the burden of paediatric influenza in the us: mortality...
TRANSCRIPT
Patsy Stinchfield, MS, CPNP, CICInfectious Disease Nurse PractitionerSenior Director, Infection Prevention & Control@InfectiousPS
The burden of paediatric influenza in the US: mortality, hospitalizations, outpatient visits and other outcomes
September 28, 2018
2 | © 2018
• No financial conflicts to disclose
• Center for Disease Control (CDC) Advisory Committee on
Immunization Practices (ACIP) Voting Member, First Nurse in the
US 2004-2008
• ACIP Liaison Member 2008-present.
• Influenza workgroup member 2008 to present.
• Vice President, National Foundation for Infectious Diseases
• Mother of 2 daughters, one of whom had H1N1 in 2009
Disclosures
3 | © 2018
At the completion of this presentation learners will:
• Review the burden of paediatric influenza in the US: mortality, hospitalizations, outpatient visits and other outcomes
• Discuss the history of pediatric influenza vaccine policy decisions in the US
• Describe the impact of influenza on a large US pediatric health system including vaccine implementation considerations
Objectives
4 | © 2018
Tell real life stories: Seasonal influenza • Television news airs photos a
family has shared of their 8 year old son “Lucio” who died of Influenza A.
• His parents’ hope is to alert parents in order to prevent other children from dying.
• Droves of parents called providers concerned asking for influenza vaccine
• Telling the real stories makes a difference
5 | © 2018
• Deadliest, most severe season in 4 decades with VE at 40%
• Record-breaking 900,000 hospitalizations
• 80,000 deaths (90% in elderly, usually 12,000 to 56,000)
• Overall vaccine rates steady for children 6 mo to 17 yrs at 57.9%
• Highest vaccinated age group are children 6 mo to 4 yrs at 67.8%
• Lowest vaccinated age group are children 13 yrs to 17 yrs at 47.7%
• Pregnant women only vaccinated at 49.1%
2017-2018 US flu season was record-breakingNFID and CDC press release 9.27.2018
6 | © 2018
7 | © 2018
Burden of influenza disease on US Children-outpatient http://www.cdc.gov/flu/weekly/overview.htm
#Outpatient
8 | © 2018
9 | © 2018
10 | © 2018
• Tracking since 2004 (low was 46 deaths in 2005, high was peak
of novel H1N1 with 282)
• Last season (2017-2018) 180 deaths—80% unvaccinated
• In 2013-2014, 115 deaths, 94 died in the hospital and only half
got Tamiflu.
• Of the 74 eligible to be vaccinated
− < 25% were vaccinated− 46% were < 5 years old
− 29% were < 2 years old
− 50% had medical condition:
§ Half had a neurological disorder
§ 30% lung disorder
§ 25% genetic disorder
§ 19% CHD/CV problems
Peds Influenza Deaths:Other Lessons From Prior Years
11 | © 2018
12 | © 2018
1930• Flu A Isolated• Flu B Isolated by 1936
1940 • Mechanical Ventilators in Use
1945 • Inactivated flu vaccine licensed for US civilians
History of Flu Vaccine Policy-United Stateshttps://www.cdc.gov/flu/pandemic-resources/1918-commemoration/pandemic-timeline-1930-and-beyond.htm
1960• US Surgeon General recommends flu vaccine for 65 and over, chronic
illness and pregnant women
2003• First nasal influenza vaccine licensed
2002 • ACIP recommends flu vaccine for babies 6-23 months of age
2006• ACIP recommends flu vaccine for health care professionals
2008• ACIP expands recommendation to include children 5 years to 18 years
2010• ACIP universal flu vaccine recommendation for all 6 months of age and
over
13 | © 2018
Evidence increases that flu vaccine reduces risk of severe flu in kids & adults
14 | © 2018
ØPediatric patients who were fully vaccinated were 74% less likely to be admitted to an intensive care unit for influenza-related illness.
• Ferdinand, Jill, Belongia, Ed, Pediatrics 2013
ØFlu Vaccine reduced risk of flu-associated deaths by 51% in children with chronic conditions and by 65% in healthy kids
• 2017 CDC study
ØIn adults, flu vaccine reduced severity, hospitalizations, ICU admission
• August, 2018 CDC study
You may still get the flu, but you are less likely to die
15 | © 2018
US Flu Vaccine Uptakehttps://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2017.htm#all-ages
16 | © 2018
Influenza Vaccine Dosing
Dosingo Infants younger than 6 monthsare too young to be immunizedwith influenza vaccine.
● Children 9 years of age andolder need only 1 dose.
● Children 6 months through 8years of age should receive 2doses of vaccine if they did notpreviously receive any dose of
vaccine
Adverse Events• Local site injection pain
• Fever within 24 hours(up to 1/3rd of younger kids)
• Mild systemic flu-like feeling
• Reports of febrile seizures when “Fluzone” given to 12-23 month olds who concurrently got 13-valent PCV13
• Egg allergy no longer a contraindication
17 | © 2018
18 | © 2018
http://www.immunize.org/catg.d/p3093.pdf
19 | © 2018
We are 2 hospitals, ~390 beds, 12 clinics, 100,000 clinic patients with 250,000 visits/year50 languages interpreted and 1 international airport
20 | © 2018
21 | © 2018
Severity of illness among influenza-associated hospitalizations at a free-standing children’s hospital, 2013-2016 Presented at Pediatric Academic Societies meeting Nov, 2017
• Retrospective cohort study evaluating severity of influenza inpts• Lab confirmed influenza, hospitalized >1 day, SII >2 days• 404 children, all ages, median age 2.6 years, 59% met SII def• 27% required ICU stay; 10% ventilated; 6 deaths • 57% not vaccinated• Characteristics of more severe influenza infection:− Ill >3 days prior to admission− 63% had underlying chronic illness− >1 missed opportunity to vaccinate
22 | © 2018
Inpatient >2-5 days (65%)Inpatient >2-5 days/ICU
stay (9%)
Inpatient 6+ days (8%)
Inpatient 6+ days/ICU stay (7%)
Inpatient 6+ days/ICU stay/vented (6%)
Inpatient >2-5 days/ICU stay/vented (4%)
Disposition of surviving patients hospitalized with severe influenza illness (N=232).
23 | © 2018
Data through May 12, 2018
• Data through May 12, 2018
Respiratory Viral Data – 2008-2018-Admissions
0
50
100
150
200
250
300
350
Oct
08
Dec
08
Feb
09Ap
r 09
Jun
09Au
g 09
Oct
09
Dec
09
Feb
10Ap
r 10
Jun
10O
ct 1
0D
ec 1
0Fe
b 11
Apr 1
1Ju
n 11
Oct
11
Dec
11
Feb
12Ap
r 12
Jun
12O
ct 1
2D
ec 1
2Fe
b 13
Apr 1
3Ju
n 13
Oct
13
Dec
13
Feb
14Ap
r 14
Jun
14O
ct 1
4D
ec 1
4Fe
b 15
Apr 1
5Ju
n 15
Oct
15
Dec
15
Feb
16Ap
r 16
Jun
16O
ct 1
6D
ec 1
6Fe
b 17
Apr 1
7Ju
n 17
Oct
17
Dec
17
Feb
18Ap
r 18
Num
ber
of A
dmis
sion
s
RSV, Influenza and Rotavirus Lab Confirmed AdmissionsChildren's Hospitals and Clinics of MN
By Month and Season
Rotavirus
Influenza
RSV
H1N1 Wave 2
2012-2013
H1N1 Wave 1
2013-2014 2014-2015 2015-2016 2016-2017 2017-20182008-2009 2009-2010 2010-2011 2011-2012
24 | © 2018
Data through May 12, 2018Total # Lab Confirmed Cases in 2017-2018 Season = 3233
•
Respiratory Viral Data - 2017-2018 Season
020406080100120140160180200220240260280300
Num
ber o
f Lab
Con
firm
ed C
ases
Lab Confirmed Viral PathogensChildren's Hospitals and Clinics of MN
By Week, 2017-2018 Season
RSV Influenza Adenovirus Metapneumovirus Rhinovirus Rotavirus Parainfluenza
25 | © 2018
Data through May 12, 2018Total # Lab Confirmed Admissions in 2017-2018 Season = 1233
•
Respiratory Viral Data-Admissions
0102030405060708090100
Num
ber
of A
dmis
sion
s
Admitted Lab Confirmed Viral PathogensChildren's Hospitals and Clinics of MN
By Week, 2017-2018 Season
RSV Influenza Adenovirus Metapneumovirus Rhinovirus Rotavirus Parainfluenza
26 | © 2018
Data through May 12, 2018Total # Lab Confirmed Influenza in 2017-2018 Season = 1773 with 191 admissions
•
Influenza - 2017-2018 Season
020406080
100120140160180200220240
35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25
Num
ber o
f Lab
Con
firm
ed C
ases
Week
Lab Confirmed InfluenzaChildren's Hospitals and Clinics of MN
By Week, This Season vs Last Season Comparison
2016-2017 Season2017-2018 Season
Sep Oct Nov Dec Jan Feb Mar Apr May Jun
27 | © 2018
Lines for vaccines H1N1 2009 PandemicWe are due for another one
28 | © 2018
29 | © 2018
Summary Thoughts• Morbidity and mortality for children from influenza is significant• Influenza vaccine options are available • While flu vaccine effectiveness is lower than we want, it is still
best tool to prevent severity, ICU hospitalization and death• Implementation considerations are numerous but manageable− Is there a “too early to vaccinate date?”− Is there a “too late” to vaccinate message?− Is there a best location to vaccinate for most?− Are there children who should not get flu vaccine?− Are systems in place to make it easy to vaccinate children?− Communication of need and dangers of disease imperative− Remember: It’s not “just the flu”
30 | © 2018
Families Fighting Flu:Working together to protect children against the fluwww.familiesfightingflu.org
31 | © 2018
Questions