Sticking It to the Kids

Physicians Urged to Ensure All Children Get Flu Shots  

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Public Health Feature -- November 2003  

By  Ken Ortolon
Senior Editor  

During last winter's flu season, some 90 school districts in 68 Texas counties canceled classes because influenza B was sweeping through the student body. Public health officials say absentee rates due to flu on some campuses hit as high as 25 percent. This year, they hope to avoid school closings and spare both children and adults across Texas from getting the flu with new recommendations that all children should be vaccinated against influenza.

Both the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) have changed their recommendations for flu vaccines this season and are recommending that a broader range of children be immunized. And AAP says universal immunization of all children should be the goal for the future.

"By immunizing kids from the flu we're going to decrease school absences as well as the spread of influenza to other people in the community," said San Angelo pediatrician Jane Rider, MD.

In recent years, mass immunization of children would have been impossible because of problems with the production and distribution of flu vaccine. But officials say there will be an adequate supply of vaccine for everyone this year. They strongly encourage pediatricians and family practitioners to immunize their pediatric patients.           

Focusing on the Very Young  

ACIP and AAP recommend that all children between ages 6 and 23 months be immunized against influenza this year. They also recommend that all close household contacts, including older children and adults, and out-of-home caregivers of children under age 2 years be immunized, as well. The previous recommendation was that only high-risk children -- such as those with asthma, suppressed immune systems, diabetes, or cardiac problems -- be given the vaccine. That recommendation, at least in part, was based on vaccine shortages in the past three years that required physicians and public health officials to give priority to high-risk children, the elderly, and others who faced the greatest chance of illness and death.

In a policy statement issued in December 2002, AAP concluded, "epidemiologic studies indicate that children with certain chronic conditions, such as asthma, and otherwise healthy children younger than 24 months are hospitalized for influenza and its complications at high rates similar to those experienced by the elderly. Currently, annual influenza immunization is recommended for all children 6 months and older with high-risk conditions. To protect these children more fully against the complications of influenza, increased efforts are needed to identify and recall high-risk children for annual influenza immunization. In addition, immunization of children 6 through 23 months of age and their household contacts and out-of-home caregivers is now encouraged to the extent feasible. The ultimate goal is a universal recommendation for influenza immunization."

Neil Pascoe, RN, an epidemiologist with the Infectious Disease Division of the Texas Department of Health (TDH), says his agency "heartily endorses" the new influenza immunization recommendations. He adds that research has shown that, while children may be at a lesser risk of death from the flu than the elderly, they actually may be at greater risk of hospitalization.

"There are specific populations among children that have higher morbidity rates that lead to hospitalization and sequelae, particularly in that youngest population under the age of 1," he said.

In fact, National Foundation for Infectious Diseases research concluded that the rate of annual influenza-related hospitalization among high-risk children under age 1 year was 1,900 per 100,000. The rate among children between ages 1 and 2 years was 800 per 100,000. That compares with a rate of 228 per 100,000 among persons aged 65 and older.

Not only will immunization of children prevent illness and hospitalization within that age group, it also will protect other groups from getting sick, Mr. Pascoe says.

"We know that children are the vectors of influenza and lots of other conditions," he said. "If we look at last year's influenza B season, it was an unprecedented bad season for children, especially in that school age group 5 to 14." That, he says, led to "overwhelming absences, school closures, parents missing work," and the spread of influenza to siblings, parents, and elderly family members.

Mr. Pascoe says evidence from influenza vaccination practices in Japan in the 1980s and 1990s shows that immunizing children can actually reduce mortality from the flu among the elderly. "For years they vaccinated their pediatric population, and it was actually lowering mortality in their elderly population," he said. "They stopped doing that for a period of time and the mortality rates went up and, of course, the morbidity rates went up."

Getting Them in the Door  

While Texas pediatricians support vaccinating children, some physicians have suggested it will be a logistical nightmare to get all their pediatric patients immunized during this flu season. Kenneth Matthews, MD, president of the Texas Pediatric Society, says pediatricians and family physicians need not try to call in every child this winter. Instead, physicians need to make sure they immunize their high-risk patients and take the opportunity to immunize other children when they are in the office for other reasons. (See " Strategies for Vaccinating Children .")

"The only kids we'll be calling in are the high-risk children -- the children with asthma, the children with immune suppression, the children with cardiac disease," Dr. Matthews said. "But when other kids come in for a well check or for a minor illness, then it can be offered to them, as well."

Dr. Rider plans to take the same approach. It likely will take several years to "ramp up" universal immunization, but physicians need to be familiar with the new recommendations and begin putting them into practice, she says.

Physicians also should be aware that the ACIP recommendations call for children under age 9 years to get two doses of the flu vaccine administered at least 28 days apart.

While many physicians planned to begin offering the vaccine in October and November, state health officials say it can be given throughout the flu season. And, Lisa Davis with the TDH Immunization Division says the Texas Vaccines for Children (VFC) program will supply the flu vaccine for VFC-eligible children. (See " Flu Vaccine Eligibility .") "We're following the ACIP-recommended age groups for children," Ms. Davis said.      

John Hellerstedt, MD, medical director for the Medicaid/CHIP Division of the Texas Health and Human Services Commission, says Medicaid will pay for flu vaccines for children not eligible through VFC. However, he urges physicians to access the vaccine through the VFC program whenever possible.

"If it's medically necessary to give the child the influenza vaccine and it's not covered by Vaccines for Children, then Medicaid will pay for it," he said. Medical necessity will be left up to the judgment of the physician, he adds. "We believe the research that shows you actually save money for everybody you vaccinate, so we want to make it as widely available as possible."

Regardless of who picks up the tab for flu vaccines, Dr. Matthew says Texas physicians need to offer it to as many children as possible.

"This recommendation is not mandatory, but it should be strongly considered," he said. "This is the first year that the flu vaccine has been recommended for all children. The vaccine is available, it's a safe vaccine, it's efficacious, and if we can reduce the incidence of influenza in young children who are the purveyors to the adult population, then maybe we can effect the herd immunity that will help prevent us from having a bad flu season."

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by e-mail at Ken Ortolon.  


Strategies for Vaccinating Children

The National Foundation for Infectious Diseases (NFID) recommends that physicians use the following strategies to increase influenza immunization rates among children:

  • Reminder and recall notices, such as computerized models, autodialers, reminders during well and sick child visits, and the like.
  • Practice assessment. "What providers believe is happening in their practices rarely matches reality once charts are examined carefully," NFID said. "One simple way to assess progress over time is to chart the number of influenza vaccine doses administered each year."
  • Use of standing orders.
  • Establishment of influenza clinics. "Setting aside specific hours within the practice for effectively managed clinics can result not only in increased rates of vaccination but decreased costs of administration," NFID said.
  • Mass influenza immunization programs at clinics and large practices.
  • Use of in-office parent education and parent take-home materials that will help them understand the importance of pediatric flu immunization.
  • Use of educational methods and materials to educate office staff on the importance of the influenza vaccine and the need to inform parents at every opportunity. Office staff also should be immunized.

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Flu Vaccine Eligibility

The Texas Vaccines for Children (VFC) program will provide vaccines for eligible children who fall within the following groups:

  • Children aged 6 months through 23 months.
  • Children and adolescents aged 6 months through 18 years with chronic disorders of the pulmonary or cardiovascular systems, including asthma.
  • Children and adolescents aged 6 months through 18 years who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases.
  • Children and adolescents aged 6 months through 18 years who are receiving long-term aspirin therapy and therefore may be at risk for developing Reye syndrome after influenza.
  • Children and adolescents aged 2 years through 18 years who are household contacts of persons in high-risk groups, such as persons aged 65 years or older, transplant recipients, persons with AIDS, and children under age 2 years.
  • Children and adolescents aged 6 months through 18 years in nursing homes and other chronic-care facilities that house persons at any age who have chronic medical conditions.
  • Adolescent females under age 19 who will be in the second or third trimester of pregnancy during flu season.

Children who are eligible for VFC vaccine include those children from birth through age 18 years who are eligible for Medicaid, have no health insurance, or are native Americans or Alaska natives. Also included are those whose health insurance does not cover immunizations, and they go to a federally qualified health center or rural health center.

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