Public health officials are underscoring the tragedy of severe influenza infections and deaths in children, adding a palpable sense of urgency for immunization in an era when some parents are suspicious of vaccine efficacy and safety.

At a recent flu press conference held by the National Foundation for Infectious Diseases (NFID), a pediatrician discussed the devastating impact of illness and death in children.

“This past winter, I remember standing next to a mother of a 9-month-old,” said Patricia Whitley-Williams, MD, president-elect of NFID and a professor of pediatrics at Rutgers Medical School. “The child had been admitted and was diagnosed as having flu.”

The child had difficulty breathing and was transferred to an intensive care unit and put on a ventilator. The patient required several more weeks of hospitalization to recover. “The mother looked at me during that first week, while her child was sedated and on the breathing machine, and said, ‘You mean I could have prevented this?’” Whitley-Williams said. “This mother did not believe in vaccinating, because she felt that the flu vaccine was not effective, and she was concerned about vaccine safety.”

The 2018-2019 flu season saw high rates of pediatric hospitalization due to flu-related complications, with deaths reported even in healthy babies and children, she said.

“Recently, there was a pediatric flu-related death in a 4-year-old child who had an underlying health condition,” Whitley-Williams said. “This past season, there were 135 pediatric deaths due to the flu, even though it was a moderate flu season.”

In addition, a published study1 found that the number of children younger than 1 year of age who are hospitalized with flu is at least double the current estimates, she added.

Another study2 found that flu shots reduce mortality in immunized children who still acquire influenza. This 2017 study showed the flu immunization prevented death in 65% of healthy children and 51% of those at high-risk of influenza flu complications.

While it did not assess mortality, a study3 presented recently at the IDWeek 2019 conference found a flu vaccination protective effect that almost halved (48%) the risk of being hospitalized for influenza. The study included seven pediatric hospitals in the New Vaccine Surveillance Network. The researchers verified vaccine receipt from state immunization registries and/or provider records.

“Having received flu vaccine prevented children from being hospitalized with flu,” said Angela Campbell, MD, MPH, a medical officer at the Centers for Disease Control and Prevention. “About 60% of the children hospitalized had an underlying medical condition. That means that 40% were previously healthy children.”

The best way to protect newborn babies is to immunize pregnant women, who are also at risk of influenza complications,4 Whitley-Williams said at the NFID meeting.

“If the pregnant woman is vaccinated, then the infant, for the first several months of life, receives protection from the mother,” she said. “That’s extremely important, because we do not vaccinate children for flu under 6 months of age.”

Concerning pregnant women, the CDC recently released a report showing women with influenza are more than twice as likely to be hospitalized if they are expecting.

“CDC recommends all pregnant women receive flu vaccine at any time during pregnancy, and whooping cough vaccine (Tdap) early in their third trimester, during each pregnancy,” the agency said in the report.5

Children who are between the ages of 6 months and 9 years of age - if they have never received a prior flu vaccine - require two doses to be protected, Whitley-Williams said.

“Those doses have to be separated by at least four weeks,” Whitley-Williams said, “so it’s important to give that first dose as early as you can.”

Elephant in the Room

Skipping flu vaccination for children is like parents not strapping them in their car seats before driving, Whitley-Williams said.

“No good parent would do that,” she said. “We all know that [flu vaccines] will not provide 100% protection. But it will reduce the severity and duration of disease. And it will save children’s lives.”

Echoing that theme at the NFID meeting was Alex Azar, JD, Secretary of the Department of Health and Human Services (HHS).

“I want to talk about flu deaths in children for a minute, because the death of a child is especially heartbreaking,” he said. “Illness occurs very quickly. Sixty-five percent of reported flu deaths in children happen within seven days after symptom onset. Thirty-eight percent of deaths occur before being admitted to the hospital. Half of the children had no preexisting medical conditions. These are frightening numbers, and each one represents a human tragedy.”

Despite such sentiments, the elephant in the room was the U.S. Customs and Border Protection’s (CBP) recent decision to not vaccinate migrants held in detention facilities against flu. The decision has been widely criticized in the infectious disease community both as unethical and as a perfect setup for an outbreak.

A letter6 submitted to Congress by clinicians at Harvard University and Johns Hopkins hospital said autopsy results show that three children have died in U.S. custody in part as the result of influenza since December 2018. (See Hospital Infection Control & Prevention, October 2019). Asked about the CBP policy at the press conference, Azar said the HHS provides vaccinations under its Unaccompanied Alien Children (UAC) program within 48 hours of their arrival at UAC facilities.

“Obviously, Customs and Border [Protection] has to deal with the logistics issues, and their own situation there,” he said. “Our recommendations, from a public health perspective, though, are clear. Every individual over the age of 6 months for whom it’s not contraindicated should receive the annual seasonal flu vaccine.”

Bill Borden, MD, a preventive cardiology specialist at George Washington (DC) University who spoke at the NFID flu meeting, said, “As a physician, as someone who works in public health, and as an American, I think that everyone - especially children - should have access to this potentially lifesaving preventive flu vaccine.”

REFERENCES

  1. Thompson, MG, Levine MZ, Bino S, et al. Underdetection of laboratory-confirmed influenza-associated hospital admissions among infants: A multicentre, prospective study. Lancet Child Adolesc Health 2019. doi:10.1016/S2352-4642(19)30246-9.
  2. Flannery B, Reynolds SB, Blanton L, et al. Influenza vaccine effectiveness against pediatric deaths: 2010–2014. Pediatrics 2017;139. pii:e20164244. doi:10.1542/peds.2016-4244. [Epub 2017 Apr 3].
  3. Campbell AP, Ogokeh CE, McGowan C, et al. Influenza vaccine effectiveness against laboratory-confirmed influenza in children hospitalized with respiratory illness in the United States, 2016-17 and 2017-18 seasons. Abstract 899. IDWeek 2019. Washington, DC, Oct. 2-6, 2019.
  4. Thompson MG, Kwong JC, Regan AK, et al. Influenza vaccine effectiveness in preventing influenza-associated hospitalizations during pregnancy: A multi-country retrospective test negative design study, 2010–2016. Clin Infect Dis 2019;68:1444-1453.
  5. CDC. Vaccinating pregnant women protects moms and babies. Vital Signs Oct. 2019. Available at: https://bit.ly/2Vqv8Lj. Accessed Oct. 17, 2019.
  6. Melinik J, Winickoff J, Sharfstein JM, et al. Letter. Aug. 1, 2019. Available at: https://bit.ly/2kqGPE0. Accessed Oct. 17, 2009.