What are the contraindications for the FluMist (influenza live attenuated) vaccine?

Contraindications for FluMist Vaccine

FluMist (live attenuated influenza vaccine) is contraindicated in individuals with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine, those with concomitant aspirin or salicylate-containing therapy in children and adolescents, and persons who are immunosuppressed. 1

Absolute Contraindications

• Severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine or to a previous dose of any influenza vaccine 1
• Concomitant aspirin- or salicylate-containing therapy in children and adolescents due to the potential risk of Reye's syndrome 1
• Immunosuppression due to any cause, including:
  • Primary or acquired immunodeficiency, including HIV 1
  • Immunosuppressive or immunomodulatory therapy 1
  • Close contacts or caregivers of severely immunocompromised individuals 1
• Cochlear implants 1
• Children aged 2-4 years with a diagnosis of asthma or whose parents or caregivers report that a health care provider has told them during the preceding 12 months that their child had wheezing or asthma, or whose medical record indicates a wheezing episode has occurred during the preceding 12 months 1
• Receiving or recently received influenza antiviral medications within 48 hours (oseltamivir, zanamivir), 5 days (peramivir), or 17 days (baloxavir) 1

Precautions (Use with Caution)

• Moderate to severe acute illness with or without fever, including COVID-19 1
• Age 2-4 years with diagnosis of asthma or history of wheezing in last 12 months 1
• Active cerebrospinal fluid leaks 1
• Anatomic or functional asplenia 1
• Pregnancy (though not a labeled contraindication per recent guidelines) 1
• Asthma in persons aged ≥5 years 1
• Other underlying medical conditions that might predispose to complications after wild-type influenza infection (e.g., chronic pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic, or metabolic disorders including diabetes mellitus) 1
• Nasal congestion that could impede vaccine delivery (consider deferring until resolution or using an alternative injectable vaccine) 1

Special Considerations

• Egg allergy: While FluMist is an egg-based vaccine, current guidelines state that persons with a history of egg allergy may receive any licensed, recommended influenza vaccine that is otherwise appropriate for their age and health status 1
• History of Guillain-Barré syndrome (GBS) within 6 weeks of receipt of a previous dose of influenza vaccine is considered a precaution for all influenza vaccines 1

Clinical Decision Making

When considering FluMist administration:

1. Screen for absolute contraindications first - if any are present, use an alternative injectable influenza vaccine instead 1
2. Evaluate precautions - weigh benefits versus risks based on individual patient factors 1
3. For patients with egg allergy:
   • Those with reactions limited to hives can receive any age-appropriate influenza vaccine 1
   • Those with more severe reactions (angioedema, respiratory distress, lightheadedness, or recurrent emesis) should be vaccinated in a medical setting under supervision of a healthcare provider able to recognize and manage severe allergic reactions 1

Common Pitfalls to Avoid

• Don't confuse contraindications with precautions - contraindications mean the vaccine should not be given, while precautions require clinical judgment 1
• Don't withhold vaccination unnecessarily from those with minor acute illness or low-grade fever 1
• Don't administer FluMist to children aged 2-4 years with a history of wheezing - this is a contraindication, not just a precaution 1
• Don't administer FluMist to immunocompromised individuals or their close contacts who require a protected environment 1

Remember that for patients with contraindications to FluMist, alternative influenza vaccines (inactivated or recombinant) may still be appropriate and should be considered to ensure protection against influenza 1.