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AAP: Flu vaccination more important than ever as flu and SARS-CoV-2 co-exist :

September 8, 2020

This season, influenza vaccination — recommended for everyone 6 months and older without medical contraindications — is vital to help protect vulnerable populations and reduce the burden of respiratory illnesses and hospitalizations during the SARS-CoV-2 pandemic, according to a new AAP influenza policy statement.

Reducing the risk among children, who have the highest rates of influenza infection, decreases the burden and transmission of virus to household and community contacts of all ages. It also can help preserve the capacity of the health care infrastructure during the ongoing COVID-19 pandemic.

The policy Recommendations for Prevention and Control of Influenza in Children, 2020-2021, from the Committee on Infectious Diseases, is available at and will be published in the October issue of Pediatrics.

Like the last two years, any licensed, recommended, age-appropriate influenza vaccine available can be administered, and there is no preference for a product or formulation. Both inactivated influenza vaccine (IIV) and live attenuated influenza vaccine (LAIV) are options. Similarly, treatment with any licensed, recommended, age-appropriate influenza antiviral medication can be used.

Antivirals are 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. Recent observational studies suggest antivirals can reduce the risk of certain flu complications, including hospitalization and death.

Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient notat high risk for influenza who 1) is confirmed or suspected of having flu, or 2) is a child whose siblings or household contacts are younger than 6 months or have a high-risk condition predisposing them to influenza complications, and 3) treatment can be started within 48 hours of illness onset.

Updates for 2020-'21

  • Composition: All pediatric vaccines are quadrivalent (no trivalents are available for children) and include four viral strain components: influenza A(H1N1)pdm09, A(H3N2), B/Victoria and B/Yamagata. All except the B/Yamagata component are new this season.
  • Vaccine formulations:Variousformulations available for children 6 through 35 months of age have been updated as follows:
    • Afluria Quadrivalent will be the only vaccine for children 6 through 35 months with a dosing volume of 0.25 mL.
    • Fluzone Quadrivalent, licensed in a 0.25-mL and a 0.5-mL dosing volume, likely will be available only in 0.5-mL volume for this age group this season.
    • Fluarix Quadrivalent and FluLaval Quadrivalent have a dosing volume of 0.5mL for this age group.

Any of these formulations can be used; there is no preference.

  • Dosages, timing: All influenza immunizations should be completed by the end of October, if possible. Children 6 months through 8 years who are receiving influenza vaccine for the first time, who have received only one dose ever prior to July 1, 2020, or whose vaccination status is unknown, should be vaccinated as soon as vaccines become available so they can receive both doses by the end of October (four weeks apart).
  • Contraindications for LAIV:  Children with immunodeficiencies, anatomic or functional asplenia, cochlear implants or active cerebrospinal fluid leaks should not receive LAIV because it is a live attenuated product. For more information on individuals who should not receive LAIV, consult the policy.

Q What do we know about influenza circulating with SARS-CoV-2? 

While the impact of the anticipated co-circulation of SARS-CoV-2 with influenza this season is unknown, there were elevated rates of influenza-like illness hospitalization toward the end of the 2019-’20 season when the COVID-19 pandemic began. The possibility of comorbidity makes it critical to receive timely flu vaccination this season.

Q Can children with confirmed or suspected COVID-19 receive influenza vaccination?

Children confirmed to have COVID-19 can receive flu vaccine when their acute illness has resolved. Children with nasal congestion that would impede delivery into the nasopharyngeal mucosa should have LAIV deferred until resolution.

Q Are special precautions recommended for vaccine administration during COVID-19?

Yes; infection protection measures should be in place for all patient encounters. Those administering vaccines should wear a surgical face mask (not N95 or respiratory mask) and eye protection if the level of community spread is moderate or elevated. Gloves should be worn during LAIV administration and changed with every patient. Gowns are not required.

Q What did we learn from the 2019-’20 influenza season?

Last season saw the highest hospitalization rates in children (68.2 per 100,000 population overall). There were 188 laboratory-confirmed flu-related pediatric deaths.  Among 168 children with available medical histories, most (57%) had no known underlying medical conditions. Of the 141 children who were 6 months or older when they became ill (meaning eligible for having had flu vaccination), most (74%) were not vaccinated. Children who died ranged from age 2 months to 17 years (median, 6 years), Among 63 of the children who died and had been previously tested, 46% had a bacterial coinfection.

Q Is it safe to offer IIV with other vaccines such as 13-valent pneumococcal conjugate vaccine (PCV13)?

Yes, simultaneous administration of IIV with PCV13 and/or other vaccines continues to be recommended for the 2020-’21 influenza season when these vaccines are indicated.

Q Can pregnant and/or women who are breastfeeding get the flu vaccine?

IIV is recommended at any time during pregnancy (LAIV is contraindicated). This will help provide protection to infants during their first six months of life when they are too young to receive the vaccine themselves. Vaccination during breastfeeding is safe for  mothers and infants.

Q What about potential allergies to influenza vaccines?

Anaphylactic reactions to any vaccine are considered a contraindication to vaccination. Children with a previous allergic reaction after a dose of influenza vaccine should be evaluated by an allergist to determine whether future receipt of the vaccine is appropriate. Those with egg allergies can receive flu vaccination without any additional precautions beyond those recommended for all vaccines.

Dr. Muñoz, a lead author of the policy statement, is a member of the AAP Committee on Infectious Diseases. 

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