PEDIATRICS Vol. 118 No. 2 August 2006, pp. 840-841 (doi:10.1542/peds.2006-0988)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
LETTER TO THE EDITOR |
Influenza Vaccine for School-Aged Children
Gerald R. Greene, MD, MPHDepartment of Pediatrics
Beaver Medical Group
Highland, CA 92346
Andrew Lowe, PharmD
Pharmacy Services
Arrowhead Regional Medical Center
Colton, CA 92324-1801
Diane D’Agostino, EdD
Pupil Personnel Service
Colton Joint Unified School District
Colton, CA 92324
To the Editor.—
In a recent commentary in Pediatrics, Yogev1 advocates moving forward with annual influenza immunizations for preschool- and school-aged children. He cites ample evidence, from the Japanese experience in the 1970s to more recent studies and statistical projections, for a significant benefit to such a program in the United States. The evidence cited strongly suggests that immunizing children, in addition to current priority recipients, will lead to a further reduction in morbidity, mortality, and economic loss each winter season. The evidence supports immunizing children for maximum benefit rather than infants and the elderly in years with a vaccine shortage. Yogev suggests using the live attenuated intranasal influenza vaccine (LAIV) for school-aged children and the inactivated vaccine for preschool-aged children.
A more recent study that tracked the timing of positive influenza cultures according to age for 3 winter seasons at 6 Massachusetts health care settings identified preschool-aged children as the harbingers of influenza each season.2 Positive cultures from 3- to 4-year-old children preceded the peak of influenza activity by up to 50 days, averaging 5 weeks before the seasonal peak in mortality. If this finding holds true for the rest of the United States and we move forward with routine annual immunization for children, 3- to 4-year-olds should be first priority as the vaccine becomes available each fall. The study suggests that targeting 3- to 4-year-old children for immunization early in the influenza season may have a disproportionately higher impact by preventing the spread of influenza to schools and the community. How should a program to immunize a representative number of children of this age be organized and promulgated? Many such children are not predictably available in Head Start or day care programs, and annual health visits occur throughout the year at these ages. If a child is influenza vaccine naive, he or she would require 2 doses. A spring "primer" dose with the previous season’s vaccine may reduce the need for a booster during the subsequent influenza season.
We are currently completing a demonstration using LAIV in an inland Southern California School District of 25000 enrollees. LAIV was provided by the manufacturer. Free vaccine was offered to enrollees and district personnel who could receive it according to current licensure. The final tallies are not yet available, but our experience has lead to awareness of a number of relevant practical issues affecting routine annual immunization against human influenza for school children. These observations may be relevant for other health interventions in schools as well.
Children receive education in a variety of settings including public, parochial, and private school systems, as well as at home. If annual influenza immunizations are to take place in schools, each of these venues will require a different approach and logistics. Schools or districts in and of themselves are unlikely to have enough health personnel or nurses to carry out such a program on an annual basis, even if an effective target would only be 20% to 50% of enrollees, as the projections suggest. Per current guidelines, many children cannot receive LAIV, even those with acute respiratory illness at the time of administration who are otherwise healthy. Children <9 years old receiving any influenza vaccine for the first time require a booster dose. Twenty-five percent of students may be "off track" in some schools. The traditional Thanksgiving, Christmas, and New Year’s holidays for schools will further affect the logistics of school-based immunizations each winter. Because of these considerations, each school would require at least 2 visits for immunization 6 to 8 weeks apart. Other health professionals beside those employed by the school (district) including a supervising health department or physician would be needed. Non–school participants may have to clear security checks. The current vaccine must remain frozen until just before use. A mechanism for reporting and processing adverse events (although rare) should be in place. Distribution of doses proportionate to local population data for school children throughout the country should be a goal.
Projections of the US census for 2004 suggest that there are 
60 million school-aged children in the United States through high school. If, at a minimum, 25% of these children were to be immunized annually with LAIV, the current production of 3 to 4 million doses per year would need to be increased by fivefold. What entity(ies) will absorb the cost of the vaccine and those who administer it on an annual basis? How would vaccine distribution be assured and volunteers identified to augment school health personnel?
As Yogev comments, there will be a significant benefit if we in the United States can organize an annual immunization against human influenza using the appropriate form of vaccine for as low as 20% of preschool- and school-aged children. School personnel might also be considered. A national and recurrent analysis of program effectiveness and benefits has been advocated.3 Even in a winter respiratory illness season with a seemingly more-than-adequate supply of inactivated vaccine for current priority recipients per Centers for Disease Control and Prevention guidelines, the Los Angeles Times editorialized about the apparent uneven distribution and lack of availability of inactivated influenza vaccine in the Los Angeles metropolitan area.4
REFERENCES
- Yogev R. Influenza vaccine confusion: a call for an alternative evidence-based approach [commentary].
Pediatrics. 2005;116
:1214
–1215
[Free Full Text] - Brownstein IS, Kleinman KP, Mandl KD. Identifying pediatric age groups for influenza vaccination using a regional surveillance system.
Am J Epidemiol. 2005;162
:686
–693
[Abstract/Free Full Text] - Halloran ME, Longini IM Jr. Community Studies for vaccinating schoolchildren against influenza.
Science. 2006;311
:615
–616
[Abstract/Free Full Text] - Flu shot? Good luck [editorial]. Los Angeles Times. December 10, 2005:B14
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
