Hospitals shunned live H1N1 vaccine as pandemic unfolded

'Our primary goal got skewed'

During the early stages of the H1N1 pandemic, the only vaccine available to hospitals was the live attenuated intranasal (LAIV) version, but many shunned LAIV out of an abundance of concern for high-risk patients.

The use of live attenuated vaccines needs to be thoroughly reviewed in the aftermath of the pandemic to determine how to better handle such situations in the future, says Ruth Carrico, PhD, RN, CIC, a veteran IP and assistant professor of health promotion and behavioral sciences at the University of Louisville (KY).

"We had so many people say, 'I don't want a live virus vaccine,'" she says. "And I would say your MMR vaccine's live and varicella's live. We use these a lot, but we don't make a big deal out of it."

Some hospitals may have balked at the higher cost of LAIV, choosing to wait for the distribution of the injectable version. The issue was confounded by a theoretical concern to highest-risk patients that was so broadly interpreted that the proverbial baby was thrown out with the bath water.

"We saw this at an executive level [by people] not really looking at the data," Carrico says. 'We allowed a theoretical problem to have too much influence. They weighed that more heavily than the existing problem, which was that we had H1N1 transmission in our communities. You have to use vaccines to prevent the opportunity for transmission. Our primary goal got skewed."

The Centers for Disease Control and Prevention recommended LAIV for health care providers who are healthy, younger than 50 years old, and not pregnant. However, in doing so the CDC warned against administering LAIV to health care workers caring for severely immunocompromised patients like those in bone marrow transplant units. The concern was that some shedding of the live weakened virus in the first week after immunization could theoretically threaten infection in those with virtually no immune system. However, the CDC emphasized that this concern was very limited in scope, even recommending LAIV in neonatal intensive care units.

"Nearly all healthy, nonpregnant health care workers, including those who come in contact with newborn infants, pregnant women, persons with a solid organ transplant, persons receiving chemotherapy (not in preparation for a bone marrow transplant), and persons with HIV/AIDS, may receive LAIV if otherwise eligible," the CDC stated.

The distinction was too subtle for some hospitals, and as a result health care workers were left unvaccinated until the injectable vaccine was available, Carrico says. "I guess we didn't really have enough experience over the last several years with this live attenuated vaccine to translate what we learned about it into the clinical setting," she says. "We just weren't prepared."

LAIV implementation got lost in translation as hospitals tried to account for various scenarios, she adds. "It came down to being really granular with the recommendations," she says. "We heard, for example, what happens if [bone marrow transplant] patients come through the emergency department? Does that mean that our emergency department staff should not use the live vaccine? How far out do we go in applying this? All we had was live attenuated vaccine — for several weeks and months — but we didn't have a standard way across the U.S. of approaching this. We need to do a better job of figuring out how we are going to introduce LAIV into heath care settings before we have to make an urgent decision."