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New flu guidance for 2023-’24 season emphasizes need to improve access to vaccination

August 29, 2023

Coincident with National Immunization Awareness Month, the AAP has released an updated policy statement and technical report with recommendations for the prevention and control of influenza in children for the 2023-’24 influenza season.

The AAP continues to recommend annual influenza vaccination of all children without medical contraindications starting at 6 months of age.

Any licensed influenza vaccine appropriate for age and health status can be administered, without preference for any product or formulation as soon as doses are available.

The policy Recommendations for Prevention and Control of Influenza in Children, 2023–2024 and a companion technical report from the Committee on Infectious Diseases are available at and They will be published in the October issue of Pediatrics.

Timely vaccination

Influenza vaccines for the 2023-’24 season have been updated to include a new influenza A (H1N1) pdm09 component. The influenza A (H3N2), influenza B Yamagata lineage and influenza B Victoria lineage components remain the same.

Prompt immunization is especially important for children who require two doses this season, including children 6 months through 8 years who are receiving influenza vaccine for the first time or who received only one dose prior to July 1, 2023, or whose vaccination status is unknown.

Last year’s flu season began earlier than typically is expected in many states, and the majority of children were not protected by vaccine.

The season was marked by a high burden of influenza disease in children, including high rates of hospitalization. Co-circulation of SARS-CoV-2 and respiratory syncytial virus created capacity problems at many hospitals caring for children. Influenza immunization to reduce the overall burden of respiratory illnesses is a vital step in preserving health care capacity, especially when other viruses are co-circulating.

Inactivated and live-attenuated vaccines can be co-administered with other vaccines, including COVID-19 vaccines. While the goal is to protect all children by the end of October, vaccination efforts should continue throughout the influenza season.

Disease burden

Each year, an estimated 9% of all U.S. children develop symptomatic influenza infection. Children of all ages may require hospitalization, although the rates are highest in those younger than 5 years.

In one cross-sectional study that included data from 14 U.S. Influenza Hospitalization Surveillance Network sites collected over nine seasons, 13,235 children were hospitalized. Of these, 2,676 (20%) were admitted to the intensive care unit (ICU), 2,262 (17%) had pneumonia and 690 (5%) required mechanical ventilation. Neurologic complications in children hospitalized with flu are common and include encephalopathy and febrile and nonfebrile seizures.


The flu takes a disproportionate toll on children who are Black, Hispanic, American Indian or Alaska Native. In a second cross-sectional study spanning 10 influenza seasons, Black, Hispanic and American Indian/Alaska Native people had higher rates of influenza-associated hospitalizations and ICU admissions, and disparities were highest in children under age 4. Influenza-associated in-hospital deaths were three to four times higher in Black, Hispanic and Asian/Pacific Islander children compared with White children, which may be due to existing causes for disparities such as inequities in health care system access or other social determinants of health.

Although flu vaccine remains the best way to protect children against severe complications associated with influenza, immunization rates fell again last year. During the 2022-’23 flu season, only 55% of children 6 months through 17 years had been vaccinated. Although overall estimates are comparable to those in the 2021-’22 influenza season, coverage levels are 7 percentage points lower than at the start of the COVID-19 pandemic. Disparities in immunization rates persist. Vaccination coverage was lowest for non-Hispanic Black children (51%) and children residing in rural areas (41%).

The policy statement and technical report provide detailed and practical recommendations for increasing immunization rates in all children, including strategies to eliminate barriers to immunization in those experiencing higher rates of adverse outcomes from influenza.

To promote influenza vaccination in communities affected by health disparities, the AAP emphasizes the necessity of engaging community members in the development of culturally relevant strategies. Public and private payers are called on to offer adequate payment for influenza vaccine supply and administration to pediatric populations, update payments for influenza vaccine so that providers are paid for administering doses in July and August and eliminate remaining “patient responsibility” cost barriers to influenza vaccination where they still exist.

Testing, treatment guidance

Recommendations for influenza testing and treatment also are provided. Influenza testing should be performed in children with signs and symptoms of influenza when test results are anticipated to impact clinical management. Testing may inform decisions to initiate antiviral therapy, pursue other diagnostic testing, initiate infection prevention and control measures, or distinguish influenza from other respiratory viruses with similar symptoms.

Antiviral treatment of influenza is recommended for children with suspected or confirmed influenza who are hospitalized, have severe or progressive disease or have underlying conditions that increase their risk of complications of influenza, regardless of duration of illness. Antivirals also may be considered for other children.

Dr. Bryant is a lead author of the policy statement and technical report. She is a member of the AAP Committee on Infectious Diseases.


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