(Influenza - Continued)

High-Risk Persons 18 Years of Age and Older

Bivalent A Vaccine: One dose of bivalent A influenza vaccine containing 200 CCA units of A/New Jersey/76 (swine influenza virus) and 200 CCA units of A/Victoria/ 75 should be given. (As noted, if additional field trials show sufficient benefit from a second dose for persons 18-24 years old, it will be recommended.)

Monovalent B Vaccine: One dose of monovalent B influenza vaccine containing 500 CCA units of B/Hong Kong/ 72 should be given. This vaccine will be available only through commercial sources. It can be given at the same time as the bivalent A vaccine or at another time. If given concurrently, slightly enhanced side effects might be observed. In vaccinating an adult who has previously experienced significant side effects from influenza vaccines, it would be prudent to give the 2 vaccines separately, preferably with the bivalent A vaccine's being given a few days or a week or more before the monovalent B vaccine. General Population 18 Years of Age or Older

Monovalent A Vaccine: One dose of monovalent A influenza vaccine containing 200 CCA units of A/New Jersey/ 76 (swine influenza virus) should be given. (As noted, if additional field trials show sufficient benefit from a second dose for persons 18-24 years old, it will be recommended.) General Population 17 Years of Age or Younger

Monovalent A Vaccine: Recommendations will be made based on results of studies now underway. Precautions

Before being vaccinated, persons known to be hypersensitive to egg protein should be given a skin test or other allergy-evaluating test using the swine influenza vaccine as the antigen. Persons with adverse reactions to such testing should not be vaccinated.

Persons with acute febrile illnesses should not be vaccinated until they have recovered.

SIDE EFFECTS AND REACTIONS, GENERAL ASPECTS Side effects of influenza vaccine are generally inconsequential and occur at low frequency. Severe reactions are uncommon, and truly disabling effects appear to be exceedingly rare. Three types of responses to influenza vaccines have been described:

1. Fever, malaise, myalgia, and other systemic symptoms of toxicity occurring 6-12 hours after vaccination and persisting 1-2 days. These responses to influenza vaccine are usually attributed to characteristics of the influenza virus itself (even though it is inactivated in available vaccines) and represent the bulk of the side effects of influenza vaccination. Such effects occur most frequently in children and in others who have had no previous experience with influenza viruses comparable to the vaccine antigen(s).

Epidemiologic Notes and Reports

2. Immediate, presumably allergic, responses, such as flare and wheal or various respiratory expressions of hypersensitivity. These reactions are exceedingly uncommon but can occur after influenza vaccination. They probably derive from exquisite sensitivity to some vaccine component, most likely to residual egg protein. Although current influenza vaccines contain only a minute quantity of egg protein, they do, on rare occasions, provoke hypersensitivity reactions.

3. Neurologic disorders, including such central nervous system conditions as encephalopathy, with at least temporal association with influenza vaccination. A survey of the medical literature since the early 1950s revealed only about a dozen such reports. Almost all persons affected were adults, and the described clinical reactions began as soon as a few hours and as late as 2 weeks after vaccination. Full recovery was almost always reported. Three fatalities have been reported in temporal association with influenza vaccination. However, in 2 instances, the patients displayed clinical characteristics and had antecedents which strongly suggested causes other than influenza vaccine, and the third was equally compatible with another viral disease.

In summary, influenza vaccine has only rarely, if ever, been associated with severe adverse reactions or permanent disability. Although vaccination relatively frequently causes transient redness and tenderness at the injection site and sometimes causes such systemic reactions as low-grade fever, malaise, and myalgia for 1-2 days, influenza vaccine is considered to be very safe and is quite suitable for widescale, community use.

PREGNANCY

Elevated rates of maternal and fetal mortality and of congenital anomalies and other fetal effects resulting from influenza infection during pregnancy have been widely discussed. Numerous reports during the 1918-19 influenza pandemic and a limited number of small but better controlled studies in 1957-58, when the Asian influenza pandemic occurred, suggest that influenza can result in increased maternal deaths and fetal wastage. However, a number of prospective studies in the past decade or more have failed to corroborate this association. Although there are no persuasive data to document that pregnancy is a risk-factor with influenza, the effect of swine influenza in pregnancy cannot be forecast with assurance.

Physicians generally avoid prescribing unnecessary drugs and biologics for pregnant women, especially in the first trimester; however, there are no data specifically to contraindicate vaccination with the available killed virus vaccine in pregnancy. Women who are pregnant should be considered as having essentially the same balance of benefits and risks regarding influenza vaccination and influenza as the general population.

Thirteen Mississippi Forestry Commission workers developed sporotrichosis in the period December 1975February 1976. Although sporotrichosis is an occupational hazard of forestry workers, these were the first cases reported to the Commission. Further investigation revealed another 4 cases of sporotrichosis which occurred among -non-Forestry Commission workers who planted pine seedlings supplied by the Mississippi Forestry Commission.

Ten of the 13 forestry workers had typical lesions on the hand and arm. The lesions began with an indolent ulcer followed by the development of subcutaneous nodules with overlying erythema along the channels of lymphatic drainage. Two workers had a solitary lesion with no satellite nodules. One person had multiple verrucous appearing lesions on the thumb and forefinger. Laboratory tests workers-cultures, fluorescent antibody tests, and

Eleven of the 13 workers had planted pine seedlings supplied by a nursery in Mt. Olive, Mississippi, 1 of the 3 Mississippi Forestry Commission nurseries. One of the other 2 men worked at the Mt. Olive nursery. The attack rate was significantly greater (P<.05) among workers in Forestry Commission districts which received pine seedlings from the Mt. Olive nursery than among workers in other districts (Table 2). Further investigation revealed the 4 additional cases among non-Forestry Commission workers; all 4 had handled pine seedlings supplied by the Mississippi Forestry Commission; 3 worked with seedlings from the Mt. Olive nursery.

Pine seedlings are harvested after the first frost, packed in bundles of 1,000, and distributed to forestry district offices, to private individuals, or to private businesses. Sphagnum moss is packed around the seedling roots to provide a moist environment. At the planting site the bundles are opened, and the seedlings separated from the moss. Sporothrix schenckii was cultured from samples of sphagnum

moss remaining at the Mt. Olive nursery and from moss at the planting sites of nursery seedlings. S. schenckii was not cultured from samples of sphagnum moss from the other 2 Mississippi Forestry Commission nurseries. The Mt. Olive nursery stored the sphagnum moss outside, while the other 2 nurseries stored the moss in buildings. Mississippi nurseries received sphagnum moss in June and July 1975 from a single supplier in Wisconsin.

Reported by A Taylor, Mississippi Forestry Commission; D Blakey, MD, State Epidemiologist, B Phillips, DPH, Mississippi State Board of Health; Fungus Immunology Br, Mycology Div, Bur of Laboratories; and Field Services Div, Bur of Epidemiology, CDC.

Editorial Note: Sporotrichosis is a subcutaneous mycotic disease of man and lower animals found in all parts of the world. It is caused by Sporothrix schenckii, a fungus which occurs naturally in soil and on vegetation. The majority of infections are contracted through a traumatic incident that introduces fungal elements into the resulting wound. The infections among the Mississippi workers resulted from their contact with the S. schenckii infested moss. At least 3 previous outbreaks of sporotrichosis among forestry workers have been traced to sphagnum moss from Wisconsin (1,2). There are no established methods for eradicating S. schenckii from contaminated moss.

References

1. Crevasse L, Ellner PD: Outbreak of sporotrichosis in Florida. JAMA 173:29-33, 1960

2. D'Alessio DJ, Leavens LJ, Strumpf GB, Smith CD: An outbreak of sporotrichosis in vermin associated with sphagnum moss as the source of infection. New Engl J Med 272:1054-1058, 1965

POSTAGE AND FEES PAID U.S. DEPARTMENT OF HEW HEW 399

HEW Publication No. (CDC) 76-8017

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