Listen to this podcast featuring highlights from our expert roundtable discussion with Dr Ravi Jhaveri, Dr Tina Q. Tan, and Dr Jennifer M. Walsh, to learn about the most pressing issues in pediatric influenza vaccines, including current vaccine technologies, recent vaccine uptake and epidemiologic trends, and how to discuss the vast benefits of timely vaccination in pediatric patients with their parents and caregivers.
Listen to this podcast featuring highlights from our expert roundtable discussion to learn about the most pressing issues in pediatric influenza vaccines, including current vaccine technologies, recent vaccine uptake and epidemiologic trends, and how to discuss the vast benefits of timely vaccination in pediatric patients with their parents and caregivers. Topics covered include:
Presenters:
Ravi Jhaveri, MD, FIDSA, FPIDS, FAAP
Division Head
Pediatric Infectious Diseases
Ann & Robert H. Lurie Children’s Hospital of Chicago
Professor of Pediatrics
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Tina Q. Tan, MD, FAAP, FIDSA, FPIDS
Professor of Pediatrics
Feinberg School of Medicine of Northwestern University
Pediatric Infectious Diseases Attending
Medical Director, International Adoptee Clinic
President, Lurie Medical/Dental Staff
Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
Jennifer M. Walsh, DNP, CPNP-PC, CNE
Certified Pediatric Nurse Practitioner, Primary Care
Assistant Professor
George Washington University
School of Nursing
Washington, DC
Link to full program:
https://bit.ly/45UVzy6
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This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Dr. Ravi Jhaveri (Ann & Robert H. Lurie Children's Hospital of Chicago): Hello, everyone. Welcome to The Pediatric Influenza Vaccine Playbook: Proven Paths to Prevention.
My name is Dr. Ravi Jhaveri. I'm at the Ann & Robert H. Lurie Children's Hospital of Chicago, and I'd like to introduce my colleagues, Dr. Tina Tan and Dr. Jennifer Walsh. Dr. Tan?
Dr. Tina Tan (Ann & Robert H. Lurie Children's Hospital of Chicago): Thank you. I'm Dr. Tina Tan. I am also at Ann & Robert H. Lurie Children's Hospital of Chicago.
Dr. Jhaveri: Dr. Walsh.
Dr. Jennifer Walsh (George Washington School of Nursing): Hi, there. My name is Jennifer Walsh. I'm an assistant professor at the George Washington School of Nursing. I'm also a certified pediatric nurse practitioner practicing in primary care in the D.C. area.
Dr. Jhaveri: All right. Wonderful. Thanks so much for joining us today.
So we're going to first start out with a section we're calling “Assessing the field: trends in influenza activity”.
And since everyone can relate to a case, we're going to start with a case that probably sounds very familiar to all of you. It's early December, and your pediatric hospital ward has started to fill with children presenting with respiratory distress. Among them is a seven year old girl, previously healthy except for some mild asthma, who presents with fever to 103 Fahrenheit or 39.5 Celsius.
Cough and myalgia for two days, increasing shortness of breath and oxygen saturation of 89% on room air. Her nasopharyngeal PCR is positive for influenza A H1N1. She is not vaccinated this season, and you note that in the emergency department, there have been several other recent admissions, including a 15 month old with congenital heart disease, a 10 year old with obesity, and a six year old with cerebral palsy, all testing positive for influenza.
All right. So, I'm going to ask both of you to just talk maybe a little bit about your perceptions and recommendations about those children who are at higher risk or at highest risk for severe influenza complications. So, Dr. Tan, maybe you can go first.
Dr. Tan: So the kids that are at highest risk for severe influenza complications need to be treated for their influenza, and they should be vaccinated and all their family members should be vaccinated.
Dr. Jhaveri: And so as we think about the sort of background of the patients we discussed, which of those clinical scenarios worry you the most, Dr. Walsh?
Dr. Walsh: I would say, honestly, all three. They all three have risk factors that put them at significant increased risk of complications, office visits, hospitalizations, and potentially death. So I would say all of them.
Dr. Jhaveri: Yeah, I would - I would definitely agree with that. And what about thinking the youngest infants, you know, we tend to think about them as being the most vulnerable for many reasons? Do you want to just maybe talk - either of you - talk a little bit about sort of the combination of factors that make young infants at highest risk for severe disease?
Dr. Tan: Well, anatomically as well as immature immunity basically puts them at much higher risk for complications.
Dr. Walsh: So, we know that children's immune systems, as well as their respiratory systems are not mature. They're continuing to develop. They're at much more risk of hypoxia and potential hospitalization. And we know that our body's response to pathogens is to send in mucus, increase inflammation, and that really has a much more significant impact on airways of children versus adults. So, definitely a concern for all of our pediatric patients because of those reasons.
Dr. Tan: Right.
Dr. Jhaveri: Yes, I completely agree. I think the – the - one other thing I might add, too, is when we think about those infants younger than six months who aren't eligible for any vaccine, right? We're really relying on perhaps some presence of maternal immunity that's passed on at delivery, which is why we vaccinate pregnant women during pregnancy. But also, obviously, the idea that we need to rely on others in the family caretakers to be vaccinated, to protect those youngest infants. And so it's a - I think a combination of all those factors that really make those youngest infants most vulnerable. What about sort of varying degrees of immune compromise? How do you - how does that factor into your thinking or decision making?
Dr. Tan: Well, the more immune compromised you are, the higher risk you are for complications, but it doesn't seem to matter. You need to be vaccinated and the people in the household need to be vaccinated.
Dr. Walsh: Completely concur, Dr. Tan.
Dr. Jhaveri: Yeah, I would just - I think I would just add a couple of things, which is that I think one, to highlight that when we think about the burden and particularly pediatric deaths. that most of the kids, in fact, don't have any risk factors. Underlying risk factors, right? So that's one of the things to remember. And I think, let's say, thinking about the scenario of those cases we ran through previously, I think we underestimate just how much immune dysfunction comes for patients who have significant obesity. I think the studies have been pretty clear about dysregulated immune system, whether they're infected with influenza or, frankly, any other virus.
And so, I think we should be thinking about immune compromise really in the broadest sense. All right. Thanks so much for that discussion.
So, now I'm going to pivot to Dr. Tan, and she's going to walk us through some of our vaccine options for children.
Dr. Tan: Thank you.
Dr. Jhaveri: Dr. Tan.
Dr. Tan: So basically, the ACIP does recommend that all individuals six months of age and older should receive an influenza vaccine on an annual basis. And basically, the CDC does recommend the use of any licensed age appropriate flu vaccine. And this would include the trivalent inactivated vaccine that could either be egg based or cell culture based, the recombinant influenza vaccine, or the live attenuated influenza vaccine. The trivalent flu vaccines protect against two influenza A strains, H1N1 and H3N2, and then one B strain of the Victoria lineage. And the shift was due to the fact that we really did not see circulation of the other B strain that used to be in the vaccine, which is the Yamagata strain.
You have egg produced for six months of age and older, cell culture produced for six months of age and older, and then the egg produced live attenuated for those individuals between two and 49 years of age that are completely healthy with no underlying conditions.
Now, the vaccine does induce antibodies that bind egg adapted viruses well, but binding to circulating viruses is less effective. And then, when you look at the cell culture or the recombinant hemagglutinin flu vaccines, these vaccines basically induce antibodies that bind both cell adapted and circulating viruses as well.
So, when you look at the differences among these vaccines, we know that the inactivated influenza vaccines are made from killed influenza viruses, so they cannot cause a flu infection.
The live attenuated influenza vaccines are made from attenuated or weakened influenza viruses. And they definitely should not cause infection. And they contain the same strains that are contained in the inactivated vaccine and is administered as a nasal spray. And then when you look at the recombinant influenza vaccines, these are made by only cloning the viruses hemagglutinin gene, which is then combined with the baculovirus, resulting in a recombinant baculovirus. And this virus then delivers genetic instructions for making flu haemagglutinin antigen into the host cell. The recombinant virus then instructs the cells to rapidly produce the haemagglutinin antigen. This is also administered by injection, and this particular vaccine never, ever uses the actual virus, but only a portion of the virus, and it contains three times the antigen content compared to just regular or standard influenza vaccine. And basically, this basically improved its vaccine effectiveness compared with the inactivated vaccines.
So, the question that always comes up is, do cell based vaccines work better? Looking at effectiveness against influenza related medical encounters between 2019 and 2020, looking at cell based quadrivalent versus egg based. For any influenza related medical event, or for outpatient influenza related medical encounters, the cell based vaccines tend to have a better effectiveness.
And basically, if you look at the cell culture based influenza vaccine and the effectiveness against the different strains, you can see that it's most effective against H1N1. And has a little bit less effectiveness against influenza B and H3N2.
So, the thing to remember about the inactivated influenza vaccines is, you can administer this vaccine with all other routinely recommended vaccines and COVID 19 vaccine, with absolutely no immune interference with any of the vaccines.
These vaccines have an excellent safety profile. Most common adverse reactions are mild fever, irritability, pain, and mild swelling and redness at the injection site. And all these reactions tend to basically resolve very quickly. And studies have shown that vaccine effectiveness does vary depending upon the year and the fitness of the strain match between those contained in the vaccine and those circulating in the community.
But in general, vaccine efficacy for the inactivated influenza vaccines is about 60% against influenza caused by any A or B strain.
And if you look at the live attenuated influenza vaccines, again, these can also be administered with all other routinely recommended vaccines and COVID 19 vaccine with no immune interference. These are very safe vaccines, with the most common adverse reactions being nasal congestion, cough, malaise and fever given that this is a nasal spray.
And studies have shown that the live attenuated influenza vaccine effectiveness does differ depending on the vaccine strain, with multiple years of poor effectiveness against the H1N1 A strain and several years of poor effectiveness against the H3N2 A strain. And the factors underlying the decrease of effectiveness included reduced thermostability of the vaccine virus and reduced replication fitness of the H1N1 strain in the vaccine. So, by changing the strain of the virus to a more thermal stable strain and one with increased replication fitness, it really stabilized and increased the effectiveness of LAIV.
And so, to Dr. Jhaveri and Dr. Walsh, how do you select among the various influenza vaccines for your patients? And how can clinicians explain why influenza shots vary in effectiveness while still reinforcing their value in preventing hospitalization and death? Dr. Jhaveri, let's start with you.
Dr. Jhaveri: Yeah. I think - you know, I've been a firm believer that the more options we can give patients, the better off we are. And it's amazing to me sometimes when I talk to patients and families like, what really resonates with them, what they're most concerned about. And so I try to talk about the multiple options that they have. And so it's not just a question of flu vaccine, yes or no. There's different types. And, depending on what their concerns might be, whether their child, you know, does well with - with vaccines or whether there's a big huge battle, in which case sometimes the - the intranasal works well. Some people have concerns about egg allergy, even though that's not a true contraindication, in which case, then, you know, discussion about cell based vaccine becomes a very easy one. And - and then we all know that patients have sort of what I would say concerns or issues that comes up that - that aren't necessarily, like a direct logic based, let's say.
And there's sort of some specific flew thinking that happens, and so sort of talking your way through that. One of the points that I like to just highlight, too, is when we think about vaccine effectiveness that's not the whole story. And one of the points that I like to make that I know we're going to reinforce is the idea that the vaccine has a really powerful effect in - in modifying disease. So, even if you do get infected, you're much less likely to be - to get severely ill. And so, obviously, there's a huge benefit to that. So, Dr. Walsh.
Dr. Walsh: So, I think thinking about what is going to be the best to cover the most amount of people for your particular practice, and that can really vary. And if you have the luxury of selecting several different options, I agree that's best for patients, it's not always possible depending upon what type of delivery is - is giving that. You know, what type of practice or what type of organization has access to that. So, those are just some things that I think about when I think about selecting influenza vaccines.
And again, I cannot agree enough that - that we really need to reframe that flu is still possible even with the vaccination. But we have excellent data, year after year after year, that it really reduces the risk significantly. Reduces the office visits, missed school, missed work, reduces ER visits, reduces hospitalization, and reduces death. So, it's really an effective and powerful tool that we have.
Dr. Tan: I'm going to turn over to Dr. Walsh.
Dr. Walsh: Thank you, Dr. Tan. So, I'm going to focus on uptake of influenza vaccines in children, reversing the trends that we've seen, especially recently.
So, that brings us to the fact that the flu vaccine is very impactful for reducing complications and the hospitalization and the burden of illness on the child and the family. So really, a totally different scenario in a vaccinated child versus a non-vaccinated or partially vaccinated child.
So, I have some questions. What signs suggest a vaccine modified illness? What do you think of when you think of a vaccine modified illness?
Dr. Tan: It's definitely milder. And these kids, even though they might have fever and other symptoms, the symptoms are definitely much milder and they don't last as long. And basically they do recover faster and don't require hospitalization.
Dr. Jhaveri: Yeah, I might just build on that. And think about that it depends on who we're talking about, you know.
For our patients with more severe underlying conditions, severe asthma or the kids maybe who are technology dependent, it's really a life or death scenario where they might survive an illness that - that - that could be fatal. And so, I think we - we - it can look different. But you, you go from what could be the worst case scenario to something that's far better and that's a win in every - in every situation.
Dr. Walsh: Excellent. How can we ensure children like this get vaccinated?
Dr. Tan: Well, it brings up the same point as everything else. I mean, you know, everyone should be vaccinated so that they don't get severe disease. And the other thing to point out, is that there's more than one strain circulating. So even if they got flu, they probably still should get the vaccine after that to protect them against the other circulating strains.
Dr. Jhaveri: Yeah. Yeah, I would - I think I would also add that perhaps we, as providers, the broader medical community, I think we need to do a better job to expecting that - or sort of bringing vaccine to patients- instead of expecting that they're going to come to us. And so I think pharmacies is only one answer. I think we could do better about providing vaccines in schools and community centers. Certainly our institution has worked hard for kids who are hospitalized for other conditions to offer vaccine when they show up, either in the ED or at our specialty clinics or on the inpatient wards.
Other colleagues around the country are doing it when children have procedures. And, you know, now there's even potentially, the - the option to get certain flu vaccines delivered to your home. So, I think just the idea that any - there are many options. And the point is we should be aware of those options and help share them with the patients so that we can just - we're far better off when more kids get a not perfect vaccine, than waiting around for a few kids to get some perfect vaccine.
Dr. Walsh: So, keys to improve vaccination in children, prioritizing vaccination, especially our high risk children which honestly, based on age, based on underlying conditions, prioritizing their caregivers, their household contacts, etc., using every opportunity.
So, well-child visits, acute care visits, we're going to talk a little bit about opportunities in other settings as well. And then educating all office providers and staff. I think it's really important that everyone's on the same page, that we - from the office staff that's scheduling to the nurses to the providers seeing the patients - that we're all on the same page, we're all recommending vaccination, we're all taking a proactive stand for it. Other, and there's many script templates that AAP has as well, training exercises, etc., for effective communication. Because sometimes that communication occurs when the patient calls up to schedule the visit before they even see a healthcare provider. So, it's really important that we're all on the same page.
And then other considerations as Dr. Jhaveri mentioned, school vaccinations, daycare vaccinations, community vaccinations. I think about all of the fall festivals we have in Northern Virginia can be an excellent place. Those pumpkin patches, etc., really great places to capture children. And then considering setting up a sensory - sensitive spot in the clinic for patients as well. I know my practice does a drive through nurse influenza clinic on the weekends, which is very effective and very - very popular.
So, systems to improve vaccination rates. There's a lot of opportunity with electronic medical records as well as AI to really help us get better at vaccination. So updating the EMR, it should prompt healthcare providers. It should also be able to gather those children under the age of five, those that will be six months and on when they come in to visit, those that have underlying health conditions, etc., to really capture those, to set up systems to help facilitate that vaccination. So, text messages, letters, postcards, messages from portals, telephone messages, also social media. I know lots of - lots of families get information on social media. And seeing that, "Hey, it's time for the flu vaccine. Hey, did you know this? You know, this helps reduce hospitalization, reduces missed school, etc.."
So, lots of ways to kind of reach those patients.
It's always important to remember effective communication, which is really what it all comes down to with our parents. So supporting parent autonomy, right? We're partners in keeping your child healthy. That's our job to keep your child as healthy and safe as possible. And then I can provide you, we can provide you with the evidence to make that decision easier. And the messages should be strong and personalized. So, this is what I chose for my child, this is what I chose for my family, and I would recommend this vaccine for children in my family.
As we mentioned earlier, presumptive recommendations are really key. So, your child needs his or her flu vaccine today. And this as well, as I mentioned, with all of the office practice or the hospital practice as well. Instead of “are you interested in getting this vaccine at your appointment?”, having that presumptive recommendation really clearly helps increase vaccine acceptance, and helps set up that conversation as well.
As Dr. Tan mentioned, influenza, we've got multiple different types of influenza vaccination. But one thing that we need to keep an eye on is making sure that children get effectively vaccinated with two doses if they are under the age of eight. So, any children from six months to eight years need two vaccines spaced out by at least four weeks in order to move on to that one dose annually at that point.
And so, vaccination uptake, best practices. We like to think of kind of a Gantt chart or some other practice type of algorithm that really has it broken down into the steps and the timing that we're going to be administering some of these best practices. So, as I mentioned earlier, run - run the report of the electronic health record for the ages, prioritizing patients with asthma, diabetes, chronic health conditions, as Dr. Jhaveri mentioned, including obesity, etc., and include all active patients. Sometimes you can exclude those that have well-child visits from August to October because you know you're going to capture them as well. But begin advertising as soon as possible with all those different message vehicles that I mentioned. Offering the vaccine to family members, siblings, parents, caregivers when they come in as well. And then nurse run clinics, as I mentioned, these can be very, very effective. So, having a designated nurse to administer the influenza vaccines. They're shorter visits, they don't need a provider, they're billable. And then also setting up nurse run clinics for after hours or weekends. Scheduling children that need a second dose on the day that you schedule the first dose, or the day that they receive it. So we've got it in the books. We know that they're coming back.
And then continuing to vaccinate through the season. One thing that is important is sometimes we think of August/September, maybe not quite - we're thinking about flu yet. Most of us think, you know, flu definitely October, flu by boo, or flu by Halloween kind of- kind of saying. But a lot of those, especially older children, might come in for their sports or their school physicals in August/September, and that might be an excellent opportunity to catch them where you might not get them back, right? Kids and families are extremely busy, and if that's not a priority for them, they can get lost in the shuffle. So, if you have it available in your practice, trying to capture those children as well.
Dr. Jhaveri: Dr. Walsh, thanks for that discussion. That was really a terrific overview about how we can all do better. Let's maybe move to close with some final thoughts. So, Dr. Tan, do you want to just share any last thoughts?
Dr. Tan: So, I think people just need to understand that influenza occurs every year. It can be severe in healthy individuals. And everyone, whether you're healthy or have an underlying condition, you should be vaccinated and your family should be vaccinated to protect individuals. And the vaccines that we have are safe and effective.
Dr. Jhaveri: Dr. Walsh.
Dr. Walsh: Yeah, she took the words right out of my mouth. They're very safe vaccines. Everybody deserves an opportunity to protect themselves and their family against illness and possible complications. And they are the greatest tool that we have to keep our population, especially those with underlying conditions, but as we mentioned, those that are completely healthy and have nothing in their history, to keep them safe out of the hospital and away from harm. So vaccinate, vaccinate, vaccinate.
Dr. Tan: I agree.
Dr. Jhaveri: Awesome. That was great. I might just finish with a closing thought or maybe a challenge perhaps to those providers who are out there to maybe choose one thing that you, your practice, your group can do to - to change how you're vaccinating flu - against flu. So, maybe it's including one different option of vaccine. Maybe it's working on a communication strategy. Maybe it's thinking about one of the outreach campaigns that Dr. Walsh mentioned in your community at the pumpkin patch or the apple orchard, or at a school event or whatever it is. Just thinking about one additional thing you could do beyond just obviously doing what you can in the office, in the hospital setting, wherever you practice. And if we can all do a little bit of those things, I think we would go a long way. All right. I think with that we'll - I appreciate Dr. Tan, Dr. Walsh, really appreciate you sharing your expertise with all of us today. My name is Ravi Jhaveri. Thank you all so much for joining us.
Dr. Walsh: Thank you.
Dr. Tan: Thank you.