Flu vaccines for all children

Max asked, “What are your thoughts on the new guidelines suggesting that all kids from 6 months to 18 years get flu vaccine every year? And what about non-needle flu vaccines?”

Influenza continues to be a significant cause of death and misery in the United States, and the new strategy of immunizing all children, if implemented, should dramatically reduce the burden of influenza for everyone.

There are about 30-40,000 deaths each year from influenza, and almost all of these are in the elderly. The current strategy calls for immunizing older adults, but that doesn’t work very well. We know that in people older than 70, influenza vaccinations are not very effective. And by 80, they don’t work at all. Although it’s become a yearly ritual for older people get their flu vaccines each year, in truth from a public health point of view this is probably not helping very much.

The best way to prevent these deaths is by preventing transmission of influenza to the elderly in the first place. In truth, that’s the goal of the new recommendations. Almost all influenza circulating in a community goes through the schools among children. Some very good computer modeling studies have shown that if most children are immunized and can’t transmit influenza, it will prevent influenza from every reaching their parents, grandparents, and other adults. This strategy will also help prevent influenza in babies less than six months old, who cannot be vaccinated.

Another good reason to consider this more-robust prevention strategy is that we’re quickly seeing resistance developing to the anti-flu medications Relenza and Tamiflu. Some people figure even if they get the flu, these medicines (which are heavily advertised) will help them—but they don’t work very well, and their effectiveness is rapidly declining.

The traditional injected flu vaccine is remarkably safe. Some people complain of pain at the injection site, and about 2% of recipients will feel lousy afterwards with mild, short-term symptoms including fever, headache, and body aches. These side effects are very mild compared with the high fevers and miserable acheyness that is part of the real flu illness. The injected flu vaccine is not a live vaccine and cannot “cause the flu.”

An option for influenza vaccination is the nasal “squirt” vaccine, which goes by the trade name Flumist. This is FDA-approved for use in otherwise healthy individuals from age 2 to 49. It is very safe, and causes few side effects other than an itchy nose and perhaps mild cold-like symptoms for a day or so in rare individuals. Some preliminary data in children shows that the Flumist may be more effective than the traditional flu shot, especially for “mismatched” strains.

Immunizing all of these children is will be difficult. It will require the chain-stores and perhaps schools to administer vaccine, in addition to doctor’s offices. In the past, most of the chain drug stores have been reluctant to immunize children because of the extra hassle and perceived risk of lawsuits. Immunizing through the schools means working through layers of administrators and educating parents, and it’s unclear that the FDA or the pediatric professional societies are going to address this in time to make it work for the 2008-2009 season. It’s also unclear that the vaccine manufacturers will manufacture and distribute enough flu vaccines early enough in the season. There may be shortages, and although it would make sense to stop immunizing the oldest patients (in whom vaccination doesn’t work!) to use those vaccines for more children, I foresee quite an outcry from the AARP crowd if “their flu shots” are not available.

So: it’s a good idea, though from a practical point of view may be difficult to implement. I’m getting my kids immunized, that’s for sure!

The new recommendations for influenza vaccination have been published at http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-3-21-08-508.pdf. They’re considered “provisional” until their official publication in the CDC’s journal, the MMWR, scheduled for June, 2008.

For excellent, comprehensive information about influenza and flu vaccinations, visit http://www.cdc.gov/flu/.

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