AAP/CDC: New Guidance On For Antibiotics For Children

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As the graphic above shows, there is considerable geographic disparity in the amount of antibiotics being prescribed across this country, with doctors some parts of the country being much quicker write ABx scripts than doctors in other regions.

 

In an attempt to bring some sensible level of standardization to the prescribing these drugs – and in so doing, hopefully reduce the creation and spread of antibiotic resistant bacteria - the American Academy of Pediatrics (AAP) and the CDC have produced a new set of guidelines for doctors to encourage  the judicious use of antibiotics when treating children with suspected bacterial infections.

 

First, some excerpts from the CDC’s press release, and then a link to the article in the journal Pediatrics.

 

New guidance limits antibiotics for common infections in children

Get Smart About Antibiotics Week 2013 calls for responsible antibiotic prescribing

Every year as many as 10 million U.S. children risk side effects from antibiotic prescriptions that are unlikely to help their upper respiratory conditions. Many of these infections are caused by viruses, which are not helped by antibiotics.

This overuse of antibiotics, a significant factor fueling antibiotic resistance, is the focus of a new report Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics by the American Academy of Pediatrics (AAP) in collaboration with the Centers for Disease Control and Prevention (CDC).

Released today during Get Smart About Antibiotics Week, the report amplifies recent AAP guidance and promotes responsible antibiotic prescribing for three common upper respiratory tract infections in children: ear infections, sinus infections, and sore throats.

Antibiotic resistance occurs when bacteria evolve and are able to outsmart antibiotics, making even common infections difficult to treat. According to a landmark CDC report from September 2013, each year more than two million Americans get infections that are resistant to antibiotics and 23,000 die as a result.

For Clinicians:

3 Principles of Responsible Antibiotic Use

1. Determine the likelihood of a bacterial infection: Antibiotics should not be used for viral diagnoses when a concurrent bacterial infection has been reasonably excluded.
2. Weigh benefits versus harms of antibiotics: Symptom reduction and prevention of complications and secondary cases should be weighed against the risk for side effects and resistance, as well as cost.
3. Implement accurate prescribing strategies: Select an appropriate antibiotic at the appropriate dose for the shortest duration required.

“Our medicine cabinet is nearly empty of antibiotics to treat some infections,” said CDC Director Tom Frieden, M.D., M.P.H.  “If doctors prescribe antibiotics carefully and patients take them as prescribed we can preserve these lifesaving drugs and avoid entering a post-antibiotic era.”

By providing detailed clinical criteria to help physicians distinguish between viral and bacterial upper respiratory tract infections, the recommendations provide guidance for physicians that will improve care for children. At the same time, it will help limit antibiotic prescriptions, giving bacteria fewer chances to become resistant and lowering children’s risk of side effects.

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The entire 11 page PDF is available online from the American Academy of Pediatrics (see link below).  The authors describe this guidance:

 

This clinical report focuses on antibiotic prescribing for key pediatric URIs that, in certain instances, may benefit from antibiotic therapy: AOM, acute bacterial sinusitis, and  pharyngitis. The specific recommendations are applicable to healthy children who do not have underlying medical conditions (eg, immunosuppression) placing themat increased risk of developing serious complications. The purpose of this report is to provide practitioners specific context using the most current recommendations and guidelines while applying 3 principles of judicious antibiotic use: (1) determination of the likelihood of a bacterial infection, (2) weighing the benefits and harms of antibiotics, and (3) implementing judicious prescribing strategies.

 

Follow the link to read and download the entire report:

 

Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics

Adam L. Hersh, Mary Anne Jackson, Lauri A. Hicks and the COMMITTEE ON INFECTIOUS DISEASES

DOI: 10.1542/peds.2013-3260 ; originally published online November 18, 2013; Pediatrics

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260

 

For more on this week’s focus on better stewardship of our antibiotic arsenal, you may wish to visit these recent blogs:

 

Surviving Winter’s Ills Without Abusing Antibiotics

The Lancet: Antibiotic Resistance - The Need For Global Solutions

ECDC: Antibiotic Resistance In the EU – 2012

Pediatrics: Influenza-Associated Pediatric Deaths

 

Credit CDC FluView

 

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Since reporting became mandatory in 2004, yearly pediatric influenza deaths have ranged from a low of 35 during the 2011-2012 flu season to a high of 282 during the 2009—2010 pandemic. The number of flu-related pediatric deaths displayed in the chart above is likely under stated since only those patients who are tested for influenza, test positive, and then are subsequently reported to the CDC are counted. 

 

In the aftermath of the H1N1 pandemic of 2009, the CDC estimated that the likely number of pediatric deaths in the United States ranged from 910 to 1880, or anywhere from 3 to 6 times higher than reported.

 

Regardless of the true number, influenza exacts a tragic toll each year among children in the United States (and around the world).

 

Today, scientists from the Influenza Division and Epidemic Intelligence Service of the Centers for Disease Control and Prevention (CDC) have published a review of pediatric deaths related to influenza infection over the past 8 years in the Journal Pediatrics.

 

Influenza-Associated Pediatric Deaths in the United States, 2004–2012

Karen K. Wong, MD, MPH, Seema Jain, MD, Lenee Blanton, MPH, Rosaline Dhara, MPH, Lynnette Brammer, MPH, Alicia M. Fry, MD, MPH, and Lyn Finelli, DrPH

ABSTRACT (Excerpts)

RESULTS: From October 2004 through September 2012, 830 pediatric influenza–associated deaths were reported. The median age was 7 years (interquartile range: 1–12 years). Thirty-five percent of children died before hospital admission. Of 794 children with a known medical history, 43% had no high-risk medical conditions, 33% had neurologic disorders, and 12% had genetic or chromosomal disorders. Children without high-risk medical conditions were more likely to die before hospital admission (relative risk: 1.9; 95% confidence interval: 1.6–2.4) and within 3 days of symptom onset (relative risk: 1.6; 95% confidence interval: 1.3–2.0) than those with high-risk medical conditions.

CONCLUSIONS: Influenza can be fatal in children with and without high-risk medical conditions. These findings highlight the importance of recommendations that all children should receive annual influenza vaccination to prevent influenza, and children who are hospitalized, who have severe illness, or who are at high risk of complications (age <2 years or with medical conditions) should receive antiviral treatment as early as possible.

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We’ve looked at other studies on influenza in pediatric patients in recent years, including:

 

BMJ: Risk Factors For Children With Pandemic Flu which identified some predictors of severe H1N1 infection and potentially fatal outcomes in children:

• History of chronic lung disease
• History of cerebral palsy/developmental delay
• Signs of chest retractions (difficulty breathing)
• Signs of dehydration
• Requires oxygen to keep blood levels normal
• Heart rate that exceeds normal range (tachycardia) relative to age

 

A report from last spring from the CDC: About 90% Of Pediatric Flu Fatalities Were Unvaccinated in the 2012-2013 flu season (to that date).

 

And yet another study in the Journal Pediatrics from August of 2012 (see Study: Kids, Underlying Conditions, And The 2009 Pandemic Flu) that found a high number of fatalities among kids with underlying neurologic conditions.

 

And lastly, in 2011 in MMWR: Influenza-Associated Pediatric Deaths 2010-2011 we looked at the first non-pandemic flu season after the end of the 2009 pandemic.  As with today’s study, they found just under half (49%) of these pediatric deaths occurred in children who had no ACIP defined high risk medical conditions. These children also saw a shorter interval between illness onset and death (4 days versus 7 days), and were more likely to die at home or in the emergency department.

 

While the flu vaccine admittedly delivers lower protection – particularly among the elderly – than we’d like, among children its effectiveness appears higher.  CIDRAP’s 2011 meta-analysis (see CIDRAP: A Comprehensive Flu Vaccine Effectiveness Meta-Analysis) found:

 

TIV showed efficacy in preventing influenza during 8 of 12 flu seasons (67%) with a combined efficacy of 59% among healthy adults (aged 18–65 years).

And among children aged 2-7, the LAIV proved even more protective, showing efficacy in 9 out of 12 flu seasons (75%) with a pooled efficacy of 83%. 

 

Last year, the the CDC has estimated flu vaccine effectiveness in children at 64% (aged 6 months to 17 years old).  While lower than hoped for, this is still a moderate level of protection.   Which is why the CDC states:

 

CDC recommends annual flu vaccination as the first and best step in preventing influenza. CDC recommends antiviral drugs as a second line of defense against flu for those people who are seriously ill and those who are at high risk of flu complications, even if they have been vaccinated.

 

To this I would add rigorous `flu hygiene’ – particularly during the flu season, but applicable year round; frequent handwashing, avoiding touching your face, covering coughs & sneezes, and staying home if sick.  For the latest updated information from the CDC about the current flu season, you may wish to visit:

 

What You Should Know for the 2013-2014 Influenza Season

BMJ: Risk Factors For Children With Pandemic Flu

 

The chart above (Aug 2012) illustrates the sharp rise in pediatric deaths from flu-related complications during the 2009-2010 H1N1 pandemic seasons in the United States.

 

# 7571

 

 

The BMJ has published this week research from an international team of medical scientists who looked at presenting symptoms and comorbidities of 265 pediatric cases from 79 emergency rooms in 12 countries presenting with the H1N1 pandemic flu. 

 

The team was able to identify several factors that they could associate with a higher risk of severe infection, complications, or death.

 

It is hoped that these findings could help guide physician decisions on treatment of children, or their admission to the hospital, in future influenza outbreaks.

 

First a link to the study (which is available, in full, online) then some excerpts from a news release from the University of Auckland.

 

Research

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4836 (Published 12 August 2013)

Cite this as: BMJ 2013;347:f4836

Stuart R Dalziel, paediatrician, John MD Thompson, senior research fellow, Charles G Macias, associate professor, Ricardo M Fernandes, paediatrician4, David W Johnson, professor, Yehezkel Waisman, professor, Nicholas Cheng, paediatrician, Jason Acworth, paediatrician, James M Chamberlain, professor, Martin H Osmond, professor, Amy Plint, associate professor, Paolo Valerio, paediatrician, Karen JL Black, paediatrician, Eleanor Fitzpatrick, research coordinator, Amanda S Newton, assistant professor, Nathan Kuppermann, professor, Terry P Klassen, professor for the Pediatric Emergency Research Networks (PERN) H1N1 working group

Abstract

(EXCERPT)

Main outcome measures Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios.

 

Results 151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age).

Conclusion These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.

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The news release from the University of Auckland provides some additional background on this study.

 

Top risk factors identified for children during influenza pandemics

14 August 2013

Auckland medical scientists have helped to identify crucial risk factors for children most susceptible to life threatening infections from the H1N1 influenza virus.

 

Lead study author Dr Stuart Dalziel and senior research fellow Dr John Thompson from The University of Auckland worked with an international team of paediatric specialists to identify the risk factors.

 

It is the first study to detail which clinical factors in children at hospital arrival with influenza-like illness and H1N1 infection, are associated with the progressive risk to either severe infection or death.

<SNIP>

The study, which assessed each patient’s clinical history and physical examination, identified the following predictors of severe H1N1 infection and potentially fatal outcomes in children:

• History of chronic lung disease
• History of cerebral palsy/developmental delay
• Signs of chest retractions (difficulty breathing)
• Signs of dehydration
• Requires oxygen to keep blood levels normal
• Heart rate that exceeds normal range (tachycardia) relative to age

“Having a more accurate idea of what to look for in paediatric cases, especially during a pandemic, would be especially important to clinicians because it provides crucial guidance for those who would be trying to direct the appropriate levels of treatment for many patients in a short time,” said one of the study’s co-authors Nathan Kuppermann, professor and chair of emergency medicine at the University of California.

(Continue . . . )

 

We’ve seen earlier studies on the impact of the 2009 H1N1 pandemic on children, some of which have produced similar findings.

 

Study: Kids, Underlying Conditions, And The 2009 Pandemic Flu

Lancet: Pediatric Mortality Related To Pandemic H1N1

Study: Pediatric Neurological Complications With H1N1

 

While it is axiomatic that - `if you’ve seen one flu pandemic . . . you’ve seen one flu pandemic’ - many of the lessons learned from the last pandemic are still likely to prove useful during the next global health crisis.

 

Even if the next pandemic differs substantially from what we went through in 2009.

CDC: About 90% Of Pediatric Flu Fatalities Were Unvaccinated

 

 

 

# 7023

 

While we’ve seen less than sterling flu vaccine effectiveness (VE) numbers over the past few years (see CIDRAP: A Comprehensive Flu Vaccine Effectiveness Meta-Analysis) and downright disappointing results this year among seniors – (see Helen Branswell’s article Flu shot gave minimal help to seniors), the effectiveness of the vaccine has generally been better for kids.

 

The CIDRAP meta-analysis published in 2011 found:

 

TIV showed efficacy in preventing influenza during 8 of 12 flu seasons (67%) with a combined efficacy of 59% among healthy adults (aged 18–65 years).

And among children aged 2-7, the LAIV proved even more protective, showing efficacy in 9 out of 12 flu seasons (75%) with a pooled efficacy of 83%. 

 

This year, the the CDC has estimated flu vaccine effectiveness in children at 64% (aged 6 months to 17 years old).  While lower than hoped for, this is still a moderate level of protection. 

 

Today we learn that of the 105 pediatric deaths reported thus far during this flu season, roughly 90% were unvaccinated.

 

 

CDC FLuView  Week 11

 

As the chart above shows – after an unusually mild 2011-2012 flu season – we are once again seeing a `normal’ number of pediatric flu fatalities.

 

This from the CDC.

 

CDC Reports About 90 Percent of Children Who Died From Flu This Season Not Vaccinated

March 22, 2013 – The number of influenza-associated pediatric deaths reported to CDC during the current season surpassed 100 this week as an additional 6 deaths were reported in FluView. This brings the total number of influenza-associated pediatric deaths reported to CDC, to date, to 105 for the 2012-2013 season.

 

Pediatric deaths are defined as flu-associated deaths that occur in people younger than 18 years. An early look at this season’s reports indicates that about 90 percent occurred in children who had not received a flu vaccination this season.

 

This review also indicated that 60 percent of deaths occurred in children who were at high risk of developing serious flu-related complications, but 40 percent of these children had no recognized chronic health problems. The proportions of pediatric deaths occurring in children who were unvaccinated and those who had high-risk conditions are consistent with what has been seen in previous seasons.

 

Children younger than 5 years of age and children of any age with certain chronic health conditions, including asthma or other lung disorders, heart disease, or a neurologic or neurodevelopmental disorder are at high risk of developing serious complications from flu infection.

 

CDC began tracking flu-associated pediatric deaths after the 2003-2004 flu season – a season that, like the current flu season, started early and was intense. In addition, it took a high toll on children. In the 2003-2004 season, 153 pediatric deaths were reported to CDC from 40 states. Flu-associated pediatric deaths became nationally reportable the following season. Since that time, reported pediatric deaths during regular influenza seasons have ranged from 34 deaths (during 2011-2012) to 122 deaths (during 2010-2011). However, during the 2009 H1N1 influenza pandemic, which lasted from April 15, 2009 to October 2, 2010, 348 pediatric deaths were reported to CDC.

 

Annual influenza vaccination has been recommended for all children 6 months to 18 years of age since the 2008-2009 influenza season. (Universal vaccination – or vaccination across all age groups – was implemented during 2010-2011.) While vaccination rates among children have risen slightly since that time, they remain relatively low.

 

According to CDC survey data, only about 40 percent of children had received a 2012-2013 influenza vaccine by mid-November of 2012. The final estimated vaccination rate among children during the 2011-2012 season was 52 percent.

 

Across all age groups, this season’s vaccine was found to be about 60 percent effective in preventing medically attended influenza illness. This number was lower among people 65 and older, but flu vaccination reduced a child’s risk of having to go to the doctor because of flu by more than 60 percent.

 

CDC recommends annual flu vaccination as the first and best step in preventing influenza. CDC recommends antiviral drugs as a second line of defense against flu for those people who are seriously ill and those who are at high risk of flu complications, even if they have been vaccinated.

 

The March 22 FluView also highlights that while influenza activity is declining in the United States, it is ongoing in much of the country. Learn more about protecting children against flu by visiting CDC’s website at Flu Information for Parents with Young Children. For more information about pediatric deaths in the United States, see CDC’s FluView Interactive tool.

Study: Kids, Underlying Conditions, And The 2009 Pandemic Flu

Credit CDC FluView

 

# 6522

 

The chart above illustrates the sharp rise in pediatric deaths from flu-related complications during the 2009-2010 H1N1 pandemic seasons in the United States.  As grim as this charts is, it probably doesn’t fully represent the burden the 2009 pandemic placed on the pediatric community.

 

In another chart, again from the CDC, we get an estimate of deaths related to the 2009 pandemic, broken down by age groups through April of 2010.

 

 

While just over 300 pediatric deaths were recorded during this time period, the CDC estimates that 4 times (n=1280) that many children likely died from flu-related illness in the United States.

 

Globally, the number was undoubtedly many times higher than that (see Lancet: Estimating Global 2009 Pandemic Mortality).

 

 

All of which serves as prelude to a new study that appears today in the journal  Pediatrics, that looks at 336 documented pH1N1-associated deaths, and finds a high number of kids with underlying neurologic conditions.

 

Two-thirds of all deaths in children under the age of 17 occurred in kids with at least 1 underlying medical condition (n=227), and just under half of all cases (n=146) involved neurological disorders, such as cerebral palsy, epilepsy, or intellectual disability.

 

 

Neurologic Disorders Among Pediatric Deaths Associated With the 2009 Pandemic Influenza

Lenee Blanton, MPH^a,Georgina Peacock, MD, MPH, FAAP^b, Chad Cox, MD, MPH^a, Michael Jhung, MD, MPH^a, Lyn Finelli, DrPH^a, and Cynthia Moore, MD, PhD^b

ABSTRACT (Excerpts)

RESULTS: Of 336 pH1N1-associated pediatric deaths with information on underlying conditions, 227 (68%) children had at least 1 underlying condition that conferred an increased risk of complications of influenza. Neurologic disorders were most frequently reported (146 of 227 [64%]), and, of those disorders, neurodevelopmental disorders such as cerebral palsy and intellectual disability were most common.

CONCLUSIONS: Neurologic disorders were reported in nearly two-thirds of pH1N1-associated pediatric deaths with an underlying medical condition. Because of the potential for severe outcomes, children with underlying neurologic disorders should receive influenza vaccine and be treated early and aggressively if they develop influenza-like illness.

 

According to a statement released last night by the CDC:

 

Of the children with neurologic disorders for whom information on vaccination status was available, only 21 (23 percent) had received the seasonal influenza vaccine and 2 (3 percent) were fully vaccinated for 2009 H1N1.

 

 

With September just around the corner, the annual push for flu vaccinations is upon us, and today’s study will hopefully help inspire parents to get all kids – regardless of underlying conditions - vaccinated against influenza.

 

While the effectiveness of flu vaccines vary from year-to-year, and indeed, from one person to the next, they remain the single most important preventative step you can take to avoid getting the flu each year.

 

Despite the hyperbolic anti-vaccine rhetoric often found on the Internet, the truth is, serious adverse reactions to the vaccine are exceedingly rare (see the CDC’s  Influenza Vaccine Safety).

 

With two new strains of seasonal flu expected to be in circulation this winter (Yamagata B, and the Victoria H3N2) – ones that will be covered by this year’s vaccine – getting the flu shot this year is doubly important.

 

CDC recommends that just about everyone aged 6 months and older get an annual influenza vaccination, and stresses their importance for those who are at greater risk of serious complications.

 

For more on vaccine safety and effectiveness, the CDC maintains extensive web pages, and resources, on seasonal flu vaccines, including:

 

What You Should Know for the 2012-2013 Influenza Season

 

Preventing Seasonal Flu With Vaccination

 

Children, the Flu, and the Flu Vaccine

Study: Kids, Pandemic H1N1 & MRSA Co-Infection

 

 

 

# 5945

 

We’ve looked at a connection between enhanced flu mortality and bacterial co-infections many times in the past, most recently last September in mBio: Lethal Synergism of H1N1 Pandemic Influenza & Bacterial Pneumonia.

 

In that study scientists at NIAID and the Institute for Systems Biology (ISB) infected experimental mice with both seasonal flu and the 2009 H1N1 pandemic flu, and after 48 hours exposed some of them to Streptococcus pneumoniae, one of the main causes of pneumonia.

 

Mice that were exposed only to the two flu strains showed expected flu symptoms, but all survived.

 

Mice that were exposed to seasonal flu and S. pneumoniae experienced minor lung damage, but once again, all survived.

 

But all of the mice infected with the pandemic H1N1 virus, and S. pneumoniae showed severe weight loss, lung damage, and 100% mortality

 

Indicating that pandemic H1N1, more than seasonal flu, exacerbated an S. pneumoniae co-infection.

 

In 2008, we saw a study in The Journal of Infectious Diseases by Morens, Taubenberger, and Fauci that looks at the role of bacterial pneumonia in the high death toll of 1918 (see Viral-Bacterial Copathogenesis).

 

An excerpt from their study reads:

 

Conclusions. The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria.

 

Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs).

 

2008 also saw additional studies published in the CDC’s EID Journal that looked at the synergy between pandemic flu and bacterial pneumonia, including:

 

Brundage JF, Shanks GD. Deaths from bacterial pneumonia during 1918–19 influenza pandemic. Emerg Infect Dis. 2008 Aug;

 

Ravindra K. Gupta,*  Robert George, and Jonathan S. Nguyen-Van-Tam Bacterial Pneumonia and Pandemic Influenza Planning Emerg Infect Dis. 2008 Aug;

 

Shanks and Brundage found, for instance, that during the 1918 pandemic 5% of the deaths attributed to the 1918 pandemic occurred in the first 3 days of infection, while the median time from illness onset to death was 7–10 days, with many deaths occurring >2 weeks after initial symptoms..

 

Which they believed was more indicative of death due to secondary bacterial infection than directly from a flu virus, or a cytokine storm response (see Influenza's One-Two Punch).

 

These studies, along with a number of others, have enforced the idea that pneumococcal vaccines like PCV7 Pneumococcal Vaccine Would Save Lives In A Pandemic.

 

Given this past research, it shouldn’t come as a terrible surprise that a study that appears today in the journal Pediatrics found, among other things, that a co-infection with MRSA was associated with a higher mortality rate among healthy kids infected with the 2009 H1N1 pandemic virus.

 

First a link to the study, and an excerpt from the abstract, then I’ll be back with more.

 

Critically Ill Children During the 2009–2010 Influenza Pandemic in the United States

Adrienne G. Randolph,Frances Vaughn, Ryan Sullivan, Lewis Rubinson, B. Taylor Thompson, Grace Yoon, Elizabeth Smoot, Todd W. Rice, Laura L. Loftis, Mark Helfaer,Allan Doctor, Matthew Paden, Heidi Flori, Christopher Babbitt, Ana Lia Graciano, Rainer Gedeit, Ronald C. Sanders, John S. Giuliano, Jerry Zimmerman, Timothy M. Uyeki

(EXCERPT)

Overall, 71 (8.5%) of the patients had a presumed diagnosis of early (within 72 hours after PICU admission) Staphylococcus aureus coinfection of the lung with 48% methicillin-resistant S aureus (MRSA). In multivariable analyses, preexisting neurologic conditions or immunosuppression, encephalitis (1.7% of cases), myocarditis (1.4% of cases), early presumed MRSA lung coinfection, and female gender were mortality risk factors. Among 251 previously healthy children, only early presumed MRSA coinfection of the lung (relative risk: 8 [95% confidence interval: 3.1–20.6]; P < .0001) remained a mortality risk factor.

Conclusions: Children with preexisting neurologic conditions and immune compromise were at increased risk of pH1N1-associated death after PICU admission. Secondary complications of pH1N1, including myocarditis, encephalitis, and clinical diagnosis of early presumed MRSA coinfection of the lung, were mortality risk factors.

 

The entire study is behind a pay wall, but we’ve a lengthy press release available with considerable detail.

 

Why Did Healthy Children Fall Critically Ill in the 2009 H1N1 Flu Pandemic?

Largest study to date finds co-infection with MRSA increased death risk 8-fold; flu vaccination urged

 

BOSTON, Nov. 7, 2011 /PRNewswire-USNewswire/ -- During the 2009 H1N1 influenza pandemic, many previously healthy children became critically ill, developing severe pneumonia and respiratory failure, sometimes fatal. The largest nationwide investigation to date of influenza in critically ill children, led by Children's Hospital Boston, found one key risk factor: Simultaneous infection with methicillin-resistant Staphylococcus aureus (MRSA) increased the risk for flu-related mortality 8-fold among previously healthy children.

 

Moreover, almost all of these co-infected children were rapidly treated with vancomycin, considered to be appropriate treatment for MRSA. The fact that they died despite this treatment is especially alarming given the rising rates of MRSA carriage among children in the community.

 

"There's more risk for MRSA to become invasive in the presence of flu or other viruses," says study leader Adrienne Randolph, MD, MsC, of the Division of Critical Care Medicine at Children's Hospital Boston. "These deaths in co-infected children are a warning sign."

 

The researchers hope their findings, published November 7 by the journal Pediatrics, (eFirst pages) will promote flu vaccination among all children aged 6 months and older. (No flu vaccine is currently available for children younger than 6 months.)

 

(Continue . . . )

 

As we’ve discussed before, a small percentage of the population is known to carry either MRSA or non-resistant S. aureus in their nasal cavities.

 

This from the CDC:

Definition of MRSA

 

While 25% to 30% of people are colonized* in the nose with staph, less than 2% are colonized with MRSA (Gorwitz RJ et al. Journal of Infectious Diseases. 2008:197:1226-34.).

*Colonized:
When a person carries the organism/bacteria but shows no clinical signs or symptoms of infection. For Staph aureus the most common body site colonized is the nose.

 

While 2% doesn’t sound like a lot, there are signs that number may be increasing. Once considered primarily a hospital acquired infection, CA-MRSA (community acquired) is growing in incidence.

 

For instance, In Firefighters & Paramedics At Greater Risk Of MRSA and Firefighters & MRSA Revisited we looked at research showing a 10x’s greater incidence of MRSA colonization (20%) among a sampling of firefighters tested in Washington State.

 

Most of the time our immune systems keep these bacteria in check, and we display no outward signs of infection.

 

But when our immune systems are weakened, such as when we are stricken by influenza, these resistant bacteria can suddenly bloom and become invasive.

 

Again, from the Press Release:

 

Influenza appears to suppress the immune response, making children who are already colonized more susceptible to invasive bacterial disease.

 

"Previously, MRSA has not been considered a common cause of pneumonia in kids but this may be changing," Randolph says. "It's likely that flu and other viral infections let MRSA invade and that there's some synergistic reaction between flu and these bacteria."

 

While this study specifically links MRSA to bad outcomes among children with pandemic H1N1, the 2008 study by Shanks and Brundage found that during the 1918 pandemic:

 

. . .  the bacteria most often recovered from the sputum, lungs, and blood of pneumonia patients, alive or dead, were common colonizers of the upper respiratory tracts of healthy persons, i.e., Hemophilus influenzae, Streptococcus pneumoniae, S. pyogenes, and/or Staphylococcus aureus.

 

Whether it is the routine carriage of bacteria in our respiratory system, or the make up of the microflora in our gut biome, scientists are increasingly linking our health, and the progression and outcome of some diseases, to our individual body’s ecosystem.

 

Which may explain, at least partially, why 99 out of 100 people can catch the flu and recover quickly and without incident, while an unlucky 1% may endure a serious and sometimes fatal illness.

 

The authors of today’s study advise:

 

Physicians seeing children with serious lower-respiratory-tract disease during flu season are urged to give early antiviral treatment (Tamiflu or zanamivir [Relenza]) and antibiotics covering MRSA and other flu-associated bacteria, even before suspected infections are confirmed in the lab, the researchers say.

 

But other approaches are urgently needed. "MRSA is hard to develop a vaccine against – researchers have been trying since the 1960s and have been unsuccessful," says Randolph. "So the only way to prevent these severe complications is to get everyone vaccinated against the flu, and do more studies of MRSA colonization so we can prevent it in the community and in kids."

 

Further evidence, as if we needed it, that influenza and its complications can be complex, difficult, and occasionally deadly foes.

Pediatrics: Effectiveness Of A Single Adjuvanted Pandemic Flu Shot In Children

 

# 5890

 

 

The recommendation by the CDC for young children receiving the (unadjuvanted) flu vaccine is that:

 

Children less than nine years of age being vaccinated for the first time should receive two doses of influenza vaccine, spaced at least 4 weeks apart in the initial year.

 

The assumption has also been that during a pandemic, even previously immunized children would require 2-doses of vaccine against any emerging novel virus. 

 

A 1-dose vaccination schedule would be highly desirable, provide savings in both time-to-immunity and resources.

 

We’ve a study that appeared yesterday in the journal Pediatrics that looks at the effectiveness of a single adjuvanted flu shot given to children during the fall of 2009 for the H1N1 pandemic (my thanks to loyal reader Anne who forwarded this link to me).

 

What they found was that a single dose of the AS03-adjuvanted vaccine conferred significant protection against influenza-related hospitalization in children aged 6 months to 9 years of age.

 

 

Effectiveness of Pandemic H1N1 Vaccine Against Influenza-Related Hospitalization in Children

Rodica Gilca, MD, PhDGeneviève Deceuninck, MD, MSc, Gaston De Serres, MD, PhD, Nicole Boulianne, MSc, Chantal Sauvageau, MD, MSc, FRCPC, Caroline Quach, MD, MSc, FRCPC, François D. Boucher, MD, FRCPC, Danuta M. Skowronski, MD, MHSc

Abstract

<SNIP>

Results: The overall effectiveness of a single pediatric dose of vaccine administered ≥14 days before illness onset was 85% (95% confidence interval [CI]: 61% to 94%), varying according to age category but with wide and overlapping CIs: 92% (95% CI: 51% to 99%) in 6–23 month-old children, 89% (95% CI: 34% to 98%) in 2–4 year-olds, and 79% (95% CI: −31% to 96%) in 5–9 year-olds. Overall vaccine effectiveness for immunization ≥10 days before illness onset was slightly lower at 80% (95% CI: 60% to 90%), with similar variation according to age.

 

Conclusion: In children aged 6 months to 9 years, a single pediatric dose of the AS03-adjuvanted pH1N1 vaccine was highly protective against hospitalization beginning at 10 and 14 days after vaccination.

 

 

Adjuvants such as AS03 are additives that are used to increase the immune response to a vaccine. While they have been used in Europe and in Canada, adjuvanted flu vaccines have not been licensed for use in the United States. 

 

With tens of millions of adjuvanted flu vaccines deployed since the pandemic of 2009, we are getting more data on their impact.

 

In February of this year, in BMJ: Effectiveness of AS03 adjuvanted pandemic H1N1 vaccine researchers found the vaccine to be 93% effective, at least in recipients under the age of 50.

 

In December of 2010, in Lancet: Immunogenicity and safety Of Adjuvanted Flu Vaccines, researchers compared the safety and immunogenicity of GSK’s adjuvanted (AS03_A) H1N1 pandemic vaccine and Baxter’s non-adjuvanted 2-Dose pandemic vaccine.

 

They found the adjuvanted split-virus vaccine achieved a stronger and faster immune response than the whole-virus non-adjuvanted vaccine.

 

They also found that a single antigen-dose sparing adjuvanted vaccination mounted a sufficient immune response in adults and adolescents, although the elderly might require a second shot.

 

Safety of the two vaccines was comparable, although recipients of the adjuvanted vaccine were more likely to report injection site soreness, and general complaints (malaise, fever, headaches) than did those who received the non-adjuvanted vaccine.

 

And in May of 2010 we saw a comparison study (see BMJ: Immunogenicity Of Adjuvanted vs. Unadjuvanted H1N1 Vaccines) between GSK’s Pandemrix, containing the adjuvant AS03, verses Baxter’s unadjuvanted Celvapan in British children.

 

Although the adjuvanted Pandemrix vaccine was associated with a higher rate of (usually mild) side effects (fever, injection site soreness), it produced a superior immune response.  

 

One unresolved question regarding the safety of adjuvants stems from the increase in narcolepsy seen among recipients of the 2009 Pandemrix vaccine in Finland (see Finland: Task Force Report On Pandemrix-Narcolepsy Link).

 

This report found:

 

In approximately one quarter of those who developed narcolepsy following Pandemrix vaccination, the THL Immunology laboratory found antibodies binding to the AS03 adjuvant component of the vaccine.

 

Adjuvants containing squalene have not previously been reported to induce the production of antibodies. The significance of this preliminary observation will be the subject of further research.

 

Whether these antibodies are in any way connected to these rare cases of narcolepsy – or in any way affects the health of the vaccine recipients – has yet to be determined.

 

Complicating matters, more than a dozen countries reported an increase in narcolepsy during the 2009 pandemic, even those where the adjuvanted vaccine was not used. 

 

You can find details on one such study in Stanford Study Finds Influenza – Narcolepsy Connection  that linked narcolepsy not to the vaccine . . . but to the influenza virus itself.

 

Even if the adjuvant is eventually linked to these cases (and the jury on that is still out), Finland’s Narcolepsy taskforce found that the use of the vaccine probably saved lives and that `overall benefit-risk balance remains positive.’

 

Despite a few nagging questions over the safety of adjuvants in some quarters, studies over the past couple of years continue to reassure in terms of both safety and efficacy.

MMWR: Influenza-Associated Pediatric Deaths 2010-2011

 

 

# 5844

 

 

The CDC’s MMWR yesterday contained an in-depth look at 115 flu-related pediatric deaths over the past 12 months (Sept 2010-Aug 2011). Notification of pediatric flu-related deaths has been nationally required since 2004.

 

Case criteria is defined as: `death from a clinically compatible illness confirmed to be influenza by a diagnostic test in a U.S. resident aged <18 years, with no period of complete recovery between illness and death’.

 

Despite being a reportable event, the number of flu-related pediatric deaths is likely under stated since only those patients who are tested for influenza, test positive, and then are subsequently reported to the CDC are counted.

 

Since reporting became mandatory, yearly pediatric influenza deaths have ranged from a low of 46 during the 2005-2006 flu season to a high of 282 during the 2009—2010 pandemic.

 

Making this past year’s total of 115 a bit higher than we’ve generally seen in a non-pandemic year.

 

FIGURE 1. Number of influenza-associated pediatric deaths (N = 115), by week of death and type of influenza virus --- United States, September 1, 2010--August 31, 2011

 

Despite surveillance numbers that showed that only 26% of the influenza viruses in circulation last year were influenza B, a disproportionately high 38% of these pediatric fatalities were attributed to the B virus.

 

Just under half (49%) of these pediatric deaths occurred in children who had no ACIP defined high risk medical conditions. These children also saw a shorter interval between illness onset and death (4 days versus 7 days), and were more likely to die at home or in the emergency department.

 

Statistics that reinforce the need for all parents to closely monitor their children when they have signs of influenza.  The CDC provides a parent’s guide with information on the danger signs in children, and advice on vaccination.

 

 

 

 

Of the 57 cases that met at least one of ACIP’s high-risk definitions, the report lists: `31 (54%) had a neurologic disorder, 17 (30%) had pulmonary disease, 14 (25%) had a chromosomal abnormality or genetic disorder, 11 (19%) had congenital heart disease or other cardiac disease, and 11 (19%) had asthma or reactive airway disease. Obesity was reported in two (4%) of the 57 children’.

 

Vaccination coverage in this age cohort (6 mos – 17yrs) during the 2010-2011 flu season was estimated to be about 49%. 

 

Of the 74 children whose vaccination status could be established, only 23% had received influenza vaccine in at least 14 days before illness onset. Among children with at least one ACIP-defined high risk condition, 31% had been vaccinated.

 

Leading the authors to conclude:

 

These findings emphasize the need to improve vaccination coverage among all children, especially those at increased risk for influenza-related complications.

To protect infants aged <6 months who are too young to be vaccinated, ACIP recommends that pregnant women (3) and household contacts and out-of-home caregivers of such infants receive vaccination against influenza (1).

Because influenza vaccination of women during pregnancy has been shown to be effective in reducing hospitalizations (1) and deaths among infants aged <6 months (3), improving vaccination rates among pregnant women is a priority.

 

 

The complete and very detailed report may be viewed at:

 

Influenza-Associated Pediatric Deaths --- United States, September 2010--August 2011

Weekly

September 16, 2011 / 60(36);1233-1238

 

The editor’s summary states:

 

What is already known on this topic?

Since influenza-associated pediatric deaths became a nationally notifiable condition in 2004, the number of deaths reported to CDC has ranged from 46 during the 2005--06 influenza season to 282 during the 2009--10 season.

 

What is added by this report?

A total of 115 influenza-associated pediatric deaths were reported to CDC that occurred from September 1, 2010 to August 31, 2011. Fifty-six (49%) children who died from influenza virus infections during the 2010--11 influenza season had no reported Advisory Committee on Immunization Practices (ACIP)--defined high-risk medical conditions. Children without high-risk conditions had a shorter interval between illness onset and death (4 days versus 7 days), were more likely to die at home or in the emergency department, and were more likely to have a positive bacterial culture from a sterile site. Among children who died from influenza, few (23%) were vaccinated, and 50% received antiviral therapy.

 

What are the implications for public health practice?

Continued efforts are needed to ensure annual influenza vaccination in all persons aged ≥6 months, and children with high-risk medical conditions should be specially targeted for vaccination. Health-care providers should be aware that severe complications of influenza can occur in children without high-risk medical conditions. Early and aggressive treatment with oseltamivir or zanamivir is recommended as soon as possible after symptom onset in patients with confirmed or suspected influenza who are hospitalized; who have severe, complicated, or progressive illness; or who are at a higher risk for influenza complications.

It’s In The Bag

 

 

 

# 5743

 

 

An interesting report appears this week in Pediatrics, the journal of the AAP, on the temperature and safety of brown-bagged school lunches prepared at home.

 

The surprising results appear in an  article called:

 

Temperature of Foods Sent by Parents of Preschool-aged Children

Fawaz D. Almansour, MS, Sara J. Sweitzer, PhD, RD, LD, Allison A. Magness, BS,  Eric E. Calloway, BS, Michael R. McAllaster, BS, Cynthia R. Roberts-Gray, PhD, Deanna M. Hoelscher, PhD, RD, LD, CNS, Margaret E. Briley, PhD, RD, LD

 

 

Essentially, researchers tested the temperature of perishable food items brought to school 90 minutes before lunch at 9 central Texas day-care centers, and found the following:

 

• 39% (n = 276) of the 705 lunches analyzed had no ice packs
• 45.1% (n = 318) had 1 ice pack
• 88.2% (n = 622) of lunches were at ambient temperatures
• Only 1.6% (n = 22) of perishable items (n = 1361) were in the safe temperature zone.
• Even with multiple ice packs, the majority of lunch items (>90%) were at unsafe temperatures.

 

In the abstract, the authors write:

 

Conclusions: These results provide initial data on how frequently sack lunches sent by parents of preschool-aged children are kept at unsafe temperatures.

Education of parents and the public must be focused on methods of packing lunches that allow the food to remain in the safe temperature zone to prevent foodborne illness.

 

 

While most parents probably believe that including one or more ice packs are enough to keep food at a safe temperature, the evidence suggests otherwise. 

 

Consuming perishable foods that have been allowed to exceed the recommended storage temperature doesn’t necessarily mean your child will get sick, but it can certainly increase the odds.

 

With that in mind, Foodsafety.gov has some tips on how to pack lunches to reduce the chances of sending an out-of-control biological experiment to school with your child.

 

 

Keep School Lunches Safe

 

Posted September 07, 2010 

By Diane Van, USDA's Food Safety and Inspection Service

As children head back to school this fall, parents and caretakers may wonder, “What’s the most important thing that the kids should take to school with them?” From my perspective as a food safety specialist, I’d recommend an insulated lunch box as the best investment of the school year. For a few dollars, an insulated lunch box can keep children healthy and engaged to learn by protecting them from foodborne illness.

If you pack perishable food in an old-fashioned brown paper bag, it can be unsafe to eat by lunchtime. When children are sent home sick or stay home because of illness, it’s difficult for them to succeed in their school work.

 

Insulated lunch boxes help maintain food at a safe temperature until lunchtime. Perishable lunch foods, such as cold cut sandwiches and yogurt, can be left out at room temperature for only 2 hours before they may become unsafe to eat. But, with an insulated lunch box and a chilled freezer gel pack, perishable food can stay cold and safe to eat until lunch.

 

Why keep food cold? Harmful bacteria multiply rapidly in the "Danger Zone" — the temperatures between 40 and 140 °F. So, perishable food transported without a cold source won't stay safe long.

 

Here are some other tips to keep food safe until lunchtime:

• Clean Hands: Always make sure your hands are clean before preparing lunches. And, make sure your children understand that they need to wash their hands thoroughly before eating lunch or snacks. “Washing hands thoroughly” means using soap and warm water, and rubbing hands for 20 seconds (the time it takes to sing “Happy Birthday” twice). If water is not available, provide moist towelettes or hand sanitizing gels in the lunch box.
• Freeze your juice box: You can freeze juice boxes and use them as freezer packs. By lunchtime, the juice should be thawed and ready to drink.
• Hot Foods: To keep hot foods hot, use an insulated bottle like a thermos for foods such as soup, chili, or stew.
• Non-Perishable Food: Some food is safe without a cold source. Lunch items that don't need to be refrigerated include whole fruits and vegetables, hard cheese, canned meat and fish, chips, breads, crackers, peanut butter, jelly, mustard, and pickles.

If the lunch box comes home with food in it, make sure to throw away any perishable food items, because they have been unrefrigerated too long!

 

If you have any other questions about packing lunches safely or have other food safety questions, feel free to contact us at the Hotline (1-888-674-6854 toll-free) or

 

 

In other words, you might want to reconsider the wisdom of sending that unrefrigerated egg-salad-sandwich in your child’s lunchbox in the middle of August.

Who knew?

Study: Prior Antibiotic Use & MRSA In Children

 

 

Photo Credit – CDC PHIL 

 

# 5730

 

Canadian researchers, examining 13 years worth of data from the UK’s General Practice Research Database (GPRD), have come up with what they are calling a `robust association’ between a prior history of antibiotic use and rates of CA-MRSA (Community Acquired Methicillin Resistant Staph Aureus) infection in children.

 

The GPRD collects anonymous data from 5 million active patients seen at 625 primary care practices throughout the UK. It represents 66 million patient-years of data, and is widely used for population based studies.

 

The study appeared online yesterday (Aug. 1st)  in the Archives of Pediatrics & Adolescent Medicine.

 

Antibacterial Drugs and the Risk of Community-Associated Methicillin-Resistant Staphylococcus aureus in Children

Verena Schneider-Lindner, MD, MSc; Caroline Quach, MD, MSc; James A Hanley, PhD; Samy Suissa, PhD

Arch Pediatr Adolesc Med. Published online August 1, 2011. doi:10.1001/archpediatrics.2011.143

 

 

What these researchers found was that while nearly half of children with MRSA in this study had no recent history of antibiotic use, the adjusted relative risk (RR) of developing MRSA was 3.5 times higher among children who had received antibiotic treatment in the previous 30-180 days before infection.

 

And that relative risk increased substantially among children who received more than one course of antibiotics.

 

The adjusted relative risk of developing MRSA was highest for those receiving Quinolones, at 14.8 and Macrolides at 5.2, while Penicillins and Sulfonamides produced the lowest RR (.8 and 1.3).

 

The authors concluded:

 

While close to half of children were diagnosed as having MRSA in the community without prior antibacterial drugs, such agents are associated with a dose-dependent increased risk, concordant with findings in adults.

 

 

Although the full study is behind a pay wall, we get more on this study, including some quotes from the authors, via Pulse Today.

 

 

'Robust association' between GP antibacterial prescriptions and MRSA in children

01 Aug 2011

 

 

While the authors are not claiming that this study conclusively proves a causal association, they are quoted as saying that ‘the association was not only dose and class dependent but also responsive to modifying the length of the exposure time window, which implies time dependency'.

 

When antibiotics are truly necessary and administered appropriately, they can often be life saving. While the possibility of later developing a MRSA infection may exist, those dangers are more than offset by the benefits of taking the drug.

 

But when antibiotics are taken inappropriately – those risks cease to be reasonable, as there is no potential health benefit in taking the antibiotic.

 

All drugs have side effects.  And there is a risk-reward calculation that we must all make when deciding to take a medication.

 

Among the risks of taking antibiotics: they can upset the balance of the normal flora in the gut, can sometimes spark difficult to treat C. Diff infections, can drive bacteria towards antimicrobial resistance, and as this study implies, may lead to an increased susceptibility to MRSA.

 

So appropriate use of our declining arsenal of effective antibiotics is imperative.In recent years many medical experts have been working to improve the way antibiotics are prescribed.

 

Some recent blogs on the judicious use of antibiotics include:

 

IDSA: Educational Guidelines Lower Antibiotic Use

World Health Day 2011

WHO: The Threat Of Antimicrobial Resistance

ECDC: Situation Update On Antimicrobial Resistance

CDC: Get Smart About Antibiotics Week

MJA: Safety Of Flu Shot In Young Children

 

 

# 5612

 

Last year a significant number of young Australian children receiving a specific brand of flu shot - FluVax or FluVax Junior (CSL) - developed adverse reactions. Most of the side effects were related to fever, with some children experiencing febrile convulsions.

 

Others experienced nausea and vomiting, or injection site inflammation (see Australia Investigating Adverse Vaccine Reactions).

 

For a while, Australia placed a moratorium on dispensing flu shots to children under the age of 5, but that was lifted after investigations found the problem was only linked to one manufacturer (see Australia Lifts Ban On Flu Vax For Under Five’s).

 

Since then, Australia, the United States, and Great Britain have recommended that CSL’s vaccine not be used in children under the age of 5 (see FDA Approves 2010-2011 Flu Vaccines), and investigations into the cause of these adverse reactions have continued.

 

On Monday, the Medical Journal of Australia (MJA) published a letter that looked at early flu-season testing of several non-CSL TIVs (Trivalent Influenza Vaccines) given to thousands of children under the age of 5. 

 

Ensuring safety of the 2011 trivalent influenza vaccine in young children

Christopher C Blyth, Tracy Y Markus, Paul V Effler and Peter C Richmond

 

Briefly, during a six week period (March 15th-April 30th) 2227 doses of TIV were administered to children under 5, out of which adverse events in four children were reported to WAVSS (Western Australian Vaccine Safety Surveillance).

 

Two reported mild fevers (38°C yet < 39.5°C), one nausea, vomiting & diarrhea, and one with fever and convulsions 4 days post vaccination (this child also had a respiratory infection at the time of vaccination).

 

All four children received other vaccines at the same time as the TIV.

 

Additionally, 144 children were enrolled in a safety study during the same time period. Adverse reactions  were reported in 10 children (7%), 2 of whom received other vaccines in addition to TIV.

 

All 10 children reported fever, and one child’s fever exceeded > 39.5°C although no convulsions were reported. Two children developed vomiting.

 

None of these children required professional medical attention.

 

The reassuring bottom line is that the pediatric flu shots manufactured by both Sanofi Pasteur and Solvay proved to be very safe when administered to young children, with no repeat of the significant number of adverse reactions reported last year.

 

The authors conclude by writing:

 

These data demonstrate that the significant adverse events that occurred after administration of TIV in 2010 have not been observed in WA during early 2011. Ongoing surveillance is underway and will continue.

 

Poor uptake of influenza vaccination in Australian children is likely to result in increased influenza-related hospitalisation, morbidity and mortality. Data such as those reported here are required to reassure the community of the safety of this vaccination program before the expected start of the 2011 influenza season.

FluView Week 12

 

 

# 5458

 

 

Although influenza season is winding down in the northern hemisphere the latest FluView report from the CDC indicates that this year’s visitation isn’t completely over.  

 

Pediatric deaths, once again, were above average with 12 reported during the last surveillance week. 

 

This year, there have been at least 89 children under the age of 18 killed by influenza in the United States. While fewer than during the pandemic (n=282) this is at the upper end of the numbers reported in recent years with several reporting weeks left to go.

 

A few excerpts follow from this week’s report ending March 26th.

 

2010-2011 Influenza Season Week 12 ending March 26, 2011

All data are preliminary and may change as more reports are received.

Synopsis:

During week 12 (March 20-26, 2011), influenza activity in the United States decreased.

• Of the 5,319 specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division, 737 (13.9%) were positive for influenza.
• The proportion of deaths attributed to pneumonia and influenza (P&I) has been at or above the epidemic threshold for the ninth consecutive week.
• Twelve influenza-associated pediatric deaths were reported, bringing the season total to 89. Four of these deaths were associated with influenza B viruses; four were associated with 2009 influenza A (H1N1) viruses; one was associated with influenza A (H3N2) virus, and three were associated with an influenza A virus for which the subtype was not determined.
• The proportion of outpatient visits for influenza-like illness (ILI) was 2.0%, below the national baseline of 2.5%. Two of the 10 regions (Regions 2 and 10) reported ILI at or above region-specific baseline levels. One state experienced high ILI activity; three states experienced low ILI activity; 46 states and New York City experienced minimal ILI activity, and the District of Columbia had insufficient data.
• The geographic spread of influenza in 10 states was reported as widespread; 21 states reported regional influenza activity; the District of Columbia and 12 states reported local influenza activity, and Guam, Puerto Rico, the U.S. Virgin Islands and six states reported sporadic influenza activity.

Pneumonia and Influenza (P&I) Mortality Surveillance

During week 12, 8.7% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage was above the epidemic threshold of 8.0% for week 12 and is the ninth consecutive week in which P&I has been at or above the epidemic threshold.

Influenza-Associated Pediatric Mortality

Twelve influenza-associated pediatric deaths were reported to CDC during week 12. Four of these deaths were associated with influenza B viruses, four were associated with 2009 influenza A (H1N1) virus, one was associated with influenza A (H3N2) viruses, and three were associated with an influenza A virus for which the subtype was not determined.