Recommendations for Prevention and Control of Influenza in Children, 2011–2012

The American Academy of Pediatrics (AAP) recommends annual trivalent seasonal influenza immunization for all children and adolescents 6 months of age and older during the 2011–2012 influenza season. Special outreach efforts should be made to vaccinate people in the following groups:

• All children, including infants born prematurely, 6 months of age and older with conditions that increase the risk of complications from influenza.

• All household contacts and out-of-home care providers of

  • children with high-risk conditions and

  • children younger than 5 years.

• All health care personnel (HCP).

• All women who are pregnant, considering pregnancy, or breastfeeding during the influenza season.

1. All people 6 months of age and older should receive trivalent seasonal influenza vaccine each year, especially those who are at high risk of influenza complications (eg, children with chronic medical conditions such as asthma, diabetes mellitus, immunosuppression, or neurologic disorders). In the United States, more than two-thirds of children younger than 6 years and almost all children older than 6 years spend significant time in child care and school settings outside the home. Exposure to groups of children increases the risk of infectious diseases. Children younger than 2 years are at an increased risk of hospitalization and complications attributable to influenza. School-aged children bear a large influenza disease burden and have a significantly higher chance of seeking influenza-related medical care compared with healthy adults. Therefore, reducing influenza transmission among children who attend child care or school should decrease the burden of childhood influenza and transmission of influenza to household contacts and community members. Most egg-allergic children can now receive influenza vaccine safely.

2. Annual trivalent seasonal influenza vaccine is recommended for household members and out-of-home care providers of children and adolescents at high risk of complications of influenza and healthy children younger than 5 years, especially infants younger than 6 months. Pediatric offices should consider serving as an alternate venue for parents and other adults who care for children to receive influenza vaccine, if this approach is acceptable to both the pediatrician and the adult to be immunized. Clinicians should still encourage adults to have a medical home and communicate their immunization status to the primary care provider. Immunization of close contacts of children at high risk of influenza-related complications is intended to reduce their risk of contagion (ie, “cocooning”). The concept of cocooning is particularly important for helping to protect infants younger than 6 months, because they are too young to be immunized with influenza vaccine. The risk of influenza-associated hospitalization in healthy children younger than 24 months has been shown to be greater than the risk of hospitalization in previously recognized high-risk groups such as the elderly. Children 24 through 59 months of age have had increased rates of outpatient visits and antimicrobial use.

3. The 2009 pandemic influenza A (H1N1) virus emerged in March 2009 and was associated with 2 significant waves of influenza activity during 2009 and 2010, as defined by the World Health Organization. This virus strain disproportionately affected the pediatric population compared with the usual seasonal influenza strains. It was 1 of 3 circulating influenza viruses during the 2010–2011 influenza season, and it is expected to circulate again during the 2011–2012 influenza season in combination with 1 or more of the other seasonal influenza strains. During the 2010–2011 season, influenza A (H3N2) was the predominant circulating strain, but weekly virus subtype activity varied regionally.

4. Although the number of hospitalizations for younger persons and outpatient visits for influenza-like illness overall was lower during the 2010–2011 season compared with the influenza A (H1N1) pandemic period, at least 114 laboratory-confirmed influenza-associated pediatric deaths were recorded during the 2010–2011 season. Seventy-one deaths were associated with influenza A virus subtypes: 30 influenza A (2009 H1N1), 21 influenza A (H3N2), and 20 undetermined subtypes. Forty-three deaths were associated with influenza B viruses. More than half of all hospitalized pediatric patients (51.8%) did not have any known underlying conditions (Fig 1). Although children with certain conditions are at higher risk of complications, substantial proportions of seasonal influenza morbidity and mortality occur among healthy children.

5. The recommended trivalent vaccine for the 2011–2012 influenza season contains the following 3 virus strains:

   • A/California/7/2009 (H1N1)–like antigen (derived from 2009 pandemic influenza A [H1N1] virus);

   • A/Perth/16/2009 (H3N2)–like antigen; and

   • B/Brisbane/60/2008–like antigen.

6. On the basis of ongoing global surveillance data, for only the fourth time in 25 years there is no need to change any of the influenza vaccine strains (Fig 2). The number of trivalent seasonal influenza vaccine doses to be administered this year depends on the child's age at the time of the first administered dose and his or her vaccine history (Fig 3):

   • Infants younger than 6 months are too young to be immunized with influenza vaccine.

   • Children 9 years of age and older need only 1 dose.

   • Children 6 months through 8 years of age should receive 2 doses of vaccine if they did not receive any dose of vaccine last season. The second dose should be administered at least 4 weeks after the first dose.

   • Children 6 months through 8 years of age who received at least 1 dose of the 2010–2011 trivalent seasonal influenza vaccine last season need only 1 dose of the 2011–2012 influenza vaccine this season.

   In most influenza seasons, children who received influenza vaccine for the first time the previous season but who received only 1 dose are recommended to receive 2 doses of vaccine in the current season, because the first vaccine dose primes the immune system, but no significant protection against disease is achieved until 1 week after the second dose. However, because the vaccine strains for the 2011–2012 season are unchanged from last season, 1 dose this season coupled with the 1 dose of last season will provide adequate protection (Fig 4). Previous recommendations for 2 doses of vaccine will resume for seasons in which 1 or more of the vaccine strains change.

7. Optimal protection is achieved through annual immunization. Antibody titers wane to 50% of their original levels 6 to 12 months after vaccination. Because the vaccine strains for the 2011–2012 season are unchanged from last season, a repeat dose this season is critical for maintaining protection in all populations.

8. As soon as the trivalent seasonal influenza vaccine is available locally, health care personnel (HCP) should be immunized, publicize vaccine availability to parents and caregivers, and begin immunization of all children 6 months of age and older, especially children at high risk of complications from influenza. HCP endorsement plays a major role in vaccine uptake. A strong correlation exists between HCP endorsement of influenza vaccine and patient acceptance. Providers should continue to offer vaccine through the vaccine expiration date. Protective immune responses persist throughout the influenza season, which can have >1 disease peak and often extends into March or later. Prompt initiation of influenza immunization and continuance of immunization throughout the influenza season, regardless of whether influenza is circulating (or has circulated) in the community, are critical components of an effective immunization strategy. This approach provides ample opportunity to administer a second dose of vaccine, because children younger than 9 years might require 2 doses to confer optimal protection.

9. HCP, influenza campaign organizers, and public health agencies should collaborate to develop improved strategies for planning, communication, and administration of vaccines.

   • Plan to make trivalent seasonal influenza vaccine easily accessible for all children. Examples of such action include creating walk-in influenza clinics, extending office hours beyond routine times during peak vaccination periods, considering how to immunize parents and adult caregivers at the same time in the same office setting as children, and working with other institutions (eg, schools, child care centers, and religious organizations) or alternative care sites, such as emergency departments, to expand venues for administering vaccine while providing appropriate documentation of immunization for the child's medical home.

   • Concerted efforts among the aforementioned groups, plus vaccine manufacturers, distributors, and payers, are also necessary to appropriately prioritize distribution to the primary care office setting, especially when vaccine supplies are delayed or limited.

   • Vaccine safety, effectiveness, and indications must be communicated properly to the public. HCP should act as role models by receiving influenza immunization annually and recommending annual immunizations to both their colleagues and patients.

10. The neuraminidase inhibitors oseltamivir (Tamiflu [Roche Laboratories, Nutley, NJ]) and zanamivir (Relenza [GlaxoSmithKline, Research Triangle Park, NC]) are the only antiviral medications routinely recommended for chemoprophylaxis or treatment during the 2011–2012 season. All strains of influenza currently anticipated to circulate are susceptible to neuraminidase inhibitors but have high rates of resistance to amantadine and rimantadine (Table 1). Resistance characteristics might change rapidly; clinicians should verify susceptibility information at the start of the influenza season and monitor it during the season through either the AAP Web site (www.aap.org or http://aapredbook.aappublications.org/flu) or the Centers for Disease Control and Prevention (CDC) Web site (www.cdc.gov/flu/index.htm).

11. As the 2011–2012 influenza season unfolds, it is critically important for HCP to be aware of new or changing recommendations from the CDC or their local and state health departments. Up-to-date information can be found on the AAP Web site (www.aap.org or http://aapredbook.aappublications.org/flu), through state-specific AAP chapter Web sites, or on the CDC Web site (www.cdc.gov/flu/index.htm).

Tables 2 and 3 summarize information on the 2 types of 2011–2012 trivalent seasonal influenza vaccines licensed for immunization of children and adults: injectable trivalent inactivated influenza vaccine (TIV) and intranasally administered live-attenuated influenza vaccine (LAIV). Both vaccines contain the identical strains of influenza A subtypes (ie, H1N1 and H3N2) and influenza B anticipated to circulate during the 2011–2012 influenza season.

TIV is an inactivated vaccine that contains no live virus and cannot produce a viral infection. TIV formulations are now available for intramuscular and intradermal use. The intramuscular formulation of TIV is licensed and recommended for children 6 months of age and older and adults, including people with and without chronic medical conditions. The most common adverse events after administration are local injection-site pain and tenderness. Fever might occur within 24 hours after immunization in approximately 10% to 35% of children younger than 2 years but rarely in older children and adults. Mild systemic symptoms such as nausea, lethargy, headache, muscle aches, and chills might occur after administration of TIV.

An intradermal formulation of TIV has been licensed for the 2011–2012 season for use in people 18 through 64 years of age. This method of delivery involves a microinjection with a needle 90% shorter than needles used for intramuscular administration. The most common adverse events are redness, induration, swelling, pain, and itching at the site of administration at a slightly higher rate than occurs with the intramuscular formulation of TIV. Headache, myalgia, and malaise might occur and tend to occur at the same rate as that with the intramuscular formulation of TIV. There is no preference for intramuscular or intradermal immunization in people 18 years of age or older; therefore, pediatricians may choose to use either the intramuscular or intradermal product in their late adolescent and young adult patients.

Increased reports of febrile seizures in the United States were noted by the Vaccine Adverse Event Reporting System (VAERS) and were associated with TIV manufactured by Sanofi Pasteur (Fluzone), mainly in children in the 12- through 23-month age group (the peak age for febrile seizures), and included some who concurrently had received 13-valent pneumococcal conjugate vaccine (PCV13). All children fully recovered. On the basis of current data, prophylactic use of antipyretic agents in TIV-immunized children is not indicated, and current AAP and Advisory Committee on Immunization Practices (ACIP) recommendations for administration of TIV in this age group are unchanged. Febrile seizures can occur anytime a child has a fever, but the typical child who has a febrile seizure recovers quickly and fully.

Previous febrile seizures or seizure disorders are not a contraindication to use of TIV or LAIV in otherwise eligible children. Use of antipyretic agents in febrile children does not reduce the incidence of febrile seizures; therefore, routine use of antipyretic agents for avoiding febrile seizures in children who receive influenza vaccine is not recommended. Approximately 2% to 5% of children 6 months through 5 years of age will have at least 1 febrile seizure not associated with vaccines in their lifetime.

LAIV is a live-attenuated influenza vaccine that is administered intranasally and is licensed by the US Food and Drug Administration for healthy people 2 through 49 years of age. It is not recommended for people with a history of asthma or other high-risk medical conditions associated with an increased risk of complications from influenza (see “Contraindications and Precautions”). LAIV has the potential to produce mild symptoms including rhinitis, headache, wheezing, vomiting, muscle aches, and fever. LAIV should not be administered to people with copious nasal congestion that would impede vaccine delivery.

Both TIV and LAIV are cost-effective strategies for preventing influenza among children and their families when circulating and vaccine strains are matched closely, but efficacy varies according to the age of the recipient. Current data from direct comparisons of the efficacy or effectiveness of these 2 vaccines are limited, because the studies were conducted in a variety of settings and in populations using several different clinical end points. In 1 study that compared LAIV with TIV in infants and young children without severe asthma or a recent history of wheezing, LAIV showed significantly better efficacy than TIV; results of other studies suggest that TIV might be more effective in young adults.

A large body of evidence demonstrates that thimerosal-containing vaccines are not associated with increased risk of autism spectrum disorders in children. However, some people might raise concerns about the minute amounts of thimerosal in TIV vaccines, and in some states, there is a legislated restriction on the use of thimerosal-containing vaccines for infants and/or children. The benefits of protecting children against the known risks of influenza are clear. Therefore, children should receive any available formulation of TIV rather than delay immunization while waiting for vaccines with reduced thimerosal content or for thimerosal-free vaccine. Although some formulations of TIV contain only a trace amount of thimerosal, certain types can be obtained with no thimerosal. LAIV does not contain thimerosal. Vaccine manufacturers are delivering increasing amounts of thimerosal-free influenza vaccine each year.

Although both TIV and LAIV are produced in eggs, recent data have shown that influenza vaccine administered in a single, age-appropriate dose is well tolerated by nearly all recipients who have egg allergy. More conservative approaches, such as skin testing or a 2-step graded challenge, are no longer recommended.

As a precaution, clinicians should determine if the presumed egg allergy is based on a mild or severe reaction. Mild reactions are defined as hives alone; severe reactions involve cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that require the use of epinephrine. Clinicians should consult with an allergist for children with a history of severe reaction. Most vaccine administration to people with egg allergy can happen without the need for referral. Data indicate that only approximately 1% of children have immunoglobulin E–mediated sensitivity to egg, and of those, a very small minority have a severe allergy.

Standard immunization practice should include the ability to respond to acute hypersensitivity reactions. Therefore, influenza vaccine should be given to people with egg allergy with the following preconditions (Fig 5):

• Appropriate resuscitative equipment must be readily available.¹ 

• Ovalbumin content up to 0.7 micrograms/0.5 mL per vaccine dose has been well tolerated (Table 2).

• After immunization, the vaccine recipient should be observed in the office for 30 minutes, the standard observation time after receiving immunotherapy.

• For children who need a second dose, the same product brand is preferred, if possible, but it does not need to be from the same lot as the first dose.

The intramuscular formulation of TIV is shipped and stored at 2°C to 8°C (35°F–46°F). It is administered intramuscularly into the anterolateral thigh of infants and young children and into the deltoid muscle of older children and adults. The volume of vaccine is age dependent; infants and toddlers older than 6 months but younger than 36 months should receive a dose of 0.25 mL, and all people aged 3 years (36 months) and older should receive 0.5 mL per dose.

The intradermal formulation of TIV also is shipped and stored at 2°C to 8°C (35°F–46°F). The package insert should be reviewed for full administration details of this new product, which is licensed for the 2011–2012 season for persons 18 through 64 years of age.

The cold-adapted LAIV formulation currently licensed in the United States must be shipped and stored at 2°C to 8°C and administered intranasally in a prefilled, single-use sprayer containing 0.2 mL of vaccine. A removable dose-divider clip is attached to the sprayer to administer 0.1 mL separately into each nostril. Any of the influenza vaccines can be administered at the same visit with all other recommended routine vaccines. After administration of any live-virus vaccine, at least 4 weeks should pass before another live-virus vaccine is administered.

Trivalent seasonal influenza immunization is recommended for all children 6 months of age and older. Healthy children 2 years of age and older can receive either TIV or LAIV. Particular focus should be on the administration of TIV for all children and adolescents who have underlying medical conditions associated with an increased risk of complications from influenza, including:

• Asthma or other chronic pulmonary diseases including cystic fibrosis.

• Hemodynamically significant cardiac disease.

• Immunosuppressive disorders or therapy.

• HIV infection.

• Sickle cell anemia and other hemoglobinopathies.

• Diseases that require long-term aspirin therapy, including juvenile idiopathic arthritis and Kawasaki disease.

• Chronic renal dysfunction.

• Chronic metabolic disease including diabetes mellitus.

• Any condition that can compromise respiratory function or handling of secretions or can increase the risk of aspiration, such as neurodevelopmental disorders, spinal cord injuries, seizure disorders, or neuromuscular abnormalities.

Although universal immunization for all people 6 months of age and older is recommended for 2011–2012, particular immunization efforts with either TIV or LAIV should be made for the following groups to prevent transmission of influenza to those at risk, unless contraindicated:

• Household contacts and out-of-home care providers of children younger than 5 years and at-risk children of all ages (healthy contacts 2–49 years of age can receive either TIV or LAIV).

• Any female who is pregnant, considering pregnancy, or breastfeeding during the influenza season (TIV only). Studies have found that infants born to immunized women have better influenza-related health outcomes. However, data suggest that no more than one-half of pregnant women receive seasonal influenza vaccine, although both pregnant women and their infants are at higher risk of complications. In addition, there is limited evidence that influenza vaccination in pregnancy might decrease the risk of preterm birth.

• HCP or health care volunteers. Despite the recent AAP recommendation for mandatory influenza immunization for all HCP,²  many HCP remain unvaccinated. As of January 2010, the CDC estimated that only 62% of HCP received the seasonal vaccine and only 37% received the 2009 H1N1 monovalent vaccine. HCP frequently come into contact with patients at high risk of influenza illness in their clinical settings, so it is paramount that HCP protect themselves against influenza to remain influenza free, to prevent disease transmission to patient populations at high risk, and to avoid lost workplace productivity.

• Close contacts of immunosuppressed people.

Minor illnesses, with or without fever, are not contraindications to the use of influenza vaccines, particularly among children with mild upper respiratory infection symptoms or allergic rhinitis.

• Infants younger than 6 months.

• Children who have a moderate-to-severe febrile illness, on the basis of clinical judgment of the provider.

• Children who are known to have experienced Guillain-Barré syndrome (GBS) within 6 weeks after a previous influenza vaccination; whether influenza vaccination specifically might increase the risk of recurrence of Guillain-Barré syndrome is unknown; the decision not to immunize should be thoughtfully balanced against the potential morbidity and mortality associated with influenza for that individual child.

• Children younger than 2 years.

• Children who have a moderate-to-severe febrile illness.

• Children with copious nasal congestion that would impede vaccine delivery.

• Children who are known to have experienced Guillain-Barré syndrome within 6 weeks after a previous influenza vaccination; whether influenza vaccination specifically might increase the risk of recurrence of Guillain-Barré syndrome is unknown; the decision not to immunize should be balanced against the potential morbidity and mortality associated with influenza for that individual child.

• Children who have received other live-virus vaccines within the previous 4 weeks; however, other live-virus vaccines can be given on the same day as LAIV.

• Children with asthma, children with other chronic disorders of the pulmonary or cardiovascular systems, or children 2 through 4 years of age with a history of recurrent wheezing or a medically attended wheezing episode in the previous 12 months.

• Children with chronic underlying medical conditions including metabolic disease, diabetes mellitus, renal dysfunction, and hemoglobinopathies.

• Children who have known or suspected immunodeficiency disease or who are receiving immunosuppressive or immunomodulatory therapies.

• Children who are receiving aspirin or other salicylates.

• Any female who is pregnant or considering pregnancy.

• Children with any condition that can compromise respiratory function or handling of secretions or can increase the risk for aspiration, such as neurodevelopmental disorders, spinal cord injuries, seizure disorders, or neuromuscular abnormalities.

LAIV is not recommended for children with asthma. In the 2- through 4-year age range, many children have a history of wheezing with respiratory tract illnesses and are eventually diagnosed with asthma. Therefore, because of the potential for increased wheezing after immunization, children younger than 5 years with recurrent wheezing or a medically attended wheezing episode in the previous 12 months of age should not receive LAIV.

When offering LAIV to children 24 through 59 months of age, the clinician should screen them by asking the parent/guardian the question, “In the previous 12 months, has a health care professional ever told you that your child had wheezing?” If a parent answers “yes” to this question, LAIV is not recommended for the child. TIV would be recommended for the child to whom LAIV is not given.

In addition, TIV is the vaccine of choice for anyone in close contact with a subset of severely immunocompromised people (ie, people in a protected environment). TIV is preferred over LAIV for contacts of severely immunocompromised people (ie, in a protected environment) because of the theoretical risk of infection in an immunocompromised contact of an LAIV-immunized person. Available data indicate that there is a very low risk of transmission of the virus in both children and adults vaccinated with LAIV. HCP immunized with LAIV may continue to work in most units of a hospital, including the NICU and general oncology wards, while using standard infection-control techniques. As a precautionary measure, people recently vaccinated with LAIV should restrict contact with severely immunocompromised patients (eg, hematopoietic stem cell transplant recipients during periods that require a protected environment) for 7 days after immunization, although there have been no reports of LAIV transmission from a vaccinated person to an immunocompromised person. In the theoretical scenario in which symptomatic LAIV infection develops in an immunocompromised host, oseltamivir or zanamivir could be prescribed, because LAIV strains are susceptible to these antiviral medications.

Information about influenza surveillance is available through the CDC Voice Information System (influenza update, 888-232-3228) or at www.cdc.gov/flu/index.htm. Although current influenza season data on circulating strains do not necessarily predict which and in what proportion strains will circulate in the subsequent season, it is instructive to be aware of 2010–2011 influenza surveillance data and use them as a guide to empiric therapy until current seasonal data are available from the CDC. Information is posted weekly by the CDC (www.cdc.gov/flu/weekly/fluactivitysurv.htm). During the 2010–2011 season, most activity was attributable to influenza A; approximately 66% was attributable to influenza A (H3N2) activity, and 34% was attributable to 2009 (H1N1) activity. Activity varied widely on a local level.

These updated recommendations for prevention and control of influenza in children will have considerable operational and fiscal effect on pediatric practice. Therefore, the AAP has developed implementation guidance on supply, payment, coding, and liability issues; these documents can be found at www.aapredbook.org/implementation.

Antiviral resistance can emerge quickly from one season to the next. If local or national influenza surveillance data indicate a predominance of a particular influenza strain with a known antiviral-susceptibility profile, then empiric treatment can be directed toward that strain. For example, during the 2010–2011 season, only 1.3% of influenza viruses tested were resistant to oseltamivir, and none were resistant to zanamivir. High levels of resistance to amantadine and rimantadine persist, and these drugs should not be used in the upcoming season unless resistance patterns change significantly (Table 1).

• Oseltamivir is available in capsule and oral-suspension formulations. The manufactured liquid formulation has a concentration of 6 mg/mL. Oral suspensions in 12 mg/mL concentrations will remain available until supplies run out. If the commercially manufactured oral suspension is not available, the capsule might be opened and the contents mixed with a sweetened liquid by retail pharmacies to a final concentration of 15 mg/mL (Table 4, footnote “a”).

• Current treatment guidelines (Table 4) are applicable to infants and children with suspected influenza when known virus strains are circulating in the community or when infants or children are confirmed to have seasonal influenza.

• Continuous monitoring of the epidemiology, change in severity, and resistance patterns of influenza strains might lead to new guidance.

Treatment should be offered for:

• Any child hospitalized with presumed influenza or with severe, complicated, or progressive illness, regardless of influenza immunization status.

• Influenza infection of any severity in children at high risk of complications of influenza infection (Table 5.)

Treatment should be considered for:

• Any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her provider if treatment can be initiated within 48 hours of illness onset.

Earlier treatment provides more optimal clinical responses, although treatment after 48 hours of symptoms in the child with moderate-to-severe disease or with progressive disease might still provide some benefit. Dosages for antiviral agents for both treatment and chemoprophylaxis in children can be found in Table 4 and on the CDC Web site http://www.cdc.gov/flu/professionals/antivirals/index.htm). Children younger than 1 year are at increased risk of influenza-related complications. Although there are no antiviral medications licensed by the Food and Drug Administration for this age group and the 2009 H1N1 pandemic Emergency Use Authorization has expired, recommendations for use of oseltamivir in this young age group can still be followed and are provided in Table 4.

Clinical judgment (based on underlying conditions, disease severity, time since symptom onset, and local influenza activity) is an important factor in treatment decisions for pediatric patients who present with influenza-likeillness. Antiviral treatment should be started as soon as possible after illness onset and should not be delayed while waiting for a definitive influenza test result. Currently available rapid antigen tests have low sensitivity, particularly for the 2009 pandemic influenza A (H1N1) virus strain and should not be used to rule out influenza. Negative results from rapid antigen tests should not be used to make treatment or infection-control decisions.

People with suspected influenza who present with an uncomplicated febrile illness typically do not require treatment with antiviral medications unless they are at higher risk of influenza complications, especially in situations with limited antiviral medication availability. Should there be a shortage of antiviral medications, local public health authorities might provide additional guidance about testing and treatment. Rapid antigen tests are not helpful in the management of children with suspected influenza.

Recommendations for chemoprophylaxis during an influenza outbreak:

• For children at high risk of complications from influenza for whom influenza vaccine is contraindicated.

• For children at high risk during the 2 weeks after influenza immunization.

• For family members or HCP who are unimmunized and are likely to have ongoing, close exposure to:

  • unimmunized children at high risk; or

  • infants and toddlers who are younger than 24 months.

• For control of influenza outbreaks for unimmunized staff and children in a closed institutional setting with children at high risk (eg, extended care facilities).

• As a supplement to immunization among children at high risk, including children who are immunocompromised and might not respond to vaccine.

• As postexposure prophylaxis for family members and close contacts of an infected person if those people are at high risk of complications from influenza.

• For children at high risk and their family members and close contacts, as well as HCP, when circulating strains of influenza virus in the community are not matched with trivalent seasonal influenza vaccine strains, on the basis of current data from the CDC and local health departments.

These recommendations apply to routine circumstances, but it should be noted that guidance might change on the basis of updated recommendations from the CDC in concert with antiviral-agent availability, local resources, clinical judgment, recommendations from local or public health authorities, risk of influenza complications, type and duration of exposure contact, and change in epidemiology or severity of influenza.

Chemoprophylaxis should not be considered a substitute for immunization. Influenza vaccine should always be offered when not contraindicated, even when influenza virus is circulating in the community. Antiviral medications currently licensed are important adjuncts to influenza immunization for control and prevention of influenza disease, but indiscriminate use might promote resistance and/or limit availability (Table 1). Providers should inform recipients of antiviral chemoprophylaxis that risk of influenza is lowered but still remains while taking medication, and susceptibility to influenza returns when medication is discontinued. For recommendations about treatment and chemoprophylaxis against influenza, see Table 4. Updates will be available at www.aapredbook.org/flu and www.cdc.gov/flu/professionals/antivirals/index.htm.

Manufacturers anticipate being able to provide adequate supplies of vaccine. Efforts should be made to create adequate outreach and infrastructure to ensure an optimal distribution of vaccine so that more people are immunized. Health care for children should be provided in the child's medical home. However, medical homes might have limited capacity to accommodate all patients (and their families) who seek influenza immunization. Because of the increased demand for immunization during each influenza season, the AAP and the CDC recommend vaccine administration at any visit to the medical home during influenza season when it is not contraindicated, at specially arranged “vaccine-only” sessions, and through cooperation with community sites, schools, and child care centers to provide influenza vaccine. If alternate venues are used, a system of patient record transfer is beneficial for ensuring maintenance of accurate immunization records. Immunization-information systems should be used whenever available.

Cost-effectiveness and logistic feasibility of vaccinating everyone continue to be concerns. With universal immunization, particular attention is being paid to vaccine supply, distribution, implementation, and financing. Potential benefits of more widespread childhood immunization among recipients, their contacts, and the community include fewer influenza cases, fewer outpatient visits and hospitalizations for influenza infection, and a decrease in the use of antimicrobial agents, absenteeism from school, and lost parent work time.

Continued evaluation of the safety, immunogenicity, and effectiveness of influenza vaccine, especially for children younger than 2 years, is important. Development of a safe, immunogenic vaccine for infants younger than 6 months is essential. Consideration of how best to offer to immunize parents and adult child care providers in the pediatric office setting continues to be investigated. Mandatory annual influenza immunization has been implemented successfully at pediatric institutions, and future efforts should include broader implementation of mandatory immunization programs. Optimal prevention of influenza in the health care setting depends on coverage of at least 90% of HCP. Finally, efforts are underway to improve the vaccine-development process to allow for a shorter interval between identification of vaccine strains and vaccine production.

Michael T. Brady, MD, Chairperson

Carrie L. Byington, MD

H. Dele Davies, MD

Kathryn M. Edwards, MD

Mary P. Glode, MD

Mary Anne Jackson, MD

Harry L. Keyserling, MD

Yvonne A. Maldonado, MD

Dennis L. Murray, MD

Walter A. Orenstein, MD

Gordon E. Schutze, MD

Rodney E. Willoughby, MD

Theoklis E. Zaoutis, MD

Margaret C. Fisher, MD

Marc A. Fischer, MD

Centers for Disease Control and Prevention

Bruce Gellin, MD

National Vaccine Program Office

Richard L. Gorman, MD

National Institutes of Health

Lucia Lee, MD

Food and Drug Administration

R. Douglas Pratt, MD

Food and Drug Administration

Jennifer S. Read, MD

National Vaccine Program Office

Joan Robinson, MD

Canadian Paediatric Society

Jane Seward, MBBS, MPH

Centers for Disease Control and Prevention

Jeffrey R. Starke, MD

American Thoracic Society

Jack Swanson, MD

Committee on Practice Ambulatory Medicine

Tina Q. Tan, MD

Pediatric Infectious Diseases Society

Carol J. Baker, MD

Red Book Associate Editor

Henry H. Bernstein, DO

Red Book Associate Editor

David W. Kimberlin, MD

Red Book Associate Editor

Sarah S. Long, MD

Red Book Associate Editor

H. Cody Meissner, MD

Red Book Associate Editor

Larry K. Pickering, MD

Red Book Editor

Lorry G. Rubin, MD

J. Dennis O'Dell, MD

Medical Home Expert

Stuart T. Weinberg, MD

Partnership for Policy Implementation

Kathryn E. Fay, BA

Research Assistant, Children's Hospital of Dartmouth

John M. Kelso, MD

Section on Allergy and Immunology

Jennifer Frantz, MPH

This AAP policy statement was prepared in parallel with CDC recommendations and reports. Much of this statement is based on literature reviews, analyses of unpublished data, and deliberations of CDC staff in collaborations with the Advisory Committee on Immunization Practices Influenza Working Group, with liaison from the AAP.

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Centers for Disease Control and Prevention. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(Early Release):1–6

Harper SA, Bradley JS, Englund JA, et al; Expert Panel of the Infectious Diseases Society of America. Seasonal influenza in adults and children: diagnosis, treatment, chemoprophylaxis, and institutional outbreak management—clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(8):1003–1032

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