Influenza vaccine recommendations for children and youth for the 2012/2013 season

This practice point updates previous recommendations for the use of influenza vaccine in children to reflect recent recommendations from the National Advisory Committee on Immunization (NACI). Starting with the 2012/2013 season, influenza vaccine is being recommended for all children aged 24 to 59 months, an age group not included in previous NACI recommendations, as well as for their household contacts and out-of-home caregivers (1). Children this age carry a significant burden of influenza illness and influenza-associated medical visits and hospitalizations. Also, they are efficient transmitters of influenza, and vaccination may help to protect other high-risk groups who may themselves be too young to be vaccinated or who may not respond well to the vaccine. The Canadian Paediatric Society encourages annual influenza vaccination for ALL children and youth six months of age and older. When this is not practical, priority should be given to individuals at high risk of influenza-related complications and to those capable of transmitting infection to individuals at high risk of complications. These groups include the following: Children six to 59 months of age Children and youth with chronic health conditions (severe enough to require regular medical follow-up or hospital care), specifically: – cardiac or pulmonary disorders including bronchopulmonary dysplasia, cystic fibrosis, asthma or conditions that result in an increased risk of aspiration – diabetes mellitus or other metabolic disease, renal disease, anemia or hemoglobinopathy – cancer, immunodeficiency, or immune suppression due to disease or therapy – morbid obesity (body mass index ≥40) – chronic conditions currently being treated with acetylsalicylic acid Aboriginal children Children who are residents of chronic care facilities Pregnant women, including adolescents, in all trimesters (for their own protection and to protect their newborn infants) Those in contact with children at risk, specifically: – household contacts (adults and children), whether or not the individual at risk has been immunized – household contacts of infants less than six months of age (these infants are at high risk but are too young to receive influenza vaccine) – members of a household expecting a newborn during influenza season – those providing regular child care to children younger than 59 months of age, whether in or out of the home – health care and other care providers in facilities and community settings Two of the three antigenic components of the influenza vaccine are different from last year’s vaccine because of changes in the predominant circulating strains. Although some vaccinated individuals may retain immunity from one season to the next, this is less likely when strain changes occur. It is, therefore, recommended that everyone be revaccinated each year, even those who have received vaccine or had documented influenza in the previous year (1). Two types of influenza vaccines are available for children in Canada: trivalent inactivated influenza vaccines (TIV) for intramuscular injection and an intranasal, live attenuated influenza vaccine (LAIV). LAIV (FluMist, MedImmune, USA) is authorized for use in individuals two to 59 years of age (2). It is not licensed for children under two old because of a small but significant increased rate of wheezing two to four weeks following vaccination in this age group. Studies demonstrate a significantly superior efficacy of LAIV over TIV against laboratory-confirmed influenza in healthy children. NACI recommends preferential use of LAIV for healthy children and youth two to 17 years of age, recognizing that programmatic considerations may impact the implementation of this recommendation in publicly funded programs. There is insufficient evidence to recommend LAIV preferentially over TIV in children with chronic health conditions; either vaccine may be used unless there are contraindications. In adults, there is some evidence that TIV may be more efficacious than LAIV. NACI states that either TIV or LAIV may be used for healthy adults, but that adults with chronic health conditions should receive TIV until there is more data on the use of LAIV in this group. The most common side effects of LAIV in children and adults are transient nasal congestion and rhinorrhea. LAIV is contraindicated for persons with immune-compromising conditions, severe asthma (defined as active wheezing, currently on oral or high-dose inhaled glucocorticosteriods, or medically attended wheezing within the previous seven days) and in pregnancy. It is also contraindicated in children and adolescents two to 17 years of age receiving chronic aspirin-containing therapy because of the association of Reye’s syndrome with aspirin and influenza infection. LAIV should not be administered until 48 hours after antiviral agents active against influenza have been discontinued. If an antiviral agent must be given within the two weeks after receipt of LAIV, another dose of vaccine should given be at least 48 hours after discontinuation of therapy. For persons with nasal congestion sufficient to impede the appropriate delivery of LAIV, vaccination should be deferred until the congestion has resolved or TIV given. The first year that a child younger than nine years of age receives influenza vaccine (either TIV or LAIV), two doses at least four weeks apart are required. If a child younger than nine years of age received at least one dose of influenza vaccine in the past, only one dose is required this season. Children nine years of age and older and adults require only one dose each year. As of the 2011/2012 influenza season, NACI recommends that children six to 35 months of age receive 0.5 mL per dose of TIV (as used in older children and adults) rather than the 0.25 mL per dose previously recommended. The rationale for this change was demonstration of improved immunity without any increase in adverse effects with the larger dose (3). The dose of LAIV, regardless of age, is 0.1 mL administered in each nostril. Influenza vaccine dosage information is shown in Table 1. Influenza vaccine dosage information by age Children <9 years of age: no previous influenza vaccine: two doses at least four weeks apart; any previous influenza vaccine: one dose annually. Children ≥9 years of age: one dose annually. TIV: Trivalent inactivated influenza vaccine; LAIV: Live attenuated influenza vaccine. See reference 1, for further details (brand names, constituents, etc) Influenza vaccine dosage information by age Children <9 years of age: no previous influenza vaccine: two doses at least four weeks apart; any previous influenza vaccine: one dose annually. Children ≥9 years of age: one dose annually. TIV: Trivalent inactivated influenza vaccine; LAIV: Live attenuated influenza vaccine. See reference 1, for further details (brand names, constituents, etc) Egg allergy is not a contraindication to the use of influenza vaccine. For safe administration of influenza vaccine to patients with an egg allergy, please see the Canadian Paediatric Society’s position statement on this subject at www.cps.ca/en/documents/position/influenza-vaccines-in-children-with-egg-allergy (4). Paediatricians and other physicians caring for children have important roles in promoting influenza vaccination and in increasing the acceptance of influenza vaccine by helping families recognize the potential severity of influenza infection in children and the efficacy and safety of vaccination.

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