COMMENTARY

Influenza Deaths in Children: Putting It Into Context

Julia Shaklee Sammons, MD, MSCE

Disclosures

February 16, 2018

Editorial Collaboration

Medscape &

Hello. My name is Julia Sammons. I'm a pediatric infectious disease physician and medical director of the Department of Infection Prevention and Control at the Children's Hospital of Philadelphia (CHOP).

As the US Centers for Disease Control and Prevention (CDC) continues to issue updated influenza activity data in its weekly field views, it's important for us as physicians to frame this information for our patients and families. This is particularly important as the media attention around this year's influenza season has been particularly high, and many have compared this season to the 2009 H1N1 swine flu pandemic in terms of the sheer volume of emergency department visits we are seeing.

There are two key messages that I'd like to convey today. The first is that while pediatric flu deaths have increased this flu season, they are not out of proportion to what we have seen in prior seasons, despite some of the media focus. The second is that while the outpatient volume of visits related to influenza-like illness (ILI) has really skyrocketed in emergency departments as well as outpatient clinics, most persons with influenza will have relatively mild disease that can be managed at home. The message should not be that every patient needs to run to their nearest primary care office or emergency department for care.

As of early February 2018, what we know from the CDC data is that influenza activity continues to be widespread across the United States. The predominant influenza virus subtype is influenza A H3N2. In particular, this season we have seen a sharp rise in outpatient visits for ILIs, and the most recent report indicates that the [proportion of all] outpatient visits due to ILI is approaching 7.7%.[1] This is approaching levels of the 2009 H1N1 swine flu pandemic.

[W]hile pediatric flu deaths have increased this flu season, they are not out of proportion to what we have seen in prior seasons, despite some of the media focus.

Hospitalization rates have also increased this season, and many have compared the overall seasonal hospitalization rate to that of the most recent severe influenza season, 2014-2015. What's interesting about this season, however, is that while persons 65 years and older are always most affected in terms of rates of hospitalization, children aged 0-4 years (who are normally the group with the second highest hospitalization rate) are not. Rates of hospitalization in children are either similar to or lower than those of prior seasons.

As of early February, CDC reports that there have been 63 pediatric deaths to date. As I noted, this is not out of proportion to what has been seen in prior seasons. This is important to put into context because influenza-related death in children is frightening, both to us as physicians as well as to our parents and families. When you look at the overall volume of influenza infection in the community, death related to flu in children is still a relatively rare outcome.

Messages for Parents

There are two messages that we can give to parents and families to empower them. The first is to be alert to the signs of severe disease and [indicators to] take children to the emergency department. Respiratory distress, lethargy, or signs of dehydration would be reasons for parents to take their children in to be seen right away.

The second message is what CDC has shared in prior influenza seasons—that over 80% of children who die related to flu are unvaccinated, and the data so far this season seem to be similar. Again, that message is important to drive home. Influenza vaccine remains our best means for prevention, and it's still not too late to get the influenza vaccine.

Messages for Clinicians

Another important message for providers is to know when to use oseltamivir (Tamiflu®) or other neuraminidase inhibitors for the management of influenza. CDC currently recommends the early use of Tamiflu for high-risk groups who are at risk for severe disease or outcomes, as well as young children. It should be administered within 48 hours of presentation. That said, most persons with influenza will have relatively mild disease, and routine use of Tamiflu is not recommended in groups outside of those high-risk indications.

Additional prevention strategies we can encourage in our parents and families are to remember the appropriate use of hand hygiene and to stay home when sick. The CDC recommends that patients with influenza stay home until fever-free, without use of fever-reducing medications, for 24 hours.

As physicians, we can also ensure that we have appropriate access to hand sanitizer, tissues, and masks for our patients so that as patients' families are coming in to see us for care, we are not contributing to the spread of disease in our clinics.

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