less rapidly than influenza A viruses. Influenza B viruses from both lineages have circulated in most recent influenza seasons (19).
Immunity to the surface antigens, particularly the hemagglutinin, reduces the likelihood of infection (20). Antibody against one influenza virus type or subtype confers limited or no protection against another type or subtype of influenza virus. Furthermore, antibody to one antigenic type or subtype of influenza virus might not protect against infection with a new antigenic variant of the same type or subtype (21). Frequent emergence of antigenic variants through antigenic drift is the virologic basis for seasonal epidemics and is the reason for annually reassessing the need to change one or more of the recommended strains for influenza vaccines.
More dramatic changes, or antigenic shifts, occur less frequently. Antigenic shift occurs when a new subtype of influenza A virus appears and can result in the emergence of a novel influenza A virus with the potential to cause a pandemic. New influenza A subtypes have the potential to cause a pandemic when they are able to cause human illness and demonstrate efficient human-to-human transmission and little or no previously existing immunity has been identified among humans (15). Novel influenza A (H1N1) virus is not a new subtype, but because the large majority of humans appear to have no pre-existing antibody to key novel influenza A (H1N1) virus hemagglutinin epitopes, substantial potential exists for widespread infection (16).

# Health-Care Use, Hospitalizations, and Deaths Attributed to Influenza
In the United States, annual epidemics of influenza typically occur during the fall or winter months, but the peak of influenza activity can occur as late as April or May (Figure 1). Influenza-related complications requiring urgent medical care, including hospitalizations or deaths, can result from the direct effects of influenza virus infection, from complications associated with age or pregnancy, or from complications of underlying cardiopulmonary conditions or other chronic diseases. Studies that have measured rates of a clinical outcome without a laboratory confirmation of influenza virus infection (e.g., respiratory illness requiring hospitalization during influenza season) to assess the effect of influenza can be difficult to interpret because of circulation of other respiratory pathogens (e.g., respiratory syncytial virus) during the same time as influenza viruses (22)(23)(24). However, increases in healthcare provider visits for acute febrile respiratory illness occur each year during the time when influenza viruses circulate. Data from the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) demonstrate the annual increase in physician visits for influenza-like illness (ILI)  and for each influenza season; for 2009, the data also indicate the recent resurgence of respiratory illness associated with circulation of novel influenza A (H1N1) virus (Figure 2) (25,26).
During seasonal influenza epidemics from 1979-1980 through 2000-2001, the estimated annual overall number of influenza-associated hospitalizations in the United States ranged from approximately 55,000 to 431,000 per annual epidemic (mean: 226,000) (7). The estimated annual number of deaths attributed to influenza from the 1990-91 influenza season through the 1998-99 season ranged from 17,000 to 51,000 per epidemic (mean: 36,000) (6). In the United States, the estimated number of influenza-associated deaths    53; therefore the week 53 data point for those seasons is an average of weeks 52 and 1.  The national baseline is the mean percentage of visits for ILI during noninfluenza weeks for the previous three seasons plus two standard deviations. A noninfluenza week is a week during which 65 years who were at increased risk for death from influenza complications (6). In one study, an average of approximately 19,000 influenza-associated pulmonary and circulatory deaths per influenza season occurred during 1976-1990 compared with an average of approximately 36,000 deaths per season during 1990-1999 (6). In addition, influenza A (H3N2) viruses, which have been associated with higher mortality (27), predominated in 90% of influenza seasons during 1990-1999 compared with compared with 57% of seasons during 1976-1990 (6).
Influenza viruses cause disease among persons in all age groups (1)(2)(3)(4)(5). Rates of infection are highest among children, but the risks for complications, hospitalizations, and deaths from influenza are higher among persons aged >65 years, young children, and persons of any age who have medical conditions that place them at increased risk for complications from influenza (1,4,5,(28)(29)(30)(31). Estimated rates of influenzaassociated hospitalizations and deaths varied substantially by age group in studies conducted during different influenza epidemics. During 1990-1999, estimated average rates of influenza-associated pulmonary and circulatory deaths per 100,000 persons were 0.4-0.6 among persons aged 0-49 years, 7.5 among persons aged 50-64 years, and 98.3 among persons aged >65 years (6).

# Children
Among children aged <5 years, influenza-related illness is a common cause of visits to medical practices and emergency departments (EDs). During two influenza seasons (2002-03 and 2003-04), the percentage of visits among children aged <5 years with acute respiratory illness or fever caused by laboratory-confirmed influenza ranged from 10%-19% of medical office visits to 6%-29% of EDs visits during the influenza season. On the basis of these data, the rate of visits to medical clinics for influenza was estimated to be 50-95 per 1,000 children, and the rate of visits to EDs was estimated to be 6-27 per 1,000 children (32). A multiyear study in New York City used viral surveillance data to estimate influenza strain-specific illness rates among ED visits. In addition to the expected variation by season and age group, influenza B epidemics were found to be an important cause of illness among school-aged children in several seasons, and annual epidemics of both influenza A and B peaked among school-aged children before other age groups (33). Retrospective studies using medical records data have demonstrated similar rates of illness among children aged <5 years during other influenza seasons (29,34,35). During the influenza season, an estimated 7-12 additional outpatient visits and 5-7 additional antibiotic prescriptions per 100 children aged <15 years have been documented when compared with periods when influenza viruses are not circulating, with rates decreasing with increasing age of the child (35). During 1993During -2004 in the Boston area, the rate of ED visits for respiratory illness that was attributed to influenza virus based on viral surveillance data among children aged <7 years during the winter respiratory illness season ranged from 22.0 per 1,000 children aged 6-23 months to 5.4 per 1,000 children aged 5-7 years (36).
Rates of influenza-associated hospitalization are substantially higher among infants and young children than among older children when influenza viruses are in circulation and are similar to rates for other groups considered at high risk for influenza-related complications (37)(38)(39)(40)(41)(42), including persons aged >65 years (35,39). During 1979-2001, on the basis of data from a national sample of hospital discharges of influenzaassociated hospitalizations among children aged <5 years, the estimated rate of influenza-associated hospitalizations in the United States was 108 hospitalizations per 100,000 personyears (7). Recent population-based studies that measured hospitalization rates for laboratory-confirmed influenza in young children have documented hospitalization rates that are similar to or higher than rates derived from studies that analyzed hospital discharge data (32,34,41,43,44). Annual hospitalization rates for laboratory-confirmed influenza decrease with increasing age, ranging from 240-720 per 100,000 children aged <6 months to approximately 20 per 100,000 children aged 2-5 years (32). Hospitalization rates for children aged <5 years with high-risk medical conditions are approximately 250-500 per 100,000 children (29,31,45).
Influenza-associated deaths are uncommon among children. An estimated annual average of 92 influenza-related deaths (0.4 deaths per 100,000 persons) occurred among children aged 65 years (6). Of 153 laboratory-confirmed influenza-related pediatric deaths reported during the 2003-04 influenza season, 96 (63%) deaths occurred among children aged <5 years and 61 (40%) among children aged <2 years. Among the 149 children who died and for whom information on underlying health status was available, 100 (67%) did not have an underlying medical condition that was an indication for vaccination at that time (46). In California during the 2003-04 and 2004-05 influenza seasons, 51% of children with laboratory-confirmed influenza who died and 40% of those who required admission to an intensive care unit had no underlying medical conditions (47). These data indicate that although children with risk factors for influenza complications are at higher risk for death, the majority of pediatric deaths occur among children with no known high-risk conditions. The annual number of influenza-associated deaths among children reported to CDC for the past four influenza seasons has ranged from 44 during 2004-05 to 84 during 2007-08 (48). As of July 8, 2009, a total of 17 deaths caused by novel influenza A (H1N1) virus infection have occurred in 2009 among children in the United States (CDC, unpublished data, 2009). Death associated with laboratory-confirmed influenza virus infection among children (defined as persons aged <18 years) is a nationally reportable condition. Deaths among children that have been attributed to co-infection with influenza and Staphylococcus aureus, particularly methicillin-resistant S. aureus (MRSA), have increased during the preceding four influenza seasons (26,49). The reason for this increase is not established but might reflect an increasing prevalence within the general population of colonization with MRSA strains, some of which carry certain virulence factors (50,51).

# Adults
Hospitalization rates during the influenza season are substantially increased for persons aged >65 years. One retrospective analysis based on data from managed-care organizations collected during 1996-2000 estimated that the risk during influenza season among persons aged >65 years with underlying conditions that put them at risk for influenza-related complications (i.e., one or more of the conditions listed as indications for vaccination) was approximately 560 influenzaassociated hospitalizations per 100,000 persons compared with approximately 190 per 100,000 healthy persons. Persons aged 50-64 years with underlying medical conditions also were at substantially increased risk for hospitalizations during influenza season compared with healthy adults aged 50-64 years. No increased risk for influenza-related hospitalizations was demonstrated among healthy adults aged 50-64 years or among those aged 19-49 years, regardless of underlying medical conditions (28).
Influenza is an important contributor to the annual increase in deaths attributed to pneumonia and influenza that is observed during the winter months (Figure 3). During 1976-2001, an estimated yearly average of 32,651 (90%) influenza-related deaths occurred among adults aged >65 years (6). Risk for influenza-related death was highest among the oldest elderly, with persons aged >85 years 16 times more likely to die from an influenza-related illness than persons aged 65-69 years (6).
The duration of influenza symptoms is prolonged and the severity of influenza illness increased among persons with human immunodeficiency virus (HIV) infection (52)(53)(54)(55)(56). A retrospective study of young and middle-aged women enrolled in Tennessee's Medicaid program determined that the attributable risk for cardiopulmonary hospitalizations among women with HIV infection was higher during influenza seasons than it was either before or after influenza was circulating. The risk for hospitalization was higher for HIV-infected women than it was for women with other underlying medical conditions (57). Another study estimated that the risk for influenza- - Each week, the vital statistics offices of 122 cities report the total number of death certificates received and the number of those for which pneumonia or influenza (P&I) was listed as the underlying or contributing cause of death by age group. The percentage of all deaths attributable to P&I are compared with a seasonal baseline and epidemic threshold value calculated for each week.  An increase of 1.645 standard deviations above the seasonal baseline deaths is considered the "epidemic threshold," i.e., the point at which the observed proportion of deaths attributed to pneumonia or influenza was significantly higher than would be expected at that time of the year in the absence of substantial influenza-related mortality.  The seasonal baseline of P&I deaths is calculated using a periodic regression model that incorporates a robust regression procedure applied to data from the previous 5 years. related death was 94-146 deaths per 100,000 persons with acquired immunodeficiency syndrome (AIDS) compared with 0.9-1.0 deaths per 100,000 persons aged 25-54 years and 64-70 deaths per 100,000 persons aged >65 years in the general population (58).
Influenza-related excess deaths among pregnant women were reported during the pandemics of 1918-1919 and 1957-1958 (59-63). Case reports and several epidemiologic studies also indicate that pregnancy increases the risk for influenza complications (64-69) for the mother. The majority of studies that have attempted to assess the effect of influenza on pregnant women have measured changes in excess hospitalizations for respiratory illness during influenza season but not laboratoryconfirmed influenza hospitalizations. Pregnant women have an increased number of medical visits for respiratory illnesses during influenza season compared with nonpregnant women (70). Hospitalized pregnant women with respiratory illness during influenza season have increased lengths of stay compared with hospitalized pregnant women without respiratory illness. Rates of hospitalization for respiratory illness were twice as common during influenza season (71). A retrospective cohort study of approximately 134,000 pregnant women conducted in Nova Scotia during 1990-2002 compared medical record data for pregnant women to data from the same women during the year before pregnancy. Among pregnant women, 0.4% were hospitalized and 25% visited a clinician during pregnancy for a respiratory illness. The rate of third-trimester hospital admissions during the influenza season was five times higher than the rate during the influenza season in the year before pregnancy and more than twice as high as the rate during the noninfluenza season. An excess of 1,210 hospital admissions in the third trimester per 100,000 pregnant women with comorbidities and 68 admissions per 100,000 women without comorbidities was reported (72). In one study, pregnant women with respiratory hospitalizations did not have an increase in adverse perinatal outcomes or delivery complications (73); another study indicated an increase in delivery complications, including fetal distress, preterm labor, and cesarean delivery. However, infants born to women with laboratory-confirmed influenza during pregnancy do not have higher rates of low birth weight, congenital abnormalities, or lower Apgar scores compared with infants born to uninfected women (64,74).

# options for Controlling Influenza
The most effective strategy for preventing influenza is annual vaccination (10,15). Strategies that focus on providing routine vaccination to persons at higher risk for influenza complications have long been recommended, although coverage among the majority of these groups remains low. Routine vaccination of certain persons (e.g., children, contacts of persons at risk for influenza complications, and health-care personnel ) who serve as a source of influenza virus transmission might provide additional protection to persons at risk for influenza complications and reduce the overall influenza burden. However, coverage levels among these persons need to be increased before effects on transmission can be measured reliably. Antiviral drugs used for chemoprophylaxis or treatment of influenza are adjuncts to vaccine but are not substitutes for annual vaccination. However, antiviral drugs might be underused among those hospitalized with influenza (75). Nonpharmacologic interventions (e.g., advising frequent handwashing and improved respiratory hygiene) are reasonable and inexpensive; these strategies have been demonstrated to reduce respiratory diseases; reductions in detectable influenza A viruses on hands after handwashing also have been demonstrated (76)(77)(78). Few data are available to assess the effects of community-level respiratory disease mitigation strategies (e.g., closing schools, avoiding mass gatherings, or using respiratory protection) on reducing influenza virus transmission during typical seasonal influenza epidemics (79,80).

# Influenza Vaccine Efficacy, Effectiveness, and Safety Evaluating Influenza Vaccine Efficacy and Effectiveness Studies
The efficacy (i.e., prevention of illness among vaccinated persons in controlled trials) and effectiveness (i.e., prevention of illness in vaccinated populations) of influenza vaccines depend in part on the age and immunocompetence of the vaccine recipient, the degree of similarity between the viruses in the vaccine and those in circulation (see Effectiveness of Influenza Vaccination when Circulating Influenza Virus Strains Differ from Vaccine Strains), and the outcome being measured. Influenza vaccine efficacy and effectiveness studies have used multiple possible outcome measures, including the prevention of medically attended acute respiratory illness (MAARI), prevention of laboratory-confirmed influenza virus illness, prevention of influenza or pneumonia-associated hospitalizations or deaths, or prevention of seroconversion to circulating influenza virus strains. Efficacy or effectiveness for more specific outcomes such as laboratory-confirmed influenza typically will be higher than for less specific outcomes such as MAARI because the causes of MAARI include infections with other pathogens that influenza vaccination would not be expected to prevent (81). Observational studies that compare less-specific outcomes among vaccinated populations to those among unvaccinated populations are subject to biases that are difficult to control for during analyses. For example, an observational study that determines that influenza vaccination reduces overall mortality might be biased if healthier persons in the study are more likely to be vaccinated (82,83). Randomized controlled trials that measure laboratory-confirmed influenza virus infections as the outcome are the most persuasive evidence of vaccine efficacy, but such trials cannot be conducted ethically among groups recommended to receive vaccine annually.

# Influenza Vaccine Composition
Both LAIV and TIV contain strains of influenza viruses that are antigenically equivalent to the annually recommended strains: one influenza A (H3N2) virus, one influenza A (H1N1) virus, and one influenza B virus. Each year, one or more virus strains in the vaccine might be changed on the basis of global surveillance for influenza viruses and the emergence and spread of new strains. For the 2009-10 influenza season, the influenza B vaccine virus strain was changed to B/Brisbane/60/2008, a representative of the B/Victoria lineage) compared with the 2008-09 season. The influenza A (H1N1 and H3N2 vaccine virus strains were not changed (84). Viruses for both types of currently licensed vaccines are grown in eggs. Both vaccines are administered annually to provide optimal protection against influenza virus infection (Table 1). Both TIV and LAIV are widely available in the United States. Although both types of vaccines are expected to be effective, the vaccines differ in several respects (Table 1).

# Major Differences Between tIV and LAIV
During the preparation of TIV, the vaccine viruses are made noninfectious (i.e., inactivated or killed) (15). Only subvirion and purified surface antigen preparations of TIV (often referred to as "split" and subunit vaccines, respectively) are available in the United States. TIV contains killed viruses and thus cannot cause influenza. LAIV contains live, attenuated influenza viruses that have the potential to cause mild signs or symptoms (e.g., runny nose, nasal congestion, fever, or sore throat). LAIV is administered intranasally by sprayer, whereas TIV is administered intramuscularly by injection. LAIV is licensed for use among nonpregnant persons aged 2-49 years; safety has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. TIV is licensed for use among persons aged >6 months, including those who are healthy and those with chronic medical conditions (Table 1).

# Correlates of Protection after Vaccination
Immune correlates of protection against influenza infection after vaccination include serum hemagglutination inhibition antibody and neutralizing antibody (20,85). Increased levels of antibody induced by vaccination decrease the risk for illness caused by strains that are antigenically similar to those strains of the same type or subtype included in the vaccine (86)(87)(88)(89). The majority of healthy children and adults have high titers of antibody after vaccination (87,90). Although immune correlates such as achievement of certain antibody titers after vaccination correlate well with immunity on a population level, the significance of reaching or failing to reach a certain antibody threshold is not well understood on the individual level. Other immunologic correlates of protection that might best indicate clinical protection after receipt of an intranasal vaccine such as LAIV (e.g., mucosal antibody) are more difficult to measure (91,92). Laboratory measurements that correlate with protective immunity induced by LAIV have been described, including measurement of cell-mediated immunity with ELISPOT assays that measure gamma-interferon (89). If not simultaneously administered, can be administered within 4 wks of an inactivated vaccine Yes Yes - Children aged 6 months-8 years who have never received influenza vaccine before should receive 2 doses. Those who only receive 1 dose in their first year of vaccination should receive 2 doses in the following year, spaced 4 weeks apart.  Persons at higher risk for complications of influenza infection because of underlying medical conditions should not receive LAIV. Persons at higher risk for complications of influenza infection because of underlying medical conditions include adults and children with chronic disorders of the pulmonary or cardiovascular systems; adults and children with chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunnosuppression; children and adolescents receiving long-term aspirin therapy (at risk for developing Reye syndrome after wild-type influenza infection); persons 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; pregnant women; and residents of nursing homes and other chronic-care facilities that house persons with chronic medical conditions.  Clinicians and immunization programs should screen for possible reactive airways diseases when considering use of LAIV for children aged 2-4 years and should avoid use of this vaccine in children with asthma or a recent wheezing episode. Health-care providers should consult the medical record, when available, to identify children aged 2-4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive LAIV.  LAIV coadministration has been evaluated systematically only among children aged 12-15 months who received measles, mumps, and rubella vaccine or varicella vaccine.  TIV coadministration has been evaluated systematically only among adults who received pneumococcal polysaccharide or zoster vaccine.

# Immunogenicity, Efficacy, and Effectiveness of tIV Children
Children aged >6 months typically have protective levels of anti-influenza antibody against specific influenza virus strains after receiving the recommended number of doses of influenza vaccine (85 90 93-97). In most seasons, one or more vaccine antigens are changed compared with the previous season. In consecutive years when vaccine antigens change, children aged <9 years who received only 1 dose of vaccine in their first year of vaccination are less likely to have protective antibody responses when administered only a single dose during their second year of vaccination compared with children who received 2 doses in their first year of vaccination (98)(99)(100).
When the vaccine antigens do not change from one season to the next, priming children aged 6-23 months with a single dose of vaccine in the spring followed by a dose in the fall engenders similar antibody responses compared with a regimen of 2 doses in the fall (101). However, one study conducted during a season when the vaccine antigens did not change compared with the previous season estimated 62% effectiveness against ILI for healthy children who had received only 1 dose in the previous influenza season and only 1 dose in the study season compared with 82% for those who received 2 doses separated by >4 weeks during the study season (102).
The antibody response among children at higher risk for influenza-related complications (e.g., children with chronic medical conditions) might be lower than those reported typically among healthy children (103,104). However, antibody responses among children with asthma are similar to those of healthy children and are not substantially altered during asthma exacerbations requiring short-term prednisone treatment (105).
Vaccine effectiveness studies also have indicated that 2 doses are needed to provide adequate protection during the first season that young children are vaccinated. Among children aged <5 years who have never received influenza vaccine previously or who received only 1 dose of influenza vaccine in their first year of vaccination, vaccine effectiveness is lower compared with children who received 2 doses in their first year of being vaccinated. Two large retrospective studies of young children who had received only 1 dose of TIV in their first year of being vaccinated determined that no decrease was observed in ILI-related office visits compared with unvaccinated children (102,106). Similar results were reported in a case-control study of children aged 6-59 months (107). These results, along with the immunogenicity data indicating that antibody responses are significantly higher when young children are given 2 doses, are the basis for the recommendation that all children aged <9 years who are being vaccinated for the first time should receive 2 vaccine doses separated by at least 4 weeks.
Estimates of vaccine efficacy or effectiveness among children aged >6 months have varied by season and study design. In a randomized trial conducted during five influenza seasons (1985)(1986)(1987)(1988)(1989)(1990) in the United States among children aged 1-15 years, annual vaccination reduced laboratory-confirmed influenza A substantially (77%-91%) (87). A limited 1-year placebo-controlled study reported vaccine efficacy against laboratory-confirmed influenza illness of 56% among healthy children aged 3-9 years and 100% among healthy children and adolescents aged 10-18 years (108). A randomized, double-blind, placebo-controlled trial conducted during two influenza seasons among children aged 6-24 months indicated that efficacy was 66% against culture-confirmed influenza illness during the 1999-00 influenza season but did not reduce culture-confirmed influenza illness significantly during the 2000-20 influenza season (109).
A case-control study conducted during the 2003-04 season found vaccine effectiveness of 49% against laboratory-confirmed influenza (107). An observational study among children aged 6-59 months with laboratory-confirmed influenza compared with children who tested negative for influenza reported vaccine effectiveness of 44% in the 2003-04 influenza season and 57% during the 2004-05 season (110). Partial vaccination (only 1 dose for children being vaccinated for the first time) was not effective in either study. During an influenza season (2003-04) with a suboptimal vaccine match, a retrospective cohort study conducted among approximately 30,000 children aged 6 months-8 years indicated vaccine effectiveness of 51% against medically attended, clinically diagnosed pneumonia or influenza (i.e., no laboratory confirmation of influenza) among fully vaccinated children and 49% among approximately 5,000 children aged 6-23 months (106). Another retrospective cohort study of similar size conducted during the same influenza season in Denver but limited to healthy children aged 6-21 months estimated clinical effectiveness of 2 TIV doses to be 87% against pneumonia or influenza-related office visits (102). Among children, TIV effectiveness might increase with age (87,111). A systematic review of published studies estimated vaccine effectiveness at 59% for children aged >2 years but concluded that additional evidence was needed to demonstrate effectiveness among children aged 6 months-2 years (112).
Because of the recognized influenza-related disease burden among children with other chronic diseases or immunosuppression and the long-standing recommendation for vaccination of these children, randomized placebo-controlled studies to study efficacy in these children have not been conducted. In a nonrandomized controlled trial among children aged 2-6 years and 7-14 years who had asthma, vaccine efficacy was 54% and 78% against laboratory-confirmed influenza type A infection and 22% and 60% against laboratory-confirmed influenza type B infection, respectively. Vaccinated children aged 2-6 years with asthma did not have substantially fewer type B influenza virus infections compared with the control group in this study (113). The association between vaccination and prevention of asthma exacerbations is unclear. One study suggested that vaccination might provide protection against asthma exacerbations (114); however, other studies of children with asthma have not demonstrated decreased exacerbations (115).
TIV has been demonstrated to reduce acute otitis media in some studies. Two studies have reported that TIV decreases the risk for influenza-related otitis media by approximately 30% among children with mean ages of 20 and 27 months, respectively (116,117). However, a large study conducted among children with a mean age of 14 months indicated that TIV was not effective against acute otitis media (109). Influenza vaccine effectiveness against a nonspecific clinical outcome such as acute otitis media, which is caused by a variety of pathogens and is not typically diagnosed using influenza virus culture, would be expected to be relatively low.

# Adults Aged <65 Years
One dose of TIV is highly immunogenic in healthy adults aged <65 years. Limited or no increase in antibody response is reported among adults when a second dose is administered during the same season (118)(119)(120). When the vaccine and circulating viruses are antigenically similar, TIV prevents laboratory-confirmed influenza illness among approximately 70%-90% of healthy adults aged <65 years in randomized controlled trials (121)(122)(123)(124). Vaccination of healthy adults also has resulted in decreased work absenteeism and decreased use of health-care resources, including use of antibiotics, when the vaccine and circulating viruses are well-matched (121)(122)(123). Efficacy or effectiveness against laboratory-confirmed influenza illness was 47%-77% in studies conducted during different influenza seasons when the vaccine strains were antigenically dissimilar to the majority of circulating strains (117,119,(121)(122)(123)(124). However, effectiveness among healthy adults against influenza-related hospitalization, measured in the most recent of these studies, was 90% (125).
In certain studies, persons with certain chronic diseases have lower serum antibody responses after vaccination compared with healthy young adults and can remain susceptible to influenza virus infection and influenza-related upper respiratory tract illness (126,127). Vaccine effectiveness among adults aged <65 years who are at higher risk for influenza complications typically is lower than that reported for healthy adults. In a case-control study conducted during the 2003-04 influenza season, when the vaccine was a suboptimal antigenic match to many circulating virus strains, effectiveness for prevention of laboratory-confirmed influenza illness among adults aged 50-64 years with high-risk conditions was 48% compared with 60% for healthy adults (125). Effectiveness against hospitalization among adults aged 50-64 years with high-risk conditions was 36% compared with 90% effectiveness among healthy adults in that age range (125). A randomized controlled trial among adults in Thailand with chronic obstructive pulmonary disease (median age: 68 years) indicated a vaccine effectiveness of 76% in preventing laboratory-confirmed influenza during a season when viruses were well-matched to vaccine viruses. Effectiveness did not decrease with increasing severity of underlying lung disease (128).
Few randomized controlled trials have studied the effect of influenza vaccination on noninfluenza outcomes. A randomized controlled trial conducted in Argentina among 301 adults hospitalized with myocardial infarction or undergoing angioplasty for cardiovascular disease (56% of whom were aged >65 years) found that a significantly lower percentage (6%) of cardiovascular deaths occurred among vaccinated persons at 1 year after vaccination compared with unvaccinated persons (17%) (129). A randomized, double-blind, placebo-controlled study conducted in Poland among 658 persons with coronary artery disease indicated that significantly fewer vaccinated persons vaccinated persons had a cardiac ischemic event during the 9 months of follow up compared with unvaccinated persons (p <0.05) (130).
Observational studies that have measured clinical endpoints without laboratory confirmation of influenza virus infection, typically have demonstrated substantial reductions in hospitalizations or deaths among adults with risk factors for influenza complications. In a case-control study conducted during 1999-2000 in Denmark among adults aged <65 years with underlying medical conditions, vaccination reduced deaths attributable to any cause 78% and reduced hospitalizations attributable to respiratory infections or cardiopulmonary diseases 87% (131). A benefit was reported after the first vaccination and increased with subsequent vaccinations in subsequent years (132). Among patients with diabetes mellitus, vaccination was associated with a 56% reduction in any complication, a 54% reduction in hospitalizations, and a 58% reduction in deaths (133). Certain experts have noted that the substantial effects on morbidity and mortality among those who received influenza vaccination in these observational studies should be interpreted with caution because of the difficulties in ensuring that those who received vaccination had similar baseline health status as those who did not (82,83). One meta-analysis of published studies concluded that evidence was insufficient to demonstrate that persons with asthma benefit from vaccination (134). However, a meta-analysis that examined effectiveness among persons with chronic obstructive pulmonary disease identified evidence of benefit from vaccination (135).

# Immunocompromised Persons
TIV produces adequate antibody concentrations against influenza among vaccinated HIV-infected persons who have minimal AIDS-related symptoms and normal or near-normal CD4+ T-lymphocyte cell counts (136)(137)(138). Among persons who have advanced HIV disease and low CD4+ T-lymphocyte cell counts, TIV might not induce protective antibody titers (138,139); a second dose of vaccine does not improve the immune response in these persons (139,140). A randomized, placebo-controlled trial determined that TIV was highly effective in preventing symptomatic, laboratory-confirmed influenza virus infection among HIV-infected persons with a mean of 400 CD4+ T-lymphocyte cells/mm3; however, a limited number of persons with CD4+ T-lymphocyte cell counts of 100 CD4+ cells and among those with <30,000 viral copies of HIV type-1/mL (53).
On the basis of certain limited studies, immunogenicity for persons with solid organ transplants varies according to transplant type. Among persons with kidney or heart transplants, the proportion who developed seroprotective antibody concentrations was similar or slightly reduced compared with healthy persons (141)(142)(143). However, a study among persons with liver transplants indicated reduced immunologic responses to influenza vaccination (144)(145)(146), especially if vaccination occurred within the 4 months after the transplant procedure (144).

# Pregnant Women and neonates
Pregnant women have protective levels of anti-influenza antibodies after vaccination (147,148). Passive transfer of anti-influenza antibodies that might provide protection from vaccinated women to neonates has been reported (147,(149)(150)(151). A retrospective, clinic-based study conducted during 1998-2003 documented a nonsignificant trend toward fewer episodes of MAARI during one influenza season among vaccinated pregnant women compared with unvaccinated pregnant women and substantially fewer episodes of MAARI during the peak influenza season (148). However, a retrospective study conducted during 1997-2002 that used clinical records data did not indicate a reduction in ILI among vaccinated pregnant women or their infants (152). In another study conducted during 1995-2001, medical visits for respiratory illness among the infants were not substantially reduced (153). One randomized controlled trial conducted in Bangladesh that provided vaccination to pregnant women during the third trimester demonstrated a 29% reduction in respiratory illness with fever and a 36% reduction in respiratory illness with fever among their infants during the first 6 months after birth. In addition, infants born to vaccinated women had a 63% reduction in laboratory-confirmed influenza illness during the first 6 months of life (154). All women in this trial breastfed their infants (mean duration: 14 weeks).

# older Adults
Adults aged >65 years typically have a diminished immune response to influenza vaccination compared with young healthy adults, suggesting that immunity might be of shorter duration (although still extending through one influenza season) (155,156). However, a review of the published literature concluded that no clear evidence existed that immunity declined more rapidly in the elderly (157), and additional vaccine doses during the same season do not increase the antibody response (118,120). Infections among the vaccinated elderly might be associated with an age-related reduction in ability to respond to vaccination rather than reduced duration of immunity (127,128). One prospective cohort study found that immunogenicity among hospitalized persons who were either aged >65 years or who were aged 18-64 years and had one or more chronic medical conditions was similar compared with outpatients (158).
The only randomized controlled trial among communitydwelling persons aged >60 years reported a vaccine efficacy of 58% (CI = 26%-77%) against laboratory-confirmed influenza illness during a season when the vaccine strains were considered to be well-matched to circulating strains (159). Additional information from this trial published separately indicated that efficacy among those aged >70 years was 57% (CI = -36%-87%), similar to younger persons. However, few persons aged >75 years participated in this study, and the wide confidence interval for the estimate of efficacy among participants aged >70 years included 0 (160). Influenza vaccine effectiveness in preventing MAARI among the elderly in nursing homes has been estimated at 20%-40% (161,162), and reported outbreaks among well-vaccinated nursing home populations have suggested that vaccination might not have any significant effectiveness when circulating strains are drifted from vaccine strains (163,164). In contrast, some studies have indicated that vaccination can be up to 80% effective in preventing influenzarelated death (161,(165)(166)(167). Among elderly persons not living in nursing homes or similar long-term-care facilities, influenza vaccine is 27%-70% effective in preventing hospitalization for pneumonia and influenza (168)(169)(170). Influenza vaccination reduces the frequency of secondary complications and reduces the risk for influenza-related hospitalization and death among community-dwelling adults aged >65 years with and without high-risk medical conditions (e.g., heart disease and diabetes) (169)(170)(171)(172)(173)(174). However, studies demonstrating large reductions in hospitalizations and deaths among the vaccinated elderly have been conducted using medical record databases and have not measured reductions in laboratory-confirmed influenza illness. These studies have been challenged because of concerns that they have not adequately controlled for differences in the propensity for healthier persons to be more likely than less healthy persons to receive vaccination (82,83,166,(175)(176)(177).

# tIV Dosage, Administration, and Storage
The composition of TIV varies according to manufacturer, and package inserts should be consulted. TIV formulations in multidose vials contain the vaccine preservative thimerosal; preservative-free, single-dose preparations also are available. TIV should be stored at 35F-46F (2C-8C) and should not be frozen. TIV that has been frozen should be discarded. Dosage recommendations and schedules vary according to age group (Table 2). Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season.
The intramuscular route is recommended for TIV. Adults and older children should be vaccinated in the deltoid muscle. A needle length of >1 inch (>25 mm) should be considered for persons in these age groups because needles of <1 inch might be of insufficient length to penetrate muscle tissue in certain adults and older children (178). When injecting into the deltoid muscle among children with adequate deltoid muscle mass, a needle length of 7/8-1.25 inches is recommended (179).
Infants and young children should be vaccinated in the anterolateral aspect of the thigh. A needle length of 7/8-1 inch should be used for children aged <12 months. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving FluMist, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive FluMist.   Two doses administered at least 4 weeks apart are recommended for children aged 2-8 years who are receiving LAIV for the first time, and those who only received 1 dose in their first year of vaccination should receive 2 doses in the following year.

# Adverse Events After Receipt of tIV Children
Studies support the safety of annual TIV in children and adolescents. The largest published postlicensure populationbased study assessed TIV safety in 251,600 children aged <18 years, (including 8,476 vaccinations in children aged 6-23 months) through the Vaccine Safety Datalink (VSD), who were enrolled in one of five health maintenance organizations (HMOs) during 1993-1999. This study indicated no increase in clinically important medically attended events during the 2 weeks after inactivated influenza vaccination compared with control periods 3-4 weeks before and after vaccination (180). A retrospective cohort study using VSD medical records data from 45,356 children aged 6-23 months provided additional evidence supporting overall safety of TIV in this age group. During the 2 weeks after vaccination, TIV was not associated with statistically significant increases in any clinically important medically attended events other than gastritis/duodenitis, and 13 diagnoses, including acute upper respiratory illness, otitis media and asthma, were significantly less common (181). On chart review, most children with a diagnosis of gastritis/duodenitis had self-limited vomiting or diarrhea. The positive or negative associations between TIV and any of these diagnoses do not necessarily indicate a causal relationship (181).
In a study of 791 healthy children aged 1-15 years, postvaccination fever was noted among 12% of those aged 1-5 years, 5% among those aged 6-10 years, and 5% among those aged 11-15 years (87). Fever, malaise, myalgia, and other systemic symptoms that can occur after vaccination with inactivated vaccine most often affect persons who have had no previous exposure to the influenza virus antigens in the vaccine (e.g., young children) (182,183). These reactions begin 6-12 hours after vaccination and can persist for 1-2 days. Data about potential adverse events among children after influenza vaccination are available from the Vaccine Adverse Event Reporting System (VAERS). Because of the limitations of passive reporting systems, determining causality for specific types of adverse events usually is not possible using VAERS data alone.
Published reviews of VAERS reports submitted after administration of TIV to children aged 6-23 months indicated that the most frequently reported adverse events were fever, rash, injection-site reactions, and seizures; the majority of the limited number of reported seizures appeared to be febrile (184,185). Seizure and fever were the leading serious adverse events (SAEs), defined using standard criteria, reported to VAERS in these studies (184,185); further investigation in VSD did not confirm an association with febrile seizures as identified in VAERS (181).

# Adults
In placebo-controlled studies among adults, the most frequent side effect of vaccination was soreness at the vaccination site (affecting 10%-64% of patients) that lasted 65 years or were aged 18-64 years and had one or more chronic medical conditions compared with outpatients (158). Adverse events in adults aged >18 years reported to VAERS during 1990-2005 were analyzed. The most common adverse events reported to VAERS in adults included injection-site reactions, pain, fever, myalgia, and headache. The VAERS review identified no new safety concerns. In clinical trials, SAEs were reported to occur after vaccination with TIV at a rate of <1%. A small proportion (14%) of the TIV VAERS reports in adults were classified as SAEs, without assessment of causality. The most common SAE reported after TIV in VAERS in adults was Guillain-Barre Syndrome (GBS) (189). The potential association between TIV and GBS has been an area of ongoing research (see Guillain-Barre Syndrome and TIV).

# Pregnant Women and neonates
FDA has classified TIV as a "Pregnancy Category C" medication, indicating that adequate animal reproduction studies have not been conducted.. Available data indicate that influenza vaccine does not cause fetal harm when administered to a pregnant woman or affect reproductive capacity. One study of approximately 2,000 pregnant women who received TIV during pregnancy demonstrated no adverse fetal effects and no adverse effects during infancy or early childhood (190). A matched case-control study of 252 pregnant women who received TIV within the 6 months before delivery determined no adverse events after vaccination among pregnant women and no difference in pregnancy outcomes compared with 826 pregnant women who were not vaccinated (148). During 2000-2003, an estimated 2 million pregnant women were vaccinated, and only 20 adverse events among women who received TIV were reported to VAERS during this time, including nine injection-site reactions and eight systemic reactions (e.g., fever, headache, and myalgias). In addition, three miscarriages were reported, but these were not known to be causally related to vaccination (191). Similar results have been reported in certain smaller studies (147,149,192), and a recent international review of data on the safety of TIV concluded that no evidence exists to suggest harm to the fetus (193). The rate of adverse events associated with TIV was similar to the rate of adverse events among pregnant women who received pneumococcal polysaccharide vaccine in one small randomized controlled trial in Bangladesh, and no severe adverse events were reported in any study group (154).

# Persons with Chronic Medical Conditions
In a randomized cross-over study of children and adults with asthma, no increase in asthma exacerbations was reported for either age group (194), and two additional studies also have indicated no increase in wheezing among vaccinated asthmatic children (114) or adults (195). One study reported that 20%-28% of children with asthma aged 9 months-18 years had local pain and swelling at the site of influenza vaccination ( 104), and another study reported that 23% of children aged 6 months-4 years with chronic heart or lung disease had local reactions (93). A blinded, randomized, cross-over study of 1,952 adults and children with asthma demonstrated that only self-reported "body aches" were reported more frequently after TIV (25%) than placebo-injection (21%) (194). However, a placebo-controlled trial of TIV indicated no difference in local reactions among 53 children aged 6 months-6 years with high-risk medical conditions or among 305 healthy children aged 3-12 years (97).
Among children with high-risk medical conditions, one study of 52 children aged 6 months-3 years reported fever among 27% and irritability and insomnia among 25% (93); and a study among 33 children aged 6-18 months reported that one child had irritability and one had a fever and seizure after vaccination (196). No placebo comparison group was used in these studies.

# Immunocompromised Persons
Data demonstrating safety of TIV for HIV-infected persons are limited, but no evidence exists that vaccination has a clinically important impact on HIV infection or immunocompetence. One study demonstrated a transient (i.e., 2-4 week) increase in HIV RNA (ribonucleic acid) levels in one HIV-infected person after influenza virus infection (197). Studies have demonstrated a transient increase in replication of HIV-1 in the plasma or peripheral blood mononuclear cells of HIV-infected persons after vaccine administration (138,198). However, more recent and better-designed studies have not documented a substantial increase in the replication of HIV (199)(200)(201)(202). CD4+ T-lymphocyte cell counts or progression of HIV disease have not been demonstrated to change substantially after influenza vaccination among HIV-infected persons compared with unvaccinated HIV-infected persons (138,203). Limited information is available about the effect of antiretroviral therapy on increases in HIV RNA levels after either natural influenza virus infection or influenza vaccination (52,204).
Data are similarly limited for persons with other immunocompromising conditions. In small studies, vaccination did not affect allograft function or cause rejection episodes in recipients of kidney transplants (141,142), heart transplants (143), or liver transplants (144).

# Immediate Hypersensitivity Reactions after Influenza Vaccines
Vaccine components can rarely cause allergic reactions, also called immediate hypersensitivity reactions, among certain recipients. Immediate hypersensitivity reactions are mediated by preformed immunoglobulin E (IgE) antibodies against a vaccine component and usually occur within minutes to hours of exposure (205). Symptoms of immediate hypersensitivity range from mild urticaria (hives) and angioedema to anaphylaxis. Anaphylaxis is a severe life-threatening reaction that involves multiple organ systems and can progress rapidly. Symptoms and signs of anaphylaxis can include but are not limited to generalized urticaria, wheezing, swelling of the mouth and throat, difficulty breathing, vomiting, hypotension, decreased level of consciousness, and shock. Minor symptoms such as red eyes or hoarse voice also might be present (179,(205)(206)(207)(208).
Allergic reactions might be caused by the vaccine antigen, residual animal protein, antimicrobial agents, preservatives, stabilizers, or other vaccine components (209). Manufacturers use a variety of compounds to inactivate influenza viruses and add antibiotics to prevent bacterial growth. Package inserts for specific vaccines of interest should be consulted for additional information. ACIP has recommended that all vaccine providers should be familiar with the office emergency plan and be certified in cardiopulmonary resuscitation (179). The Clinical Immunization Safety Assessment (CISA) network, a collaboration between CDC and six medical research centers with expertise in vaccination safety, has developed an algorithm to guide evaluation and revaccination decisions for persons with suspected immediate hypersensitivity after vaccination (205).
Immediate hypersensitivity reaction after TIV and LAIV are rare. A VSD study of children aged <18 years in four HMOs during 1991-1997 estimated the overall risk of postvaccination anaphylaxis to be less than 1 case per 500,000 doses administered and in this study no cases were identified in TIV recipients (210). Reports of anaphylaxis occurring after receipt of TIV and LAIV in adults have rarely been reported to VAERS (189). Some immediate hypersensitivity reactions after TIV or LAIV are caused by the presence of residual egg protein in the vaccines (211). Although influenza vaccines contain only a limited quantity of egg protein, this protein can induce immediate hypersensitivity reactions among persons who have severe egg allergy. Asking persons if they can eat eggs without adverse effects is a reasonable way to determine who might be at risk for allergic reactions from receiving influenza vaccines (179). Persons who have had symptoms such as hives or swelling of the lips or tongue, or who have experienced acute respiratory distress after eating eggs, should consult a physician for appropriate evaluation to help determine if future influenza vaccine should be administered. Persons who have documented (IgE)-mediated hypersensitivity to eggs, including those who have had occupational asthma related to egg exposure or other allergic responses to egg protein, also might be at increased risk for allergic reactions to influenza vaccine, and consultation with a physician before vaccination should be considered (212)(213)(214). A regimen has been developed for administering influenza vaccine to asthmatic children with severe disease and egg hypersensitivity (213).
Hypersensitivity reactions to other vaccine components also can rarely occur. Although exposure to vaccines containing thimerosal can lead to hypersensitivity (215), the majority of patients do not have reactions to thimerosal when it is administered as a component of vaccines, even when patch or intradermal tests for thimerosal indicate hypersensitivity (216,217). When reported, hypersensitivity to thimerosal typically has consisted of local delayed hypersensitivity reactions (216).

# ocular and Respiratory Symptoms after tIV
Ocular or respiratory symptoms have occasionally been reported within 24 hours after TIV administration, but these symptoms typically are mild and resolve quickly without specific treatment. In some trials conducted in the United States, ocular or respiratory symptoms included red eyes (<1%-6%), cough (1%-7%), wheezing (1%), and chest tightness (1%-3%) (207,208,(218)(219)(220). However, most of these trials were not placebo-controlled, and causality cannot be determined. In addition, ocular and respiratory symptoms are features of a variety of respiratory illnesses and seasonal allergies that would be expected to occur coincidentally among vaccine recipients unrelated to vaccination. A placebo-controlled vaccine effectiveness study among young adults found that 2% of persons who received the 2006-07 formulation of Fluzone (Sanofi Pasteur) reported red eyes compared with none of the controls (p = 0.03) (221). A similar trial conducted during the 2005-06 influenza season found that 3% of Fluzone recipients reported red eyes compared with 1% of placebo recipients; however the difference was not statistically significant (222) .
Oculorespiratory syndrome (ORS), an acute, self-limited reaction to TIV with prominent ocular and respiratory symptoms, was first described during the 2000-01 influenza season in Canada. The initial case-definition for ORS was the onset of one or more of the following within 2-24 hours after receiving TIV: bilateral red eyes and/or facial edema and/or respiratory symptoms (coughing, wheezing, chest tightness, difficulty breathing, sore throat, hoarseness or difficulty swallowing, cough, wheeze, chest tightness, difficulty breathing, sore throat, or facial swelling) (223). ORS was first described in Canada and strongly associated with one vaccine preparation (Fluviral S/F, Shire Biologics, Quebec, Canada) not available in the United States during the 2000-01 influenza season (224). Subsequent investigations identified persons with ocular or respiratory symptoms meeting an ORS case-definition in safety monitoring systems and trials that had been conducted before 2000 in Canada, the United States, and several European countries (225)(226)(227).
The cause of ORS has not been established; however studies suggest the reaction is not IgE-mediated (228). After changes in the manufacturing process of the vaccine preparation associated with ORS during 2000-01, the incidence of ORS in Canada was greatly reduced (226). In one placebo-controlled study, only hoarseness, cough, and itchy or sore eyes (but not red eyes) were significantly associated with a reformulated Fluviral preparation. These findings indicated that ORS symptoms following use of the reformulated vaccine were mild, resolved within 24 hours, and might not typically be of sufficient concern to cause vaccine recipients to seek medical care (229).
Ocular and respiratory symptoms reported after TIV administration, including ORS, have some similarities with immediate hypersensitivity reactions. One study indicated that the risk for ORS recurrence with subsequent vaccination is low, and persons with ocular or respiratory symptoms (e.g., bilateral red eyes, cough, sore throat, or hoarseness) after TIV that did not involve the lower respiratory tract have been revaccinated without reports of SAEs after subsequent exposure to TIV (230). VAERS routinely monitors for adverse events such as ocular or respiratory symptoms after receipt of TIV.

# Contraindications and Precautions for Use of tIV
TIV is contraindicated and should not be administered to persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine unless the recipient has been desensitized. Prophylactic use of antiviral agents is an option for preventing influenza among such persons. Information about vaccine components is located in package inserts from each manufacturer. Persons with moderate to severe acute febrile illness usually should not be vaccinated until their symptoms have abated. Moderate or severe acute illness with or without fever is a precaution  for TIV. GBS within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines.

# Revaccination in Persons Who Experienced ocular or Respiratory Symptoms After tIV
When assessing whether a patient who experienced ocular and respiratory symptoms should be revaccinated, providers should determine if concerning signs and symptoms of Ig-E mediated immediate hypersensitivity are present (see Immediate Hypersensitivity after Influenza Vaccines). Healthcare providers who are unsure whether symptoms reported or observed after TIV represent an IgE-mediated hypersensitivity immune response should seek advice from an allergist/immunologist. Persons with symptoms of possible IgE-mediated hypersensitivity after TIV should not receive influenza vaccination unless hypersensitivity is ruled out or revaccination is administered under close medical supervision (205).
Ocular or respiratory symptoms observed after TIV often are coincidental and unrelated to TIV administration, as observed among placebo recipients in some randomized controlled studies. Determining whether ocular or respiratory symptoms are coincidental or related to possible ORS might not be possible. Persons who have had red eyes, mild upper facial swelling, or mild respiratory symptoms (e.g., sore throat, cough, or hoarseness) after TIV without other concerning signs or symptoms of hypersensitivity can receive TIV in subsequent seasons without further evaluation. Two studies showed that persons who had symptoms of ORS after TIV were at a higher risk for ORS after subsequent TIV administration; however, these events usually were milder than the first episode (230,231).

# Guillain-Barre Syndrome and tIV
The annual incidence of GBS is 10-20 cases per 1 million adults (232). Substantial evidence exists that multiple infectious illnesses, most notably Campylobacter jejuni gastrointestinal infections and upper respiratory tract infections, are associated with GBS (233)(234)(235). A recent study identified serologically confirmed influenza virus infection as a trigger of GBS, with time from onset of influenza illness to GBS of 3-30 days. The estimated frequency of influenza-related GBS was four to seven times higher than the frequency that has been estimated for influenza-vaccine-associated GBS (236).
The 1976 swine influenza vaccine was associated with an increased frequency of GBS, estimated at one additional case of GBS per 100,000 persons vaccinated (237,238). The risk for influenza-vaccine-associated GBS was higher among persons aged >25 years than among persons aged <25 years (239). However, obtaining epidemiologic evidence for a small increase in risk for a rare condition with multiple causes is difficult, and no evidence consistently exists for a causal relation between subsequent vaccines prepared from other influenza viruses and GBS.
None of the studies conducted using influenza vaccines other than the 1976 swine influenza vaccine has demonstrated a substantial increase in GBS associated with influenza vaccines. During three of four influenza seasons studied during 1977-1991, the overall relative risk estimates for GBS after influenza vaccination were not statistically significant in any of these studies (240)(241)(242). However, in a study of the 1992-93 and 1993-94 seasons, the overall relative risk for GBS was 1.7 (CI = 1.0-2.8; p = 0.04) during the 6 weeks after vaccination, representing approximately one additional case of GBS per 1 million persons vaccinated; the combined number of GBS cases peaked 2 weeks after vaccination (238). Results of a study that examined health-care data from Ontario, Canada, during 1992-2004 demonstrated a small but statistically significant temporal association between receiving influenza vaccination and subsequent hospital admission for GBS. However, no increase in cases of GBS at the population level was reported after introduction of a mass public influenza vaccination program in Ontario beginning in 2000 (243). Data from VAERS have documented decreased reporting of GBS occurring after vaccination across age groups over time, despite overall increased reporting of other non-GBS conditions occurring after administration of influenza vaccine (237). Published data from the United Kingdom's General Practice Research Database (GPRD) found influenza vaccine to be associated with a decreased risk for GBS, although whether this was associated with protection against influenza or confounding because of a "healthy vaccinee" (e.g., healthier persons might be more likely to be vaccinated and also be at lower risk for GBS) (244) is unclear. A separate GPRD analysis found no association between vaccination and GBS for a 9-year period; only three cases of GBS occurred within 6 weeks after administration of influenza vaccine (245). A third GPRD analysis found that GBS was associated with recent ILI, but not influenza vaccination (246).  A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity (179).
The estimated risk for GBS (on the basis of the few studies that have demonstrated an association between vaccination and GBS) is low (i.e., approximately one additional case per 1 million persons vaccinated). The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death substantially outweigh these estimates of risk for vaccine-associated GBS. No evidence indicates that the casefatality ratio for GBS differs among vaccinated persons and those not vaccinated.

# Use of tIV Among Patients with a History of GBS
The incidence of GBS among the general population is low, but persons with a history of GBS have a substantially greater likelihood of subsequently experiencing GBS than persons without such a history (232). Thus, the likelihood of coincidentally experiencing GBS after influenza vaccination is expected to be greater among persons with a history of GBS than among persons with no history of this syndrome. Whether influenza vaccination specifically might increase the risk for recurrence of GBS is unknown. Among 311 patients with GBS who responded to a survey, 11 (4%) reported some worsening of symptoms after influenza vaccination; however, some of these patients had received other vaccines at the same time, and recurring symptoms were generally mild (247). However, as a precaution, persons who are not at high risk for severe influenza complications and who are known to have experienced GBS within 6 weeks generally should not be vaccinated. As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these persons. Although data are limited, the established benefits of influenza vaccination might outweigh the risks for many persons who have a history of GBS and who also are at high risk for severe complications from influenza.

# Vaccine Preservative (thimerosal) in Multidose Vials of tIV
Thimerosal, a mercury-containing antibacterial compound, has been used as a preservative in vaccines and other medications since the 1930s (248) and is used in multidose vial preparations of TIV to reduce the likelihood of bacterial growth. No scientific evidence indicates that thimerosal in vaccines, including influenza vaccines, is a cause of adverse events other than occasional local hypersensitivity reactions in vaccine recipients. In addition, no scientific evidence exists that thimerosal-containing vaccines are a cause of adverse events among children born to women who received vaccine during pregnancy. The weight of accumulating evidence does not suggest an increased risk for neurodevelopment disorders from exposure to thimerosal-containing vaccines (249)(250)(251)(252)(253)(254)(255)(256)(257)(258). The U.S. Public Health Service and other organizations have recommended that efforts be made to eliminate or reduce the thimerosal content in vaccines as part of a strategy to reduce mercury exposures from all sources (249,250,259) Also, continuing public concerns about exposure to mercury in vaccines has been viewed as a potential barrier to achieving higher vaccine coverage levels and reducing the burden of vaccine-preventable diseases. Since mid-2001, vaccines routinely recommended for infants aged <6 months in the United States have been manufactured either without or with greatly reduced (trace) amounts of thimerosal. As a result, a substantial reduction in the total mercury exposure from vaccines for infants and children already has been achieved ( 179)). ACIP and other federal agencies and professional medical organizations continue to support efforts to provide thimerosal-preservative-free vaccine options.
The benefits of influenza vaccination for all recommended groups, including pregnant women and young children, outweigh concerns on the basis of a theoretical risk from thimerosal exposure through vaccination. The risks for severe illness from influenza virus infection are elevated among both young children and pregnant women, and vaccination has been demonstrated to reduce the risk for severe influenza illness and subsequent medical complications. In contrast, no scientifically conclusive evidence has demonstrated harm from exposure to vaccine containing thimerosal preservative. For these reasons, persons recommended to receive TIV may receive any age-and risk factor-appropriate vaccine preparation, depending on availability. An analysis of VAERS reports found no difference in the safety profile of preservative-containing compared with preservative-free TIV vaccines in infants aged 6-23 months (184).
Nonetheless, as of May 2009, some states have enacted legislation banning the administration of vaccines containing mercury; the provisions defining mercury content vary (260). LAIV and many of the single-dose vial or syringe preparations of TIV are thimerosal-free, and the number of influenza vaccine doses that do not contain thimerosal as a preservative is expected to increase (Table 2). However, these laws might present a barrier to vaccination unless influenza vaccines that do not contain thimerosal as a preservative are easily available in those states.
The U.S. vaccine supply for infants and pregnant women is in a period of transition as manufacturers expand the availability of thimerosal-reduced or thimerosal-free vaccine to reduce the cumulative exposure of infants to mercury. Other environmental sources of mercury exposure are more difficult or impossible to avoid or eliminate (249).

# LAIV Dosage, Administration, and Storage
Each dose of LAIV contains the same three vaccine antigens used in TIV. However, the antigens are constituted as live, attenuated, cold-adapted, temperature-sensitive vaccine viruses. Providers should refer to the package insert, which contains additional information about the formulation of this vaccine and other vaccine components. LAIV does not contain thimerosal. LAIV is made from attenuated viruses that are able to replicate efficiently only at temperatures present in the nasal mucosa. LAIV does not cause systemic symptoms of influenza in vaccine recipients, although a minority of recipients experience nasal congestion or fever, which is probably a result of effects of intranasal vaccine administration or local viral replication or fever (261).
LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal, or intravenous route. LAIV is not licensed for vaccination of children aged 49 years. LAIV is supplied in a prefilled, single-use sprayer containing 0.2 mL of vaccine. Approximately 0.1 mL (i.e., half of the total sprayer contents) is sprayed into the first nostril while the recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. LAIV is shipped at 35F-46F (2C-8C). LAIV should be stored at 35F-46F (2C-8C) on receipt and can remain at that temperature until the expiration date is reached (261). Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season.

# Shedding, transmission, and Stability of Vaccine Viruses
Available data indicate that both children and adults vaccinated with LAIV can shed vaccine viruses after vaccination, although in lower amounts than occur typically with shedding of wild-type influenza viruses. In rare instances, shed vaccine viruses can be transmitted from vaccine recipients to unvaccinated persons. However, serious illnesses have not been reported among unvaccinated persons who have been infected inadvertently with vaccine viruses.
One study of 197 children aged 8-36 months in a child care center assessed transmissibility of vaccine viruses from 98 vaccinated children to the other 99 unvaccinated children; 80% of vaccine recipients shed one or more virus strains (mean duration: 7.6 days). One influenza type B vaccine strain isolate was recovered from a placebo recipient and was confirmed to be vaccine-type virus. The type B isolate retained the coldadapted, temperature-sensitive, attenuated phenotype, and it possessed the same genetic sequence as a virus shed from a vaccine recipient who was in the same play group. The placebo recipient from whom the influenza type B vaccine strain was isolated had symptoms of a mild upper respiratory illness but did not experience any serious clinical events. The estimated probability of acquiring vaccine virus after close contact with a single LAIV recipient in this child care population was 1%-2% (262).
Studies assessing whether vaccine viruses are shed have been based on viral cultures or PCR detection of vaccine viruses in nasal aspirates from persons who have received LAIV. Among 345 subjects aged 5-49 years, 30% had detectable virus in nasal secretions obtained by nasal swabbing after receiving LAIV. The duration of virus shedding and the amount of virus shed was inversely correlated with age, and maximal shedding occurred within 2 days of vaccination. Symptoms reported after vaccination, including runny nose, headache, and sore throat, did not correlate with virus shedding (263). Other smaller studies have reported similar findings (264,265). Vaccine strain virus was detected from nasal secretions in one (2%) of 57 HIV-infected adults who received LAIV, none of 54 HIV-negative participants (266), and three (13%) of 23 HIV-infected children compared with seven (28%) of 25 children who were not HIV-infected (267). No participants in these studies had detectable virus beyond 10 days after receipt of LAIV. The possibility of person-to-person transmission of vaccine viruses was not assessed in these studies (264)(265)(266)(267).
In clinical trials, viruses isolated from vaccine recipients have retained attenuated phenotypes. In one study, nasal and throat swab specimens were collected from 17 study participants for 2 weeks after vaccine receipt (268). Virus isolates were analyzed by multiple genetic techniques. All isolates retained the LAIV genotype after replication in the human host, and all retained the cold-adapted and temperature-sensitive phenotypes. A study conducted in a child care setting demonstrated that limited genetic change occurred in the LAIV strains following replication in the vaccine recipients (269).

# Immunogenicity, Efficacy, and Effectiveness of LAIV
LAIV virus strains replicate primarily in nasopharyngeal epithelial cells. The protective mechanisms induced by vaccination with LAIV are not understood completely but appear to involve both serum and nasal secretory antibodies. The immunogenic-ity of the approved LAIV has been assessed in multiple studies conducted among children and adults (270)(271)(272)(273)(274)(275)(276).

# Healthy Children
A randomized, double-blind, placebo-controlled trial among 1,602 healthy children aged 15-71 months assessed the efficacy of LAIV against culture-confirmed influenza during two seasons (277,278). This trial included a subset of children aged 60-71 months who received 2 doses in the first season. During season one (1996-97), when vaccine and circulating virus strains were well-matched, efficacy against culture-confirmed influenza was 94% for participants who received 2 doses of LAIV separated by >6 weeks, and 89% for those who received 1 dose. During season two (1997-98), when the A (H3N2) component in the vaccine was not well-matched with circulating virus strains, efficacy (1 dose) was 86%, for an overall efficacy for two influenza seasons of 92%. Receipt of LAIV also resulted in 21% fewer febrile illnesses and a significant decrease in acute otitis media requiring antibiotics (277,279). Other randomized, placebo-controlled trials demonstrating the efficacy of LAIV in young children against culture-confirmed influenza include a study conducted among children aged 6-35 months attending child care centers during consecutive influenza seasons (280) in which 85%-89% efficacy was observed, and a study conducted among children aged 12-36 months living in Asia during consecutive influenza seasons in which 64%-70% efficacy was documented (281). In one community-based, nonrandomized open-label study, reductions in MAARI were observed among children who received 1 dose of LAIV during the 1990-00 and 2000-01 influenza seasons even though antigenically drifted influenza A/H1N1 and B viruses were circulating during that season (282). LAIV efficacy in preventing laboratory-confirmed influenza also has been demonstrated in studies comparing the efficacy of LAIV with TIV rather than with a placebo (see Comparisons of LAIV and TIV Efficacy or Effectiveness).

# Healthy Adults
A randomized, double-blind, placebo-controlled trial of LAIV effectiveness among 4,561 healthy working adults aged 18-64 years assessed multiple endpoints, including reductions in self-reported respiratory tract illness without laboratory confirmation, work loss, health-care visits, and medication use during influenza outbreak periods . The study was conducted during the 1997-98 influenza season, when the vaccine and circulating A (H3N2) strains were not well-matched. The frequency of febrile illnesses was not significantly decreased among LAIV recipients compared with those who received placebo. However, vaccine recipients had significantly fewer severe febrile illnesses (19% reduction) and febrile upper respiratory tract illnesses (24% reduction), and significant reductions in days of illness, days of work lost, days with health-care-provider visits, and use of prescription antibiotics and over-the-counter medications (283). Efficacy against culture-confirmed influenza in a randomized, placebo-controlled study was 57% in the 2004-05 influenza season and 43% in the 2005-06 influenza season, although efficacy in these studies was not demonstrated to be significantly greater than placebo (221,222).

# Adverse Events after Receipt of LAIV Healthy Children Aged 2-18 Years
In a subset of healthy children aged 60-71 months from one clinical trial, certain signs and symptoms were reported more often after the first dose among LAIV recipients (n = 214) than among placebo recipients (n = 95), including runny nose (48% and 44%, respectively); headache (18% and 12%, respectively); vomiting (5% and 3%, respectively); and myalgias (6% and 4%, respectively) (277). However, these differences were not statistically significant. In other trials, signs and symptoms reported after LAIV administration have included runny nose or nasal congestion (20%-75%), headache (2%-46%), fever (0-26%), vomiting (3%-13%), abdominal pain (2%), and myalgias (0-21%) (270,272,273,280,(284)(285)(286)(287). These symptoms were associated more often with the first dose and were self-limited. A placebo-controlled trial in 9,689 children aged 1-17 years assessed prespecified medically attended outcomes during the 42 days after vaccination (286). Following >1,500 statistical analyses in the 42 days after LAIV, elevated risks that were biologically plausible were observed for the following conditions: asthma, upper respiratory infection, musculoskeletal pain, otitis media with effusion, and adenitis/ adenopathy. The increased risk for wheezing events after LAIV was observed among children aged 18-35 months (RR: 4.06; 90% CI = 1.3-17.9). In this study, the rate of SAEs was 0.2% in LAIV and placebo recipients; none of the SAEs was judged to be related to the vaccine by the study investigators (286).
In a randomized trial published in 2007, LAIV and TIV were compared among children aged 6-59 months (288). Children with medically diagnosed or treated wheezing within 42 days before enrollment or with a history of severe asthma were excluded from this study. Among children aged 24-59 months who received LAIV, the rate of medically significant wheezing, using a prespecified definition, was not greater compared with those who received TIV (288). Wheezing was observed more frequently among younger LAIV recipients aged 6-23 months in this study; LAIV is not licensed for this age group. In a previous randomized placebo-controlled safety trial among children aged 12 months-17 years without a history of asthma by parental report, an elevated risk for asthma events (RR: 4.1; CI = 1.3-17.9) was documented among 728 children aged 18-35 months who received LAIV. Of the 16 children with asthma-related events in this study, seven had a history of asthma on the basis of subsequent medical record review. None required hospitalization, and elevated risks for asthma were not observed in other age groups (286).
Another study was conducted among >11,000 children aged 18 months-18 years in which 18,780 doses of vaccine were administered for 4 years. For children aged 18 months-4 years, no increase was reported in asthma visits 0-15 days after vaccination compared with the prevaccination period. A significant increase in asthma events was reported 15-42 days after vaccination, but only in vaccine year 1 (289). A 4-year, open-label field trial study assessed LAIV safety of more than 2000 doses administered to children aged 18 months-18 years with a history of intermittent wheeze who were otherwise healthy. Among these children, no increased risk was reported for medically attended acute respiratory illnesses, including acute asthma exacerbation, during the 0-14 or 0-42 days after LAIV compared with the pre-and postvaccination reference periods (290).
Initial data from VAERS during 2007-2008, following ACIP's recommendation for LAIV use in healthy children aged 2-4 years, did not suggest a concern for wheezing after LAIV in young children. However data also suggest uptake of LAIV was limited, and safety monitoring for wheezing events after LAIV is ongoing (CDC, unpublished data, 2008).

# Adults Aged 19-49 Years
Among adults, runny nose or nasal congestion (28%-78%), headache (16%-44%), and sore throat (15%-27%) have been reported more often among vaccine recipients than placebo recipients (277,291). In one clinical trial among a subset of healthy adults aged 18-49 years, signs and symptoms reported significantly more often (p<0.05) among LAIV recipients (n = 2,548) than placebo recipients (n = 1,290) within 7 days after each dose included cough (14% and 11%, respectively), runny nose (45% and 27%, respectively), sore throat (28% and 17%, respectively), chills (9% and 6%, respectively), and tiredness/weakness (26% and 22%, respectively) (92). A review of 460 reports to VAERS after distribution of approximately 2.5 million doses during the 2003-04 and 2004-05 influenza seasons did not indicate any new safety concerns (292). Few of the LAIV VAERS reports (9%) were SAEs; respiratory events were the most common conditions reported.

# Persons at Higher Risk for Influenza-Related Complications
Limited data assessing the safety of LAIV use for certain groups at higher risk for influenza-related complications are available. In one study of 54 HIV-infected persons aged 18-58 years and with CD4+ counts >200 cells/mm 3 who received LAIV, no SAEs were reported during a 1-month follow-up period (266). Similarly, one study demonstrated no significant difference in the frequency of adverse events or viral shedding among HIV-infected children aged 1-8 years on effective antiretroviral therapy who were administered LAIV compared with HIV-uninfected children receiving LAIV (267). LAIV was well-tolerated among adults aged >65 years with chronic medical conditions (293). These findings suggest that persons at risk for influenza complications who have inadvertent exposure to LAIV would not have significant adverse events or prolonged viral shedding and that persons who have contact with persons at higher risk for influenza-related complications may receive LAIV.

# Comparisons of LAIV and tIV Efficacy or Effectiveness
Both TIV and LAIV have been demonstrated to be effective in children and adults. However, data directly comparing the efficacy or effectiveness of these two types of influenza vaccines are limited and insufficient to identify whether one vaccine might offer a clear advantage over the other in certain settings or populations. Studies comparing the efficacy of TIV to that of LAIV have been conducted in a variety of settings and populations using several different outcomes. One randomized, double-blind, placebo-controlled challenge study that was conducted among 92 healthy adults aged 18-41 years assessed the efficacy of both LAIV and TIV in preventing influenza infection when challenged with wild-type strains that were antigenically similar to vaccine strains (294). The overall efficacy in preventing laboratory-documented influenza from all three influenza strains combined was 85% and 71%, respectively, when challenged 28 days after vaccination by viruses to which study participants were susceptible before vaccination. The difference in efficacy between the two vaccines was not statistically significant in this limited study. No additional challenges were conducted to assess efficacy at time points later than 28 days (294). In a randomized, double-blind, placebo-controlled trial that was conducted among young adults during the 2004-05 influenza season, when the majority of circulating H3N2 viruses were antigenically drifted from that season's vaccine viruses, the efficacy of LAIV and TIV against culture-confirmed influenza was 57% and 77%, respectively. The difference in efficacy was not statistically significant and was attributable primarily to a difference in efficacy against influenza B (222). A similar study conducted during the 2005-06 influenza season found no significant difference in vaccine efficacy (221).
A randomized controlled clinical trial conducted among children aged 6-59 months during the 2004-05 influenza season demonstrated a 55% reduction in cases of culture-confirmed influenza among children who received LAIV compared with those who received TIV (288). In this study, LAIV efficacy was higher compared with TIV against antigenically drifted viruses and well-matched viruses (288). An open-label, nonrandomized, community-based influenza vaccine trial conducted during an influenza season when circulating H3N2 strains were poorly matched with strains contained in the vaccine also indicated that LAIV, but not TIV, was effective against antigenically drifted H3N2 strains during that influenza season. In this study, children aged 5-18 years who received LAIV had significant protection against laboratory-confirmed influenza (37%) and pneumonia and influenza events (50%) (295). A recent observational study conducted among military personnel aged 17-49 years over three influenza seasons indicated that persons who received TIV had a significantly lower incidence of health-care encounters resulting in diagnostic coding for pneumonia and influenza compared with those who received LAIV. However, among new recruits being vaccinated for the first time, the incidence of pneumonia-and influenza-coded health-care encounters among those received LAIV was similar to those receiving TIV (296).
Although LAIV is not licensed for use in persons with risk factors for influenza complications, certain studies have compared the efficacy of LAIV to TIV in these groups. LAIV provided 32% increased protection in preventing culture-confirmed influenza compared with TIV in one study conducted among children aged >6 years and adolescents with asthma (297) and 52% increased protection compared with TIV among children aged 6-71 months with recurrent respiratory tract infections (298).

# Effectiveness of Vaccination for Decreasing transmission to Contacts
Decreasing transmission of influenza from caregivers and household contacts to persons at high risk might reduce ILI and complications among persons at high risk. Influenza virus infection and ILI are common among HCP (299-301). Influenza outbreaks have been attributed to low vaccination rates among HCP in hospitals and long-term-care facilities (302)(303)(304). One serosurvey demonstrated that 23% of HCP had serologic evidence of influenza virus infection during a single influenza season; the majority had mild illness or subclinical infection (299). Observational studies have demonstrated that vaccination of HCP is associated with decreased deaths among nursing home patients (305,306). In one clusterrandomized controlled trial that included 2,604 residents of 44 nursing homes, significant decreases in mortality, ILI, and medical visits for ILI care were demonstrated among residents in nursing homes in which staff were offered influenza vaccination (coverage rate: 48%) compared with nursing homes in which staff were not provided with vaccination (coverage rate: 6%) (307). A review concluded that vaccination of HCP in settings in which patients also were vaccinated provided significant reductions in deaths among elderly patients from all causes and deaths from pneumonia (308).
Epidemiologic studies of community outbreaks of influenza demonstrate that school-aged children typically have the highest influenza illness attack rates, suggesting routine universal vaccination of children might reduce transmission to their household contacts and possibly others in the community. Results from certain studies have indicated that the benefits of vaccinating children might extend to protection of their adult contacts and to persons at risk for influenza complications in the community. However, these data are limited, and studies have not used laboratory-confirmed influenza as an outcome measure. A single-blinded, randomized controlled study conducted as part of a 1996-1997 vaccine effectiveness study demonstrated that vaccinating preschool-aged children with TIV reduced influenza-related morbidity among some household contacts (309). A randomized, placebo-controlled trial among children with recurrent respiratory tract infections demonstrated that members of families with children who had received LAIV were significantly less likely to have respiratory tract infections and reported significantly fewer workdays lost compared with families with children who received placebo (310). In nonrandomized community-based studies, administration of LAIV has been demonstrated to reduce MAARI (311,312) and ILI-related economic and medical consequences (e.g., workdays lost and number of health-care provider visits) among contacts of vaccine recipients (312). Households with children attending schools in which school-based LAIV vaccination programs had been established reported less ILI and fewer physician visits during peak influenza season compared with households with children in schools in which no LAIV vaccination had been offered. However a decrease in the overall rate of school absenteeism was not reported in communities in which LAIV vaccination was offered (312). During an influenza outbreak during the 2005-06 influenza season, countywide school-based influenza vaccination was associated with reduced absenteeism among elementary and high school students in one county that implemented a school based vaccination program compared with another county without such a program (313). These community-based studies have not used laboratory-confirmed influenza as an outcome.
Some studies also have documented reductions in influenza illness among persons living in communities where focused programs for vaccinating children have been conducted. A community-based observational study conducted during the 1968 pandemic using a univalent inactivated vaccine reported that a vaccination program targeting school-aged children (coverage rate: 86%) in one community reduced influenza rates within the community among all age groups compared with another community in which aggressive vaccination was not conducted among school-aged children (314). An observational study conducted in Russia demonstrated reductions in ILI among the community-dwelling elderly after implementation of a vaccination program using TIV for children aged 3-6 years (57% coverage achieved) and children and adolescents aged 7-17 years (72% coverage achieved) (315). In a nonrandomized community-based study conducted over three influenza seasons, 8%-18% reductions in the incidence of MAARI during the influenza season among adults aged >35 years were observed in communities in which LAIV was offered to all children aged >18 months (estimated coverage rate: 20%-25%) compared with communities that did not provide routine influenza vaccination programs for all children (311). In a subsequent influenza season, the same investigators documented a 9% reduction in MAARI rates during the influenza season among persons aged 35-44 years in intervention communities, where coverage was estimated at 31% among school children. However, MAARI rates among persons aged >45 years were lower in the intervention communities regardless of the presence of influenza in the community, suggesting that lower rates could not be attributed to vaccination of school children against influenza (295).
The largest study to examine the community effects of increasing overall vaccine coverage was an ecologic study that described the experience in Ontario, Canada, which was the only province to implement a universal influenza vaccination program beginning in 2000. On the basis of models developed from administrative and viral surveillance data, influenzarelated mortality, hospitalizations, ED use, and physicians' office visits decreased significantly more in Ontario after program introduction than in other provinces, with the largest reductions observed in younger age groups (316).

# Effectiveness of Influenza Vaccination When Circulating Influenza Virus Strains Differ from Vaccine Strains
Manufacturing trivalent influenza virus vaccines is a challenging process that takes 6-8 months to complete. Vaccination can provide reduced but substantial cross-protection against drifted strains in some seasons, including reductions in severe outcomes such as hospitalization. Usually one or more circulating viruses with antigenic changes compared with the vaccine strains are identified in each influenza season. In addition, two distinct lineages of influenza B viruses have co-circulated in recent years, and limited cross-protection is observed against the lineage not represented in the vaccine (48). However, assessment of the clinical effectiveness of influenza vaccines cannot be determined solely by laboratory evaluation of the degree of antigenic match between vaccine and circulating strains. In some influenza seasons, circulating influenza viruses with significant antigenic differences predominate, and reductions in vaccine effectiveness sometimes are observed compared with seasons when vaccine and circulating strains are wellmatched, (107,121,125,173,222). However, even during years when vaccine strains were not antigenically well matched to circulating strains (the result of antigenic drift), substantial protection has been observed against severe outcomes, presumably because of vaccine-induced cross-reacting antibodies (121,125,222,283). For example, in one study conducted during the 2003-04 influenza season, when the predominant circulating strain was an influenza A (H3N2) virus that was antigenically different from that season's vaccine strain, effectiveness against laboratory-confirmed influenza illness among persons aged 50-64 years was 60% among healthy persons and 48% among persons with medical conditions that increased the risk for influenza complications (125). An interim, withinseason analysis during the 2007-08 influenza season indicated that vaccine effectiveness was 44% overall, 54% among healthy persons aged 5-49 years, and 58% against influenza A, despite the finding that viruses circulating in the study area were predominately a drifted influenza A (H3N2) and an influenza B strain from a different lineage compared with vaccine strains (317). Among children, both TIV and LAIV provide protection against infection even in seasons when vaccines and circulating strains are not well-matched. Vaccine effectiveness against ILI was 49%-69% in two observational studies, and 49% against medically attended, laboratory-confirmed influenza in a case-control study conducted among young children during the 2003-04 influenza season, when a drifted influenza A (H3N2) strain predominated, based on viral surveillance data (102,106). However, continued improvements in collecting representative circulating viruses and use of surveillance data to forecast antigenic drift are needed. Shortening manufacturing time to increase the time to identify good vaccine candidate strains from among the most recent circulating strains also is important. Data from multiple seasons that are collected in a consistent manner are needed to better understand vaccine effectiveness during seasons when circulating and vaccine virus strains are not well-matched.
Seasonal influenza vaccines are not expected to provide protection against novel influenza A (H1N1) virus infection because this novel strain hemagglutinin is substantially different from seasonal influenza A (H1N1). Preliminary immunologic data indicate that few persons have antibody that shows evidence of cross-reactivity against novel influenza A (H1N1) virus, and few show increases in antibody titer to novel influenza A (H1N1) virus after vaccination with the 2007-08 or the 2008-09 seasonal influenza vaccines (318). Vaccines currently are being developed that are specific to novel influenza A (H1N1) virus.

# Cost-Effectiveness of Influenza Vaccination
Economic studies of influenza vaccination are difficult to compare because they have used different measures of both costs and benefits (e.g., cost-only, cost-effectiveness, costbenefit, or cost-utility). However, most studies find that vaccination reduces or minimizes health care, societal, and individual costs and the productivity losses and absenteeism associated with influenza illness. One national study estimated the annual economic burden of seasonal influenza in the United States (using 2003 population and dollars) to be $87.1 billion, including $10.4 billion in direct medical costs (319).
Studies of influenza vaccination in the United States among persons aged >65 years have estimated substantial reductions in hospitalizations and deaths and overall societal cost savings (168,169). Studies comparing adults in different age groups also find that vaccination is economically beneficial. One study that compared the economic impact of vaccination among persons aged >65 years with those aged 15-64 years indicated that vaccination resulted in a net savings per quality-adjusted life year (QALY) and that the Medicare program saved costs of treating illness by paying for vaccination (320). A study of a larger population comparing persons aged 50-64 years with those aged >65 years estimated the cost-effectiveness of influenza vaccination to be $28,000 per QALY saved (in 2000 dollars) in persons aged 50-64 years compared with $980 per QALY saved among persons aged >65 years (321).
Economic analyses among adults aged <65 years have reported mixed results regarding influenza vaccination. Two studies in the United States found that vaccination can reduce both direct medical costs and indirect costs from work absenteeism and reduced productivity (322,323). However, another U.S. study indicated no productivity and absentee savings in a strategy to vaccinate healthy working adults, although vaccination was still estimated to be cost-effective (324).
Cost analyses have documented the considerable financial burden of illness among children. In a study of 727 children conducted at a medical center during 2000-2004, the mean total cost of hospitalization for influenza-related illness was $13,159 ($39,792 for patients admitted to an intensive care unit and $7,030 for patients cared for exclusively on the wards) (325). A strategy that focuses on vaccinating children with medical conditions that confer a higher risk for influenza complications are more cost-effective than a strategy of vaccinating all children (324). An analysis that compared the costs of vaccinating children of varying ages with TIV and LAIV indicated that costs per QALY saved increased with age for both vaccines. In 2003 dollars per QALY saved, costs for routine vaccination using TIV were $12,000 for healthy children aged 6-23 months and $119,000 for healthy adolescents aged 12-17 years compared with $9,000 and $109,000 using LAIV, respectively (326). Economic evaluations of vaccinating children have demonstrated a wide range of cost estimates, but have generally found this strategy to be either cost-saving or cost-beneficial (327)(328)(329)(330).
Economic analyses are sensitive to the vaccination venue, with vaccination in medical care settings incurring higher projected costs. In a published model, the mean cost (year 2004 values) of vaccination was lower in mass vaccination ($17.04) and pharmacy ($11.57) settings than in scheduled doctor's office visits ($28.67) (331). Vaccination in nonmedical settings was projected to be cost saving for healthy adults aged >50 years and for high-risk adults of all ages. For healthy adults aged 18-49 years, preventing an episode of influenza would cost $90 if vaccination were delivered in a pharmacy setting, $210 in a mass vaccination setting, and $870 during a scheduled doctor's office visit (331). Medicare payment rates in recent years have been less than the costs associated with providing vaccination in a medical practice (332).

# Vaccination Coverage Levels
Continued annual monitoring is needed to determine the effects on vaccination coverage of vaccine supply delays and shortages, changes in influenza vaccination recommendations and target groups for vaccination, reimbursement rates for vaccine and vaccine administration, and other factors related to vaccination coverage among adults and children. One of the Healthy People 2010 objectives (objective no. 14-29a) includes achieving an influenza vaccination coverage level of 90% for persons aged >65 years and among nursing home residents (333,334); new strategies to improve coverage are needed to achieve this objective (335,336). Increasing vaccination coverage among persons who have high-risk conditions and are aged <65 years, including children at high risk, is the highest priority for expanding influenza vaccine use.
On  3) and are only slightly lower than coverage levels observed before the 2004-05 vaccine shortage year (337)(338)(339). In the 2006-07 and 2007-08 influenza seasons, estimated vaccination coverage levels among adults with high-risk conditions aged 18-49 years were 25% and 30%, respectively, substantially lower than the Healthy People 2000 and Healthy People 2010 objectives of 60% (Table 3) (333,334).
Studies conducted among children and adults indicate that opportunities to vaccinate persons at risk for influenza complications (e.g., during hospitalizations for other causes) often are missed. In one study, 23% of children hospitalized with influenza and a comorbidity had a previous hospitalization during the preceding influenza vaccination season (340). In a study of hospitalized Medicare patients, only 31.6% were vaccinated before admission, 1.9% during admission, and 10.6% after admission (341). A study in New York City conducted during 2001-2005 among 7,063 children aged 6-23 months indicated that 2-dose vaccine coverage increased from 1.6% to 23.7% over time; however, although the average number of medical visits during which an opportunity to be vaccinated decreased during the course of the study from 2.9 to 2.0 per child, 55% of all visits during the final year of the study still represented a missed vaccination opportunity (342). Using standing orders in hospitals increases vaccination rates among hospitalized persons (343), and vaccination of hospitalized patients is safe and stimulates an appropriate immune response (158). In one survey, the strongest predictor of receiving vaccination was the survey respondent's belief that he or she was in a high-risk group, based on data from one survey; however, many persons in high-risk groups did not know that they were in a group recommended for vaccination (344).
Reducing racial/ethnic health disparities, including disparities in influenza vaccination coverage, is an overarching national goal that is not being met (334). Estimated vaccination coverage levels in 2007 among persons aged >65 years were 70% for non-Hispanic whites, 58% for non-Hispanic blacks, and 54% for Hispanics (345). Among Medicare beneficiaries, other key factors that contribute to disparities in coverage include variations in the propensity of patients to actively seek vaccination and variations in the likelihood that providers recommend vaccination (346,347). One study estimated that eliminating these disparities in vaccination coverage would have an impact on mortality similar to the impact of eliminating deaths attributable to kidney disease among blacks or liver disease among Hispanics (348).
Reported vaccination levels are low among children at increased risk for influenza complications. Coverage among children aged 2-17 years with asthma for the 2004-05 influenza season was estimated to be 29% (349). One study reported 79% vaccination coverage among children attending a cystic fibrosis treatment center (350). During the first season for which ACIP recommended that all children aged 6 months-23 months receive vaccination, 33% received 1 or more doses of influenza vaccine, and 18% received 2 doses if they were unvaccinated previously (351). Among children enrolled in HMOs who had received a first dose during 2001-2004, second dose coverage varied from 29% to 44% among children aged 6-23 months and from 12% to 24% among children aged 2-8 years (352). A rapid analysis of influenza vaccination coverage levels among members of an HMO in Northern California demonstrated that during the 2004-05 influenza season, the first year of the recommendation for vaccination of children aged 6-23 months, 1-dose coverage was 57% (353). During the 2006-07 influenza season, the second season for which ACIP recommended that all children aged 6 months-23 months receive vaccination, coverage remained low and did not increase substantially from the 2004-05 season. Data collected in 2007 by the National Immunization Survey indicated that for the 2006-07 season, 32% of children aged 6-23 months received at least 1 dose of influenza vaccine and 21% were fully vaccinated (i.e., received 1 or 2 doses depending on previous vaccination history); however, results varied substantially among states (354). As has been reported for older adults, a physician recommendation for vaccination and the perception that having a child be vaccinated "is a smart idea" were associated positively with likelihood of vaccination of children aged 6-23 months (355). Similarly, children with asthma were more likely to be vaccinated if their parents recalled a physician recommendation to be vaccinated or believed that the vaccine worked well (356). Implementation of a reminder/recall system in a pediatric clinic increased the percentage of children with asthma receiving vaccination from 5% to 32% (357).
Although annual vaccination is recommended for HCP and is a high priority for reducing morbidity associated with influenza in health-care settings and for expanding influenza vaccine use (358)(359)(360), national survey data demonstrated a vaccination coverage level of only 42% among HCP during the 2005-06 season, and 44% during the 2006-07 season (Table   Adults categorized as being at high risk for influenza-related complications self-reported one or more of the following: 1) ever being told by a physician they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; 2) having a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer) or ever being told by a physician they have lymphoma, leukemia, or blood cancer during the previous 12 months (post coding for a cancer diagnosis was not yet completed at the time of this publication so this diagnosis was not include in the 2006-07 season data.); 3) being told by a physician they have chronic bronchitis or weak or failing kidneys; or 4) reporting an asthma episode or attack during the preceding 12 months. For children aged <18 years, high-risk conditions included ever having been told by a physician of having diabetes, cystic fibrosis, sickle cell anemia, congenital heart disease, other heart disease, or neuromuscular conditions (seizures, cerebral palsy, and muscular dystrophy), or having an asthma episode or attack during the preceding 12 months.   Aged 18-44 years, pregnant at the time of the survey and without high-risk conditions.   Adults were classified as health-care workers if they were employed in a health-care occupation or in a health-care-industry setting, on the basis of standard occupation and industry categories recoded in groups by CDC's National Center for Health Statistics. * Interviewed sample child or adult in each household containing at least one of the following: a child aged <5 years, an adult aged 65 years, or any person aged 5-17 years at high risk (see previous footnote   ). To obtain information on household composition and high-risk status of household members, the sampled adult, child, and person files from NHIS were merged. Interviewed adults who were health-care workers or who had high-risk conditions were excluded. Information could not be assessed regarding high-risk status of other adults aged 18-64 years in the household; therefore, certain adults aged 18-64 years who lived with an adult aged 18-64 years at high risk were not included in the analysis. Also note that although the recommendation for children aged 2-4 years was not in place during the 2005-06 season, children aged 2-4 years in these calculations were considered to have an indication for vaccination to facilitate comparison of coverage data for subsequent years.
3). Vaccination of HCP has been associated with reduced work absenteeism (300) and with fewer deaths among nursing home patients (305,307) and elderly hospitalized patients (308). Factors associated with a higher rate of influenza vaccination among HCP include older age, being a hospital employee, having employer-provided health-care insurance, having had pneumococcal or hepatitis B vaccination in the past, or having visited a health-care professional during the preceding year. Non-Hispanic black HCP were less likely than non-Hispanic white HCP to be vaccinated (361). HCP who decline vaccination frequently express doubts about the risk for influenza and the need for vaccination, are concerned about vaccine effectiveness and side effects, and dislike injections (362).
Vaccine coverage among pregnant women increased during the 2007-08 influenza season with 24% of pregnant women reporting vaccination, excluding pregnant women who reported diabetes, heart disease, lung disease, and other selected high-risk conditions (Table 3). However, the sample size is small, and the increase in coverage compared with previous seasons was not statistically significant. In a study of influenza vaccine acceptance by pregnant women, 71% of those who were offered the vaccine chose to be vaccinated (363). However, a 1999 survey of obstetricians and gynecologists determined that only 39% administered influenza vaccine to obstetric patients in their practices, although 86% agreed that pregnant women's risk for influenza-related morbidity and mortality increases during the last two trimesters (364).
Influenza vaccination coverage in all groups recommended for vaccination remains suboptimal. Despite the timing of the peak of influenza disease, administration of vaccine decreases substantially after November. According to results from the NHIS regarding the two most recent influenza seasons for which these data are available, approximately 84% of all influenza vaccination were administered during September-November. Among persons aged >65 years, the percentage of September-November vaccinations was 92% (365). Because many persons recommended for vaccination remain unvaccinated at the end of November, CDC encourages public health partners and health-care providers to conduct vaccination clinics and other activities that promote seasonal influenza vaccination annually during National Influenza Vaccination Week (December 6-12, 2009) and throughout the remainder of the influenza season.
Self-report of influenza vaccination among adults compared with determining vaccination status from the medical record, is a sensitive and specific source of information (366,367). Patient self-reports should be accepted as evidence of influenza vaccination in clinical practice (367). However, information on the validity of parents' reports of pediatric influenza vaccination is not yet available.

# Recommendations for Using tIV and LAIV During the 2009-10 Influenza Season
Both TIV and LAIV prepared for the 2009-10 season will include A/Brisbane/59/2007 (H1N1)-like, A/ Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens. The influenza B virus component of the 2009-10 vaccine is from the Victoria lineage (368). These viruses will be used because they are representative of seasonal influenza viruses that are predicted to be circulating in the United States during the 2009-10 influenza season and have favorable growth properties in eggs. Seasonal influenza vaccines are not expected to provide substantial protection against infection with the recently identified novel influenza A (H1N1) (318), and guidance for the prevention of infection against this virus will be published separately.
TIV and LAIV can be used to reduce the risk for influenza virus infection and its complications. Vaccination providers should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected.
Healthy, nonpregnant persons aged 2-49 years can choose to receive either vaccine. Some TIV formulations are FDAlicensed for use in persons as young as age 6 months (see Recommended Vaccines for Different Age Groups). TIV is licensed for use in persons with high-risk conditions (Table 2). LAIV is FDA-licensed for use only for persons aged 2-49 years. In addition, FDA has indicated that the safety of LAIV has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. All children aged 6 months-8 years who have not been vaccinated previously at any time with at least 1 dose of either LAIV (if appropriate) or TIV should receive 2 doses of ageappropriate vaccine in the same season, with a single dose during subsequent seasons.

# target Groups for Protection through Vaccination
Influenza vaccine should be provided to all persons who want to reduce the risk for becoming ill with influenza or of transmitting it to others. However, emphasis on providing routine vaccination annually to certain groups at higher risk for influenza infection or complications is advised, including all children aged 6 months-18 years, all persons aged >50 years, and other adults at risk for medical complications from influenza. In addition, all persons who live with or care for persons at high risk for influenza-related complications, including contacts of children aged <6 months, should receive influenza vaccine annually (Boxes 1 and 2). Approximately 85% of the U.S. population is included in one or more of these target groups; however, <40% of the U.S. population received an influenza vaccination during the 2008-09 influenza season.

# Children Aged 6 Months-18 Years
Beginning with the 2008-09 influenza season, annual vaccination for all children aged 6 months-18 years was recommended. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children.
Healthy children aged 2-18 years can receive either LAIV or TIV. Children aged 6-23 months, and those aged 2-4 years who have evidence of asthma wheezing or who have medical conditions that put them at higher risk for influenza complications should receive TIV (see Considerations When Using LAIV). All children aged 6 months-8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first year they are vaccinated.

# Persons at Risk for Medical Complications
Vaccination to prevent influenza is particularly important for the following persons, who are at increased risk for severe complications from influenza, or at higher risk for influenzarelated outpatient, ED, or hospital visits: all children aged 6 months- facilities. For children, the risk for severe complications from seasonal influenza is highest among those aged <2 years, who have much higher rates of hospitalization for influenza-related complications compared with older children (7,32,39). Medical care and ED visits attributable to influenza are increased among children aged <5 years compared with older children (32).
Chronic neurologic and neuromuscular conditions include 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 (30).

# 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) also is recommended for the following persons. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to these persons: HCP; - household contacts (including children) and caregivers - of children aged 50 years; and household contacts (including children) and caregivers - of persons with medical conditions that put them at higher risk for severe complications from influenza.

# Children Aged <6 Months
Children aged <6 months are not recommended for vaccination, and antivirals are not licensed for use among infants. Protection of young infants, who have hospitalization rates similar to those observed among the elderly, depends on vaccination of the infants' close contacts. A recent study conducted in Bangladesh demonstrated that infants born to vaccinated women have significant protection from laboratory-confirmed influenza, either through transfer of influenza-specific maternal antibodies or by reducing the risk for exposure to influenza that might occur through vaccination of the mother (154). All household contacts, health-care and day care providers, and other close contacts of young infants should be vaccinated.

# Vaccination of Specific Populations Children Aged 6 Months-18 Years
All children aged 6 months-18 years should be vaccinated against influenza annually. In 2004, ACIP recommended routine vaccination for all children aged 6-23 months, and in 2006, ACIP expanded the recommendation to include all children aged 24-59 months. Recommendations to provide routine influenza vaccination to all children and adolescents aged 6 months-18 years are made on the basis of 1) accumulated evidence that influenza vaccine is effective and safe for children (see Influenza Vaccine Efficacy, Effectiveness, and Safety); 2) increased evidence that influenza has substantial adverse impacts among children and their contacts (e.g., school absenteeism, increased antibiotic use, medical care visits, and parental work loss) (see Health-Care Use, Hospitalizations, and Deaths Attributed to Influenza); and 3) an expectation that a simplified age-based influenza vaccine recommendation for all children and adolescents will improve vaccine coverage levels among children who already have a risk-or contact-based indication for annual influenza vaccination.
Children typically have the highest attack rates during community outbreaks of influenza and serve as a major source of transmission within communities (1,2). If sufficient vaccination coverage among children can be achieved, potential benefits include the indirect effect of reducing influenza among persons who have close contact with children and reducing overall transmission within communities. Achieving and sustaining community-level reductions in influenza will require mobilization of community resources and development of sustainable annual vaccination campaigns to assist health-care providers and vaccination programs in providing influenza vaccination services to children of all ages. In many areas, innovative community-based efforts, which might include mass vaccination programs in school or other community settings, will be needed to supplement vaccination services provided in health-care providers' offices or public health clinics. In nonrandomized community-based controlled trials, reductions in ILI-related symptoms and medical visits among household contacts have been demonstrated in communities where vaccination programs among school-aged children were established compared with communities without such vaccination programs (295,314,315).Reducing influenza-related illness among children who are at high risk for influenza complications should continue to be a primary focus of influenza-prevention efforts. Children who should be vaccinated because they are at high risk for influenza complications include all children aged 6-59 months, children with certain medical conditions, children who are contacts of children aged 50 years, and children who are contacts of persons at high risk for influenza complications because of medical conditions.
All children aged 6 months-8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first influenza season that they are vaccinated. The second dose should be administered 4 or more weeks after the initial dose. When only 1 dose is administered to children aged 6 months-8 years during their first year of vaccination, 2 doses should be administered in the following season. However, 2 doses should only be administered in the first season of vaccination, or in the season that immediately follows if only 1 dose is administered in the first season. For example, children aged 6 months-8 years who were vaccinated for the first time with the 2008-09 influenza vaccine but received only 1 dose should receive 2 doses of the 2009-10 influenza vaccine. All other children aged 6 months-8 years who have previously received 1 or more doses of influenza vaccine at any time should receive 1 dose of the 2009-10 influenza vaccine. Children aged 6 months-8 years who received only a single vaccination during a season before 2007-08 should receive 1 dose of the 2009-10 influenza vaccine. If possible, both doses should be administered before onset of influenza season. However, vaccination, including the second dose, is recommended even after influenza virus begins to circulate in a community.

# HCP and other Persons Who Can transmit Influenza to those at High Risk
Healthy persons who are infected with influenza virus, including those with subclinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. In addition to HCP, groups that can transmit influenza to high-risk persons and that should be vaccinated include employees of assisted living and other residences for All HCP and persons in training for health-care professions should be vaccinated annually against influenza. Persons working in health-care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient-care settings, medical emergency-response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and long-term-care facilities who have contact with patients or residents, and students in these professions who will have contact with patients (359,360,371).
Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. Health-care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications (360,372,373). Influenza vaccination rates among HCP within facilities should be regularly measured and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration (360). Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and by using strategies that increase vaccine acceptance (358,360,374).
Efforts to increase vaccination coverage among HCP are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission on Accreditation of Health-Care Organizations has approved an infection-control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with close patient contact. The standard became an accreditation requirement beginning January 1, 2007 (375). In addition, the Infectious Diseases Society of America has recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons (376). Some states have regulations regarding vaccination of HCP in long-term-care facilities (377), require that health-care facilities offer influenza vaccination to HCP, or require that HCP either receive influenza vaccination or indicate a religious, medical, or philosophic reason for not being vaccinated (378,379).

# Close Contacts of Immunocompromised Persons
Immunocompromised persons are at risk for influenza complications but might have inadequate protection after vaccination. Close contacts of immunocompromised persons, including HCP, should be vaccinated to reduce the risk for influenza transmission. TIV is recommended for vaccinating household members, HCP, and others who have close contact with severely immunosuppressed persons (e.g., patients with hematopoietic stem cell transplants) during those periods in which the immunosuppressed person requires care in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the cor-ridor, high-efficiency particulate air filtration, and frequent air changes) (360,380).
LAIV transmission from a recently vaccinated person causing clinically important illness in an immunocompromised contact has not been reported. The rationale for avoiding use of LAIV among HCP or other close contacts of severely immunocompromised patients is the theoretical risk that a live, attenuated vaccine virus could be transmitted to the severely immunosuppressed person. As a precautionary measure, HCP who receive LAIV should avoid providing care for severely immunosuppressed patients requiring a protected environment for 7 days after vaccination. Hospital visitors who have received LAIV should avoid contact with severely immunosuppressed persons in protected environments for 7 days after vaccination but should not be restricted from visiting less severely immunosuppressed patients.
No preference is indicated for TIV use by persons who have close contact with persons with lesser degrees of immunosuppression (e.g., persons with diabetes, persons with asthma who take corticosteroids, persons who have recently received chemotherapy or radiation but who are not being cared for in a protective environment as defined above, or persons infected with HIV) or for TIV use by HCP or other healthy nonpregnant persons aged 2-49 years in close contact with persons in all other groups at high risk.

# Pregnant Women
Pregnant women and newborns are at risk for influenza complications, and all women who are pregnant or will be pregnant during influenza season should be vaccinated. The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians also have recommended routine vaccination of all pregnant women (381). No preference is indicated for use of TIV that does not contain thimerosal as a preservative (see Vaccine Preservative  in Multidose Vials of TIV) for any group recommended for vaccination, including pregnant women. LAIV is not licensed for use in pregnant women. However, pregnant women do not need to avoid contact with persons recently vaccinated with LAIV.

# Breastfeeding Mothers
Vaccination is recommended for all persons, including breastfeeding women, who are contacts of infants or children aged <5 years because infants and young children are at high risk for influenza complications and are more likely to require medical care or hospitalization if infected. Breastfeeding does not affect the immune response adversely and is not a con-traindication for vaccination (179). Unless contraindicated because of other medical conditions, women who are breastfeeding can receive either TIV or LAIV. In one randomized controlled trial conducted in Bangladesh, infants born to women vaccinated during pregnancy had a lower risk for laboratory-confirmed influenza. However, the contribution to protection from influenza of breastfeeding compared with passive transfer of maternal antibodies during pregnancy was not determined (154).

# travelers
The risk for exposure to influenza during travel depends on the time of year and destination. In the temperate regions of the Southern Hemisphere, influenza activity occurs typically during April-September. In temperate climate zones of the Northern and Southern Hemispheres, travelers also can be exposed to influenza during the summer, especially when traveling as part of large tourist groups (e.g., on cruise ships) that include persons from areas of the world in which influenza viruses are circulating (382,383). In the tropics, influenza occurs throughout the year. In a study among Swiss travelers to tropical and subtropical countries, influenza was the most frequently acquired vaccine-preventable disease (384).
Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, persons at high risk for complications of influenza and who were not vaccinated with influenza vaccine during the preceding fall or winter should consider receiving influenza vaccine before travel if they plan to travel to the tropics, - with organized tourist groups at any time of year, or - to the Southern Hemisphere during April-September. - No information is available about the benefits of revaccinating persons before summer travel who already were vaccinated during the preceding fall, and revaccination is not recommended. Persons at high risk who receive the previous season's vaccine before travel should be revaccinated with the current vaccine the following fall or winter. Persons at higher risk for influenza complications should consult with their health-care practitioner to discuss the risk for influenza or other travel-related diseases before embarking on travel during the summer.

# General Population
Vaccination is recommended for any persons who wish to reduce the likelihood of their becoming ill with influenza or transmitting influenza to others should they become infected. Healthy, nonpregnant persons aged 2-49 years might choose to receive either TIV or LAIV. All other persons aged >6 months should receive TIV. Persons who provide essential community services should be considered for vaccination to minimize disruption of essential activities during influenza outbreaks. Students or other persons in institutional settings (e.g., those who reside in dormitories or correctional facilities) should be encouraged to receive vaccine to minimize morbidity and the disruption of routine activities during influenza epidemics (385,386).

# Recommended Vaccines for Different Age Groups
When vaccinating children aged 6-35 months with TIV, health-care providers should use TIV that has been licensed by the FDA for this age group (i.e., TIV manufactured by Sanofi Pasteur ) (219). TIV from Novartis (Fluvirin) is FDA-approved in the United States for use among persons aged >4 years (220). TIV from GlaxoSmithKline (Fluarix and FluLaval) or CSL Biotherapies (Afluria) is labeled for use in persons aged >18 years because data to demonstrate immunogenicity or efficacy among younger persons have not been provided to FDA (207,208,218). LAIV from MedImmune (FluMist) is recommended for use by healthy nonpregnant persons aged 2-49 years (Table 2) (291). If a pediatric vaccine dose (0.25mL) is administered to an adult, an additional pediatric dose (0.25 mL) should be given to provide a full adult dose (0.5mL). If the error is discovered later (after the patient has left the vaccination setting), an adult dose should be administered as soon as the patient can return. No action needs to be taken if an adult dose is administered to a child. Several new vaccine formulations are being evaluated in immunogenicity and efficacy trials; when licensed, these new products will increase the influenza vaccine supply and provide additional vaccine choices for practitioners and their patients.

# Influenza Vaccines and Use of Influenza Antiviral Medications
Unvaccinated persons who are receiving antiviral medications for treatment or chemoprophylaxis often also are recommended for vaccination. Administration of TIV to persons receiving influenza antivirals is acceptable. The effect on safety and effectiveness of LAIV coadministration with influenza antiviral medications has not been studied. However, because influenza antivirals reduce replication of influenza viruses, LAIV should not be administered until 48 hours after cessation of influenza antiviral therapy, and influenza antiviral medications should not be administered for 2 weeks after receipt of LAIV. Persons receiving antivirals within the period 2 days before to 14 days after vaccination with LAIV should be revaccinated at a later date with any approved vaccine formulation (179,291).

# Considerations When Using LAIV
LAIV is an option for vaccination of healthy, nonpregnant persons aged 2-49 years, including HCP and other close contacts of high-risk persons (excepting severely immunocompromised persons who require care in a protected environment). No preference is indicated for LAIV or TIV when considering vaccination of healthy,  nonpregnant persons aged 2-49 years. Possible advantages of LAIV include its potential to induce a broad mucosal and systemic immune response in children, its ease of administration, and the possibly increased acceptability of an intranasal rather than intramuscular route of administration.
If the vaccine recipient sneezes after administration, the dose should not be repeated. However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness, or TIV should be administered instead. No data exist about concomitant use of nasal corticosteroids or other intranasal medications (261).
Although FDA licensure of LAIV excludes children aged 2-4 years with a history of asthma or recurrent wheezing, the precise risk, if any, of wheezing caused by LAIV among these children is unknown because experience with LAIV among these young children is limited. Young children might not have a history of recurrent wheezing if their exposure to respiratory viruses has been limited because of their age. Certain children might have a history of wheezing with respiratory illnesses but have not had asthma diagnosed.
The following screening recommendations should be used to assist persons who administer influenza vaccines in providing the appropriate vaccine for children aged 2-4 years.
Clinicians and vaccination programs should screen - for asthma or wheezing illness (or history of wheezing illness) when considering use of LAIV for children aged 2-4 years, and should avoid use of this vaccine in children with asthma or a recent wheezing episode within the previous 12 months. Health-care providers should consult the medical record, when available, to identify children aged 2-4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive LAIV. TIV is available for use in children with asthma or wheezing (387).LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness.

# Contraindications and Precautions for Use of LAIV
The effectiveness or safety of LAIV is not known for the following groups and administration of LAIV is contraindicated:
persons ing aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection); or pregnant women. - A moderate or severe illness with or without fever is a precaution for use of LAIV. GBS within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines. LAIV should not be administered to close contacts of immunosuppressed persons who require a protected environment.  Use of the term "healthy" in this recommendation refers to persons who do not have any of the underlying medical conditions that confer high risk for severe complications (see Contraindications and Precautions for Use of LAIV).

# Personnel Who Can Administer LAIV
Low-level introduction of vaccine viruses into the environment probably is unavoidable when administering LAIV. The risk for acquiring vaccine viruses from the environment is unknown but is probably low. Severely immunosuppressed persons should not administer LAIV. However, other persons at higher risk for influenza complications can administer LAIV. These include persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged >50 years.

# Concurrent Administration of Influenza Vaccine with other Vaccines
Use of LAIV concurrently with measles, mumps, rubella (MMR) alone and MMR and varicella vaccine among children aged 12-15 months has been studied, and no interference with the immunogenicity to antigens in any of the vaccines was observed (261,388). Among adults aged >50 years, the safety and immunogenicity of zoster vaccine and TIV was similar whether administered simultaneously or spaced 4 weeks apart (389). In the absence of specific data indicating interference, following ACIP's general recommendations for vaccination is prudent (179). Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. Inactivated or live vaccines can be administered simultaneously with LAIV. However, after administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered.

# Recommendations for Vaccination Administration and Vaccination Programs
Although influenza vaccination levels increased substantially during the 1990s, little progress has been made since 2000 toward achieving national health objectives, and further improvements in vaccine coverage levels are needed to reduce the annual impact of influenza substantially. Strategies to improve vaccination levels, including using reminder/recall systems and standing orders programs (335,336,345), should be implemented whenever feasible. Vaccination efforts should begin as soon as vaccine is available and continue through the influenza season. Vaccination coverage can be increased by administering vaccine before and during the influenza season to persons during hospitalizations or routine health-care visits. Vaccinations can be provided in alternative settings (e.g., pharmacies, grocery stores, workplaces, or other locations in the community), thereby making special visits to physicians' offices or clinics unnecessary. Coordinated campaigns such as the National Influenza Vaccination Week (December 6-12, 2009) provide opportunities to refocus public attention on the benefits, safety, and availability of influenza vaccination throughout the influenza season. When educating patients about adverse events, clinicians should provide access to Vaccine Information Sheets (available at . gov/vaccines/pubs/vis), and emphasize that 1) TIV contains noninfectious killed viruses and cannot cause influenza, 2) LAIV contains weakened influenza viruses that cannot replicate outside the upper respiratory tract and are unlikely to infect others, and 3) concomitant symptoms or respiratory disease unrelated to vaccination with either TIV or LAIV can occur after vaccination. Adverse events after influenza vaccination should be reported promptly to VAERS at . gov even if the health-care professional is not certain that the vaccine caused the event.

# Information About the Vaccines for Children Program
The Vaccines for Children (VFC) program supplies vaccine to all states, territories, and the District of Columbia for use by participating providers. These vaccines are to be provided to eligible children without vaccine cost to the patient or the provider, although the provider might charge a vaccine administration fee. All routine childhood vaccines recommended by ACIP are available through this program, including influenza vaccines. The program saves parents and providers out-ofpocket expenses for vaccine purchases and provides cost savings to states through CDC's vaccine contracts. The program results in lower vaccine prices and ensures that all states pay the same contract prices. Detailed information about the VFC program is available at / vfc/default.htm.

# Influenza Vaccine Supply Considerations
The annual supply of influenza vaccine and the timing of its distribution cannot be guaranteed in any year. During the 2008-09 influenza season, 113 million doses of influenza vaccine were distributed in the United States. For the 2009-10 season, total production of seasonal influenza vaccine for the United States is anticipated to be >130 million doses, depending on demand and production yields. However, influenza vaccine distribution delays or vaccine shortages remain possible. One factor that affects production is the inherent critical time constraints in manufacturing the vaccine given the annual updating of the influenza vaccine strains. Multiple manufacturing and regulatory issues, including the anticipated need to produce a separate vaccine against novel influenza A (H1N1), also might affect the production schedule. To ensure optimal use of available doses of influenza vaccine, health-care providers, persons planning organized campaigns, and state and local public health agencies should develop plans for expanding outreach and infrastructure to vaccinate more persons in targeted groups and others who wish to reduce their risk for influenza. They also should develop contingency plans for the timing and prioritization of administering influenza vaccine if the supply of vaccine is delayed or reduced.
If supplies of TIV are not adequate, vaccination should be carried out in accordance with local circumstances of supply and demand based on the judgment of state and local health officials and health-care providers. Guidance for tiered use of TIV during prolonged distribution delays or supply short falls is available at  and will be modified as needed in the event of shortage. CDC and other public health agencies will assess the vaccine supply on a continuing basis throughout the manufacturing period and will inform both providers and the general public if any indication exists of a substantial delay or an inadequate supply.
Because LAIV is recommended for use only in healthy nonpregnant persons aged 2-49 years, no recommendations for prioritization of LAIV use are made. Either LAIV or TIV can be used when considering vaccination of healthy, nonpregnant persons aged 2-49 years. However, during shortages of TIV, LAIV should be used preferentially when feasible for all healthy nonpregnant persons aged 2-49 years (including HCP) who desire or are recommended for vaccination to increase the availability of inactivated vaccine for persons at high risk.

# timing of Vaccination
Vaccination efforts should be structured to ensure the vaccination of as many persons as possible over the course of several months, with emphasis on vaccinating before influenza activity in the community begins. Even if vaccine distribution begins before October, distribution probably will not be completed until December or January. The following recommendations reflect this phased distribution of vaccine.
In any given year, the optimal time to vaccinate patients cannot be determined precisely because influenza seasons vary in their timing and duration, and more than one outbreak might occur in a single community in a single year. In the United States, localized outbreaks that indicate the start of seasonal influenza activity can occur as early as October. However, in >80% of influenza seasons since 1976, peak influenza activity (which often is close to the midpoint of influenza activity for the season) has not occurred until January or later, and in >60% of seasons, the peak was in February or later (Figure 1). In general, health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health-care visits or during hospitalizations whenever vaccine is available. The potential for addition of a novel influenza A (H1N1) vaccine program to the current burden on vaccination programs and providers underscores the need for careful planning of seasonal vaccination programs. Beginning use of seasonal vaccine as soon as available, including in September or earlier, might reduce the overlap of seasonal and novel influenza vaccination efforts.
Vaccination efforts should continue throughout the season, because the duration of the influenza season varies, and influenza might not appear in certain communities until February or March. Providers should offer influenza vaccine routinely, and organized vaccination campaigns should continue throughout the influenza season, including after influenza activity has begun in the community. Vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons. The majority of adults have antibody protection against influenza virus infection within 2 weeks after vaccination (390,391).
All children aged 6 months-8 years who have not received vaccination against influenza previously should receive their first dose as soon after vaccine becomes available as is feasible and should receive the second dose >4 weeks later. This practice increases the opportunity for both doses to be administered before or shortly after the onset of influenza activity.
Vaccination clinics should be scheduled through December, and later if feasible, with attention to settings that serve children aged >6 months, pregnant women, other persons aged 50 years, HCP, and persons who are household contacts of children aged <59 months or other persons at high risk. Planners are encouraged to develop the capacity and flexibility to schedule at least one vaccination clinic in December. Guidelines for planning large-scale vaccination clinics are available at / vaccination/vax_clinic.htm.
During a vaccine shortage or delay, substantial proportions of TIV doses might not be released and distributed until November and December or later. When the vaccine is substantially delayed or disease activity has not subsided, providers should consider offering vaccination clinics into January and beyond as long as vaccine supplies are available. Campaigns using LAIV also can extend into January and beyond.

# Strategies for Implementing Vaccination Recommendations in Health-Care Settings
Successful vaccination programs combine publicity and education for HCP and other potential vaccine recipients, a plan for identifying persons recommended for vaccination, use of reminder/recall systems, assessment of practice-level vaccination rates with feedback to staff, and efforts to remove administrative and financial barriers that prevent persons from receiving the vaccine, including use of standing orders programs (336,392). The use of standing orders programs by long-term-care facilities (e.g., nursing homes and skilled nursing facilities), hospitals, and home health agencies ensures that vaccination is offered. Standing orders programs for influenza vaccination should be conducted under the supervision of a licensed practitioner according to a physician-approved facility or agency policy by HCP trained to screen patients for contraindications to vaccination, administer vaccine, and monitor for adverse events. The Centers for Medicare and Medicaid Services (CMS) has removed the physician signature requirement for the administration of influenza and pneumococcal vaccines to Medicare and Medicaid patients in hospitals, long-term-care facilities, and home health agencies (393). To the extent allowed by local and state law, these facilities and agencies can implement standing orders for influenza and pneumococcal vaccination of Medicare-and Medicaideligible patients. Payment for influenza vaccine under Medicare Part B is available (394,395) Other settings (e.g., outpatient facilities, managed care organizations, assisted living facilities, correctional facilities, pharmacies, and adult workplaces) are encouraged to introduce standing orders programs (396). In addition, physician reminders (e.g., flagging charts) and patient reminders are recognized strategies for increasing rates of influenza vaccination. Persons for whom influenza vaccine is recommended can be identified and vaccinated in the settings described in the following sections.

# outpatient Facilities Providing ongoing Care
Staff in facilities providing ongoing medical care (e.g., physicians' offices, public health clinics, employee health clinics, hemodialysis centers, hospital specialty-care clinics, and outpatient rehabilitation programs) should identify and label the medical records of patients who should receive vaccination. Vaccine should be offered during visits throughout the influenza season. The offer of vaccination and its receipt or refusal should be documented in the medical record or vaccination information system. Patients for whom vaccination is recommended and who do not have regularly scheduled visits during the fall should be reminded by mail, telephone, or other means of the need for vaccination.

# outpatient Facilities Providing Episodic or Acute Care
Acute health-care facilities (e.g., EDs and walk-in clinics) should offer vaccinations throughout the influenza season to persons for whom vaccination is recommended or provide written information regarding why, where, and how to obtain the vaccine. This written information should be available in languages appropriate for the populations served by the facility.

# nursing Homes and other Long-term-Care Facilities
Vaccination should be provided routinely to all residents of long-term-care facilities. If possible, all residents should be vaccinated at one time before influenza season. In the majority of seasons, TIV will become available to long-term-care facilities in October or November, and vaccination should commence as soon as vaccine is available. As soon as possible after admission to the facility, the benefits and risks of vaccination should be discussed and education materials provided (397). Signed consent is not required (398). Residents admitted after completion of the vaccination program at the facility should be vaccinated at the time of admission.
Since October 2005, CMS has required nursing homes participating in the Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines and to document the results. According to the requirements, each resident is to be vaccinated unless contraindicated medically, the resident or a legal representative refuses vaccination, or the vaccine is not available because of shortage. This information is to be reported as part of the CMS Minimum Data Set, which tracks nursing home health parameters (395,399).

# Acute-Care Hospitals
Hospitals should serve as a key setting for identifying persons at increased risk for influenza complications. Unvaccinated persons of all ages (including children) with high-risk conditions and persons aged 6 months-18 years or >50 years who are hospitalized at any time during the period when vaccine is available should be offered and strongly encouraged to receive influenza vaccine before they are discharged. Standing orders to offer influenza vaccination to all hospitalized persons should be considered.

# Visiting nurses and others Providing Home Care to Persons at High Risk
Nursing-care plans should identify patients for whom vaccination is recommended, and vaccine should be administered in the home if necessary as soon as influenza vaccine is available and throughout the influenza season. Caregivers and other persons in the household (including children) should be referred for vaccination.

# other Facilities Providing Services to Persons Aged >50 Years
Facilities providing services to persons aged >50 years (e.g., assisted living housing, retirement communities, and recreation centers) should offer unvaccinated residents, attendees, and staff annual on-site vaccination before the start of the influenza season. Continuing to offer vaccination throughout the fall and winter months is appropriate. Efforts to vaccinate newly admitted patients or new employees also should be continued, both to prevent illness and to avoid having these persons serve as a source of new influenza infections. Staff education should emphasize the benefits for self, staff and patients of protection from influenza through vaccination.

# Health-Care Personnel
Health-care facilities should offer influenza vaccinations to all HCP, including night, weekend, and temporary staff. Particular emphasis should be placed on providing vaccinations to workers who provide direct care for persons at high risk for influenza complications. Efforts should be made to educate HCP regarding the benefits of vaccination and the potential health consequences of influenza illness for their patients, themselves, and their family members. All HCP should be provided convenient access to influenza vaccine at the work site, free of charge, as part of employee health programs (360,374,375).

# Future Directions for Research and Recommendations Related to Influenza Vaccine
Although available influenza vaccines are effective and safe, additional research is needed to improve prevention efforts. Most mortality from influenza occurs among persons aged >65 years (6), and more immunogenic influenza vaccines are needed for this age group and other groups at high risk for mortality. Additional research also is needed to understand potential biases in estimating the benefits of vaccination among older adults in reducing hospitalizations and deaths (82,175,400). Additional studies of the relative cost-effectiveness and cost utility of influenza vaccination among children and adults, especially those aged <65 years, are needed and should be designed to account for year-to-year variations in influenza attack rates, illness severity, hospitalization costs and rates, and vaccine effectiveness when evaluating the long-term costs and benefits of annual vaccination (401). Additional data on indirect effects of vaccination also are needed to quantify the benefits of influenza vaccination of HCP in protecting their patients (308) and the benefits of vaccinating children to reduce influenza complications among those at risk. Because expansions in ACIP recommendations for vaccination will lead to more persons being vaccinated, much larger research networks are needed that can identify and assess the causality of very rare events that occur after vaccination, including GBS. Ongoing studies of safety in pediatric populations with expanded recommendations are needed and are underway. These research networks also could provide a platform for effectiveness and safety studies in the event of a pandemic. A recent study showed that influenza vaccines contain structures that can induce anti-GM1 antibodies after inoculation into mice (402). Further research on potential biologic or genetic risk factors for GBS in humans also is needed (397). In addition, a better understanding is needed of how to motivate persons at risk to seek annual influenza vaccination.
ACIP continues to review new vaccination strategies to protect against influenza, including the possibility of expanding routine influenza vaccination recommendations toward universal vaccination or other approaches that will help reduce or prevent the transmission of influenza and reduce the burden of severe disease (403)(404)(405)(406)(407)(408). The 2009 ACIP expansion of annual vaccination recommendations to include all children aged 6 months-18 years will require a substantial increase in resources for epidemiologic research to develop long-term studies capable of assessing the possible effects on community-level transmission. Additional planning to improve surveillance systems capable of monitoring effectiveness, safety and vaccine coverage, and further development of implementation strategies will also be necessary. In addition, as noted by the National Vaccine Advisory Committee, strengthening the U.S. influenza vaccination system will require improving vaccine financing and demand and implementing systems to help better understand the burden of influenza in the United States (409). Vaccination programs capable of delivering annual influenza vaccination to a broad range of the population could potentially serve as a resilient and sustainable platform for delivering vaccines and monitoring outcomes for other urgently required public health interventions (e.g., vaccines for pandemic influenza or medications to prevent or treat illnesses caused by acts of terrorism).

# Seasonal Influenza Vaccine and Influenza Viruses of Animal origin
Human infection with novel or nonhuman influenza A virus strains, including influenza A viruses of animal origin, is a nationally notifiable disease (410). Human infections with nonhuman or novel human influenza A virus should be identified quickly and investigated to determine possible sources of exposure, identify additional cases, and evaluate the possibility of human-to-human transmission because transmission patterns could change over time with variations in these influenza A viruses.
Sporadic severe and fatal human cases of infection with highly pathogenic avian influenza A (H5N1) virus have been identified in Asia, Africa, Europe, and the Middle East, primarily among persons who have had direct or close unprotected contact with sick or dead birds associated with the ongoing H5N1 panzootic among birds (411)(412)(413)(414)(415)(416)(417)(418)(419). Limited, nonsustained human-to-human transmission of H5N1 virus has likely occurred in some case clusters (420,421). To date, no evidence exists of genetic reassortment between human influenza A and H5N1 viruses. However, influenza viruses derived from strains circulating among poultry (e.g., the H5N1 virus that has caused outbreaks of avian influenza and occasionally have infected humans) have the potential to recombine with human influenza A viruses (422,423). To date, highly pathogenic H5N1 virus has not been identified in wild or domestic birds or in humans in the United States. Guidance for testing suspected cases of H5N1 virus infection among persons in the U.S. and follow-up of contacts is available (424,425).
Human illness from infection with different avian influenza A subtype viruses also have been documented, including infections with low pathogenic and highly pathogenic viruses. A range of clinical illness has been reported for human infection with low pathogenic avian influenza viruses, including conjunctivitis with influenza A (H7N7) virus in the United Kingdom, lower respiratory tract disease and conjunctivitis with influenza A (H7N2) virus in the United Kingdom, and uncomplicated ILI with influenza A (H9N2) virus in Hong Kong and China (426)(427)(428)(429)(430)(431)(432). Two human cases of infection with low pathogenic influenza A (H7N2) were reported in the United States (429). Although human infections with highly pathogenic A (H7N7) virus infections typically have ILI or conjunctivitis, severe infections, including one fatal case in the Netherlands, have been reported (433,434). Conjunctivitis also has been reported because of human infection with highly pathogenic influenza A (H7N3) virus in Canada and low pathogenic A (H7N3) in the United Kingdom (426,434). In contrast, sporadic infections with highly pathogenic avian influenza A (H5N1) virus have caused severe illness in many countries, with an overall case-fatality proportion of >60% (421,435).
Swine influenza A (H1N1), A (H1N2), and A (H3N2) viruses, including reassortant viruses, are endemic among pig populations in the United States (436). Two clusters of influenza A (H2N3) virus infections among pigs have been reported recently (437). Outbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. An estimated 30% of the pig population in the United States has serologic evidence of having had swine influenza A (H1N1) virus infection. Sporadic human infections with a variety of swine influenza A viruses occur in the United States, but the incidence of these human infections is unknown (438)(439)(440)(441)(442)(443). Persons infected with swine influenza A viruses typically report direct contact with ill pigs or places where pigs have been present (e.g., agricultural fairs or farms), and have symptoms that are clinically indistinguishable from infection with other respiratory viruses (440,441,444,445). Clinicians should consider swine influenza A virus infection in the differential diagnosis of patients with ILI who have had recent contact with pigs. The sporadic cases identified in recent years have not resulted in sustained human-to-human transmission of swine influenza A viruses or community outbreaks (368,445). Although immunity to swine influenza A viruses appears to be low (<2%) in the overall human population, 10%-20% of persons exposed occupationally to pigs (e.g., pig farmers or pig veterinarians) have been documented in certain studies to have antibody evidence of prior swine influenza A (H1N1) virus infection (438,446).
In April 2009, a novel influenza A (H1N1) virus similar to influenza viruses previously identified in swine was determined to the cause of an influenza-like respiratory illness among humans that spread across North America and throughout most of the world by May 2009 (9,447). The epidemiology of influenza caused by this novel influenza virus is still being studied, and whether this virus will achieve long-term circulation among humans or even replace one of the other seasonal influenza viruses as the cause of annual epidemics is unknown.
Current seasonal influenza vaccines are not expected to provide protection against human infection with avian influenza A viruses, including influenza A (H5N1) viruses, or to provide protection against currently circulating swine influenza A or the novel influenza A (H1N1) viruses (318,448). However, reducing seasonal influenza risk through influenza vaccination of persons who might be exposed to nonhuman influenza viruses (e.g., H5N1 virus) might reduce the theoretical risk for recombination of influenza A viruses of animal origin and human influenza A viruses by preventing seasonal influenza A virus infection within a human host.
CDC has recommended that persons who are charged with responding to avian influenza outbreaks among poultry receive seasonal influenza vaccination (448,449). As part of preparedness activities, the Occupational Safety and Health Administration (OSHA) has issued an advisory notice regarding poultry worker safety that is intended for implementation in the event of a suspected or confirmed avian influenza outbreak at a poultry facility in the United States. OSHA guidelines recommend that poultry workers in an involved facility receive vaccination against seasonal influenza; OSHA also has recommended that HCP involved in the care of patients with documented or suspected avian influenza should be vaccinated with the most recent seasonal human influenza vaccine to reduce the risk for co-infection with human influenza A viruses (449).

# Recommendations for Using Antiviral Agents for Seasonal Influenza
Annual vaccination is the primary strategy for preventing complications of influenza virus infections. Antiviral medications with activity against influenza viruses are useful adjuncts in the prevention of influenza, and effective when used early in the course of illness for treatment. Four influenza antiviral agents are licensed in the United States: amantadine, rimantadine, zanamivir, and oseltamivir.
During the 2007-08 influenza season, influenza A (H1N1) viruses with a mutation that confers resistance to oseltamivir became more common in the United States and other countries (450)(451)(452). As of July 2009, in the United States, approximately 99% of human influenza A (H1N1) viruses tested, and none of the influenza A (H3N2) or influenza B viruses tested have been resistant to oseltamivir. As of July 2, 2009, with few exceptions, novel influenza A (H1N1) viruses that began circulating in April 2009 remained sensitive to oseltamivir (453). Oseltamivir resistance among circulating seasonal influenza A (H1N1) virus strains presents challenges for the selection of antiviral medications for treatment and chemoprophylaxis of influenza, and provides additional reasons for clinicians to test patients for influenza virus infection and to consult surveillance data when evaluating persons with acute respiratory illnesses during influenza season. CDC has published interim guidelines to provide options for treatment or chemoprophylaxis of influenza in the United States if oseltamivir-resistant seasonal influenza A (H1N1) viruses are circulating widely in a community or if the prevalence of oseltamivir-resistant influenza A (H1N1) viruses is uncertain (8). Updated guidance on antiviral use will be available from ACIP before the start of the 2009-10 influenza season. This guidance will include a summary of antiviral resistance data from the 2008-09 influenza season, and will be published separately from the vaccination recommendations. Until the ACIP recommendations for use of antivirals against influenza are published, CDC's previously published recommendations for use of influenza antiviral medications should be consulted for guidance on antiviral use (8). New guidance on clinical management of influenza, including use of antivirals, also is available from the Infectious Diseases Society of America (454).

# Sources of Information Regarding Influenza and its Surveillance
Information regarding influenza surveillance, prevention, detection, and control is available at . During October-May, surveillance information is updated weekly. In addition, periodic updates regarding influenza are published in MMWR (). Additional information regarding influenza vaccine can be obtained by calling 1-800-CDC-INFO (1-800-232-4636). State and local health departments should be consulted about availability of influenza vaccine, access to vaccination programs, information related to state or local influenza activity, reporting of influenza outbreaks and influenza-related pediatric deaths, and advice concerning outbreak control.

# Vaccine Adverse Event Reporting System (VAERS)
Adverse events after influenza vaccination should be reported promptly to VAERS at , even if the reporter is unsure whether vaccine caused the event. Clinically significant adverse events that follow vaccination should be reported to VAERS at . Reports may be filed securely online or by telephone at 1-800-822-7967 to request reporting forms or other assistance.

# national Vaccine Injury Compensation Program
The National Vaccine Injury Compensation Program (VICP), established by the National Childhood Vaccine Injury Act of 1986, as amended, provides a mechanism through which compensation can be paid on behalf of a person determined to have been injured or to have died as a result of receiving a vaccine covered by VICP. The Vaccine Injury Table lists the vaccines covered by VICP and the injuries and conditions (including death) for which compensation might be paid. If the injury or condition is not on the Table, or does not occur within the specified time period on the Table, persons must prove that the vaccine caused the injury or condition.
For a person to be eligible for compensation, the general filing deadlines for injuries require claims to be filed within 3 years after the first symptom of the vaccine injury; for a death, claims must be filed within 2 years of the vaccine-related death and not more than 4 years after the start of the first symptom of the vaccine-related injury from which the death occurred. When a new vaccine is covered by VICP or when a new injury/ condition is added to the Table, claims that do not meet the general filing deadlines must be filed within 2 years from the date the vaccine or injury/condition is added to the Table for injuries or deaths that occurred up to 8 years before the Table change. Persons of all ages who receive a VICP-covered vaccine might be eligible to file a claim. Both the intranasal (LAIV) and injectable (TIV) trivalent influenza vaccines are covered under VICP. Additional information about VICP is available at http//www.hrsa.gov/vaccinecompensation or by calling 1-800-338-2382.

# Additional Information Regarding Influenza Virus Infection Control Among Specific Populations
Each year, ACIP provides general, annually updated information regarding control and prevention of influenza. Other reports related to controlling and preventing influenza among specific populations (e.g., immunocompromised persons, HCP, hospital patients, pregnant women, children, and travelers) also are available in the following publications: CDC.