Guidelines Updated for Influenza Vaccination and Antiviral Therapy in Children

Laurie Barclay, MD

August 30, 2010

August 30, 2010 — The American Academy of Pediatrics (AAP) has updated guidelines for use of trivalent seasonal influenza vaccine and antiviral medications to prevent and treat influenza in children, according to an AAP policy statement posted early online on August 30. The new guidelines, "Recommendations for Prevention and Control of Influenza in Children, 2010-2011," will also be published in the October 2010 print issue of Pediatrics.

"The 2009 influenza A (H1N1) pandemic virus is expected to circulate, with infants and children at increased risk of severe illness and death," write AAP 2010-2011 Committee on Infectious Diseases chairperson Michael T. Brady, MD, and colleagues. "This year's trivalent seasonal influenza vaccine contains A/California/7/2009 (H1N1)-like antigen (derived from the 2009 pandemic influenza A [H1N1] virus); A/Perth/16/2009 (H3N2)-like antigen; and B/Brisbane/60/2008-like antigen."

All children and adolescents at least 6 months old should receive annual trivalent seasonal influenza immunization. However, groups most susceptible to influenza-related complications should be specially targeted for vaccination: all family members, household contacts, and out-of-home care providers of children younger than 5 years; children with asthma, diabetes, neurologic diseases, or other high-risk conditions; healthcare personnel; and pregnant women.

Only 1 type of trivalent vaccine is being made for the current 2010-2011 seasonal influenza vaccine schedule, although 2 influenza vaccines were recommended last year. In the 2010-2011 trivalent seasonal influenza vaccine, the 2009 pandemic influenza A (H1N1) strain has replaced last year's influenza A (H1N1) strain. The 2010-2011 trivalent seasonal influenza vaccine also includes 2 other influenza strains.

The child's age when receiving the first influenza vaccine dose and vaccination history determines the number of influenza vaccine doses each child needs, as summarized in a flow chart provided in the policy statement.

Specific Guidelines

Specific guidelines concerning the required number of influenza vaccine doses are as follows:

  • Children younger than 6 months are too young to receive influenza vaccine.

  • Only 1 dose is needed for children at least 9 years old.

  • Children younger than 9 years require at least 2 doses of 2009 pandemic H1N1 vaccine. They will need 2 doses of seasonal influenza vaccine this year if they did not receive the H1N1 vaccine during last year's influenza season.

  • Children younger than 9 years who have never before received the seasonal influenza vaccine will require 2 doses.

  • Children younger than 9 years who received seasonal influenza vaccine before the 2009-2010 influenza season need only 1 dose this year if they received at least 1 dose of the H1N1 vaccine last year, but they need 2 doses this year if they did not receive at least 1 dose of the H1N1 vaccine last year.

  • Children younger than 9 years who received seasonal influenza vaccine for the first time last year, but who only received 1 dose, require 2 doses this year.

  • For children younger than 9 years who received influenza vaccine last year, but for whom it cannot be determined whether it was a seasonal influenza vaccine or the H1N1 influenza vaccine, 2 doses are recommended this year.

  • For all children who require 2 doses, the second dose should be administered at least 4 weeks after the first dose.

"Pediatricians continue to have a leadership role in the prevention of influenza through vaccine use and public education," the guidelines authors write. "In addition, pediatricians should promptly identify influenza infections to enable rapid treatment of influenza, when indicated, to reduce childhood morbidity and mortality."

Relevant Points

Key points relevant for the 2010-2011 influenza season include the following:

  1. All children at least 6 months old, especially those with chronic medical conditions putting them at high risk for influenza complications, should receive trivalent seasonal influenza vaccine each year. These chronic conditions include asthma, diabetes, morbid obesity, immunosuppression, and neurologic disorders.

  2. "Cocooning," or immunization of close contacts of children at high risk, should lower the risk for influenza exposure for these children, especially for infants younger than 6 months because they are too young to be vaccinated against influenza. Annual trivalent seasonal influenza vaccine is therefore important for household members and out-of-home care providers of children and adolescents at high risk, healthy children younger than 5 years, and infants younger than 6 months.

  3. With use of technology currently available for seasonal influenza vaccine production, a monovalent vaccine was produced as quickly as possible to protect against the 2009 pandemic influenza A (H1N1) virus and is recommended to be given in addition to the 2009-2010 seasonal influenza vaccine, because the 2009 pandemic influenza A (H1N1) virus is again expected to circulate during the 2010-2011 influenza season.

  4. Compared with the usual seasonal influenza strains, morbidity and mortality rates from the current 2009 influenza A (H1N1) pandemic virus have affected the pediatric population disproportionately.

  5. Two influenza vaccines were recommended last year, but only a single trivalent seasonal influenza vaccine is being made for the current 2010-2011 seasonal influenza vaccine schedule, with the 2009 pandemic influenza A (H1N1) strain replacing the 2009 seasonal influenza A (H1N1) strain. The recommended trivalent vaccine for 2010-2011 contains A/California/7/2009 (H1N1)-like antigen (derived from 2009 pandemic influenza A [H1N1] virus); A/Perth/16/2009 (H3N2)-like antigen; and B/Brisbane/60/2008-like antigen.

  6. The number of trivalent seasonal influenza vaccine doses to be administered this year depends on the child's age and vaccine history.

  7. As soon as trivalent seasonal influenza vaccine is available, healthcare providers should inform parents and caregivers of all children 6 months and older, especially those at high risk for influenza complications.

  8. During the 2010-2011 season, the only antiviral medications routinely recommended for chemoprophylaxis or treatment are the neuraminidase inhibitors oseltamivir and zanamivir. All strains of influenza currently anticipated to circulate are susceptible to these antivirals but are resistant to amantadine and rimantadine, although resistance patterns may change rapidly and should be verified.

New recommendations from local and state health departments can be found on the Web site of the US Centers for Disease Control and Prevention, the AAP Web site, or the AAP Red Book Online Influenza Resource Page.

Pediatrics. Published online August 30, 2010.

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