Patsy Stinchfield, MS, CPNP, CICInfectious Disease Nurse PractitionerSenior Director, Infection Prevention & Control@InfectiousPS

The burden of paediatric influenza in the US: mortality, hospitalizations, outpatient visits and other outcomes

September 28, 2018

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• No financial conflicts to disclose

• Center for Disease Control (CDC) Advisory Committee on

Immunization Practices (ACIP) Voting Member, First Nurse in the

US 2004-2008

• ACIP Liaison Member 2008-present.

• Influenza workgroup member 2008 to present.

• Vice President, National Foundation for Infectious Diseases

• Mother of 2 daughters, one of whom had H1N1 in 2009

Disclosures

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At the completion of this presentation learners will:

• Review the burden of paediatric influenza in the US: mortality, hospitalizations, outpatient visits and other outcomes

• Discuss the history of pediatric influenza vaccine policy decisions in the US

• Describe the impact of influenza on a large US pediatric health system including vaccine implementation considerations

Objectives

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Tell real life stories: Seasonal influenza • Television news airs photos a

family has shared of their 8 year old son “Lucio” who died of Influenza A.

• His parents’ hope is to alert parents in order to prevent other children from dying.

• Droves of parents called providers concerned asking for influenza vaccine

• Telling the real stories makes a difference

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• Deadliest, most severe season in 4 decades with VE at 40%

• Record-breaking 900,000 hospitalizations

• 80,000 deaths (90% in elderly, usually 12,000 to 56,000)

• Overall vaccine rates steady for children 6 mo to 17 yrs at 57.9%

• Highest vaccinated age group are children 6 mo to 4 yrs at 67.8%

• Lowest vaccinated age group are children 13 yrs to 17 yrs at 47.7%

• Pregnant women only vaccinated at 49.1%

2017-2018 US flu season was record-breakingNFID and CDC press release 9.27.2018

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Burden of influenza disease on US Children-outpatient http://www.cdc.gov/flu/weekly/overview.htm

#Outpatient

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• Tracking since 2004 (low was 46 deaths in 2005, high was peak

of novel H1N1 with 282)

• Last season (2017-2018) 180 deaths—80% unvaccinated

• In 2013-2014, 115 deaths, 94 died in the hospital and only half

got Tamiflu.

• Of the 74 eligible to be vaccinated

− < 25% were vaccinated− 46% were < 5 years old

− 29% were < 2 years old

− 50% had medical condition:

§ Half had a neurological disorder

§ 30% lung disorder

§ 25% genetic disorder

§ 19% CHD/CV problems

Peds Influenza Deaths:Other Lessons From Prior Years

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1930• Flu A Isolated• Flu B Isolated by 1936

1940 • Mechanical Ventilators in Use

1945 • Inactivated flu vaccine licensed for US civilians

History of Flu Vaccine Policy-United Stateshttps://www.cdc.gov/flu/pandemic-resources/1918-commemoration/pandemic-timeline-1930-and-beyond.htm

1960• US Surgeon General recommends flu vaccine for 65 and over, chronic

illness and pregnant women

2003• First nasal influenza vaccine licensed

2002 • ACIP recommends flu vaccine for babies 6-23 months of age

2006• ACIP recommends flu vaccine for health care professionals

2008• ACIP expands recommendation to include children 5 years to 18 years

2010• ACIP universal flu vaccine recommendation for all 6 months of age and

over

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Evidence increases that flu vaccine reduces risk of severe flu in kids & adults

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ØPediatric patients who were fully vaccinated were 74% less likely to be admitted to an intensive care unit for influenza-related illness.

• Ferdinand, Jill, Belongia, Ed, Pediatrics 2013

ØFlu Vaccine reduced risk of flu-associated deaths by 51% in children with chronic conditions and by 65% in healthy kids

• 2017 CDC study

ØIn adults, flu vaccine reduced severity, hospitalizations, ICU admission

• August, 2018 CDC study

You may still get the flu, but you are less likely to die

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US Flu Vaccine Uptakehttps://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2017.htm#all-ages

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Influenza Vaccine Dosing

Dosingo Infants younger than 6 monthsare too young to be immunizedwith influenza vaccine.

● Children 9 years of age andolder need only 1 dose.

● Children 6 months through 8years of age should receive 2doses of vaccine if they did notpreviously receive any dose of

vaccine

Adverse Events• Local site injection pain

• Fever within 24 hours(up to 1/3rd of younger kids)

• Mild systemic flu-like feeling

• Reports of febrile seizures when “Fluzone” given to 12-23 month olds who concurrently got 13-valent PCV13

• Egg allergy no longer a contraindication

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http://www.immunize.org/catg.d/p3093.pdf

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We are 2 hospitals, ~390 beds, 12 clinics, 100,000 clinic patients with 250,000 visits/year50 languages interpreted and 1 international airport

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Severity of illness among influenza-associated hospitalizations at a free-standing children’s hospital, 2013-2016 Presented at Pediatric Academic Societies meeting Nov, 2017

• Retrospective cohort study evaluating severity of influenza inpts• Lab confirmed influenza, hospitalized >1 day, SII >2 days• 404 children, all ages, median age 2.6 years, 59% met SII def• 27% required ICU stay; 10% ventilated; 6 deaths • 57% not vaccinated• Characteristics of more severe influenza infection:− Ill >3 days prior to admission− 63% had underlying chronic illness− >1 missed opportunity to vaccinate

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Inpatient >2-5 days (65%)Inpatient >2-5 days/ICU

stay (9%)

Inpatient 6+ days (8%)

Inpatient 6+ days/ICU stay (7%)

Inpatient 6+ days/ICU stay/vented (6%)

Inpatient >2-5 days/ICU stay/vented (4%)

Disposition of surviving patients hospitalized with severe influenza illness (N=232).

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Data through May 12, 2018

• Data through May 12, 2018

Respiratory Viral Data – 2008-2018-Admissions

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RSV, Influenza and Rotavirus Lab Confirmed AdmissionsChildren's Hospitals and Clinics of MN

By Month and Season

Rotavirus

Influenza

RSV

H1N1 Wave 2

2012-2013

H1N1 Wave 1

2013-2014 2014-2015 2015-2016 2016-2017 2017-20182008-2009 2009-2010 2010-2011 2011-2012

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Data through May 12, 2018Total # Lab Confirmed Cases in 2017-2018 Season = 3233

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Respiratory Viral Data - 2017-2018 Season

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Lab Confirmed Viral PathogensChildren's Hospitals and Clinics of MN

By Week, 2017-2018 Season

RSV Influenza Adenovirus Metapneumovirus Rhinovirus Rotavirus Parainfluenza

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Data through May 12, 2018Total # Lab Confirmed Admissions in 2017-2018 Season = 1233

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Respiratory Viral Data-Admissions

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Admitted Lab Confirmed Viral PathogensChildren's Hospitals and Clinics of MN

By Week, 2017-2018 Season

RSV Influenza Adenovirus Metapneumovirus Rhinovirus Rotavirus Parainfluenza

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Data through May 12, 2018Total # Lab Confirmed Influenza in 2017-2018 Season = 1773 with 191 admissions

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Influenza - 2017-2018 Season

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Lab Confirmed InfluenzaChildren's Hospitals and Clinics of MN

By Week, This Season vs Last Season Comparison

2016-2017 Season2017-2018 Season

Sep Oct Nov Dec Jan Feb Mar Apr May Jun

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Lines for vaccines H1N1 2009 PandemicWe are due for another one

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Summary Thoughts• Morbidity and mortality for children from influenza is significant• Influenza vaccine options are available • While flu vaccine effectiveness is lower than we want, it is still

best tool to prevent severity, ICU hospitalization and death• Implementation considerations are numerous but manageable− Is there a “too early to vaccinate date?”− Is there a “too late” to vaccinate message?− Is there a best location to vaccinate for most?− Are there children who should not get flu vaccine?− Are systems in place to make it easy to vaccinate children?− Communication of need and dangers of disease imperative− Remember: It’s not “just the flu”

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Families Fighting Flu:Working together to protect children against the fluwww.familiesfightingflu.org

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Questions