ECHW-Flu Webinar

Shawn Dietrich: Welcome, and thank you for standing by. My name is Shawn Dietrich, and I'm the

Program Coordinator for Disaster Preparedness and Response Initiatives at the American Academy of

Pediatrics. I'm pleased to welcome you to today's National Center on Early Childhood Health and

Wellness webinar.

The webinar today will describe recommendations for this year's influenza season, discuss why it's

important for everyone who works Head Start and other child care programs to be vaccinated for flu,

and share strategies that can be used in child care settings to prevent or control the spread of influenza.

Before we begin the presentation, I have some brief announcements. All participants will be muted

throughout the presentation portion of the webinar. There is a slide presentation being shown through

the webinar system. If you have a technical question, please type in the chat feature of the webinar, call

1-800-843-9166, or e-mail support at ReadyTalk.com.

There is a lot to cover within the next hour and a half. You may submit your questions at any time by

typing in the webinar chat box feature. Only you and webinar staff will see your question. We will

answer some questions right away. For questions that we do not have time to cover, we will answer

these via e-mail after the webinar.

At the end of the presentation portion of the webinar, there will be a moderated question and answer

session. Immediately following the webinar, you will be prompted to take an evaluation. Only those who

take the evaluation will get a certificate. The certificate will be emailed to you in 10 days on Monday,

November 28. This webinar is being recorded, and an archived version, along with the slides, will be

available.

For today's session, we have two expert speakers. Our first speaker, at Dr. Hank Bernstein, is a professor

of pediatrics at Hofstra Northwell School of Medicine in New York. He has served as a general

pediatrician in private practice and academia at urban, suburban, and rural children's hospitals to

promote the health and well-being of children, families, and communities. He is an ex-officio member of

the American Academy of Pediatrics Committee on Infectious Diseases, associate editor of Redbook

online, and the AAP liaison to the CDC advisory Committee on Immunization Practices, Influenza Work

Group, and founding editor in chief of Pedialink, the AAP online learning center.

Dr. Bernstein maintains his certification through the American Board of Pediatrics. He completed his

residency training in pediatrics at St. Christopher's Hospital for children in Philadelphia. After earning his

medical degree from the University of Medicine and Dentistry of New Jersey School of Osteopathic

Medicine, Dr. Bernstein also earned a Master's degree in health care management from Harvard School

of Public Health in 2013.

Our second speaker, Dr. Timothy Shope, is an associate professor of Pediatrics at the University of

Pittsburgh School of Medicine. He retired from the Navy in 2011 where he served as a child care health

consultant for the Navy's mid-Atlantic region, and for the Department of Defense for 10 years. He also

served on the American Academy of Pediatrics executive committee of the section on early education

and child care for four years. He is the co-editor of Managing Diseases in Child Care and Schools, fourth

edition, the technical panel chair of Caring For Our Children, third edition, and the co-author of

Curriculum for Managing Infectious Diseases in Early Education and Child Care Settings, as well as a

subject matter expert for the managing infectious diseases in child care education and child care online

module. And with that, I will invite Dr. Bernstein to begin his presentation.

Dr. Hank Bernstein: Super. Thank you very much for that welcome. I appreciate it, and I'm excited to be

talking with all of you. And when we're going to talk today, I hope to talk about three important aspects

of influenza. One, that the virus is incredibly unpredictable. And number two is that influenza vaccine is

the best preventive measure that we have. And number three, that even when somebody has received

influenza vaccine, that sometimes they need anti-viral medication to treat influenza. And that's

important to keep in mind, should somebody get sick. So let's start with why young children are at risk

for infectious diseases.

I'm sure this audience knows better than I do that all of these kids put hands and objects in their

mouths. Their immune systems have not been exposed to as much as older children and adults. It's

probably the first time they're experiencing certain germs, and they obviously use their hands to wipe

their noses, touch their eyes, and handle toys and touch other children that they've been playing with.

We also know that the kids eat closely together, and they're great transmitters and share disease very

easily. And we also know that they don't wash their hands as well. They don't always cover their cough.

We want them to be sure to be vaccinated, and we want caregivers to stay home when they are ill.

Now, influenza, as I mentioned earlier, is incredibly unpredictable. But we know that there are 325

million people in the United States, and anywhere, 10 percent to 20 percent, if not more, people get

influenza in any given year. Which translates into 50 to 60 million infections and illnesses, resulting in

about 25 million visits to a physician, hundreds of thousands of hospitalizations, and anywhere from

3,000 to 48,000 deaths a year from influenza.

So this brings us to the first question. Which combination of symptoms best describes a common

presentation of the flu? A, cough, chills, spots on the throat. B, red, itchy skin rash, chills, and headache.

C, headache, fever, vomiting, and diarrhea. Or four, cough, fever, sore throat, or body aches. And this is

an incredibly bright audience, and they know very well what influenza is all about. And as you can see,

the answer is D, cough, fever, sore throat, and body aches.

And when we think about influenza, we know that it is primarily a viral infection of our breathing

system, so it involves the nose and the throat and the lungs, and it does spread easily from person to

person.

And the symptoms that we just described in that question are the classic symptoms, but there are other

signs or symptoms that are associated with influenza. And, in fact, not everyone who has influenza,

particularly young children and seniors, don't necessarily have to have the fever that goes along with it.

Lots of kids do get some belly pain and vomiting or diarrhea associated with it as well. We also know

that it spreads very easily. And as you can see from this picture, you can imagine all the germs that are

spread by droplets. And this is why, when people wear masks, the spread is anywhere from three to six

feet. But you can imagine also if someone touches their eyes, their nose, and their mouth, and then

shares that with others, that that's how germs can spread very easily.

Now, a lot of people wonder when they're contagious, if they have what is described as an influenza-like

illness. Interestingly enough, both children and adults can spread the infection even when they're just

infected and not necessarily showing typical signs of influenza. It can also be while they've been exposed

and it's incubating in their bodies and ready to develop a full-blown influenza. And also they sometimes

shed the virus after they've had influenza illness and they're in the recovery phase, but they still can

shed the virus and spread it to others. All of this makes it very difficult and challenging to control the

spread of germs.

Now, the incubation period for influenza is very short. It's usually just one to four days. It can spread

from the day before you start out with the illness, and it can last as much as seven days, if not longer.

And I mentioned to you earlier about viral shedding, that it can happen during the recovery phase, and

certainly children tend to shed virus longer than adults do.

Now, people ask, are there many viruses that cause influenza-like illnesses? So every respiratory illness

in the winter is not necessarily the flu, although people talk about it routinely with every respiratory

illness. The common cold is a respiratory illness, just like the flu, but the symptoms with a cold tend to

be much more mild, where influenza tends to have, as we talked about before, the fever, sore throat,

cough, and body aches, and other symptoms.

A common cold generally does not end up with hospitalization, but as I mentioned also in an earlier

slide, that influenza can result in hundreds of thousands of hospitalizations, of children of all ages, and

even can cause death. There is no vaccine to prevent the common cold, but there is a vaccine to prevent

influenza. And there really isn't a test to identify the common cold, per se, but there are tests to identify

influenza, as well as other viruses that can present and look just like influenza.

When we have the vaccine, which is the best preventive measure available, everyone should be getting

the vaccine as soon as it's available in their community. And we would hope that they would start to get

it as early as October, but it's definitely not too late to get it if they have not received it in November,

December, or even after the new year.

You'll probably recall that the peak influenza season, in general, is in January, February, and March.

Those are usually the peak months. However, influenza can start early and become a problem in

November or December, and sometimes it can last into April or May, and even June. So, in a sense, we

should be offering the vaccine throughout the entire year.

When we look at selected underlying medical conditions in patients hospitalized with influenza, and this

data is from the CDC last year, what you see is that there are certain medical conditions that put

children at higher risk for complications, such as needing to be hospitalized, and those are listed in the

upper right hand corner. You can see asthma is number one, neurologic disorders number two, and

cardiovascular disease, not a surprise, is number three.

But I also want to point out, at the bottom of this slide, you'll notice that 50 percent of the hospitalized

children were healthy. That means they had no underlying medical conditions whatsoever. So it's

important to realize that it's not just children that you would think would be at risk for complications,

but perfectly healthy children can get influenza and actually have severe morbidity and mortality

associated with it. Now, this slide highlights the last 10 years of influenza, and it highlights the deaths

and hospitalizations in the pediatric population.

When we look at it, and we see the red box there, we notice that the number of deaths in the pediatric

population is, on average, around 100. And you can see in the last five years, it has varied from 37 up to

171. But there are still lots of children who died from influenza, and many of those, or a majority of

those, actually have not been vaccinated against influenza. And then when we look at hospitalizations,

and we break out hospitalizations for children under five years of age versus children 5 through 17 years

of age, you'll notice over the last 10 years that children under five are much more likely to require

hospitalization when they get influenza in comparison to children 5 through 17 years of age. But all age

groups end up being hospitalized. It's just the younger ones are more at risk for hospitalization.

And this is a picture that is intended to highlight how germs can spread, and how young toddlers

certainly can pick up the swine flu. And this reminds us of the pandemic, the pandemic H1N1, that

occurred beginning in 2009. And that particular H1N1 pandemic virus had a real problem for children

and young adults, more so than older adults. When we look at the influenza vaccine for this season, the

box that's highlighted in red shows that two of the three strains in the Trivalent vaccine have changed,

and so that is important to understand that, with that change, that is important for everyone to receive

the flu vaccine each and every year to optimize their protection.

The other aspect of the flu vaccine is that the World Health Organization and a global surveillance

network try to predict which influenza streams will be circulating in communities around our country

and around the world. And when we look, we can see here, the last two seasons, that sometimes the

strains that circulate in the community do not match as well with the strains that were predicted to

circulate in the vaccine itself.

So, on the left, you see in 2014, 2015, H3N2 influenza A was very common, but unfortunately, the

strains that were in the vaccine did not match well with those circulating in the community. However, a

year later in 2015, 2016, just last year, as you can see from this puzzle, the circulating strains and the

vaccine strains were much better matched, and therefore the vaccine effectiveness was much higher in

comparison to the previous season.

So, this brings us to our next question. Children can receive the flu vaccine either as a shot or as a nasal

spray during this 2016, 2017 influenza. Season A, true. B, false. C, not sure. So we have quite a mix of

answers, here. So there's a percentage, a little under 10 percent, are not sure. 40 percent think that that

is true, and around 50 percent think that that is false. And this is important for people to realize,

because this is something new that has not happened in the recent past. And that is, that the answer

actually is false. And the reason this is false is shown in the next few slides.

LAIV4, which is the flumist, the flu vaccine that is sprayed up the nose, is not to be used in any clinical

setting during this 2016, 2017 season. That means that all children, and adults of course, can only, if

they're getting the flu vaccine, will only receive the shot. The nasal spray is not to be used this season.

Why is that? Because the track record of the intranasal flumist vaccine in the last three seasons has not

been as good as we would like it to be.

This particular slide shows the vaccine effectiveness for the intranasal LAIV versus the injectable,

inactivated influenza vaccine, and in children two through 17 years of age. And if you look at the left-

hand side of the slide, you can see that the vaccine effectiveness for LAIV against any influenza strain

was only 3 percent, where the shot, the vaccine effectiveness was 63 percent. So there was a dramatic

difference. And as you look at the other panels on the rest of the slide, going left to right, the pattern is

such that the performance of the LAIV intranasal product was not nearly as good, and the injectable

vaccine outperformed the intranasal product against all influenza strains.

So, therefore, when we look at a comparison, again, of LAIV and the IIV, the intranasal versus the shot,

in two through 17-year-olds, we can see the children who received the intranasal product last year were

more than two and half times as likely to get any influenza, more than 3 and 1/2 times as likely to get

the pandemic H1N1, and were one and half times as likely to get influenza B.

So, once again, the vaccine effectiveness of influenza intranasal product was a problem. And that's why

this Norman Rockwell picture is so apropos. That LAIV4, the intranasal, has struck out. Because the last

three seasons, the vaccine effectiveness of the intranasal product was outperformed by the injectable

product. So LAIV4 should not be used at all. That was a recommendation from the Centers for Disease

Control and Prevention, as well as the American Academy of Pediatrics, and the American Academy of

Family Practice.

So this leads us to another question. Eighteen-month-old Jill received two doses of the flu vaccine last

year. How many doses of the flu shot does she need this season? A, no doses. B, one dose. C, two doses,

given two weeks apart. Or D, two doses given at least four weeks apart. We doing OK on time?

So just like the previous question, there were some differences of opinion as to the answer for this

question. So, when we look at this question, we see here that the answer is actually one dose. And the

question is why? Well, the question is answered best by thinking about Dr. Seuss. So one fish, two fish,

so we need to think about one dose, or two doses. And children who receive the vaccine for the very

first time, have never gotten flu vaccine before, they actually need two doses in order to be optimally

protected.

But then, when we look at some children who have already received vaccines in the past, if a child has

received at least two doses of influenza vaccine prior to July one of this year, 2016, they only need one

dose. If they have never received two doses or more prior to July one of 2016, then they actually need

two doses, and the interval between the two doses is four weeks.

Now, I just told you that LAIV4, the intranasal product, was not effective, against influenza in the last

three years. However, children who received that, the intranasal product, in the last three years should

still have appropriately primed their immune system. So if they receive two doses of the intranasal

product last year, that still counts as the two doses prior to July one of 2016, so they would only need

one dose.

Here's the next question. For whom is influenza vaccine not recommended? A, health care personnel. B,

pregnant women in any trimester. C, women who are breastfeeding. D, infants under six months of age.

E, contacts of healthy children less than five years of age. Or F, children with high risk conditions. I'll give

you a moment to place your answers. Still growing. So, a majority of the audience got this question

right. Children under six months of age cannot, the flu vaccine is not licensed for children under six

months of age, which only emphasizes and highlights the importance of women, pregnant women,

receiving the flu vaccine so they can pass on their protection to their newborn babies to be protected in

those first six months of life.

But health care personnel, pregnant women, women who are breastfeeding, and any contacts of

healthy children under five, as well as any contacts of children with high risk conditions, all of those

individuals should receive the influenza vaccine each and every year. And this leads us to the American

Academy of Pediatrics policy statement, the Recommendations for Prevention and Control of Influenza

in Children for this particular season. And everyone six months of age and older should get a flu shot this

year. Notice I said flu shot. We are not giving the intranasal product this season. And when we think

about influenza vaccine, we want to give it to healthy children, but we also want to focus on particularly

children under five years of age, who, as I mentioned earlier, require hospitalization should they get the

flu.

Healthcare personnel are very much in contact with individuals who would not do well if they got

influenza. Any household contacts of children, particularly those at high risk for complications from

influenza, or children under the age of five, and then pregnant women, as I mentioned just a minute

ago.

Now, this leads us to another question. The parents of three-year-old Jack say he is allergic to eggs. They

are concerned because they've heard that flu vaccine is made in eggs. What do you tell them? A, Jack

should not get the flu shot because of his egg allergy. B, Jack should only get a flu shot that is egg-free.

C, Jack should get the flu shot because egg-allergic children can get the flu shot like any other routine

vaccine. Or D, jack can receive a flu shot, but it must be given by an allergist. I'll give you a moment to

answer. And the answer is that Jack should get the flu shot, because egg-allergic children can get it like

any other routine vaccine. And this is a new recommendation this year. And this has been the direction

that we've been going.

There used to be, all flu vaccines are made in egg, or most of the products are made in egg, and

therefore expose children who had allergy to egg protein, and in the past we had to ask certain

questions about the type of reaction that children had when they were exposed to egg. And years ago,

we used to not give the flu vaccine, or they gave the flu vaccine, but only in the allergist's office. There

are not egg-free products available for all children of all ages, but fortunately, at this point, we know

that we can give the vaccine to children who are egg-allergic and not be as concerned as we have in

years past.

We now have evidence of 28 studies, with over 4,000 children being studied, and the 4,000 children

were egg-allergic, and almost 700 of them has severe allergies, and severe allergies included respiratory

distress, wheezing, and low blood pressure. But in those children, they were able to tolerate the flu

vaccine without significant issue. And this has resulted in a change in the policy from the Centers for

Disease Control and Prevention, and the AAP, that all children with egg allergies can receive the

influenza vaccine with no special precautions than those recommended for routine vaccines.

Now, here's another question. Did you receive a flu vaccine last year? A, yes. B, no. I do not need vaccine

every year. C, no, I do not think the vaccine works. D, no, I worry about the vaccine side effects. Or E, no,

I did not have convenient access to the vaccine. I'll give you a moment to answer. There's still some

movement. So it's great to see that 2/3 of the audience did receive flu vaccine last year, but it looks like

as many as a third have some concerns. There's a small number that feel that they do not need the

vaccine each and every year, and the science supports the need for it every year, because, as I

mentioned earlier, influenza virus is totally unpredictable, and those strains that are circulating this year

are likely to be different than the circulating strains in the community last year.

There are a number of people, as you can see, a little over 8 percent, that don't think the vaccine works.

And I can understand where some people feel the vaccine is imperfect. And, really, nothing in this world

is perfect, but as I mentioned on one of the earlier slides, a vaccine effectiveness of 63 percent for the

inactivated vaccine, the shot last year, 63 percent is better than 0 percent. And when there are going to

be anywhere from 40 to 60 million influenza infections in a year of people of all ages, particularly some

who would not do well, it is important for them to get the vaccine and to understand that the vaccine

does provide some protection, albeit not 100 percent.

People do worry about the side effects, so it's not a surprise that just about 15 percent question that

about the side effects of the vaccine. There's no question that when we give the vaccine that there can

be local redness, soreness, and swelling at the site, and the vaccine can cause people to feel a little bit

under the weather briefly. It usually does not last more than 24 hours. But I should reassure you that the

influenza vaccine shot does not cause the flu.

People, if they end up getting the flu around the time that they receive the flu vaccine, it wasn't the

vaccine that caused them to get the flu. They actually must have been exposed to the flu virus in their

particular community. And the last answer, there were a 6 percent that said they didn't have convenient

access, and increasingly, patient-centered medical homes pharmacies, hospitals, employers, people are

trying to make flu vaccine as accessible to everyone as much as possible.

And this is the vaccine schedule, and as you can see, influenza vaccine, one dose annually, is

recommended for all adults. That's 19 years on up. And when we think about the importance of

everyone getting the flu vaccine, there's a topic called cocooning. And the idea with cocooning is that if

you give the flu vaccine to caregivers, they, in turn, are less likely to get a flu illness, in which case the

chances of a child being exposed to influenza is lower. And if their exposure to flu is less, then the

children are less likely to get influenza. And so that is the ideal, so we try to not only immunize the

children, but immunize all their caretakers and all the people that they keep in close contact with.

Now, when we look at the influenza vaccination rates for adults last season, the 2015, 2016 season, and

compare it to the season before. We'll start in the upper left hand corner, and we see that the rate for

adults 18 through 64 is only 36 percent, and it was lower this past season in comparison with the

previous season. And then, when we look at the upper right hand corner, we see for adults 65 and older

that their rate has also dropped in comparison to the previous season, although their rate is as much as

63 percent in comparison to the younger adults. In the lower right hand corner, we see health care

personnel are up to 79 percent, and that, fortunately, is on the rise.

But we would hope that health care personnel, we could get that rate above 90 percent if not closer to

100 percent. And then, when we look at pregnant women, as I mentioned, pregnant women need to get

vaccinated themselves with each pregnancy, and that can be in any trimester, the first, second, or third.

There are four million births a year in this country. So if the rate is at 50 percent, that means two million

women are not receiving the flu vaccine while they're pregnant. And I mentioned earlier that pregnant

women who receive the vaccine protect themselves, but they also pass their antibodies on to their baby

and protect their baby for the first six months of life. Since, as we also mentioned earlier, children under

six months of age, the vaccine is not licensed for that particular age group.

Now, this is a study from Australia that looked at what is the percentage of the public that believes that

health care personnel and child care providers should be vaccinated for influenza. And, as you can see

on the left hand side, 91 percent thinks nurses have an obligation to be vaccinated. Ninety-one percent

think doctors have an obligation to be vaccinated. And 90 percent think child care providers have an

obligation to be vaccinated against the flu.

Now, this is data about health care personnel flu vaccine coverage. And what it shows is, on the left

hand side, that bar shows that the rate for health care all health care personnel is around 79 percent.

But then, when we look at a mandatory recommendation, so health care personnel are required to get

the flu vaccine each year, you can see that it exceeds the Healthy People 2020 goal of 90 percent and

actually is at 97 percent. And the right hand bar shows various strategies that people have tried not

mandating, but making it voluntary, but doing things like promoting the vaccine or offering it on site.

But as you can see, no matter what strategies they choose, it does not achieve as high a rate as

mandating the flu vaccine for health care personnel. And this is a bill that commenced September 1 of

2016 in the state of California, and it prohibits a person from being employed or volunteering at a

daycare center or a family day care home if he or she has not been immunized against influenza,

whooping cough, and measles. And you'll remember, there was a measles outbreak in 2014 in

Disneyland. Whooping cough is a problem for young children, and as we have been talking so far,

influenza is a huge problem for all of us, but especially children.

And now, the American Academy of Pediatrics has released a new policy statement that looks at medical

versus non-medical immunization exemptions for child care and school attendance. And basically, what

this policy statement suggests is that non-medical exemptions to immunization requirements are quite

problematic. And the only reasons that children and adults should not receive the flu vaccine is if they

have a true contraindication or a true medical indication contraindication to the vaccine.

Philosophical and religious exemptions should not come into play when we're dealing with vaccine

requirements. And this is a map from the internet that looks at influenza prevention mandates for

children in day care and schools. And as you can see, in Connecticut, Rhode Island, and New Jersey, and

New York City, there are mandates that children in day care and schools should receive the vaccine, and

I anticipate that this number will grow over time.

The last slide that I have is just to remind you, as I mentioned, that influenza, the virus itself is

unpredictable, that the influenza vaccine, the shot this year is the best preventive measure that we

have, but also, just because people have received the vaccine does not mean they cannot get the flu.

And therefore, if someone is diagnosed with the flu, it is important to know that there are anti-viral

medications that are available. You are likely to have heard of Tamiflu, and then there's also Relenza,

which is an anti-viral against the flu that it's is inhaled, where also Tamiflu is given by mouth. So I thank

you for your attention, and I'll turn the mic over to Dr. Shope to continue our discussion.

Dr. Shope: Thank you, Dr. Bernstein. It's great to be with everybody this afternoon. I do want to remind

you that we will have some time at the end to answer questions. I have been seeing some of them

coming in on the chat board, and you can continue to type your questions there. And also you can call in

live at the end of our session and we'll answer your questions directly that way also. So what I want to

do is go from Dr. Bernstein's excellent review of influenza, and specifically apply some of what we

learned into your settings in early education and child care.

Again, to review, what makes this group so at risk is the fact that they're younger, so they're at a higher

risk of influenza complications such as death, hospitalization, school absence, doctor visits, ear

infections. You also take care of an extremely vulnerable group of children under six years of age, who

are not vaccinated themselves, and may not have received any benefit from maternal immunization

during pregnancy, which we recommend. These kids are very curious and want to play with each other

and get close, and we say social distancing is what we need to employ to keep from getting sick.

We can't keep these kids from being within three to six feet of each other, and we can't teach them to

cough and sneeze in their shoulder or their elbow. We can try, but it is very difficult to do so. And,

obviously, the flu is spread by coughing and sneezing and touching things, so that makes a very rich

environment for spread. But the other thing is that these kids in your settings bring influenza home to

their families, and we know that they also spread it into communities. So, for this reason, you're caring

for an extremely important group, a population, that actually has a very large impact on the spread of

influenza across the country.

So let's start with a case, here. You're the director of a child care center, and last year, during the flu

season, two infants from your center were hospitalized with complications from influenza. Fortunately,

they recovered and did not suffer any long term health problems. However, this experience made you

determined to do the best job to address this season's expected influenza outbreak. The question for

you is, what can you do to control influenza in your setting? And I'm going to give you the answers here.

You can immunize, you can perform excellent infection control and prevention measures, or you can use

exclusion. And exclusion is denying admission of an ill child at the daily health check, or staff member, or

asking them to leave if they're already present and they become ill.

So, the question for you is, which of these three methods is the most effective for preventing influenza

in child care settings. And I'll give you a little bit of time to think that over and respond. See the answers

streaming in rapidly. OK. And I'm going to see if we can see the results, here. Yeah. So, as you see,

immunization was selected by 80 percent of you, which is excellent. Infection control and prevention,

also important, was selected by about 16 percent of you, and exclusion, about 5 percent. And so, let's

see here, go to the next slide. OK.

So, you are correct. Immunization is the most effective method, followed by infection control and

exclusion. We're going to talk about all three of those and give you an idea of just how effective they

are. By infection control, and we'll go into this more in detail, we're referring to using hand hygiene,

teaching how to catch a cough or sneeze, cleaning, sanitizing, disinfecting, surfaces, and exclusion we

went over. So, influenza immunization effectiveness, Dr. Bernstein gave you a little bit of that.

Let me present it in a little bit of a different way. If children did not get the influenza immunization, then

about half in child care settings may get infected with influenza. That's different from becoming sick

with influenza. These studies are done by actually drawing blood on children and see if they developed

antibodies. So somebody can get infected much more commonly than they actually get ill, and in child

care, there's not much research in that setting, but it appears that the rate of infection is quite high. But

in any given year, anywhere from 10 percent to 40 percent of children may get ill, probably on average

around 20 percent.

Now, the immunization, the shot, is 50 percent at worst and up to 95 percent effective at best. And like

Dr. Bernstein said, that depends on the fit between the immunization that we predict. We try to predict

which virus strains are going to occur each year, and how well that match occurs determines how

effective the shot is. The intranasal vaccine is no longer indicated, and so the conclusion is, even though

the vaccine isn't 100 percent effective, if you get vaccinated, you're much less likely to catch the flu or to

get seriously ill. That's the take-hope point.

Now, it's interesting to look at how many child care centers across the United States actually require the

influenza vaccine. We asked child care center directors this year in a national survey. And for children,

only 24 percent of directors required the flu vaccine. And most of them could not tell us how many of

the kids in their care had got immunized against influenza, because they didn't track it. For adults only

13 percent of the directors required the flu vaccination, and 51 percent of the centers did not track

whether the staff in their centers got the immunization.

So, certainly that's quite far from where we would like, and I looked very closely at the poll that Dr.

Bernstein asked you about whether you received the vaccinations, and I noticed that, even though it

looked like the majority, there were a bunch of abstentions there, people there who didn't answer. So

we need to improve on that.

OK, so question for you. As we move toward talking about infection control, how does influenza spread?

Hands that are dirty through diaper changing, floats in the air and goes in the lungs, droplets landing on

people's faces, contaminated surfaces that people touch with their hands and then they touch their

face. So select all that are correct. It's possible that more than one of those are correct. Answers are

streaming in, again. Give you some time. OK, so things are slowing down a little bit. Let's look at the

results and what you guys have said.

You can see that about a third think that diaper changing may have something to do with it. About 80

percent think that floats in the air and then goes into people's lungs, and then droplets and

contaminated surfaces a little over 70 percent. So let's close the poll and we will look at the answers. So

the primary two methods, remember that picture of the sneeze with the droplets going? So, actually,

those droplets come shooting out of people mouth, and then they actually land on other people's faces,

in the eyes and the nose and the mouth. That's the main way that influenza spreads.

But sometimes those droplets make it all the way down onto a table or a plate or a doorknob, and then

other people come by and touch them, and then they touch their own nose or mouth, and so that's the

second most common way. Actually, we don't think that influenza is spread through diaper changing.

And it doesn't float in the air very long. Usually those big droplets go immediately down onto the floor,

so, actually, that's different than other diseases like measles or chicken pox, that gloat through

ventilation systems and things like that.

So, here is a visual of what I just said. And the way we try to combat this is through hand hygiene and

surface cleaning, sanitizing and disinfecting, and cough and sneeze etiquette, like we discussed before.

These recommendations are covered extensively in Caring For Our Children, third edition, which is

available for free on the internet. There's a direct link to the standard that refers to this. And again, you

can use Caring For Our Children to search any type of question that you may have in your child care

setting. It has a searchable database. Another reference that you can use is Managing Infectious

Diseases in Child Care and Schools, which we learned in our national survey just recently, that actually

73 percent of all licensed child care centers use this reference, so that's fantastic.

What makes this a little different than Caring For Our Children is that it has individual quick reference

sheets for every common infection or symptom that you may experience among your children in your

care, including influenza. These are generally two-page handouts that can be copied and given to

parents so that you have a unified way in which you're handling reducing infection. Each sheet goes over

how you control infection, what are the indications for exclusion and what are the indications for return

to care. So a lot of folks find this very helpful to give to parents. And all the statements in there are

approved by the American Academy of Pediatrics.

All right, our next question. So, to what extent can we reduce respiratory illness in group child care using

excellent infection control methods? All those methods that we just went over. Can we reduce the

spread of infection by 100 percent, 75 percent, 50 percent, 25 percent. Give you a little time, there. All

right, let's take a look. So, there are about 13 percent of you that think that we can reduce it 100

percent. And then a big chunk, 2/3 almost, that we can reduce it by 35 percent. And 20 percent think we

can reduce it by 50 percent. And only 3 percent think we can reduce it by 25 percent. So I'm closing the

poll, here, and let's look at the answer.

Actually, it's discouraging, I think, for a lot of you. In terms of reducing respiratory illness and influenza,

we can only reduce that by a fairly small amount. Let's go over some detail, there. What we know is

actually using infection control is pretty good for older children. For kids that are in school, over five

years of age, and maybe we get as much as 50 percent reduction, there. But in the younger children that

you're taking care of, studies vary, but it's somewhere between 17 and 35 percent for respiratory illness

or influenza-like illness depending on the intervention.

One study actually used hourly hand sanitizer use, which I know is very difficult to do in practice, and

they got a higher reduction rate of 35 percent. But what you typically employ in your settings every day,

another study only saw a benefit in children under two years of age. Didn't see any benefit for the two

to five-year-olds. And so that's for a reduction in actual incidence of illness.

When we look at reduction in absence, two studies show only about a 10 percent decrease in absence

from respiratory illness. So it's somewhat discouraging, and so the message is that it's nowhere near as

effective as immunization. Now, I'm definitely not saying stop doing infection control. You have to do

that. It helps prevent the spread of other infections, especially diarrheal illnesses, which involve diaper

changing much more, and contamination of surfaces. You shouldn't change your practice for flu season.

You could consider more frequent alcohol-based hand sanitizer or hand washing to the extent that

you're able to do that, and what's practical.

But I think the key issue, remember those two pictures of the kids sneezing, those droplets spread

through the air and they land on other people. And that limits the effectiveness of what we can do with

infection control, unless we put little barriers or masks on all these kids, and that's not practical. So it

just drives home the message that immunization is really the most important way to stop the spread.

So, let's look at this other case, here. Who's In and Who's not? A teacher caregiver in a toddler room

sees reports in the media that it's flu season, and she sees Susie has been flushed, laying on the floor for

the past hour, and has a cough and runny nose. She wants to be held all the time. The caregiver takes

her temperature and it's 104. When Susie's mother is called, she's frustrated that she has to come pick

her up. When she arrives, she notices Susie's classmate, Bobby, also has a runny nose, and says, why

doesn't he need to be excluded too?

Bobby's playful and running around with the other children. You probably see this often. So let's have a

quiz, here. What are the reasons, specifically, why Suzy is being excluded. I think you all agree she needs

to go home. Is it that she has a runny nose and a cough, that she has a fever, that she's requiring too

much care, cannot participate in activities, or that she has fever and respiratory symptoms? And, again,

there may be more than one correct answer. Answers are streaming in. You guys are quick answerers, I

see. Got about half of the folks have responded so far. Still coming in. OK, so let's take a look at the

results.

And 14 percent say Susie needs to go because she has a runny nose and cough. Sixty-two percent says

she needs to go because she has a fever. Seventeen percent because she's requiring too much care.

Forty-five percent because she can't participate in activities. And about 60 percent say that it's because

she has both fever and respiratory symptoms.

So let's take a look at what the correct answer is. It's actually the bottom three. And it's a little tricky,

here. We'll start with the final answer, fever and respiratory symptoms is a reason for exclusion. But

having runny nose or cough alone, or fever alone, are not necessarily a reason for exclusion.

Any child would need to be excluded if they're requiring too much care, because if a child care provider

has to take care of that child to the exclusion of all the other children that they're charged with, that

affects their safe ratios, and that cannot be acceptable. And D, if she can't participate in activities, that's

just not an appropriate environment for her to be in. OK. So we went over those three reasons why

she's being excluded, and Bobby is acting normal and doesn't have a fever, despite the fact that he does

have a runny nose. So we definitely want to exclude the child for the first two reasons, unable to

participate, and requiring too much care. That applies to any disease, regardless of if it looks like

influenza or something else.

Fever with respiratory symptoms is a reason for exclusion until the fever resolves without fever-reducing

medicine. And there's a lot of other reasons that could merit exclusion. These are described in detail in

Managing Infectious Diseases. So we don't exclude solely for the prevention of spread. We don't have

any actual research to know how effective exclusion is, but it's probably not very effective. And we'll go

over some of those reasons why.

First of all, we can't tell who has influenza versus common cold viruses. Dr. Bernstein went over the

different characteristics, however, influenza can be very mild or even children can be infected and not

have any symptoms at all. And some common cold viruses can be very severe, so that's not a real good

way for us to be able to tell, just looking at how sick the child is. The influenza virus can be shed, or

present in their secretions, for definitely over one week. As a matter of fact, the majority of children

who are infected with influenza still have the influenza virus in their secretions, and some even up as

long as two weeks.

We can't exclude these kids when they're feeling fine five or six days down the road. We can't keep

them out for a full 14 days. That wouldn't be practical. Lots of children are infected and infectious with

influenza but don't show symptoms, as we said. Most kids with fever and respiratory symptoms actually

don't have influenza, even though it looks a lot like influenza, even in the middle of a flu epidemic. Most

of those kids are sick from a different virus.

And so, for those reasons, we don't know that exclusion really reduces the spread of influenza, but we

do know that, when children are sick with influenza, they have the greatest quantity of virus When they

have fever and respiratory symptoms at that time. So we can't exclude everyone who might have

influenza, like Bobby, if he's not requiring extra care and he's participating in activities. But, by targeting

the kids with fever and respiratory symptoms, we may reduce some of influenza, and influenza is really

bad. So we want to try to do what we can.

So, after considering the effectiveness of the various options for controlling for flu, hopefully you decide,

as I recommend, that you really focus on immunizations this year. Much, much, much, more effective

than the other methods. So you decide to develop a strategy for both adult caregivers and for children.

So let's first talk about adults and what some ideas are that we can use to increase the immunization

rates. And what I mean by adults are the staff and caregivers at your site. We can require that adults

receive the flu vaccine as a condition of employment at the program. We can appeal to adults' intellect

and consciousness, and we can also understand why adults don't get immunized and try to address

those specific reasons. So let's talk about all three of those strategies.

As Dr. Bernstein already alluded to, requirement among health care providers definitely has a large

effect, and increases the immunization rates, so why should child care be any different? People expect

their doctor to be immunized to protect themselves, to protect the patients, and because the patients

are vulnerable. Well, it's the exact same situation when you're caring for children in child care. The

public expects you to be immunized so that you don't unintentionally give a virus to a child who's

vulnerable.

And we have to keep in mind, again, those children under six months, that they don't get to make the

decision. We need to try to immunize everybody around them, the children and the caregivers, and

provide a protective cocoon. I do want to point out that the American Committee on Immunization

Practices recommends influenza immunization. Guess what? They recommend all the other

immunizations that you're already giving to children, like the MMR, the diphtheria, tetanus, pertussis,

polio vaccine, just as strongly. It's just as strong of a recommendation.

And, as was pointed out, we're seeing a wave now of requirements across states, and there is no law

preventing you from requiring immunization in your own center, even though your state doesn't require

it. So there's no reason why you should not just start that right now. Can we appeal to people's intellect

and consciousness?

Well, one thing that may matter to some adults is that getting sick from influenza would result in lost

work, and lost work is lost wages. When child care providers can't work, then the remaining child care

providers have to work harder. That affects staffing ratios. That is a concern. Again, since you're working

in such a hot bed in childcare, you can potentially spread influenza into the community and into families.

You're certainly at higher risk, based on where you work, of getting influenza. And just showing others

that it's the right thing to do. I think all those are important things to think about.

Research shows us that the reasons why adults don't get the flu immunization. Again, saw this in our

own survey, was that some people believe that healthy people don't need it. Sometimes there's a lack of

physician recommendations. Certainly, if the doctor is not recommending it, you might not get it. People

are afraid of the vaccine side effects, and again, Dr. Bernstein went over those. Those include mainly

only local soreness and slight muscle aches. If you don't go to the doctor, then it's unlikely you will

receive a recommendation or a flu vaccination. Although there are more places where flu vaccinations

can be obtained, at many, many places that aren't necessarily a doctor's office. That's no longer a

important of a reason.

People are afraid of needles. Again, we can't do much about that without the nasal flu vaccine. Cost and

inconvenience can be a barrier, sometimes. So let's look at some strategies to address that. First of all,

it's important to educate adults about the flu vaccine. And we have some resources for that. Improve

access and eliminate cost or provide incentives. So let's talk about some of those. First of all, there's lots

of great resources available through the Centers for Disease Control website about influenza.

Certainly, it's important to, every summer, start to inform staff about the influenza vaccine

recommendations. You can actually give them an active project, an influenza quiz, to see how much they

know and encourage gentle competition. It's a 10-question quiz available for free. You can put up

posters and circulate frequently asked questions and try to address other barriers and health beliefs.

One common belief is that I don't ever get the flu. Well, it's true, it only occurs one out of every 10, or

maybe every five years, but when you get it, you could be out for seven days in a row. The flu vaccine

causes me to get sick.

Again, we addressed that previously. I don't trust the flu vaccine. Some people think it's a secret plot by

the government. I can understand why you might not trust the government. I worked in the government

for 21 years. However, the vaccines are actually not made by the government, they're made by private

corporations. And, obviously, they want it to be safe and effective, or they don't make money on it.

So, as far as access goes, there are some options you can explore. You can talk with your local health

department and see if they provide on-site immunizations. I checked with ours and learned that they

don't. Health consultants may help arrange immunizations on site. There are some companies, like this

Passport Health, that actually come and give immunizations on site. If you work for a large franchise

child care, perhaps they might pay for that.

If you can't get it on site, make it convenient for staff to get it. Find information about local sites, give

scheduled time off, doesn't have to be much time. And just generally make influenza vaccine a part of

the yearly habit, like just make it a routine. As far as cost issues go, giving influenza immunization is cost

effective for employers. They make more money by people being present and at work than they lose by

paying for immunization. So some businesses pay for it free. Again, if you are in a large franchise, ask

about that and try to push for that.

One study showed that the two most important predictors of vaccination for those already receiving

free and on site were getting a little $5 gift card, which doesn't seem like much, and being able to

choose how they got it. Well, we no longer have the nasal vaccine as an option, but that may come back

in the future. OK. So let's move from adults to children.

How do you get the children in your care immunized against influenza? Well, it's challenging to get

compliance because you're dealing with a parent in between, and they have to take their child to a

medical site. But the model should be exactly the same as all the immunizations that you already do

monitor and require, such as the MMR, the varicella, polio, et cetera, et cetera.

We shouldn't look at influenza as any different. Let's start with educating parents. And I think it's

important to refer to influenza vaccine as required. This is a requirement. And there's lots of wonderful

resources available at the Centers for Disease Control for parents. You can print them and use them. You

can educate parents that the risk of influenza is higher, as we discussed extensively in this talk, for

younger children. Some people aren't aware of that.

Use multiple methods of communication, verbal, written, translation, if you have a lot of non-English

speaking parents. You can send this home, you can post it in centers, and, as we learned from a recent

national survey, over half of child care centers use Facebook or Twitter. They tend to use it more for

their business and not much for health care, but this is something that you certainly could post

information about influenza on social media. And I encourage you to do that.

You can talk about the likelihood of the child getting infected. Again, it's somewhere around 20, 25

percent. So most years they're not going to get infected, but some years they well. That's going to be

seven days out of school, and that affects the ability for parents to work. And, again, it's a reality. It

sounds like a fear tactic, but talking about mortality or death with influenza, I think, is important. People

don't realize that flu, 100 kids every year die of this. So we definitely need to mention that. OK.

So, lots of resources here. You can pick through these when we're finished with the talk. There's letters

for parents, there's fact sheets. You can sign up as child care providers for messaging from the American

Academy of Pediatrics that we put out frequently. And you can also sign up for a monthly newsletter.

So, if those interest you, after the webinar, you can go ahead and sign up for all those resources. Now,

we can also appeal to parents' pocketbook. Again, we talked about days missed from work, lost income.

Sometimes that, on top of the frequent illnesses that they get throughout the year, and I've seen

parents lose jobs because their kids get sick so often.

So you want to go over with parents the exclusion criteria and when they might have to have their child

excluded, and how that might affect their workplace. The fever can last three to five days, but the child

may not be normal for a week. I've seen some kids with fever for seven days with influenza. So it's

significant. OK.

So, the other issue with immunizing children is the children who spread influenza into the community.

And we know that by immunizing zero to five-year-old children in child care, we can reduce the infection

rate in household contacts by 42 percent. So it affects the whole family whether those young children

are immunized. And older school-aged children, there's even a larger effect, an 80 percent reduction.

Immunizing children is actually more effective at reducing flu spread than immunizing adults,

interestingly.

By vaccinating 20 percent of school age, and this hasn't been done in childcare yet, but school-aged

children, is more effective than vaccinating 90 percent of adults in terms of reducing mortality of older

adults. And, again, that's a high-risk group, just like young children, they're a high risk group.

So we talked about requirements or mandates, and I think that's really important. Many states require

all the ACIP recommended immunizations. Influenza is one of those. We need to jump on board, just like

Connecticut, New Jersey, and Rhode Island already have done, and develop rules for your children as

they apply to children and adults. Requiring the regular health checks is important, and so I encourage

you to continue to do that because of its effect on influenza vaccine. If they're in the doctor's office,

they're more likely to get immunized. So continue to do that.

And again, you can try to arrange on-site vaccination for the children, or consider a voucher towards

reduced fees for immunizing children. So, using some type of reward might be another thing to

consider. And finally, it's important to emphasize that both seasonal and pandemic influenza can be very

severe. Some years it can reach such a severe level that public health authorities might even

recommend closing schools and child care centers.

And so it's important for you to have a written plan that addresses mild and severe influenza. What

would you do to meet payroll? What would children's secondary source of care be? And how would you

communicate with people in the event of a closure of the child care center? So, this link has an example

of some of the components of a plan that you might consider writing. You can form a committee,

including a health consultant, if you have one, to try to address that, and assign someone responsible to

monitor information about seasonal influenza, and identify who in the community has the right legal

authority to close child care programs in the event of a severe influenza outbreak.

And you can compile community services in your plan that may help children and their families deal with

the stress and other problems caused by a flu outbreak. And talk to other child care programs about

how they handle that. So I'd be very interested in hearing from any of you in our question and answer

session coming up here what you've done and what has worked in your programs. Feel free to share

that, please.

The take-home point, influenza is the most common cause of vaccine-preventable deaths in children.

And children spread influenza to caregivers and families in the community. Immunization is by far the

best influenza prevention tactic. Infection control is important, but nowhere near as effective. Exclusion

should be used when needed, but not as a method, really, to reduce the spread. And child care

programs have a very important role and opportunity to improve influenza immunization rates.

More resources that you can go through here, later. And wanted to acknowledge that we were

supported by a grant from the Centers for Disease Control and American Academy of Pediatrics. And so

now, I want to turn it over to a question and answer session. Just on time, because I'm losing my voice.

Thank you.

Shawn: Thank you very much, both Dr. Bernstein and Dr. Shope for that wonderful presentation. We'd

now like to offer people an opportunity on the phone to ask live questions. If you have a question,

please dial star one on your phone to ask a live question. And while we allowed us to queue up, we did

have a few questions come into the chat feature, so I'll ask one now. If the same flu strains are prevalent

in successive years, do we still need a vaccine the second year?

Dr. Hank Bernstein: So, this is Hank Bernstein. I'll take a crack at that. The answer is yes. And the reason

is that the protection that it develops after one flu vaccine, how long that protection lasts, usually at

least 50 percent of the protection is no longer 6 to 12 months after receiving the vaccine. So for the

following season, to be optimally protected, people would still need the vaccine. As far as children is

concerned, if the vaccine strains do not change from one year to the next, and that's all strains in the

vaccine, the number of doses, whether or not they need one or two doses, that in and of itself may

change.

But everyone does need a vaccine each and every year, even when the vaccine strains do not change.

And by the way, there's only been about five seasons in the last 30 plus seasons, when the vaccine

strains have not changed from the previous year. And I'll just add to that we don't know. They make a

prediction about what's going to come into the community each year and design the vaccine based on.

And it may not change the vaccine sometimes, but, like Dr. Bernstein said, influenza is so unpredictable

that we try to take a best guess, and we actually cannot very well predict what flu strains are going to

occur in each community each year. So the vaccine actually has protection against multiple different

potential influenza viruses, and every year multiple influenza viruses occur, both A and B.

Shawn: Thank you both very much. Operator, do we have any live questions that came in?

Operator: No, we have no audio questions at this time.

Shawn: OK, we'll go to another chat box feature while we give people an opportunity to dial in. Does the

frequent use of anti-viral sprays, such as Lysol, on door handles, nap mats, or faucet handles make a

difference in preventing influenza?

Dr. Shope: I'll take that one. So, what we recommend as far as cleaning needs, sanitizing and

disinfecting, are outlined very clearly in Caring For Our Children, and you can look that up online. Does

not cost anything. Free. And I would stick to those recommendations. Usually, on the products they're

labeled whether they meet the criteria of a disinfectant. And there are tables in both Managing

Infectious Diseases and Caring For Our Children that go over how frequently you should either clean,

sanitize, or disinfect the various surfaces, such as diaper changing tables, doorknobs, tables where

people eat, et cetera. And obviously the surfaces that are used more often and are more associated with

high contamination need to be sanitized and disinfected more commonly, like the diaper changing table.

But Lysol is not one of those products, no.

Shawn: Thank you very much. Operator, did we have any questions come through?

Operator: No questions at this time. We had another question come through the chat. What are some

of the contraindications for the influenza vaccine in childhood?

Dr. Bernstein: So, this is Hank Bernstein, and there really are not many contraindications. People will

remember that there is a vaccine information statement that the Centers for Disease Control and

Prevention puts out every year. It's available at CDC.gov.

Certainly, if someone has had an allergic reaction to a previous flu vaccine, they should not receive the

flu vaccine in the office or in a pharmacy, and they should talk with an allergist. The other

contraindication is whether as there is a personal history of Guillan-Barre syndrome, which is an

autoimmune disease that causes weakness and other neurologic deficits. But that, in and of itself, is also

particularly rare in children under 18.

Shawn: Thank you very much, Dr. Bernstein. We had another question come through, asking if you could

please just remind the audience about the new recommendations regarding children with egg allergies.

Dr. Bernstein: So, this is Hank again. The recommendation is that we should treat influenza vaccine just

as we do any of the other routine universal vaccines that are administered in a pediatrician's or family

doctor's office. We do not need to do any special testing. They do not need to be sent to an allergist.

They don't even need to wait in the office longer than they do for any other universal vaccine that's

administered in the office. We used to have the same experience with MMR, where there was concern

about allergy to egg in measles vaccine, and that no longer is an issue and flu vaccine has followed the

same path.

So the flu vaccine can be administered in an office without any special precautions other than the usual

precautions that are taken in the office with the administration of any universal vaccine.

Shawn: Thank you very much. Operator, did we have any live questions come through yet?

Operator: There are no live questions.

Shawn: Thank you. We had another question come through the chat, and this person asked, isn't it more

effective to wash hands rather than use hand sanitizer? They mentioned that parents have concerns

about hand sanitizer being safe.

Dr. Shope: Yeah, I'll take that question. This is Tim. So, this was a little bit of a controversial issue when

we first introduced the concept that you could use alcohol-based hand sanitizers. Hand washing is the

most effective way to reduce germs, but there are definitely situations where you may be outside or

may not have access to sinks everywhere you are. And then studies in hospital settings show that people

are more likely to use hand sanitizers than wash their hands, so there's a little bit of a compromise

there. Alcohol-based hand sanitizers do not reduce some diseases, such as norovirus, which is the most

common cause of diarrhea in child care settings.

And then some other organisms that produce spores, like C. diff, diarrhea, and giardia. And these things

do exist in children in child care, so, whenever possible, we recommend washing your hands with soap

and water. Also, soap and water is always necessary if there is particulate matter on your hands, like

stool. So, yeah, that's the answer, there.

Shawn: Thank you very much Dr. Shope. Another question that came through the chat, how does a child

receive protection when a pregnant mother received the flu vaccine?

Dr. Bernstein: This is Hank. What happens is the mom, her immune system produces antibodies that

protect her, and, in turn, are passed trans-placentally, through the placenta, to her newborn. And now,

when newborn is a young infant and is on his or her own, those antibodies remain in the young infant's

body for several months and provide protection since those infants under six months of age are not

licensed to get flu vaccine. So it passes through the placenta from mom to baby.

And how about when she's breastfeeding? So, the anti-body passage is really trans-placental is really

protective, and not breastfeeding is not an ideal way of providing protection for the infant from mom.

Now, there's no question that breastfeeding does protect against many infectious diseases and is good

in that regard. But it's not nearly as good as mom receiving the vaccine, developing your own antibodies

to provide protection for the young infant. Breastfeeding is by far a wonderful way to provide

advantages, including less infectious diseases.

Shawn: Thank you, Dr. Bernstein. Operator, did we have any live questions come through yet?

Operator: There are no audio questions.

Shawn: If we don't have any live questions, I think we'll probably stop the question and answer period

here. And if we didn't have time to answer your question live, we will respond to you directly via e-mail

with an answer to each of your questions. But I'd like to take a moment to thank Doctors Bernstein and

Shope for this very engaging presentation. If you want more information, or have additional questions,

please feel free to contact the National Center on Early Childhood Health and Wellness at

health@ecetta.info. Or call the toll free number, 1-888-227-5125. That now concludes this webinar.

Thank you very much for your participation.