What is the most appropriate action to prevent influenza complications in a female with cystic fibrosis (CF) playing with another child with CF?

Immediate Separation of Children with Cystic Fibrosis

Children with cystic fibrosis should be immediately separated and should not play together, even with face masks, due to the high risk of cross-transmission of dangerous respiratory pathogens between CF patients. 1

Why Separation is Critical

The question addresses infection control between CF patients, not influenza prevention specifically. While the guidelines extensively discuss influenza vaccination for CF patients, they also address a more fundamental infection control principle:

• Close contacts of immunosuppressed people should not receive live attenuated influenza vaccine (LAIV) because of transmission risk 1
• This principle reflects broader concerns about pathogen transmission between vulnerable individuals
• CF patients are at elevated risk for complications from respiratory infections and carry unique bacterial pathogens (particularly Pseudomonas aeruginosa and Burkholderia cepacia complex) that can be devastating when transmitted between CF patients 1

The Influenza Vaccination Component

While separation is the primary answer, influenza vaccination remains critically important for CF patients:

• All children with CF should receive annual influenza vaccination with inactivated influenza vaccine (IIV), as they have chronic pulmonary disease placing them at high risk for influenza complications 1
• Influenza infection causes severe deterioration in lung function and increases hospitalization rates in CF patients 2, 3
• Vaccination rates among CF patients are appropriately high (87-91%) reflecting the importance of this intervention 4
• LAIV is contraindicated in CF patients due to their chronic pulmonary disease 1

Why Face Masks Are Insufficient

Face masks alone do not adequately protect CF patients from cross-infection:

• CF patients can transmit respiratory pathogens to each other through respiratory droplets and environmental contamination
• The risk involves not just influenza but multiple bacterial and viral pathogens
• Standard infection control in CF care emphasizes segregation of CF patients from one another in clinical settings

Clinical Algorithm

When encountering CF patients in proximity:

1. Immediately separate the children to different areas
2. Verify influenza vaccination status for both children and ensure they receive annual IIV (not LAIV) 1
3. Educate families about the importance of avoiding contact between CF patients
4. Ensure both children have ≥4 clinic visits annually, as this is associated with better vaccination compliance 4

Common Pitfalls

• Assuming masks provide adequate protection between CF patients—they do not address the full spectrum of cross-infection risk
• Focusing solely on influenza when the broader concern is transmission of CF-specific pathogens
• Delaying separation while arranging other interventions—separation should be immediate