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Pediatric influenza immunization: Gaining ground, but more to do
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It’s that time of year when our attention turns away from influenza vaccination and toward the increasing number of patients with respiratory illness flooding our practices. But for the long-term good of our patients and our communities, we must keep vaccinating as long as influenza viruses are circulating and vaccines are available. This is especially true because 171 US children died of influenza and its complications last year.
In my role as chair of the National Foundation for Infectious Diseases (NFID) Childhood Influenza Immunization Coalition (CIIC), I have worked with other medical and public health groups focused on the importance of vaccinating children — those aged at least 6 months — against influenza. As a nation, we have come a long way since CIIC was created in 2007. Influenza vaccination rates have increased each year, with a record 56.6% of children vaccinated this past influenza season. But additional progress must be made. Although we must keep increasing rates so that all children are offered protection, there are two specific influenza vaccination opportunities I want to address.
First-time immunization of young children
Two doses of influenza vaccine are necessary for immunization of all children aged 6 months to 8 years who are being vaccinated for the first time. Two doses also are needed for those who were not fully immunized against the 2009 H1N1 pandemic (H1N1p) strain in previous seasons. This distinction matters. The 2009 H1N1 virus is the most common one circulating this season, and this strain disproportionately affects younger adults and children.
Based on data collected by the CDC, millions of children fall into the incompletely immunized category. During the 2011-2012 season, 59% of children aged 6 to 23 months received their first vaccine dose, but only 43% were fully vaccinated with a second dose — a 16% gap. The gap is considerable for older children, at 11.5%, in both the 24- to 59-month-old and the 5- to 8-year-old age groups. The bad news is that the rate for older children starting the vaccine series drops, so the starting point from which we measure the 11.5% gap is even lower.
Carol J. Baker
It is critical that we look for ways to ensure that parents bring their infants and children back to our practices for the second dose. The earlier in the season the better, but vaccination into February or March is still beneficial. Although influenza usually peaks around February, it can occur earlier or peak later. In any case, the peak is just that — one moment in time. Millions of influenza cases will happen after the peak. But even beyond this year’s dangers, the two vaccine doses are essential so these children can move into the “one dose a year” category in future years.
Closing the vaccination gap in teens
Influenza vaccination rates are inversely related to a child’s age. The difference in vaccination coverage from the youngest to oldest children is 35%, dropping from 77% in the 6- to 23-month age group for the 2012-2013 season, to 42% in teens. And although it is true that infants are more likely to have the worst outcomes, teens, even the healthiest teens, can suffer the worst outcomes of influenza infection. In fact, a teen infected with H1N1 was the first pediatric influenza death reported in my area this year.
We had a big increase in the influenza vaccination rate among teens in the 2012-2013 season — up nearly 9% from the previous season. This is a positive sign that indicates it is time to work even harder. Now we know this can be done — that we can get through to teens and their parents.
There are some unique vaccination challenges in teens. For instance, only 53% of those aged 12 to 17 years have a medical home, and estimates show that as many as 25% to 30% do not get annual checkups. Other challenges are common across all ages. Teens (and their parents) lack knowledge about influenza and its effect as a serious illness. They believe they are immune to influenza complications, including death. They also may mistake colds and stomach viruses for influenza and see no need to vaccinate against these self-limited illnesses.
Multiple interventions needed
There is no magic bullet for increasing influenza vaccine uptake among teens. Multiple approaches and interventions are needed. Not all are in our control as health care professionals. But one is our responsibility and it also is the one that studies repeatedly show has the greatest effect on vaccination decisions — our strong, unequivocal vaccine recommendation. And yes, this is true even for our teen patients, who confirmed in a recent survey that physicians are their most trusted sources of health information.
When teens come to our offices, or even an urgent care clinic, we must be sure we integrate vaccination to the greatest extent possible. But some teens may never enter an office before or during flu season, so we also must support extending vaccination opportunities beyond traditional medical offices and into schools and other venues (eg, pharmacies, community-based clinics, etc) where teens frequent.
In short, it does not matter where the influenza vaccine is given, so long as it is given. We must do whatever it takes to get the second dose into young children, increase the vaccination rates in teens and, of course, continue to increase the rates in other children as well. Yes, this is a challenge, but even one preventable death is too many, so it’s a challenge we must conquer.
References:
CDC. FluView: 2013-2014 Influenza Season, week 52 ending December 28, 2013 (preliminary data). Available at: www.cdc.gov/flu/weekly/. Accessed Jan. 3, 2014.
CDC. MMWR Recomm Rep. 2013;62(7):1-43.
Healthy People 2020. Healthy People 2020 summary of objectives. Available at: www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf. Accessed Jan. 7, 2014.
Strickland BB. Pediatrics. 2011;127:604-611.
The case for improving adolescent health: Helping prepare adolescents for a healthy future. A report from the National Foundation for Infectious Diseases and Pfizer Inc. Available at: http://adolescentvaccination.org/resources/case-for-improving-adolescent-health.pdf. Accessed Jan. 5, 2014.
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Disclosure: Baker serves as an advisory board member and consultant for Novartis Vaccines.