Updated Influenza vaccine policy by the AAP - any relevance to India?

Highlights of updated AAP policy on influenza

1. Henry H. Bernstein, D.O., M.H.C.M., FAAP

The beginning of autumn reminds us that it is time to prepare for the 2014-’15 influenza season. The Academy’s updated recommendations for the prevention and treatment of influenza in children are available atwww.pediatrics.org/cgi/doi/10.1542/peds.2014-2413and will be published in the November issue of Pediatrics.

The 2013-’14 influenza season was less severe than the 2012-’13 one, with a lower percentage of outpatient visits for influenza-like illness, lower rates of hospitalization, and fewer deaths attributed to pneumonia and influenza. Still, providers must remain vigilant since the influenza virus is unpredictable.

The influenza season may start early in the fall/winter, have more than one disease peak in a community and even extend into late spring. Therefore, as soon as the seasonal influenza vaccine is available locally, health care personnel should be immunized, parents and caregivers should be notified about vaccine availability, and immunization of all children 6 months and older, especially children at high risk of complications from influenza, should begin.

Dr. Bernstein

Following are key messages from the updated policy statement.

THE INFLUENZA VACCINE COMPOSITION IS UNCHANGEDFROM LAST SEASON.

The 2014-’15 influenza vaccine will be available in both trivalent and quadrivalent formulations. (Neither the Centers for Disease Control and Prevention [CDC] nor the Academy has a preference.)

The trivalent vaccine contains the following three virus strains:

• A/California/7/2009 (H1N1)-like virus
• A/Texas/50/2012 (H3N2) virus
• B/Massachusetts/2/2012-like virus (B/Yamagata lineage)

The quadrivalent influenza vaccine includes the same three strains as the trivalent vaccine plus an additional B strain: B/Brisbane/60/2008-like virus (B/Victoria lineage).

ANNUAL UNIVERSAL INFLUENZA IMMUNIZATION IS INDICATED FOR ALL CHILDREN AND ADOLESCENTS 6 MONTHS OF AGE AND OLDER.

Optimal protection is achieved through annual immunization. Antibody titers wane to 50% of their original levels six to 12 months after vaccination. Although the vaccine strains for the 2014-’2015 season are unchanged from last season, a repeat dose this season is critical for maintaining protection in all populations.

Outreach efforts should be made to vaccinate people in the following groups:

• all children 6 months of age and older, especially those with conditions that increase the risk of complications from influenza (e.g., asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression or neurologic and neurodevelopmental disorders);
• children of American Indian/Alaska Native heritage;
• all household contacts and out-of-home care providers of:
  • children with high-risk conditions, and
  • children younger than 5 years, especially infants younger than 6 months;
• all health care personnel;
• all child care providers and staff; and
• all women who are pregnant, are considering pregnancy, are in the postpartum period or are breastfeeding during the influenza season.

WHEN READILY AVAILABLE, LIVE ATTENUATED INFLUENZA VACCINE (LAIV) SHOULD BE CONSIDERED FOR HEALTHY CHILDREN 2 THROUGH 8 YEARS OF AGE WHO HAVE NO CONTRAINDICATIONS OR PRECAUTIONS TO THE INTRANASAL VACCINE.

This consideration is based on a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis done by the CDC, which concluded that there is an increased relative efficacy of LAIV as compared with inactivated influenza vaccine (IIV) against laboratory-confirmed influenza among younger children.

If LAIV is not readily available, IIV should be used; vaccination should not be delayed in order to obtain LAIV.

THE DOSING ALGORITHM FOR CHILDREN 6 MONTHS THROUGH 8 YEARS (BELOW) REFLECTS THAT VIRUS STRAINS IN THE VACCINE HAVE NOT CHANGED FROM LAST SEASON.

• Children 6 months through 8 years of age receiving the seasonal influenza vaccine for the first time should receive a second dose this season at least four weeks after the first dose.
• Children 6 months through 8 years of age need only one dose of vaccine in 2014-’15 if they have received it according to any one of the following scenarios (otherwise they need two doses):
  • At least one dose of 2013-’14 seasonal influenza vaccine.
  • Two or more doses of seasonal vaccine since July 1, 2010.
  • Two or more doses of seasonal influenza vaccine from any prior season and at least one clearly documented dose of a pH1N1-containing vaccine (i.e., any seasonal vaccine since July 1, 2010, or a monovalent pH1N1 vaccine during the 2009-’10 season).

ANTIVIRAL MEDICATIONS CONTINUE TO BE IMPORTANT IN THE CONTROL OF INFLUENZA.

Treatment should be offered for:

• any child hospitalized with presumed influenza or with severe, complicated or progressive illness attributable to influenza, regardless of influenza immunization status or whether onset of illness has been greater than 48 hours prior to admission; and
• influenza infection of any severity in children at high risk of complications of influenza, such as children younger than 2 years.

Treatment should be considered for:

• any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her pediatrician. The greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset but still should be considered if later in the course of illness.

The neuraminidase inhibitors oral oseltamivir and inhaled zanamivir are the only antiviral medications routinely recommended for treatment or chemoprophylaxis of influenza for the 2014-’15 season. Chemoprophylaxis should never be a substitute for immunization.

Given preliminary pharmacokinetic data and limited safety data, oseltamivir can be used to treat influenza in both term and preterm infants from birth as benefits of therapy are likely to outweigh possible risks of treatment. Chemoprophylaxis should be considered only in term infants.

FOOTNOTES

• Dr. Bernstein is Red Book Online associate editor and an ex officio member of the AAP Committee on Infectious Diseases.
• Source

Comments: As far as India is concerned, we are using Influenza vaccine for selected 'high risk' cases. These would include children between 6 months to 2 years ( & possibly up to 5 years), and children with chronic illnesses like diabetes, heart, lung, liver & kidney problems. Since the LAIV (nasal flu vaccine) called Nasovac S has recently become available, it is preferable to use this vaccine in children between 2-8 years age as it is found to be more effective in many western studies.