Influenza-associated pediatric deaths in the United States, 2004-2012

Burden of Influenza-Related Hospitalizations and Attributable Mortality in Pediatric Acute Lymphoblastic Leukemia

BACKGROUND

Influenza can be severe in patients with underlying malignancy; however, the rate of influenza hospitalizations and attributable mortality in children with cancer is unknown.

METHODS

We performed a retrospective cohort study among 10 698 children with new-onset acute lymphoblastic leukemia (ALL) from 41 US children's hospitals between January 1999 and September 2011. Influenza-related hospitalizations were identified using ICD-9 discharge diagnosis codes, excluding hospitalizations during low-prevalence influenza periods. Follow-up was censored at the earliest of 5 events: end of study period, expected end of chemotherapy, last known hospitalization, hematopoietic stem cell transplant, or death. Data were collected on hospitalization characteristics and resource utilization. Hospitalization rates were calculated using season-adjusted person-time. Crude attributable in-hospital mortality was calculated using baseline mortality for noninfluenza hospitalizations during the same period. Subgroup analysis was performed by time from ALL diagnosis and by age category.

RESULTS

The rate of influenza-related hospitalizations was 618.3 per 100 000 person-months. Rates were similar by time from ALL diagnosis and across age categories. Overall attributable in-hospital mortality was 1.0% (95% confidence interval [CI], 0.3%-2.3%) and was highest for children <6 months from diagnosis (1.6%; 95% CI, 0.4%-4.5%) and children <2 years of age (6.7%; 95% CI, 1.3%-22.7%). Total length of stay, days of broad-spectrum antibiotic exposure, and duration of intensive care were significantly greater for influenza-related hospitalizations compared with noninfluenza hospitalizations.

CONCLUSIONS

The burden of influenza-related hospitalizations in children with ALL is high and associated with significantly increased resource utilization and attributable mortality.

Febrile seizures after 2009 influenza A (H1N1) vaccination and infection: a nationwide registry-based study

Background

During the 2009 influenza A (H1N1) pandemic, a monovalent pandemic strain vaccine containing the oil-in-water adjuvant AS03 (Pandemrix®) was offered to the Norwegian population. The coverage among children reached 54 %. Our aim was to estimate the risk of febrile seizure in children after exposure to pandemic influenza vaccination or infection.

Methods

The study population comprised 226,889 children born 2006–2009 resident in Norway per October 1st, 2009. Febrile seizure episodes were defined by emergency hospital admissions / emergency outpatient hospital care with International Classification of Diseases, Version 10, codes R56.0 or R56.8. The self-controlled case series method was applied to estimate incidence rate ratios (IRRs) in pre-defined risk periods compared to the background period. The total observation window was ± 180 days from exposure day. Among 113,068 vaccinated children, 656 (0.6 %) had at least one febrile seizure episode.

Results

The IRR of febrile seizures 1–3 days after vaccination was 2.00 (95 % confidence interval [CI]: 1.15–3.51). In the period 4–7 days after vaccination, no increased risk was observed. Among the 8172 children diagnosed with pandemic influenza, 84 (1.0 %) had at least one febrile seizure episode. The IRR of febrile seizures on the same day as a diagnosis of influenza was 116.70 (95 % CI: 62.81–216.90). In the period 1–3 days after a diagnosis of influenza, a tenfold increased risk was observed (IRR 10.12, 95 % CI: 3.82 – 26.82).

Conclusions

In this large population-based study with precise timing of exposures and outcomes, we found a twofold increased risk of febrile seizures 1–3 days after pandemic influenza vaccination. However, we found that pandemic influenza infection was associated with a much stronger increase in risk of febrile seizures.

Clinical Endpoints for Respiratory Syncytial Virus Prophylaxis Trials in Infants and Children in High-income and Middle-income Countries

Respiratory syncytial virus (RSV) continues to cause significant clinical and economic burden around the world. Historically, RSV-associated hospitalization was used as a primary endpoint for RSV prophylaxis trials in infants. However, because of the changing epidemiology and healthcare system landscape, this endpoint has become a critical bottleneck on the pathway to licensure for new therapeutics. A panel of 7 RSV experts was convened (Chicago, IL, May 22, 2014) to evaluate the challenges of defining RSV prevention endpoints for clinical trials and to develop endpoints that are clinically meaningful while minimizing subjectivity and bias to achieve sufficient consistency of response for regulatory approval. Particular consideration was given to the ability to collect data systematically and consistently in countries with different healthcare practices and systems, while capturing the greatest proportion of disease impact. The group consensus was that a clinically meaningful primary endpoint could include medically attended RSV illness in settings beyond RSV-associated hospitalizations alone, in particular, a composite reduction in hospitalization, emergency room or urgent care center visits because of an RSV respiratory infection. Relevant secondary endpoints included reductions in RSV lower respiratory tract infection, RSV-related intensive care unit rates, subsequent recurrent wheezing or asthma and direct and indirect costs.

The ESPID/ESWI Joint Symposium - A strong vote for universal influenza vaccination in children in Europe

During this year's 33rd annual meeting in Leipzig, Germany, the European Society of Paediatric Infectious Diseases (ESPID) jointly together with the European Scientific Working group on Influenza (ESWI), organized a staged debate on the motion of universal annual immunization of children against influenza as a cost-effective health intervention in Europe. Six invited speakers, all experts in the field of influenza vaccination, who were not necessary confident with their given position of pro or contra, battled each other with short oral presentations to convince the audience to vote for or against the motion.

Advax delta inulin adjuvant overcomes immune immaturity in neonatal mice thereby allowing single-dose influenza vaccine protection

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A single dose of Advax-adjuvanted influenza vaccine in 7-day-old pups protected against lethal influenza infection.

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Advax adjuvant enhanced both B-cell and T-cell memory in neonates.

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Influenza protection in Advax-immunized neonates was dependent on memory B-cells.

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Advax adjuvant confirmed to be safe and well tolerated in neonates.

Neonates are at high risk for influenza morbidity and mortality due to immune immaturity and lack of priming by prior influenza virus exposure. Inactivated influenza vaccines are ineffective in infants under six months and to provide protection in older children generally require two doses given a month apart. This leaves few options for rapid protection of infants, e.g. during an influenza pandemic. We investigated whether Advax™, a novel polysaccharide adjuvant based on delta inulin microparticles could help overcome neonatal immune hypo-responsiveness. We first tested whether it was possible to use Advax to obtain single-dose vaccine protection of neonatal pups against lethal influenza infection. Inactivated influenza A/H1N1 vaccine (iH1N1) combined with Advax™ adjuvant administered as a single subcutaneous immunization to 7-day-old mouse pups significantly enhanced serum influenza-specific IgM, IgG1, IgG2a and IgG2b levels and was associated with a 3–4 fold increase in the frequency of splenic influenza-specific IgM and IgG antibody secreting cells. Pups immunized with Advax had significantly higher splenocyte influenza-stimulated IFN-γ, IL-2, IL-4, and IL-10 production by CBA and a 3–10 fold higher frequency of IFN-γ, IL-2, IL-4 or IL-17 secreting T cells by ELISPOT. Immunization with iH1N1 + Advax induced robust protection of pups against virus challenge 3 weeks later, whereas pups immunized with iH1N1 antigen alone had no protection. Protection by Advax-adjuvanted iH1N1 was dependent on memory B cells rather than memory T cells, with no protection in neonatal μMT mice that are B-cell deficient. Hence, Advax adjuvant overcame neonatal immune hypo-responsiveness and enabled single-dose protection of pups against otherwise lethal influenza infection, thereby supporting ongoing development of Advax™ as a neonatal vaccine adjuvant.

Fatal Fulminant Pneumonia Caused by Methicillin-Sensitive Staphylococcus aureus Negative for Major High-Virulence Factors Following Influenza B Virus Infection

Patient: Male, 32

Final Diagnosis: MSSA pneumonia

Symptoms: Cough • dyspnea • fever

Medication: Meropenem • levofloxacin • vancomycin • peramivir

Clinical Procedure: Diagnosed based on CT images • sputum culture • PCR

Specialty: Infectious Diseases

ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Influenza vaccination in children with neurologic or neurodevelopmental disorders

BACKGROUND

Children with neurologic or neurodevelopmental disorders (NNDDs) are at increased risk of complications from influenza. Although the Advisory Committee on Immunization Practices (ACIP) has recognized NNDDs as high-risk conditions for influenza complications since 2005, little is known about influenza vaccination practices in this population.

METHODS

CDC collaborated with Family Voices, a national advocacy group for children with special healthcare needs, to recruit parents of children with chronic medical conditions. Parents were surveyed about their knowledge, attitudes, and practices surrounding influenza vaccination. The primary outcome of interest was parental report of vaccination, or intent to vaccinate, at the time of survey participation. CDC also collaborated with the American Academy of Pediatrics to recruit primary care and specialty physicians who provide care for high-risk children, specifically those with neurologic conditions. The primary outcome was physician recognition of ACIP high-risk influenza conditions.

RESULTS

2138 surveys were completed by parents of children with high-risk conditions, including 1143 with at least one NNDD. Overall, 50% of children with an NNDD were vaccinated, or their parents planned to have them vaccinated against influenza. Among all 2138 children, in multivariable analysis, the presence of a respiratory condition and prior seasonal influenza vaccination was significantly associated with receipt or planned current season influenza vaccination, but the presence of an NNDD was not. 412 pediatricians completed the provider survey. Cerebral palsy was recognized as a high-risk influenza condition by 74% of physician respondents, but epilepsy (51%) and intellectual disability (46%) were less commonly identified.

CONCLUSIONS

Our estimates of influenza vaccination in children with NNDDs are comparable to published reports of vaccination in healthy children, which continue to be suboptimal. Education of parents of children with NNDDs and healthcare providers about influenza and the benefit of annual influenza vaccination is needed.

Seasonal influenza vaccination rates and reasons for non-vaccination in children with gastrointestinal disorders

OBJECTIVES

Despite advances in the treatment and prevention of influenza, it is still considered an important cause of morbidity and mortality worldwide. Annual vaccination is the safest and most effective mean of prevention. Our study aims were to explore the uptake of influenza vaccination among children with gastrointestinal disorders, and to characterize non-adherent patients.

METHODS

The present cross-sectional study included parents of pediatric patients attending the Gastroenterology Institute at Schneider Children's Medical Center of Israel between September and October 2011. Parents were asked to complete a questionnaire concerning demographic and clinical parameters, influenza vaccination of the child, and reasons for not vaccinating the child, when appropriate.

RESULTS

The study population included 273 patients (50% female), with a median age of 10 years (range, 2-18 years). Overall, the rate of seasonal influenza vaccination was 30.8%. Higher rates were found among immunosuppressed patients (46.1%), and in patients with inflammatory bowel disease (50%). There was no significant effect of patient age, gender, ethnic origin or parental level of education on the vaccination rate. Vaccination rates were significantly associated with parents' information and knowledge of, as well as their personal beliefs regarding the vaccine (P<0.001).

CONCLUSIONS

Influenza vaccination rates are relatively low in the pediatric population attending gastroenterology clinics, in both high- and low-risk groups. The importance of parental knowledge in compliance with influenza vaccination of children should prompt general pediatricians and gastroenterologists to discuss and address the common misconceptions regarding the vaccine.

Safety and efficacy of peramivir for influenza treatment

Objective

This report presents a review of the efficacy and safety of peramivir, a neuraminidase inhibitor that was granted Emergency Use Authorization by the US Food and Drug Administration (FDA) from October 23, 2009 to June 23, 2010 during the 2009 H1N1 pandemic.

Methods

Literature was accessed via PubMed (January 2000–April 2014) using several search terms: peramivir; BCX-1812; RWJ 270201; H1N1, influenza; antivirals; and neuraminidase inhibitors. The peramivir manufacturers, Shionogi and Co Ltd and BioCryst Pharmaceuticals, were contacted to obtain unpublished data and information presented at recent scientific meetings. Information was obtained from the Centers for Disease Control and Prevention (CDC) and from US FDA websites. English-language and Japanese-language reports in the literature were reviewed and selected based on relevance, along with information from the CDC, US FDA, and the drug manufacturers.

Results

We obtained eleven clinical trial reports of intravenous peramivir, two of which described comparisons with oseltamivir. Seven of nine other recently reported published studies was a dose–response study. Clinical reports of critically ill patients and pediatric patients infected with pandemic H1N1 described that early treatment significantly decreased mortality. Peramivir administered at 300 mg once daily in adult patients with influenza significantly reduces the time to alleviation of symptoms or fever compared to placebo. It is likely to be as effective as other neuraminidase inhibitors.

Conclusion

Although peramivir shows efficacy for the treatment of seasonal and pH1N1 influenza, it has not received US FDA approval. Peramivir is used safely and efficiently in hospitalized adult and pediatric patients with suspected or laboratory-confirmed influenza. Peramivir might be a beneficial alternative antiviral treatment for many patients, including those unable to receive inhaled or oral neuraminidase inhibitors, or those requiring nonintravenous drug delivery.

The role of multiplex PCR in respiratory tract infections in children

BACKGROUND

Infants, toddlers, and children of primary-school age without any special risk factors generally have three to ten febrile respiratory infections per year. Most such infections are of viral origin and self-limiting, but viral infection is often hard to distinguish from bacterial infection. The use of a multiplex polymerase chain reaction (PCR) to detect viruses in respiratory secretions is potentially beneficial, as it might help physicians avoid giving antibiotics unnecessarily.

METHOD

This article is based on a selective review of the literature and on the findings of the authors' own investigations.

RESULTS

Multiplex PCR is a highly sensitive, highly specific test for the detection of viral nucleic acids in respiratory secretions. If PCR reveals the presence of RNA derived from respiratory syncytial virus, human metapneumovirus, parainfluenza virus, or influenza virus, then an acute infection caused by the corresponding pathogen is probably present, and further treatment can be given accordingly. On the other hand, the nucleic acids of adeno-, boca-, rhino- or coronaviruses can be found in relatively trivial infections as well as in asymptomatic persons, probably reflecting either a prior infection or a current subclinical one. For children in particular, upper respiratory infections are so common in the winter months that acute and prior infections with these pathogens cannot be distinguished by multiplex PCR. The use of multiplex PCR in children has not been shown to shorten hospital stays or to lessen antibiotic consumption or overall cost.

CONCLUSION

The detectability of viral nucleic acids is an important contribution to the diagnostic assessment of children with severe respiratory infection. For these highly sensitive diagnostic tests to be used optimally, primary viral infections must be distinguished from bacterial superinfections.

Severe complications in influenza-like illnesses

OBJECTIVE

Data on complications from upper respiratory infection are limited. We examined development of severe complications in children presenting to the emergency department (ED) for moderate to severe influenza-like illness (ILI).

METHODS

Prospective cohort study of children 0 to 19 years presenting to a tertiary care children's hospital ED during peak respiratory viral seasons from 2008 to 2010. Subjects included had moderate to severe ILI, defined by performance of venipuncture and nasopharyngeal multiplex polymerase chain reaction for respiratory viruses. Severe complications (respiratory failure, encephalopathy, seizures, pneumonia, bacteremia, death) were prospectively determined. Risk factors for severe complications were collected, including demographics, comorbidities, and household exposures.

RESULTS

There were 241 enrolled subjects with median age of 27.4 months (interquartile range 8.9-68.5); 59.3% were boys and 48.5% were black. High-risk conditions were present in 53.5%. Severe complications developed in 35.3% (95% confidence interval [CI] 29.3-41.3), most frequently pneumonia (26.1%). The risk for severe complications was increased in subjects with neurologic or neuromuscular conditions (relative risk 4.0; 95% CI 1.9-8.2). No specific respiratory virus was associated with development of severe complications. Among patients with influenza, severe complications were greater with subtype H1N1 infection (relative risk 1.45, 95% CI 0.99-2.13, P = .048), and were at highest risk for pneumonia (relative risk 4.2, 95% CI 1.2-15.9).

CONCLUSION

In children presenting to the ED for moderate to severe ILI, those with neurologic and neuromuscular disease are at increased risk for severe complications. Development of severe complications did not differ by infecting virus; however, risk of severe complications was greater with subtype H1N1 compared with other influenza.

Influenza vaccination and treatment in children with neurologic disorders

Influenza viruses cause substantial morbidity in children each year, especially among children with specific chronic conditions. In particular, neurologic disorders have emerged as a strong risk factor for influenza-related complications. Children with these disorders may be vulnerable due to diminished respiratory muscle strength, decreased muscle tone or impaired mobility, which can compromise pulmonary function and the ability to handle secretions. Although they represent a small fraction of the general pediatric population, children with neurologic disorders make up a disproportionately high number of those children who are hospitalized and die as a result of influenza-associated complications. Annual vaccination is the most effective way to prevent influenza and its complications, and is recommended for all children 6 months through 18 years of age, including children with neurologic disorders. Family members and those who work with these children in institutional, educational and daycare settings should also be vaccinated against influenza annually. However, there have been few studies of influenza vaccination specifically in this population. In addition, vaccine effectiveness may vary from year to year and vaccination will not prevent all infections. Early empiric antiviral treatment should be started promptly in these children if they present to healthcare providers with symptoms suspicious for influenza. This article reviews influenza epidemiology in children with neurologic disorders and what is known about vaccines and other methods of protecting this vulnerable population from influenza-related complications.

Estimated paediatric mortality associated with influenza virus infections, United States, 2003–2010

Death certificate reports and laboratory-confirmed influenza deaths probably underestimate paediatric deaths attributable to influenza. Using US mortality data for persons aged <18 years who died during 28 September 2003 to 2 October 2010, we estimated influenza-attributable deaths using a generalized linear regression model based on seasonal covariates, influenza-certified deaths (deaths for which influenza was a reported cause of death), and occurrence during the 2009 pandemic period. Of 32 783 paediatric deaths in the death categories examined, 853 (3%) were influenza-certified. The estimated number of influenza-attributable deaths over the study period was 1·8 [95% confidence interval (CI) 1·3–2·8] times higher than the number of influenza-certified deaths. Influenza-attributable deaths were 2·1 (95% CI 1·5–3·4) times higher than influenza-certified deaths during the non-pandemic period and 1·1 (95% CI 1·0–1·8) times higher during the pandemic. Overall, US paediatric deaths attributable to influenza were almost twice the number reported by death certificate codes in the seasons prior to the 2009 pandemic.