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What's the Latest with the Flu?

June 2018

Current Influenza Situation

Although flu activity is winding down in most of the country, it's important to appreciate that flu viruses continue to circulate at low levels even during the summer. Providers should continue to encourage annual influenza vaccination through June 30, when this season's vaccine expires.  With 174 pediatric deaths from influenza already reported this season, it is wise to be vigilant. According to a recent AAP News article, about 80% of the children who died were not vaccinated.

Use of Live Attenuated Influenza Vaccine Use for the 2018-2019 Influenza Season

The American Academy of Pediatrics (AAP) recommends intramuscular inactivated influenza vaccine (IIV) for children in the 2018-2019 season as it has been more consistently effective against most strains of flu in recent seasons, but says the nasal vaccine (LAIV) may be an option for kids who otherwise will not be vaccinated.

In February 2018, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices reviewed MedImmune data as well as past seasons' vaccine effectiveness data and voted to recommend LAIV4 as an option for the 2018-2019 season. However, the data on whether or not LAIV4 will be effective are not known, which contributed to the AAP recommendation that children receive IIV, administered intramuscularly, for the upcoming influenza season. While IIV effectiveness varies each season, it has been consistently better than LAIV in recent years. Review the AAP News article for additional information.

Formulation of Flu Vaccines

In March 2018, the US Food and Drug Administration (FDA) Vaccines and Related Biological Products Advisory Committee convened an expert panel to review the World Health Organization (WHO) recommendations for the Northern Hemisphere flu vaccines and global influenza surveillance data to confirm the composition of US seasonal flu vaccines. For the 2018-2019 influenza season, the trivalent flu vaccines will contain:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;

  • an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus; and

  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage).

The quadrivalent flu vaccine will also include a B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage), in addition to the viruses listed above.

Prepare for the Next Flu Season!

The AAP Influenza Implementation Guidance has gone digital. The comprehensive guide assists pediatricians, nurses, office managers and staff with steps to help ensure a smooth flu season. Get answers to practice management questions on vaccine ordering and storage, patient scheduling, payment and coding, and more. Find links to the current AAP influenza policy statement and practice policies on health care worker vaccination and liability and risk management. Access parent-friendly materials and speaking points to share influenza messages with families.

This year marks 100 years since the 1918 influenza pandemic, the most severe pandemic in recent history. Reflecting back reminds us that it's always important to prepare in advance for severe flu seasons, including pandemics. To prepare for next flu season, initiate team meetings on the following topics:

  1. Discuss what worked or didn't work in the office this past season and determine what improvements might be made to increase influenza immunization rates.

  2. Develop or update written infection control measures or office protocols for minimizing transmission of influenza and other infectious diseases.

  3. Plan and schedule staff training on standard precautions, infection control, seasonal and pandemic influenza, and the importance of immunization.

For more information, see section 9 in the AAP Preparedness Checklist for Pediatric Practices.

Now is a good time to lay the groundwork for requiring that health care personnel get vaccinated for the flu next season. Take steps to implement a mandatory influenza immunization policy for your clinic staff. See the AAP policy statement "Influenza Immunization for All Health Care Personnel: Keep It Mandatory" for more information.

Additional Information

See the AAP Red Book Online Influenza Resource page or CDC FluView for additional information. Each "What's the Latest with the Flu" messages will be archived. Also see the AAP Seasonal Flu Collection.

This will be the last "What's the Latest with the Flu" message for the 2017-2018 influenza season. The AAP Disaster Preparedness Advisory Council and the AAP Committee on Infectious Diseases would like to thank everyone for their influenza prevention and control efforts. For more information, e-mail DisasterReady@aap.org.

    March 2018

    Current Influenza Situation

    US influenza activity has begun to decrease, although Influenza activity is expected to continue for several more weeks. To date, state health departments have reported 119 children have died from influenza this season. See the American Academy of Pediatrics (AAP) article "Flu Activity Continues to Slow, But 5 More Children Die".

    Availability of Antiviral Medications for Treatment of Influenza

    Given current high influenza activity, clinicians should consider influenza as a likely diagnosis in patients with fever, cough and other respiratory symptoms, regardless of their age and whether or not they have received a flu vaccine this season. Persons of any age who are hospitalized, particularly with severe or progressive illness, and all high-risk patients with suspected or lab-confirmed influenza should be treated as soon as possible with antiviral medications. Children younger than 5 years of age, but especially those younger than 2 years of age, adults over 65 years of age, pregnant women, and anyone with certain underlying medical conditions, are at high risk for serious influenza complications.

    Note that some manufacturers are reporting delays in filling influenza antiviral medication orders. The Centers for Disease Control and Prevention (CDC) has an Antiviral Drug Supply Web page that is updated regularly. Also see the CDC Web page, Influenza Antiviral Medications: Summary for Clinicians.

    Vaccine Effectiveness Update

    Interim influenza vaccine effectiveness is estimated to be 36% overall this season with the highest effectiveness (59%) for young children 6 months through 8 years of age, according to interim estimates from a CDC Morbidity and Mortality Weekly Report (MMWR) on February 16, 2018.

    It is not too late to get your flu shot. The AAP and the CDC continue to encourage everyone aged 6 months and older to be vaccinated. Vaccination will still prevent influenza illness, including hospitalizations and deaths this season. See the AAP News article, "CDC: Flu Vaccine 36% Effective, Highest for Young Children".

    Archived Influenza Presentations for Clinicians

    In February 2018, the CDC conducted a webinar titled, "Update on the 2017-2018 Influenza Season for Clinicians". During this webinar, CDC influenza experts addressed clinical issues for influenza patients, including those with severe disease, and provided the latest updates on the 2017-2018 influenza season. The archived version of the webinar and presentation materials/resources can be viewed online.

    In January 2018, the CDC held a Grand Rounds session titled, "Public Health Response to Severe Influenza". This session provided key information for public health professionals on how to reduce the spread of seasonal influenza in communities and how to adjust to spot shortages of antiviral drugs in some areas because of high influenza activity. The archived version of the Grand Rounds is available online.

    In November 2017, the AAP collaborated with CDC to conduct a webinar titled "What's New for the 2017-2018 Flu Season: Recommendations for Children". During this webinar, subject matter experts from the AAP and CDC highlighted valuable information about this year's influenza season and discussed strategies primary care providers and medical subspecialists could use to improve influenza prevention and control in children. The archived version of the webinar, a transcript, and presentation materials/resources can be viewed online.

    Influenza Prevention and Control – Strategies for Early Education and Childcare 2017-2018

    Partnering with early education and child care programs or schools to encourage proper influenza prevention and control strategies for all children, staff, and caregivers is hugely beneficial. Consider sharing the free AAP online PediaLink course "Influenza Prevention and Control – Strategies for Early Education and Childcare 2017-2018" with staff and others who work in Head Start and other early education and child care programs. After completion of this course, participants will be able to recognize the signs and symptoms of influenza, explain how influenza is spread, describe national and AAP recommendations regarding influenza, discuss the role of caregivers and teachers in preventing and controlling the spread of influenza, and much more. The course is approved for 1.0 contact hour.  ​​

    Additional Information

    See the AAP Red Book Online Influenza Resource pageCDC FluView, or the CDC Digital Media Toolkit: 2017-18 Flu Season. Each "What's the Latest with the Flu" messages will be archived. Also see the AAP Seasonal Flu Collection.​


    February 2018

    ​​February 2018

    Current Flu Situation

    Flu activity is elevated in the US with increasing illness anticipated during the coming weeks. Centers for Disease Control and Prevention (CDC) surveillance systems show that nationally, the flu season may be peaking now. To date, 37 children have died from influenza this flu season. That number is expected to rise. It is estimated that 85 percent of the children who die from the flu likely have not been vaccinated.​

    Antiviral Medications for Treatment of Influenza are an Important Adjunct to Annual Vaccination

    The CDC issued a Health Alert Network (HAN) Health Advisory on December 27, 2017, to notify clinicians that influenza A(H3N2) viruses are predominating in the US this season and to provide guidance on treatment. Previously, influenza A(H3N2) virus-predominant influenza seasons have been associated with more hospitalizations and deaths in young children and persons aged 65 years and older compared with other influenza virus strains.

    Given this widespread influenza activity, clinicians should consider influenza infection as a highly possible diagnosis in patients with fever, cough and other respiratory symptoms, regardless of age.  People with severe or progressive illness, hospitalized patients, and all high-risk patients with suspected influenza should be treated as soon as possible with antiviral medications. High-risk patients, including children younger than 5 years of age, adults over 65 years of age, pregnant women, and anyone with underlying medical conditions, are predisposed to complications of influenza.

    While the total reported national supply of influenza antiviral drugs should be sufficient to meet even high seasonal demand, some manufacturers are reporting delays in filling orders. The CDC is aware of spot shortages of antiviral drugs in some places experiencing high influenza activity. The CDC is working with manufacturers to address any existing gaps in the market. Clinicians can consider including mention of the potential shortages when writing a prescription so families are aware they may need to call a pharmacy in advance.

    See the American Academy of Pediatrics (AAP) policy "Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018" for updated recommendations on the routine use of seasonal influenza vaccines and antiviral medications for the prevention and treatment of influenza in children.

    Annual Flu Vaccination Continues to be the Best Way to Prevent Influenza.

    Even though we are already in the flu season, annual vaccination remains the best available preventive measure against influenza. While the effectiveness of flu vaccines can vary from season to season, recent studies show vaccine reduces the impact of flu by about 30% to 60% among the overall population during seasons when most circulating flu viruses match well with those viruses used to produce the vaccine that season. The CDC monitors circulating viruses throughout the year and provides new and updated information about their similarity with the flu vaccine viruses as it becomes available.

    Influenza surveillance data is published weekly in FluView and summarized at intervals in the Morbidity and Mortality Weekly Report (MMWR). Vaccine effectiveness estimates are also provided when available. In previous seasons, vaccine effectiveness against H3N2 viruses has been around 30%, whereas effectiveness against H1N1 viruses has been about 50% and effectiveness against influenza B viruses has been around 60%. Similar vaccine effectiveness is expected this year. For more information on the effectiveness of flu vaccines, see Frequently Asked Flu Questions 2017-2018 Influenza Season on the CDC website.

    The influenza epidemic is likely to continue for several more weeks. Therefore, it is important to continue to recommend annual influenza vaccination to everyone 6 months of age and older, particularly contacts of children too young to be vaccinated and of children with high-risk underlying conditions. In addition, please ensure that children 6 months through 8 years, who need 2 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. See the AAP News article, "CDC urges vaccination for flu as hospitalizations rise", for additional information.

    Many Strategies Exist to Reach Families

    Informing families about the importance of influenza prevention and control through various messaging strategies can make a real difference. The recent CDC Public Health Matters Blog outlines how to talk to friends, family, and patients about flu vaccines. Pediatricians can share a link to this blog with families and encourage them to take important steps to protect themselves from influenza. Also consider sharing the Vaccine Locator. This tool identifies the locations where influenza vaccine is available in a particular area. Does your practice have a Web site or a social media outlet? If not, consider creating one to easily share updates and reminders with families throughout flu season.

    Archived Webinar: What's New for the 2017-2018 Flu Season: Recommendations for Children

    In November 2017, the AAP collaborated with CDC to conduct a webinar titled "What's New for the 2017-2018 Flu Season: Recommendations for Children". During this webinar, subject matter experts from the AAP and CDC highlighted valuable information about this year's flu season and discussed strategies 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.

    Additional Information

    See the AAP Red Book Online Influenza Resource pageCDC FluView, or the CDC Digital Media Toolkit: 2017-18 Flu Season. Each "What's the Latest with the Flu" messages will be archived. Also see the AAP Seasonal Flu Collection.​

    December 2017

    Current Flu Situation

    Flu activity is increasing in the US. There have already been 8 pediatric deaths from influenza reported, so it's critically important to recommend influenza vaccination to all of your patients. With family and friends gathering for the holidays, now is an ideal time to remind those not already vaccinated to get vaccinated for seasonal flu. 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 important step anyone can take to protect themselves and their loved ones against influenza and its complications.

    Pregnant Women

    Pregnant women should receive the influenza vaccine at any time during pregnancy to protect themselves as well as their young infants during the first 6 months of life. Unfortunately, the CDC reports that nearly two-thirds of pregnant women have not been vaccinated against flu this season. See the American Academy of Pediatrics (AAP) AAP News article, "CDC: 64% of Pregnant Women Not Vaccinated Against Flu", for additional information.

    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. Pediatric offices may serve as an alternate venue for providing influenza immunization for parents and other care providers of children. See the American Academy of Pediatrics (AAP) policy statement, "Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018", for additional information.

    Archived Webinar: What's New for the 2017-2018 Flu Season: Recommendations for Children

    In November 2017, the AAP collaborated with the CDC to conduct a webinar titled "What's New for the 2017-2018 Flu Season: Recommendations for Children". During this webinar, subject matter experts from the AAP and CDC highlighted valuable information about this year's flu season and discussed strategies 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.

    CDC Flu Flighter Campaign

    The CDC created a Flu Fighter Campaign to highlight people and the work they are doing to contribute to flu prevention in the US and around the world. The AAP nominated Henry Bernstein, DO, MHCM, FAAP, to recognize him for his contributions in this area. Dr Bernstein leads the AAP influenza efforts, including the development of the annual AAP influenza policy. Dr Bernstein's Flu Fighter profile can be found here.

    Additional Information

    See the AAP Red Book Online Influenza Resource page, CDC FluView, or the CDC Digital Media Toolkit: 2017-18 Flu Season. Each "What's the Latest with the Flu" messages will be archived​.

    October 2017

    ​The American Academy of Pediatrics (AAP) policy "Recommendations for Prevention and Control of Influenza in Children, 2017-2018" offers updated recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. Highlights of the updated recommendations include:

    • Vaccination is the best available preventive measure against influenza.
    • Annual seasonal influenza vaccination is recommended for everyone 6 months and older.
    • Both trivalent and quadrivalent inactivated influenza vaccines are available in the US.
    • Quadrivalent live attenuated influenza vaccine (LAIV4) is not recommended for use in any setting in the US during the 2017-2018 influenza season.
    • Children should receive their influenza vaccine by the end of October, if possible.
    • The number of recommended doses of influenza vaccine depends on a child's age at the time of the first administered dose and vaccine history.
    • All children with egg allergy of any severity can receive influenza vaccine without any additional precautions beyond those recommended for any vaccine. As such, there is no need to ask specific questions regarding history of egg allergy prior to influenza vaccination.
    • Pregnant women may receive influenza vaccine at any time during pregnancy.
    • All health care personnel should receive an annual seasonal influenza vaccine, a crucial step in preventing influenza and reducing health care-associated influenza infections.
    • Antiviral medications can reduce the duration of symptoms and prevent serious complications of influenza, but they are not a substitute for influenza vaccination.

    For additional information, refer to the updated Vaccine Status Table and Influenza Resource Page within Red Book Online, which have been updated to reflect the 2017-2018 influenza policy statement. Also see the recent AAP News article for an overview of these expanded recommendations.

    Both trivalent and quadrivalent inactivated influenza vaccines are available in the United States for the 2017-2018 season. Neither inactivated vaccine formulation is preferred over the other. Although manufacturers anticipate an adequate supply of quadrivalent vaccine, pediatricians should administer whichever formulation is available in their communities in order to immunize as many people as possible this influenza season. Both inactivated vaccine formulations contain an A/Michigan/45/2015 (H1N1)pdm09-like virus, an A/HongKong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (B/Victoria lineage). Quadrivalent influenza vaccines also contain the B/Phuket/3073/2013-like virus (B/Yamagata lineage). The influenza A (H1N1) virus in both formulations differs from that contained in the 2016-2017 seasonal vaccines.

    Children 6 months through 8 years of age need two doses of flu vaccine if they have never received at least two doses of any trivalent or quadrivalent influenza vaccine before July 1, 2017. A child 8 years of age and younger requires only one dose if they have previously received two or more total doses of any trivalent or quadrivalent influenza vaccine before July 1, 2017. The two previous doses do not need to have been received during the same influenza season or consecutive influenza seasons. See the updated AAP dosing algorithm:


     

    The 2 doses need not have be​en 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.

    Upcoming Influenza-Focused Webinar
    Plan to participate in the Centers for Disease Control and Prevention (CDC) Clinician Outreach and Communication Activity (COCA) pediatric-focused influenza prevention and control webinar on Tuesday, November 7, 2017, at 2:00pm ET/1:00pm CT. Flor Munoz, MD, FAAP, member, AAP Committee on Infectious Diseases, will present on behalf of the AAP. Angela Campbell, MD, MPH, FAAP, will present on behalf of the CDC. To receive a calendar appointment, e-mailDisasterReady@aap.org. Additional information will be provided in the next "What's the Latest with the Flu" message.​

    Flu Deaths in Children for 2016-17 Season
    106 flu-associated deaths in children were reported to the CDC during the 2016-2017 influenza season. While full information on the vaccination status of these children is not yet available, in past seasons, between 80% and 85% of flu-associated pediatric deaths have occurred in children who had not gotten a flu vaccine that season. According to a recent CDC study, flu vaccination can reduce the risk of flu deaths in children.

    Article - The Role of Patient Engagement in Addressing Parents' Perceptions About Immunizations
    In July 2017, a viewpoint was published in JAMA Pediatrics titled, "The Role of Patient Engagement in Addressing Parents' Perceptions About Immunizations". The article describes how physicians, nurses, and other health care professionals should increase efforts to build relationships with parents, especially when they express hesitation or have misconceptions about vaccinations.

    New Vaccine Adverse Event Reporting System Website
    The Vaccine Adverse Event Reporting System (VAERS) is a national early warning system to detect possible safety concerns in US-licensed vaccines. This system is co-managed by the CDC and the US Food and Drug Administration (FDA). Anyone can report an adverse event to VAERS. Health care professionals are required to report certain adverse events, and vaccine manufacturers are required to report all adverse events that come to their attention.

    Additional Information
    See the AAP Red Book Online Influenza Resource pageCDC FluView, or the CDC Digital Media Toolkit: 2017-18 Flu Season


     

    November 2017

    Flu activity is still low in the US, but flu cases have now been reported in several southern states. Because flu is unpredictable, it's not possible to say when, where, or how quickly flu activity might increase, how severe it will be, or which viruses will predominate.

    As with each influenza season, the American Academy of Pediatrics (AAP) urges all clinicians to take action to ensure that all children get vaccinated against flu. Clinicians should 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 new letters and a fact sheet for health care providers. The AAP also provides a Web page for parents that explains why the nasal spray flu vaccine (live attenuated influenza vaccine or LAIV4) is not recommended for the second season in a row due to poor vaccine effectiveness the past few years.

    2017-2018 Flu Season

    The AAP and CDC recommend that all children 6 months and older receive a flu vaccine each year. Vaccination is especially important for children with special health care needs, such as conditions that increase the risk for complications from influenza, including children with chronic medical conditions such as pulmonary diseases like asthma, metabolic diseases like diabetes mellitus, hemoglobinopathies like sickle cell disease, 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.

    Although children with chronic medical conditions are at high risk of influenza complications, their immunization coverage rates are lower than that of the general population. More work is needed to raise awareness about the importance of influenza vaccination for these children. Take steps to increase vaccination rates among children at high risk:

    1. Talk with parents about the importance of influenza immunization and advise them to vaccinate their child as soon as possible.
    2. Consider using a tracking mechanism or registry to flag children with certain conditions, as this may be useful for getting high risk patients in to be vaccinated.
    3. Talk about the importance of "cocooning" or immunizing family members and child care providers who spend time with children who are at high risk or who cannot get vaccinated. Immunization of close contacts of children at high risk reduces their risk of contagion. Immunizing mothers and all family members is especially important to protect infants younger than 6 months, because they are too young to receive an influenza vaccine.

    See the AAP policy "Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018" for updated recommendations on the routine use of seasonal influenza vaccines and antiviral medications for the prevention and treatment of influenza in children. Also see the recent AAP News article noting an update to the policy to provide the latest dosage and administration information for intravenous peramivir, a neuraminidase inhibitor.

    How to Code for Influenza Vaccine in the 2017-2018 Flu Season

    It is important for clinicians to know the specific vaccine product being administered in their office and to ensure that each patient meets the recommended age for each vaccine. See the recent AAP News article for details on code descriptors.

    CDC COCA Webinar

    On November 7, 2017, the AAP collaborated with CDC to conduct a Clinician Outreach and Communication Activity (COCA) webinar titled, "What's New for the 2017-2018 Flu Season: Recommendations for Children." During this COCA webinar, subject matter experts from the AAP and CDC highlighted critical information about this flu season and discussed strategies that primary care providers and medical subspecialists could use to improve flu prevention and control in children. The PowerPoint slides from the webinar and a recording of the presentation will be posted on the webinar Web page.

    Interactive Map Highlights Child Vaccination Rates Across America

    The AAP 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 posed by 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 about the protection vaccines offer not only to the public at large, but also for the most vulnerable people. These include infants younger than 6 months of age who cannot receive some vaccines themselves and children with chronic medical conditions. The map illustrates that much work remains to increase vaccination coverage rates, particularly to guard against influenza.

    ​Additional Information

    See the AAP Red Book Online Influenza Resource pageCDC FluView, or the CDC Digital Media Toolkit: 2017-18 Flu Season. Each "What's the Latest with the Flu" messages will be archived.​

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