The Case for Flu VaccinationThe Case for Flu Vaccinationin the Pediatric Populationin the Pediatric Population

James C. Wiley, M.D., F.A.A.P.James C. Wiley, M.D., F.A.A.P.

Vice President, Alabama Chapter of theVice President, Alabama Chapter of theAmerican Academy of PediatricsAmerican Academy of Pediatrics

Epidemiology of InfluenzaEpidemiology of Influenza

1,200 deaths annually1,200 deaths annually114,000 hospitalizations114,000 hospitalizations

annuallyannually77thth leading cause of death inleading cause of death in

the USthe US88thth leading cause of death inleading cause of death in

Alabama (2003)Alabama (2003)Season typically DecemberSeason typically December

through March but maythrough March but mayextend from October toextend from October toMay, especially in theMay, especially in theSouthSouth

Timing is EverythingTiming is Everything

•• TIV (shot, killed) typicallyTIV (shot, killed) typicallyavailable early Octoberavailable early October

•• LAIV (nose spray, live)LAIV (nose spray, live)can be given earlier, i.e.can be given earlier, i.e.during backduring back--toto--schoolschoolcheck ups during thecheck ups during thesummersummer

•• Takes 2 weeks to beTakes 2 weeks to beprotectiveprotective

•• If vaccine naIf vaccine naïïve, dosesve, dosesmust be given 4 weeks ormust be given 4 weeks or6 weeks apart for TIV6 weeks apart for TIVand LAIV, respectivelyand LAIV, respectively

Why Immunize All Kids?Why Immunize All Kids?

•• To keep them healthyTo keep them healthy

•• To avoid missed school, parentTo avoid missed school, parent’’s works work

•• To prevent outpatient visits, hospitalizations andTo prevent outpatient visits, hospitalizations anddeathsdeaths

Pediatric Hospitalization RatesPediatric Hospitalization Rates

•• 108 hospitalizations108 hospitalizationsper 100,000 patientper 100,000 patientyears in childrenyears in childrenunder 5 years,under 5 years,similar for othersimilar for otherhighhigh--risk groupsrisk groupsincluding those overincluding those overthe age of 65the age of 65

Hospitalization rates last fourHospitalization rates last fourseasons in children under 4 yearsseasons in children under 4 years

Influenza Deaths In ChildrenInfluenza Deaths In Children

•• Fortunately rare in children <5 yearsFortunately rare in children <5 years

•• 92 per year on average in the 1990s92 per year on average in the 1990s

•• .4 per 100,000 people.4 per 100,000 people

•• Represent a substantial proportion ofRepresent a substantial proportion ofvaccinevaccine--preventable deathspreventable deaths

•• NotNot predicted by risk factorspredicted by risk factors

153 lab153 lab--confirmed influenza deathsconfirmed influenza deathsreported to the CDC in 2003reported to the CDC in 2003--20042004

•• 96 (63%) were under 5 years96 (63%) were under 5 years

•• 61 (40%) were under 2 years61 (40%) were under 2 years

•• 100 (67%) didn100 (67%) didn’’t have an underlyingt have an underlyinghealth condition that would have led tohealth condition that would have led toimmunization under the CDC ACIPimmunization under the CDC ACIPrecommendations at the timerecommendations at the time

Effectiveness of the Flu VaccineEffectiveness of the Flu Vaccine

•• Varies because of drift/vaccine mismatchVaries because of drift/vaccine mismatch

•• Varies according to outcome measuredVaries according to outcome measured

•• Varies by age groupVaries by age group

•• Varies by health status of the patientVaries by health status of the patient

•• Varies by the choice of vaccineVaries by the choice of vaccine

•• Varies by the timing of vaccine and theVaries by the timing of vaccine and thenumber of vaccines givennumber of vaccines given

Effectiveness of the Flu VaccineEffectiveness of the Flu Vaccine

•• Similar to other vaccinesSimilar to other vaccines

•• When first immunized children who get twoWhen first immunized children who get twodoses four weeks apart have equal protection todoses four weeks apart have equal protection topreviously immunizedpreviously immunized

•• Depending on age, outcome, drift and vaccineDepending on age, outcome, drift and vaccinegiven, effectiveness is between 50 and 90% atgiven, effectiveness is between 50 and 90% atpreventing clinically significant diseasepreventing clinically significant disease

•• Secondary outcomesSecondary outcomes-- decrease in complicationsdecrease in complications--pneumonia, asthma exacerbations and AOMpneumonia, asthma exacerbations and AOM

Immunize KidsImmunize Kids--Protect theProtect theCommunityCommunity

•• Several studies haveSeveral studies havedemonstrated thatdemonstrated thatvaccination of childrenvaccination of childrendecreases influenzadecreases influenzadisease burden in highdisease burden in high--risk populations.risk populations.

•• Studies suggest that thisStudies suggest that thismay be a better publicmay be a better publichealth strategy thanhealth strategy thantargeting the elderly.targeting the elderly.

Reichert TA et al. N Engl J Med. 2001;344:889-896.

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Ok, letOk, let’’s vaccinate. Whichs vaccinate. Whichvaccine?vaccine?

•• One thing is on the mind of all of ourOne thing is on the mind of all of ourpatientspatients in pediatricsin pediatrics……

““Can I get the kind thatCan I get the kind that’’s not as not ashot?shot?””

LAIV has come a longLAIV has come a longwayway……but still hasbut still haslimitationslimitations

LAIV Limitations in ChildrenLAIV Limitations in Children

•• Not indicated under 2 years due toNot indicated under 2 years due toincrease in hospitalizations for wheezingincrease in hospitalizations for wheezing

•• Not indicated in kids with asthma orNot indicated in kids with asthma orrecurrent wheezing because of increasedrecurrent wheezing because of increasedrisk of wheezing/hospitalizationrisk of wheezing/hospitalization

Improvements in LAIVImprovements in LAIV

•• Price is down but still higher than TIVPrice is down but still higher than TIV

•• Fridge not freezerFridge not freezer

•• Lower volume of vaccine to squirt up theLower volume of vaccine to squirt up thechildchild’’s nose (.2 mls nose (.2 ml vsvs 2ml)2ml)

•• Age indication is now down to 2 yearsAge indication is now down to 2 years

Advantages of LAIV over TIVAdvantages of LAIV over TIV

•• More effective,More effective,especially in years ofespecially in years ofvaccine mismatchvaccine mismatch

•• Likely involves moreLikely involves moreof the immune systemof the immune systemin defensein defense-- i.e.i.e.secretorysecretory immunityimmunity

•• ItIt’’s NOT a SHOTs NOT a SHOT

Primary Change In FluPrimary Change In FluVaccine RecommendationsVaccine Recommendations

The 2008 ACIP recommendationsThe 2008 ACIP recommendationsinclude a big changeinclude a big change

New RecommendationsNew Recommendations

•• These recommendations were presentedThese recommendations were presentedto the full ACIP and approved in Februaryto the full ACIP and approved in February2008. Modifications were made to the2008. Modifications were made to theACIP statement during the subsequentACIP statement during the subsequentreview process at CDC to update andreview process at CDC to update andclarify wording in the document. Dataclarify wording in the document. Datapresented in this report were current as ofpresented in this report were current as ofJuly 1, 2008. Further updates, if needed,July 1, 2008. Further updates, if needed,will be posted at CDC's influenza websitewill be posted at CDC's influenza website((http://http://www.cdc.govwww.cdc.gov/flu/flu).).

All children should get a fluAll children should get a fluimmunizationimmunization

•• Beginning with theBeginning with the 20082008--0909 influenzainfluenzaseason, annual vaccination of all childrenseason, annual vaccination of all childrenaged 5aged 5--18 years is recommended. Annual18 years is recommended. Annualvaccination of all children aged 5vaccination of all children aged 5--18 years18 yearsshouldshould begin in Septemberbegin in September or as soon asor as soon asvaccine is available for the 2008vaccine is available for the 2008--09 influenza09 influenzaseason, if feasible, but annual vaccination ofseason, if feasible, but annual vaccination ofall children aged 5all children aged 5--18 years should begin no18 years should begin nolater than during the 2009later than during the 2009--10 influenza10 influenzaseason.season.

DonDon’’t forget the higher riskt forget the higher riskgroupsgroups

Annual vaccination of all children aged 6Annual vaccination of all children aged 6monthsmonths--4 years (59 months) and older children4 years (59 months) and older childrenwith conditions that place them at increased riskwith conditions that place them at increased riskfor complications from influenza should continue.for complications from influenza should continue.Children and adolescents at high risk forChildren and adolescents at high risk forinfluenza complications should continue to be ainfluenza complications should continue to be afocus of vaccination efforts as providers andfocus of vaccination efforts as providers andprograms transition toprograms transition to routinely vaccinatingroutinely vaccinatingall children.all children.

Current RecommendationsCurrent Recommendationson Who Gets Whaton Who Gets WhatEither TIV or LAIV can be used when vaccinating healthy peopleEither TIV or LAIV can be used when vaccinating healthy peopleages 2ages 2--49 years. Children ages 6 months49 years. Children ages 6 months--8 years should receive8 years should receive2 doses of vaccine if they have not been vaccinated previously2 doses of vaccine if they have not been vaccinated previouslyat any time with either LAIV or TIV (doses separated byat any time with either LAIV or TIV (doses separated by >>44weeks); 2 doses are required for protection in these children.weeks); 2 doses are required for protection in these children.Children ages 6 monthsChildren ages 6 months----8 years who received only 1 dose in8 years who received only 1 dose intheir first year of vaccination should receive 2 doses thetheir first year of vaccination should receive 2 doses thefollowing year. LAIV should not be administered to childrenfollowing year. LAIV should not be administered to childrenages <5 years with possible reactive airways disease, such asages <5 years with possible reactive airways disease, such asthose who have had recurrent wheezing or a recent wheezingthose who have had recurrent wheezing or a recent wheezingepisode. Children with possible reactive airways disease, peopleepisode. Children with possible reactive airways disease, peopleat higher risk for influenza complications because of underlyingat higher risk for influenza complications because of underlyingmedical conditions, children ages 6medical conditions, children ages 6----23 months, and people23 months, and peopleages >49 years should receive TIV.ages >49 years should receive TIV.

Summary of CurrentSummary of CurrentRecommendationsRecommendations

•• All children 6 months to 18 years should beAll children 6 months to 18 years should beimmunized against influenzaimmunized against influenza-- goal is to have thisgoal is to have thisdone in the 2008done in the 2008--2009 season, meaning starting2009 season, meaning startingnownow

•• 2 doses of vaccine for children who haven2 doses of vaccine for children who haven’’t beent beenvaccinated previously or if they only got onevaccinated previously or if they only got onedose in the first year of immunizationdose in the first year of immunization

•• Priority for highPriority for high--risk groups including children 6risk groups including children 6months to 59 months and those with chronicmonths to 59 months and those with chronicdisease such as asthma, diabetes anddisease such as asthma, diabetes andneurological disease that will increase the risk ofneurological disease that will increase the risk ofinfluenza and its complications.influenza and its complications.

Practical Bedside ExperiencePractical Bedside Experience

•• Parents who are told that their insuranceParents who are told that their insurancemay covermay cover the flu vaccine tend tothe flu vaccine tend to WAITWAIT

•• Parents who are told that their insuranceParents who are told that their insurancecoverscovers the flu vaccine universallythe flu vaccine universally WANTWANT

Barriers to ProtectionBarriers to Protection

•• Vaccine has to be ordered in the spring for fallVaccine has to be ordered in the spring for falladministration. Providers need to know theadministration. Providers need to know thecommitment of insurers to pay for the vaccinecommitment of insurers to pay for the vaccinemonths in advance to avoid the expense ofmonths in advance to avoid the expense ofunused vaccine.unused vaccine.

•• Not having a uniform benefit for this universallyNot having a uniform benefit for this universallyneeded vaccine creates uncertainty amongneeded vaccine creates uncertainty amongproviders and parents that leads to decreasedproviders and parents that leads to decreasedimmunization rates.immunization rates.

SummarySummary

•• CDC now recommends flu vaccine forCDC now recommends flu vaccine for allallchildrenchildren

•• Flu vaccine is similar to other vaccines inFlu vaccine is similar to other vaccines ineffectivenesseffectiveness

•• 2 doses of vaccine are needed in children2 doses of vaccine are needed in childrenunder eight who are being vaccinated forunder eight who are being vaccinated forthe first timethe first time

•• LAIV has advantages over TIV but alsoLAIV has advantages over TIV but alsohas limitationshas limitations

SummarySummary

•• Providers need to preorder vaccine in theProviders need to preorder vaccine in thespring for administration in the fallspring for administration in the fall