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To the editor: We greatly appreciate the editorial by Penttinen and Friede summarising the data regarding recent observations in the United States (US) of decreased effectiveness of the influenza A(H1N1)pdm09 strains (A/California/7/2009 and A/Bolivia/559/2013) included in live attenuated influenza vaccines (LAIV) [1]. Multiple hypotheses have been suggested as potential explanations for the reduced effectiveness compared with inactivated influenza vaccines (IIV). The most frequently cited hypotheses include poor replicative fitness of the A(H1N1)pdm09 LAIV strains, vaccine–virus interference in the quadrivalent formulation, reduced LAIV replication due to preexisting anti-influenza immunity from prior influenza vaccinations, and poor thermostability of A(H1N1)pdm09 LAIV strains. We have systematically evaluated each of these hypotheses and would like to share our assessments in case they might benefit ongoing international scientific discussions regarding LAIV effectiveness.

Letter to the editor: Potential causes of the decreased effectiveness of the influenza A(H1N1)pdm09 strain in live attenuated influenza vaccines