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What's the Latest with the Flu?

April 2017

Current Flu Situation
As of April 18, 2017, flu activity has decreased, but remains elevated in the United States. While the virus circulating in the US is on the decline, most states continue to experience widespread influenza activity. With 72 pediatric deaths from influenza reported so far this flu season, even one preventable death is too many.

A new study reporting on the deaths from influenza in children over four flu seasons found that most deaths (74%) occurred in unvaccinated children (ages 6 months through 17 years). From July 2010 through June 2014, 358 laboratory-confirmed influenza-associated pediatric deaths were reported in the US. Among 153 deaths of children with underlying high-risk medical conditions, only 31% had been vaccinated. See the American Academy of Pediatrics (AAP) Pediatrics article, “Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010-2014” for additional details. Therefore, more can be done to protect children against influenza and its complications by encouraging influenza immunization.

Late Season Vaccination
Providers should continue to encourage annual influenza vaccination, and vaccinate children as long as influenza viruses are circulating in communities. This includes infants who were previously too young to get flu vaccine, but now are at least 6 months of age. Children 6 months through 8 years of age need 2 doses if they have received fewer than 2 doses of any trivalent or quadrivalent influenza vaccine before July 1, 2016. The interval between the 2 doses should be at least 4 weeks. This age cohort requires only 1 dose if these children have previously received 2 or more total doses of any trivalent or quadrivalent influenza vaccine before July 1, 2016. The 2 previous doses do not need to have been received during the same influenza season or even in consecutive influenza seasons. See the graphic below, and the AAP policy, “Recommendations for Prevention and Control of Influenza in Children, 2016–2017”, for more information.
The chart above can be accessed here: http://pediatrics.aappublications.org/content/early/2016/09/01/peds.2016-2527

*The 2 doses need not have been received during the same season or consecutive seasons.
†Receipt of LAIV4 in the past is still expected to have primed a child’s immune system, despite recent evidence for poor effectiveness. There currently are no data that suggest otherwise.

It is critically important to encourage vaccination for pregnant women. A May 2016 article in Pediatrics, “Influenza in Infants Born to Women Vaccinated During Pregnancy,” noted that infants 6 months and younger were 70% less likely to get the flu if their mothers got the flu vaccine during pregnancy. It also showed an 80% decrease in flu-related hospitalizations among infants whose mothers were vaccinated during pregnancy.

Ready Wrigley Preparedness for Flu Season
The AAP worked with the Centers for Disease Control and Prevention (CDC) to develop and endorse a new Ready Wrigley Activity Booklet on influenza. Each book aims to build capacity in children’s preparedness by inspiring youth readiness and promoting individual resilience. The books are designed for children 2 through 8 years of age. The Ready Wrigley Activity Book series is produced by the CDC Children’s Preparedness Unit and CDC health communication specialists. The AAP would like to thank the CDC Office of Infectious Diseases for its assistance with the development of this booklet.

CDC Webinar: 2016-2017 Influenza Season Activity and Recommendations for Clinicians
In February 2017, the CDC Clinician Outreach and Communication Activity (COCA) hosted a webinar titled, “2016-2017 Influenza Season Activity and Recommendations for Clinicians.” During this webinar, clinicians learned about 2016-2017 influenza activity to date and heard an overview of CDC and AAP recommendations for health care providers including influenza vaccination and the use of antiviral medications for the treatment of influenza. An archived version of the webinar, a transcript, and presentation materials are available online at no charge.

Request for Volunteers - Pediatric Preparedness Ambassadors
The AAP is in the process of soliciting members with expertise in infectious diseases, child care health and safety, or emergency preparedness, and who are interested in being trained as Pediatric Preparedness Ambassadors. This group of pediatricians will be trained on preparedness approaches that are effective in child care settings. In addition, they will be offered the opportunity to present at conferences and/or connect with child care programs at the community-level. Once the Pediatric Preparedness Ambassadors complete this training, they will be matched with opportunities for direct outreach based on need and high yield impact. If you are interested in this opportunity, please email DisasterReady@aap.org.

Additional Information
For more information, see the AAP Red Book Online Influenza Resource page and CDC FluView. All AAP “What’s the Latest with the Flu” messages are archived. Members of the AAP also have access to Flu Vaccine Recommendations and Key Speaking Points.

Do you have suggestions for future AAP activities specific to influenza prevention and control? If so, e-mail DisasterReady@aap.org.

Past Flu Situation
As of March 7, flu activity was still elevated in the United States and expected to continue for several weeks. The season so far has been moderate. The majority of states reported widespread influenza activity at this time. With 40 pediatric deaths from influenza reported so far this flu season, even one preventable death is too many. Flu-related deaths in children younger than 18 years old should be reported through the Influenza-Associated Pediatric Mortality Surveillance System. The number of flu-associated deaths among children reported during this 2016-2017 flu season will be updated each week and can be found at www.cdc.gov/flu/weekly.

It is important to continue to recommend influenza vaccination. Children 6 months through 8 years of age need 2 doses if they have received fewer than 2 doses of any trivalent or quadrivalent influenza vaccine before July 1, 2016. The interval between the 2 doses should be at least 4 weeks. This age cohort requires only 1 dose if these children have previously received 2 or more total doses of any trivalent or quadrivalent influenza vaccine before July 1, 2016. The 2 previous doses do not need to have been received during the same influenza season or in consecutive influenza seasons. See the American Academy of Pediatrics (AAP) policy, “Recommendations for Prevention and Control of Influenza in Children, 2016–2017”, for more information.

The Centers for Disease Control and Prevention (CDC) released a new Morbidity and Mortality Weekly Report (MMWR) titled, “Update: Influenza Activity — United States, October 2, 2016–February 4, 2017.” The report summarizes U.S. influenza activity for the dates listed.

More Influenza Illness Suggests Need for More Rapid Antiviral Treatment
Children clinically presumed to have influenza should be considered for early antiviral treatment, when indicated, independent of laboratory confirmation or receipt of influenza vaccine. This crucial approach can help minimize morbidity and mortality, particularly in young children, and those who are hospitalized or who have underlying co-morbidities. Antiviral treatment should be started as soon as possible after influenza illness onset and should not be delayed while waiting for a confirmatory test result because early therapy provides the best outcomes.

Treating high risk children or children who are very sick with flu with antiviral drugs is very important. It can mean the difference between having a milder illness instead of a very serious one that could result in a hospital stay. See the AAP policy or visit the CDC Antiviral Drugs Web page for information about how antiviral medications can be used to prevent or treat influenza when influenza activity is present in the community. A summary of antiviral recommendations for clinicians is available on the CDC Web page Influenza Antiviral Medications: Summary for Clinicians.

CDC Webinar: 2016-2017 Influenza Season Activity and Recommendations for Clinicians
On February 16, 2017, the CDC Clinician Outreach and Communication Activity (COCA) hosted a webinar titled “2016-2017 Influenza Season Activity and Recommendations for Clinicians.” During this webinar, clinicians learned about 2016-2017 influenza activity to date and heard an overview of CDC recommendations for health care providers including influenza vaccination and the use of antiviral medications for the treatment of influenza. An archived version of the webinar, a transcript, and presentation materials are available online.

Ready Wrigley Preparedness for Flu Season
The AAP worked with the CDC to develop and endorse a new Ready Wrigley Activity Booklet on influenza. Each book aims to build capacity in children’s preparedness by inspiring youth readiness and promoting individual resilience. The books are designed for children 2 to 8 years of age. The Ready Wrigley Activity Book series is produced by the CDC Children’s Preparedness Unit and CDC communication specialists.

Additional Information
For more information, see the AAP Red Book Online Influenza Resource page and CDC FluView. All AAP “What’s the Latest with the Flu” messages are archived. Members of the AAP also have access to Flu Vaccine Recommendations and Key Speaking Points.

Flu activity is elevated in the US, and is expected to continue to increase at this time of year. So far, influenza A (H3N2) viruses have been most commonly isolated this season. Overall, the viruses identified to be circulating in communities appear to be well matched with the vaccine viruses recommended in this season’s influenza vaccines. Five deaths in children from influenza have been reported this flu season. 

It is important to continue to recommend influenza vaccination to our patients and ensure children 6 months through 8 years, who need two doses to be adequately protected, receive both doses 4 weeks apart. It is especially important to identify and vaccinate infants who turned 6 months old since the beginning of this year’s flu season.

​Importance of Antiviral Medications 
People at high risk of serious flu complications (such as children younger than 5 years of age, adults 65 years of age and older, pregnant women, people with certain medical conditions, and residents of nursing homes and other long-term care facilities) and people who are very sick with flu (such as those hospitalized because of flu) should get antiviral treatment. It should be recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated illness, regardless of previous health or vaccination status. This can help minimize morbidity and mortality. 

Initiation of influenza antiviral treatment should never be delayed while waiting for a confirmatory test result, because early therapy results in the best outcomes. Educating parents about the importance of contacting a health care provider early on if their child has influenza-like symptoms, particularly if either younger than 5 years of age or otherwise at high risk for influenza complications, is a best practice in influenza control. While antiviral medication is not a substitute for influenza immunization, it is important in the control of influenza. For more information, see the Centers for Disease Control and Prevention (CDC) Web site on this topic. 

​Many Strategies Exist to Reach Families 
Informing families about the importance of influenza prevention (eg, vaccine) and control (eg, antiviral medicine) through a variety of messaging strategies can make a real difference. For example, the CDC Public Health Matters Blog outlines steps to protect people from the flu. Pediatricians can share a link to this blog with families and encourage them to take important steps in preparing for whenever flu strikes their community. Also consider sharing the Vaccine Locator. This tool identifies the locations where influenza vaccine is available in a person’s area. Does your practice have a Web site or a social media outlet? If not, consider creating one to easily send updates and reminders throughout the flu season. 

​Additional Information
For more information, see the AAP Red Book Online Influenza Resource page and CDC FluView. All AAP “What’s the Latest with the Flu” messages are archived. Members of the AAP also have access to Flu Vaccine Recommendations and Key Speaking Points.​


December 2016

Current Flu Situation 
Flu activity is increasing in the US. With flu being unpredictable, it's not possible to say when, where, or how quickly flu activity might increase more, how severe it will be, or which viruses will predominate.

​It's critically important to recommend influenza vaccination to your patients who have not yet received it. With family and friends gathering for the holidays, now is a fine time to get the flu vaccine, if you have not already done so. Remind families that it takes about two weeks after vaccination for antibodies to develop in the body that protect against influenza infection. Vaccination is the most valuable step anyone can take to protect themselves and their loved ones against influenza and its complications.

In health care settings, optimal prevention of influenza depends on the timely vaccination of all health care personnel. See the recent American Academy of Pediatrics (AAP) News articles, "What's New for 2016-'17 Influenza Season?" and "Don't Chance It: Annual Flu Shot will Cut Children's Risk of Illness".

​National Influenza Vaccination Week 
National Influenza Vaccination Week (NIVW) is currently underway, taking place December 4-10, 2016. This special week was initiated to continue to encourage vaccination, as vaccine uptake tends to wane this month. While circulation of the influenza viruses is unpredictable, the peak months for influenza illness usually happen in January, February, or March.

Pediatricians are encouraged to join in on the NIVW activities. See the AAP Immunization Campaigns Web page for ways to participate. This Web page includes key points to share with families, flu posters, and resources to share with child care providers.

​New Interactive Map Highlights Child Vaccination Rates Across America 
The AAP has developed an interactive digital map that highlights state immunization rates for vaccine-preventable diseases, as well as state laws regarding vaccine exemptions. The map, available at https://immunizations.aap.org/, includes data on how each state measures up against immunization thresholds that are important to ensure protection for all.

​When a high number of people in a community are vaccinated, it is less likely that a virus will spread, lowering the risk of that disease for the entire community. This "community immunity" threshold varies for each vaccine-preventable disease, which is illustrated in the map.  

The AAP supports increasing immunization rates by raising awareness of the protection vaccines offer not only to the public at large, but for the most vulnerable, such as infants less than 6 months of age who cannot receive the vaccine themselves and children who cannot be vaccinated for medical reasons. The map illustrates that much work remains to increase vaccination rates, particularly to guard against influenza.

CDC Clinician Outreach and Communication Activity Webinar 
In October 2016, the AAP collaborated with the Centers for Disease Control and Prevention (CDC) to conduct a webinar titled "What's New for the 2016-2017 Flu Season: Recommendations for Children". Presenters highlighted critical information specific to the 2016-2017 flu season, and discussed strategies that primary care providers and medical subspecialists could use to improve flu prevention and control in children. The archived version of the webinar, a transcript, and presentation materials/resources can be viewed online.

​AAP Influenza PediaLink Course 
Prevention and Control of Influenza 2016-2017
This four-part, online course series for clinicians provides key information about the 2016-2017 flu season and identifies critical actions for pediatric clinicians to take. The first course reviews this year's recommendations to prevent and treat influenza. The second activity focuses on the importance of vaccination among all health care personnel. The third module highlights that influenza vaccine can routinely be given in the office to everyone, even those with presumed egg allergy. The final course covers rapid influenza diagnostic testing.

Challenging Cases: Vaccine Hesitancy 
Parents often have questions and concerns about vaccines and look to pediatricians and other medical professionals for valued, accurate information. The Challenging Cases: Vaccine Hesitancy PediaLink course provides strategies to promote vaccine uptake in vaccine-hesitant parents, including case studies on infant vaccination and Measles, Mumps, and Rubella (MMR) vaccination.

​Additional Information
For more information, see the AAP Red Book Online Influenza Resource page and CDC FluView. All AAP "What's the Latest with the Flu" messages are archived. Members of the AAP also have access to Flu Vaccine Recommendations and Key Speaking Points.​

​November 2016​

As with each influenza season, the American Academy of Pediatrics (AAP) urges all clinicians to take action to ensure that all children receive the flu vaccine. This year, clinicians can review influenza prevention and control strategies and take steps to educate others. The AAP has worked with the Centers for Disease Control and Prevention (CDC) to produce messaging and resources, including a new letter and handout for health care providers and a Web page for parents that explains why the nasal spray vaccine (Flumist) is not recommended this year.

2016-2017 Flu Season
The AAP and the CDC recommend that all children 6 months and older receive the flu vaccine each year. It is especially important to vaccinate those children and adolescents at increased risk of complications from influenza, including those with chronic medical conditions, such as asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression, or neurologic and neurodevelopmental disorders. Children younger than 5 years of age, but particularly children younger than 2, are also at an increased risk of hospitalization and complications attributable to influenza.​

See the American Academy of Pediatrics (AAP) policy "Recommendations for Prevention and Control of Influenza in Children, 2016-2017" for updated recommendations on the routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. Everyone should only receive the flu SHOT, since the intranasal spray (Flumist) is not recommended this year, which also is explained in the AAP Policy Statement.​

Take Steps to Educate Others​
Families
Sharing messages to families about the seriousness of influenza and the importance of influenza vaccine through a variety of communication vehicles can extend your reach and make a real difference. For example, a new Public Health Matters Blog outlines the importance of getting a flu vaccine. Pediatricians can share a link to this blog with families and encourage them to take important steps to prepare for the flu season. Also, consider sharing the Vaccine Locator, a tool that provides nearby locations in an individual's community where influenza vaccine is available. 

Health Care Personnel
Health care-associated influenza can contribute significantly to patient morbidity and mortality and create a financial burden on health care systems. Optimal prevention of influenza in the health care setting depends on the vaccination of all health care personnel. The CDC recommends that all health care providers get the annual flu vaccine, as only an estimated 79% of health care workers received it last season. The AAP supports a mandatory influenza immunization policy for all health care personnel since flu vaccine coverage rates increase with mandatory programs in comparison with voluntary programs. See the AAP policy, "Influenza Immunization for All Health Care Personnel: Keep It Mandatory", for additional information.

Pregnant Women
Flu is more likely to cause severe illness in pregnant women than in those who are not. Studies show that a confident and routine vaccine recommendation from a health care provider is influential. Pediatricians also play a crucial role in promoting vaccination to help keep women and their newborns healthy. The AAP recommends annual seasonal influenza immunization of all women who are pregnant, are considering pregnancy, are in the postpartum period, or are breastfeeding during the influenza season. Pediatric offices may choose to serve as an alternate venue for providing influenza immunization for parents and other care providers of children. Medical liability issues and medical record documentation requirements need to be considered before a pediatrician begins immunizing adults in the office.

CDC COCA Webinar
On October 27, 2016, the AAP collaborated with CDC to conduct a Clinician Outreach and Communication Activity (COCA) webinar titled, "What's New for the 2016-2017 Flu Season: Recommendations for Children." During this COCA webinar, subject matter experts from the AAP and CDC highlighted critical information and discussed strategies that primary care providers and medical subspecialists could use to improve flu prevention and control in children. The archived version of the webinar, a transcript, and presentation materials/resources are available here. ​

AAP PediaLink Courses
Prevention and Control of Influenza 2016-2017
This four-part, online course series for clinicians provides key information about the 2016-2017 flu season and identifies specific actions for pediatric clinicians to consider. The first course reviews this year's prevention and treatment of influenza recommendations. The second activity focuses on the importance of vaccination among all health care personnel. The third module highlights the latest approach to egg allergy and influenza vaccination. The final course discusses rapid influenza diagnostic testing.

Challenging Cases: Vaccine Hesitancy
Parents often have questions and concerns about vaccines and they look to pediatricians and other medical professionals for answers. The Challenging Cases: Vaccine Hesitancy PediaLink course provides strategies to promote vaccine confidence in vaccine-hesitant parents, including case studies on infant vaccination and Measles, Mumps, and Rubella (MMR) vaccination.

Additional Information
For more information, see the AAP Red Book Online Influenza Resource page and CDC FluView. All AAP "What's the Latest with the Flu" messages will be archived. Members of the AAP also have access to Flu Vaccine Recommendations and Key Speaking Points.


September 2016

The American Academy of Pediatrics (AAP) policy "Recommendations for Prevention and Control of Influenza in Children, 2016-2017" offers updated recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. Important details are highlighted in the AAP News articles "Intranasal Flu MISSED its Target" and "AAP Updates Recommendations for Flu Vaccine in Children". In addition, see the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices" for more information.

Consider taking the following steps to be prepared for the upcoming flu season:

  • Get vaccinated and talk with colleagues about why they should get vaccinated, too.
  • Encourage all of your patients to get vaccinated. Make a special effort to identify those patients at increased risk of complications from influenza and encourage them to get vaccinated.
  • Protect children younger than 6 months of age by immunizing their caregivers and close contacts of those infants to reduce their exposure to influenza.
  • Meet with staff to discuss what worked and improve what didn't work in the office during the last flu season.
  • Train staff on standard precautions, infection control, seasonal influenza, and strategies for communicating the importance of immunization.
  • As a large number of children are enrolled in Head Start or other early education and child care programs throughout the country, partner with these programs to encourage vaccination of all children, staff, and caregivers. Share information about AAP training materials and other resources.

The 2016-2017 vaccines strains have been updated from last season. This year, the trivalent inactivated vaccine includes an A/California/7/2009 (H1N1) pdm09-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus. The quadrivalent vaccine contains an additional B virus (B/Phuket/3073/2013-like virus). There is no preference for any licensed or recommended injectable vaccine over another.

The intranasal live attenuated influenza vaccine (or LAIV4) sold under the trade name "FluMist Quadrivalent" should NOT be used in any setting during the 2016-2017 influenza season in light of the evidence for its poor effectiveness in recent seasons, particularly against influenza A (H1N1) pdm09 viruses.

Some children 6 months through 8 years of age need 2 doses (given 4 weeks apart) of seasonal influenza vaccine if they have received fewer than 2 doses of any trivalent or quadrivalent influenza vaccine (including LAIV) prior to July 1, 2016. The second dose is sometimes missed, so attention to follow-up is needed. See the updated AAP dosing algorithm:


The chart above can be accessed here: http://pediatrics.aappublications.org/content/early/2016/09/01/peds.2016-2527

*The 2 doses need not have been received during the same season or consecutive seasons.

†Receipt of LAIV4 in the past is still expected to have primed a child's immune system, despite recent evidence for poor effectiveness. There currently are no data that suggest otherwise.

Optimal protection is achieved through annual immunization. The AAP and CDC recommend annual seasonal influenza vaccine for all people 6 months and older. Not everyone understands the importance of annual immunization, so it is valuable for you, as a clinician, to explain why getting a flu vaccine is crucial.

Guidelines for giving flu vaccine to presumed egg allergic children have been updated. Children with an egg allergy can receive any licensed influenza vaccine that is otherwise appropriate for their age, without special considerations. The CDC provides additional information about updated recommendations for flu vaccine and people with egg allergies.

It is especially important to vaccinate children and adolescents who are at an increased risk of complications from influenza, including those with chronic medical conditions, such as asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression, or neurologic and neurodevelopmental disorders. Children younger than 5, but particularly children younger than 2 years old, are also at an increased risk of hospitalization and complications attributable to influenza.

Another far less common, but still an important concern associated with influenza, is possible exposure and infection with animal influenza viruses. For example, swine have their own influenza viruses that usually do not infect people, but can cause illness in people on rare occasion. When that happens, these are called "variant" infections. Local fairs in the US typically bring an increase in interactions between people and swine, which increases the risk of these types of infections. As of August 26, 2016, 18 human infections with influenza A (H3N2) variant viruses have been detected. The CDC posted an online spotlight describing the first four infections reported and issued guidance for people attending agricultural fairs where swine might be present during fairs. The guidance includes additional precautions for people who are at high risk for serious flu complications. This year, no person-to-person transmission of these variant viruses has been identified. The Michigan Department of Health has also issued a news release.

Plan to participate in the CDC Clinician Outreach and Communication Activity pediatric-focused influenza prevention and control webinar on October 27, 2016, at 2:00pm ET. To receive a calendar appointment, e-mail DisasterReady@aap.org.

For more information, see the AAP Red Book Online Influenza Resource page or the CDC FluView. All What's the Latest with the Flu messages will be archived. Members of the AAP also have access to Flu Vaccine Recommendations Speaking Points.​

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