pediatrics-2012--780-92

POLICY STATEMENT

Recommendations for Prevention and Control ofInuenza in Children, 20122013

abstractThe purpose of this statement is to update recommendations for rou-tine use of trivalent seasonal inuenza vaccine and antiviral medica-tions for the prevention and treatment of inuenza in children. The keypoints for the upcoming 20122013 season are: (1) this years trivalentinuenza vaccine contains A/California/7/2009 (H1N1)like antigen(derived from inuenza A [H1N1] pdm09 [pH1N1] virus); A/Victoria/361/2011 (H3N2)like antigen; and B/Wisconsin/1/2010like antigen(the inuenza A [H3N2] and B antigens differ from those containedin the 20102011 and 20112012 seasonal vaccines); (2) annual uni-versal inuenza immunization is indicated; and (3) an updated dosingalgorithm for administration of inuenza vaccine to children 6 monthsthrough 8 years of age has been created. Pediatricians, nurses, andall health care personnel should promote inuenza vaccine use andinfection control measures. In addition, pediatricians should promptlyidentify inuenza infections to enable rapid treatment, when indi-cated, to reduce morbidity and mortality. Pediatrics 2012;130:780792

INTRODUCTION

The American Academy of Pediatrics (AAP) recommends annual tri-valent seasonal inuenza immunization for all individuals, including allchildren and adolescents, aged 6 months during the 20122013inuenza season. In addition, special efforts should be made to vac-cinate individuals in the following groups:

All children, including infants born preterm, who are 6 months of agewho have conditions that increase the risk of complications from in-uenza (eg, children with chronic medical conditions such as asthma,diabetes mellitus, immunosuppression, or neurologic disorders);

All household contacts and out-of-home care providers of: children with high-risk conditions; and

children aged

of inuenza complications (eg, chil-dren with chronic medical condi-tions such as asthma, diabetesmellitus, immunosuppression, orneurologic disorders). In theUnited States, more than two-thirds of children 6years spend signicant time inchild care and school settings out-side the home. Exposure to groupsof children increases the risk ofinfectious diseases. Children aged

dose this season at least 4 weeksafter the rst dose.

Children 6 months through 8years of age who received triva-lent seasonal inuenza vaccinebefore the 20122013 inuenzaseason:

Need only 1 dose of vaccine, ifthey previously received a totalof 2 doses of seasonal vac-cine since July 1, 2010

Need 2 doses of vaccine, ifthey did not previously receivea total of 2 doses of seasonalvaccine since July 1, 2010

Need only 1 dose of inu-enza vaccine if there is clear

documentation of having re-ceived at least 2 seasonal in-uenza vaccines from anyprevious season and at least1 dose of a pH1N1-containingvaccine, which could havebeen in 1 of the seasonal vac-cines (20102011 or 20112012) or as the monovalentpH1N1 vaccine from 20092010.

6. As soon as the trivalent seasonalinuenza vaccine is available locally,HCP should be immunized, parentsand caregivers should be notiedabout vaccine availability, and im-munization of all children aged 6months, especially children at high

risk of complications from inu-enza, should begin. HCP endorse-ment plays a major role in vaccineuptake. A strong correlation existsbetween HCP endorsement of inu-enza vaccine and patient acceptance.Prompt initiation of inuenza immu-nization and continuance of immuni-zation throughout the inuenzaseason, whether or not inuenza iscirculating (or has circulated) in thecommunity, are critical componentsof an effective immunization strat-egy. Giving the vaccine promptlyand early during the inuenza sea-son does not pose a risk that immu-nity might wane before the end ofthe season.

7. Providers should continue to offervaccine until the vaccine expirationdate because inuenza is so un-predictable. Protective immuneresponses persist throughout the in-uenza season, which can have >1disease peak and often extends intoMarch or later. Although most inu-enza activity in the United Statestends to occur in January throughMarch, inuenza activity can occurin early fall (ie, October and Novem-ber) or late spring (eg, 1 statereported widespread activity duringthe third week in May 2012). Thisapproach provides ample opportu-nity to administer a second dose ofvaccine because children aged 30;and renal disease includes conditions such as acute or chronic renal failure, nephrotic syndrome,glomerulonephritis, and impaired creatinine clearance. Asthma is included in both the asthma andchronic lung disease categories; otherwise, the categories are mutually exclusive. Data given hereonly include cases for which data collection has been completed through the medical chart reviewstage. Source: Centers for Disease Control and Prevention. FluView 20112012 inuenza seasonweek 20 ending May 19, 2012. Available at: http://www.cdc.gov/u/weekly.

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clinics, extending hours beyondroutine times during peak vacci-nation periods, considering howto immunize parents and adultcaregivers at the same time inthe same ofce setting as chil-dren,1 and working with otherinstitutions (eg, schools, childcare centers, religious organiza-tions) or alternative care sites,such as emergency departments,to expand venues for administer-ing vaccine, with appropriate doc-umentation of immunization to beprovided to the medical homes ofchildren and adults immunized.

Concerted efforts among theaforementioned groups, plusvaccine manufacturers, distribu-tors, and payers, also are neces-sary to appropriately prioritizedistribution to the primary careofce setting before other ven-ues, especially when vaccinesupplies are delayed or limited.

Vaccine safety, effectiveness, andindications must be properlycommunicated to the public. HCPshould act as role models by re-ceiving inuenza immunizationannually as well as recommend-ing annual immunizations to bothcolleagues and patients.

Beginning in 2012, as an immuni-zation core measure, the Centers

for Medicare & Medicaid Serv-ices, the US federal agency thatadministers Medicare, Medicaid,and the State Childrens HealthInsurance Program, requireshospitals and certain other inpa-tient facilities to screen for andimmunize against inuenza allhospitalized patients aged 6months between October andMarch, unless contraindicatedor the patient or family refuses.

9. Antiviral medications also are im-portant in the control of inuenza.The neuraminidase inhibitors oraloseltamivir (Tamiu [Roche Labo-ratories, Nutley, NJ]) and inhaledzanamivir (Relenza [GlaxoSmithK-line, Research Triangle Park, NC])are the only antiviral medicationsroutinely recommended for chemo-prophylaxis or treatment duringthe 20122013 season. Intravenouspreparations are not routinely avail-able at the present time. Withinfectious diseases consultation, in-travenous use through experimentalprotocols could be considered forsome critically ill children, especiallythose who are immunocompro-mised. All strains of inuenza cur-rently anticipated to circulate aresusceptible to neuraminidase inhibi-tors but have high rates of resistanceto amantadine and rimantadine

(Table 1). Resistance characteris-tics may change rapidly; pediatri-cians should verify susceptibilitydata at the start of the inuenzaseason and monitor them duringthe season. Up-to-date informationcan be found on the AAP Web site(www.aap.org or http://aapredbook.aappublications.org/u), through state-specic AAP chapter Web sites, oron the CDC Web site (www.cdc.gov/u/index.htm).

TRIVALENT SEASONAL INFLUENZAVACCINES

Tables 2 and 3 summarize informationon the 2 types of 20122013 trivalentseasonal inuenza vaccines licensedfor immunization of children and adults:injectable trivalent inactivated inuenzavaccine (TIV) and intranasally adminis-tered live-attenuated inuenza vaccine(LAIV). Both vaccines contain the iden-tical strains of inuenza A subtypes (ie,H1N1 and H3N2) and inuenza B antic-ipated to circulate during the 20122013 inuenza season.

TIV is an inactivated vaccine thatcontains no live virus. TIV formulationsare now available for intramuscular(IM) and intradermal (ID) use. The IMformulation of TIV is licensed andrecommended for children aged 6months and adults, including peoplewith and without chronic medicalconditions. The most common adverseevents after administration are localinjection site pain and tenderness.Fever may occur within 24 hours afterimmunization in 10% to 35% ofchildren

System and were associated withTIV manufactured by Sano Pasteur(Fluzone [the only inuenza vaccinelicensed for children aged

use of TIV or LAIV in otherwise eligiblechildren. Because use of antipyreticagents in febrile children does notreduce the incidence of febrile seiz-ures, routine use of antipyretic agentsto avoid febrile seizures in childrenreceiving inuenza vaccine is not rec-ommended. Approximately 2% to 5% ofchildren 6 months through 5 years ofage will have at least 1 febrile seizurenot associated with vaccines in theirlifetime. A report of a febrile seizure tothe Vaccine Adverse Event ReportingSystem does not mean that there isa causal relationship between the eventand the vaccine. There is no change inthe recommendations for the use of TIVor 13-valent pneumococcal conjugate

vaccine for the 20122013 inuenzaseason. Simultaneous administration

should be used when both vaccines

are indicated.

An ID formulation of TIV is licensed forthe 20122013 inuenza season foruse in individuals aged 18 through64 years. ID vaccine administrationinvolves a microinjection with a nee-dle 90% shorter than needles used forIM administration. The most commonadverse events are redness, indura-tion, swelling, pain, and itching at thesite of administration at a slightlyhigher rate than occurs with the IMformulation of TIV. Headache, myalgia,and malaise may occur and tend tooccur at the same rate as that with

the IM formulation of TIV. There is nopreference for IM or ID immunizationin individuals aged 18 years; pedia-tricians may therefore choose to useeither the IM or ID product in theirlate adolescent and young adultpatients.

LAIV is administered intranasally andis licensed by the US Food and DrugAdministration (FDA) for healthy indi-viduals 2 through 49 years of age. It isnot recommended for those who havea history of asthma or other high-riskmedical conditions associated with anincreased risk of complications frominuenza (see Contraindications andPrecautions). LAIV has the potential toproduce mild symptoms, includingrhinitis, headache, wheezing, vomiting,muscle aches, and fever. LAIV shouldnot be administered to people withnotable nasal congestion that wouldimpede vaccine delivery.

Both TIV and LAIV are produced in eggsand contain measurable amounts of eggprotein, expressed as the concentrationof ovalbumin per dose (Table 2). How-ever, recent data have shown thatTIV administered in a single, age-appropriate dose is well tolerated bynearly all recipients who have egg al-lergy. More conservative approaches,such as skin testing or a 2-step gradedchallenge, no longer are recommended.No data exist on the safety of admin-istering LAIV to egg-allergic recipients.

As a precaution, pediatricians shoulddetermine whether the presumed eggallergy is based on amild (ie, hives alone)or severe (ie, anaphylaxis involving car-diovascular changes, respiratory and/orgastrointestinal tract symptoms, orreactions that required the use of epi-nephrine) reaction. Pediatricians shouldconsult with an allergist for children whohave a history of severe reaction. Mostvaccine administration to individualswith egg allergy can happen without theneed for referral. Data indicate that only1% of children have immunoglobulin

TABLE 3 LAIV Compared With TIV

Vaccine Characteristic LAIV TIV

Route of administration Intranasal spray IM or ID injectiona

Type of vaccine Live virus Killed virusProduct Attenuated,

cold-adaptedInactivated subvirion

or surface antigenNo. of included virus strains 3 (2 inuenza A,

1 inuenza B)3 (2 inuenza A,

1 inuenza B)Vaccine virus strains updated Annually AnnuallyFrequency of administrationb Annually AnnuallyApproved age groups All healthy people

aged 249 yAll people aged 6

mo (ID 1864 y)Interval between 2 doses in children 4 wk 4 wkCan it be given to persons with medical risk factors

for inuenza-related complications?No Yes

Can it be given to children with asthma or childrenaged 2 through 4 y with wheezing in the previous year?

Noc Yes

Can it be simultaneously administeredwith other vaccines?

Yesd Yesd

If not simultaneously administered, can itbe administered within 4 wk of another live vaccine?

No, prudent tospace 4 wk apart

Yes

Can it be administered within 4 wk of an inactivated vaccine? Yes Yes

Sources: American Academy of Pediatrics, Committee on Infectious Diseases. Recommendations for prevention andcontrol of inuenza in children, 2011-2012. Pediatrics. 2011;128(4):813825; and Fiore AE, Fry A, Shay D, Gubareva L,Bresee JS, Uyeki TM; Centers for Disease Control and Prevention (CDC). Antiviral agents for the treatment and chemo-prophylaxis of inuenzarecommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR RecommRep. 2011;60(1):124.a The preferred site of TIV IM injection for infants and young children is the anterolateral aspect of the thigh.b See Fig 2 for decision algorithm to determine number of doses of 20122013 seasonal inuenza vaccine recommendedfor children this year.c LAIV is not recommended for children who have a history of asthma. In the 2- to 4-year-old age group, there are childrenwho have a history of wheezing with respiratory illnesses in whom reactive airways disease is diagnosed and in whomasthma may later be diagnosed. Therefore, because of the potential for increased wheezing after immunization, children 2through 4 years of age with recurrent wheezing or a wheezing episode in the previous 12 months should not receive LAIV.When offering LAIV to children in this age group, a pediatrician should screen those who might be at higher risk ofasthma by asking the parents/guardians of 2-, 3-, and 4-year-olds (24- through 59-month-olds) the question: In theprevious 12 months, has a health care professional ever told you that your child had wheezing? If the parents answeryes to this question, LAIV is not recommended for these children.d LAIV coadministration has been evaluated systematically only among children 12 to 15 months of age with measles-mumps-rubella and varicella vaccines. TIV coadministration has been evaluated systematically only among adults withpneumococcal polysaccharide and zoster-vaccines.

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Emediated sensitivity to egg, and ofthose, a very small minority havea severe allergy.

Standard immunization practice shouldinclude the ability to respond to acutehypersensitivity reactions. Therefore,inuenza vaccine should be given toindividuals with egg allergy with thefollowing preconditions (Fig 3):

Appropriate resuscitative equip-ment must be readily available.2

The vaccine recipient should be ob-served in the ofce for 30 minutesafter immunization, the standardobservation time for receiving im-munotherapy.

Both TIV and LAIV are cost-effectivestrategies for preventing inuenzaamong children and their families whencirculating and vaccine strains arematched closely, but efcacy variesaccording to the age of the recipient.Current data from direct comparisons ofthe efcacy or effectiveness of these 2vaccines are limited because studieswere conducted in a variety of settingsand in populations using several dif-ferent clinical end points. In one studythat compared LAIV with TIV in infantsand young children without severeasthma or a recent history of wheezing,LAIV showed signicantly better efcacythan TIV; results of other studies suggestthat TIV may be more effective in youngadults. The CDC has recently beguna new, comprehensive, and systematicapproach to grading the quality of evi-dence and strength of recommendationsfor inuenza vaccines using an evidence-based framework called Grading ofRecommendations Assessment, Develop-ment and Evaluation. Initial assess-ments will focus on the use of inuenzavaccines in healthy children and thebasis for age-based preferential rec-ommendations of TIV or LAIV.

A large body of evidence demonstratesthat thimerosal-containing vaccines arenot associated with increased risk ofautism spectrum disorders in children.

As such, the AAP extends its stron-gest support to the recent WorldHealth Organization recommendationsto retain the use of thimerosal in theglobal vaccine supply. Some individu-als may still raise concerns aboutthe minute amounts of thimerosal inTIV vaccines, and in some states, thereis a legislated restriction on the useof thimerosal-containing vaccines. Thebenets of protecting children againstthe known risks of inuenza are clear.Therefore, children should receive anyavailable formulation of TIV rather thandelaying immunization while waiting forvaccines with reduced-thimerosal con-tent or for thimerosal-free vaccine. Al-though some formulations of TIV containonly a trace amount of thimerosal, cer-tain types can be obtained thimerosalfree. LAIV does not contain thimerosal.Vaccine manufacturers are deliveringincreasing amounts of thimerosal-freeinuenza vaccine each year.

VACCINE STORAGE ANDADMINISTRATION

Any of the inuenza vaccines canbe administered at the same visit

with all other recommended routinevaccines.

IM Vaccine

The IM formulation of TIV is shippedand stored at 2C to 8C (35F46F). Itis administered intramuscularly intothe anterolateral thigh of infants andyoung children and into the deltoidmuscle of older children and adults.The volume of vaccine is age de-pendent; infants and toddlers 6months through 35 months of ageshould receive a dose of 0.25 mL, andall individuals 3 years (36 months)and older should receive 0.5 mL perdose.

ID Vaccine

The ID formulation of TIV also isshipped and stored at 2C to 8C (35F46F). It is administered intradermallyonly to individuals 18 through 64 yearsof age, preferably over the deltoidmuscle, and only using the device in-cluded in the vaccine package. Vac-cine is supplied in a single-dose,prelled microinjection system (0.1mL) for adults. The package insert

FIGURE 3Precautions for administering TIV to presumed egg-allergic individuals. BP, blood pressure.


should be reviewed for full adminis-tration details of this product.

Live-Attenuated (Intranasal)Vaccine

The cold-adapted LAIV formulationcurrently licensed in the United Statesmust be shipped and stored at 2C to8C (35F46F) and administered in-tranasally in a prelled, single-usesprayer containing 0.2 mL of vaccine.A removable dose-divider clip is at-tached to the sprayer to administer0.1 mL separately into each nostril.After administration of any live virusvaccine, at least 4 weeks should passbefore another live virus vaccine isadministered.

CURRENT RECOMMENDATIONS

Trivalent seasonal inuenza immuni-zation is recommended for all childrenaged 6 months. Healthy childrenaged 2 years can receive either TIVor LAIV. Particular focus should be onthe administration of TIV for all chil-dren and adolescents who have un-derlying medical conditions associatedwith an increased risk of complica-tions from inuenza, including:

Asthma or other chronic pulmonarydiseases, including cystic brosis.

Hemodynamically signicant car-diac disease.

Immunosuppressive disorders ortherapy.

HIV infection. Sickle cell anemia and other hemo-

globinopathies.

Diseases that require long-termaspirin therapy, including juvenileidiopathic arthritis or Kawasakidisease.

Chronic renal dysfunction. Chronic metabolic disease, includ-

ing diabetes mellitus.

Any condition that can compromiserespiratory function or handling of

secretions or can increase the riskof aspiration, such as neurodeve-lopmental disorders, spinal cordinjuries, seizure disorders, or neu-romuscular abnormalities.

Although universal immunization forall individuals aged 6 months isrecommended for the 20122013 in-uenza season, particular immuniza-tion efforts with either TIV or LAIVshould be made for the followinggroups to prevent transmission of in-uenza to those at risk, unless con-traindicated:

Household contacts and out-of-home care providers of childrenaged

Any female who is pregnant orconsidering pregnancy.

Children with any condition thatcan compromise respiratory func-tion or handling of secretions orcan increase the risk for aspira-tion, such as neurodevelopmentaldisorders, spinal cord injuries, sei-zure disorders, or neuromuscularabnormalities.

Children aged 2 through 4 yearswith a history of recurrent wheez-ing or a medically attended wheez-ing episode in the previous 12months because of the potentialfor increased wheezing after im-munization. In this age range,many children have a history ofwheezing with respiratory tract ill-nesses and are eventually diag-nosed with asthma. Therefore,when offering LAIV to children 24through 59 months of age, the pe-diatrician should screen them byasking the parent/guardian thequestion, In the previous 12months, has a health care profes-sional ever told you that your childhad wheezing? If a parent answersyes to this question, LAIV is notrecommended for the child. TIVwould be recommended for thechild to whom LAIV is not given.

Children taking an inuenza antivi-ral medication should not receiveLAIV until 48 hours after stoppingthe inuenza antiviral therapy. Ifa child recently received LAIV buthas an inuenza illness for whichantiviral agents are appropriate,the antiviral agents should be given.Reimmunization may be indicatedbecause of the potential effects ofantiviral medications on LAIV repli-cation and immunogenicity.

PRECAUTIONS

TIV is the vaccine of choice for anyonein close contact with a subset of se-verely immunocompromised people

(ie, individuals in a protected envi-ronment). TIV is preferred over LAIV forcontacts of severely immunocompro-mised people (ie, in a protected envi-ronment) because of the theoreticalrisk of infection in an immuno-compromised contact of an LAIV-immunized person. Available dataindicate a very low risk of transmissionof the virus in both children and adultsvaccinated with LAIV. HCP immunizedwith LAIV may continue to work in mostunits of a hospital, including the NICUand general oncology wards, usingstandard infection control techniques.As a precautionary measure, peoplerecently vaccinated with LAIV shouldrestrict contact with severely immu-nocompromised patients (eg, hemato-poietic stem cell transplant recipientsduring periods that require a protectedenvironment) for 7 days after immu-nization, although there have beenno reports of LAIV transmissionfrom a vaccinated person to animmunocompromised person. Inthe theoretical scenario in whichsymptomatic LAIV infection developsin an immunocompromised host,oseltamivir or zanamivir couldbe prescribed, because LAIV strainsare susceptible to these antiviralmedications.

SURVEILLANCE

Information about inuenza surveil-lance is available through the CDCVoice Information System (inuenzaupdate, 888-232-3228) or at www.cdc.gov/u/index.htm. Although currentinuenza season data on circulatingstrains do not necessarily predictwhich and in what proportion strainswill circulate in the subsequent sea-son, it is instructive to be aware of20112012 inuenza surveillance dataand use them as a guide to empiricaltherapy until current seasonal dataare available from the CDC. In-formation is posted weekly on the CDC

Web site (www.cdc.gov/u/weekly/uactivity.htm).

VACCINE IMPLEMENTATION

These updated recommendations forprevention and control of inuenza inchildren will have considerable oper-ational and scal effect on pediatricpractice. Therefore, the AAP has de-veloped implementation guidance onsupply, payment, coding, and liabilityissues; these documents can be foundat http://aapredbook.aappublications.org/site/implementation/.

USE OF ANTIVIRAL MEDICATIONS

Antiviral resistance can emergequickly from 1 season to the next.If local or national inuenza surveil-lance data indicate a predominanceof a particular inuenza strain witha known antiviral susceptibility prole,then empirical treatment can be di-rected toward that strain. For example,all of the inuenza B and inuenzaA (H3N2) viruses tested were sensitiveto oseltamivir and zanamivir duringthe 20112012 inuenza season.Among the pH1N1 viruses tested forresistance, only 1.4% were found tobe resistant to oseltamivir andnone was found to be resistant tozanamivir. High levels of resistance toamantadine and rimantadine persist,and these drugs should not be usedin the upcoming season unless re-sistance patterns change signicantly(Table 1).

Current treatment guidelines forantiviral medications (Table 4)are applicable to both infants andchildren with suspected inuenzawhen known virus strains are cir-culating in the community or wheninfants or children are conrmedto have seasonal inuenza.

Oseltamivir is available in capsuleand oral suspension formulations.The commercially manufactured


liquid formulation has a concentra-tion of 6 mg/mL. If the commerciallymanufactured oral suspension isnot available, the capsule may beopened and the contents mixedwith a sweetened liquid by retailpharmacies to a nal concentrationof 15 mg/mL.

Continuous monitoring of the epi-demiology, change in severity, andresistance patterns of inuenzastrains may lead to new guidance.

Treatment should be offered for:

Any child hospitalized with pre-sumed inuenza or with severe,complicated, or progressive illnessattributable to inuenza, regardlessof inuenza immunization status.

Inuenza infection of any severity inchildren at high risk of complica-tions of inuenza infection (Table 5).

Treatment should be considered for:

Any otherwise healthy child withinuenza infection for whom a de-crease in duration of clinical symp-toms is felt to be warranted by hisor her pediatrician if treatmentcan be initiated within 48 hoursof illness onset.

Reviews of available studies by theCDC, the World Health Organization,and independent investigators haveconsistently found that timely oselta-mivir treatment can reduce the risksof complications, including thoseresulting in hospitalization and death.Earlier treatment provides more op-timal clinical responses; treatmentafter 48 hours of symptoms in the childwith moderate to severe disease orwith progressive disease is likely toprovide some benet.

Dosages for antiviral agents for bothtreatment and chemoprophylaxis inchildren can be found in Table 4 andon the CDC Web site (http://www.cdc.gov/u/professionals/antivirals/index.htm). Children aged

of an infected person if those peo-ple are at high risk of complica-tions from inuenza.

For children at high risk and theirfamily members and close contacts,as well as HCP, when circulatingstrains of inuenza virus in thecommunity are not matched withtrivalent seasonal inuenza vaccinestrains, on the basis of current datafrom the CDC and local healthdepartments.

These recommendations apply toroutine circumstances, but it shouldbe noted that guidance may changeon the basis of updated recom-mendations from the CDC in concertwith antiviral availability, local re-sources, clinical judgment, recommen-dations from local or public healthauthorities, risk of inuenza compli-cations, type and duration of exposurecontact, and change in epidemiologyor severity of inuenza.

Chemoprophylaxis should not be con-sidered a substitute for immunization.Inuenza vaccine should always beoffered when not contraindicated, evenwhen inuenza virus is circulating inthe community. Antiviral medicationscurrently licensed are importantadjuncts to inuenza immunization forcontrol and prevention of inuenzadisease, but there are toxicities as-sociated with antiviral agents, andindiscriminate use might limit avail-ability (Table 1). Pediatricians shouldinform recipients of antiviral chemo-prophylaxis that risk of inuenza islowered but still remains while takingthe medication, and susceptibility toinuenza returns when medication isdiscontinued. For recommendationsabout treatment and chemoprophylaxisagainst inuenza, see Table 4. Updateswill be available at www.aapredbook.org/u and http://www.cdc.gov/u/professionals/antivirals/index.htm.

FUTURE NEEDS

Currently, inuenza vaccines are tri-valent and contain antigens from onlya single inuenza B virus. However,since 1985, there have been 2 anti-genically distinct lineages of inuenzaB viruses circulated globally, the Vic-toria and the Yamagata lineages. Be-cause there is little cross-protectionconferred against B virus strains of 1lineage by vaccination against a B vi-rus strain in the other lineage, tri-valent vaccines offer limited immunityagainst circulating inuenza B strainsof the lineage not present in the vac-cine. Furthermore, in recent years, ithas proven difcult to predict whichB lineage will predominate during agiven inuenza season. Therefore, ithas been proposed that a quadrivalentinuenza vaccine, containing inuenzaB strains of both lineages, would offersuperior protection.

The FDA approved a new quadrivalentLAIV, FluMist Quadrivalent (MedImmune

TABLE 4 Recommended Dosage and Schedule of Inuenza Antiviral Medications for Treatmentand Chemoprophylaxis for the 20122013 Inuenza Season: United States

Medication Treatment (5 d) Chemoprophylaxis (10 d)

Oseltamivira

Adults 75 mg twice daily 75 mg once dailyChildren >12 moBody weight15 kg (33 lb) 30 mg twice daily 30 mg once daily>1523 kg (3351 lb) 45 mg twice daily 45 mg once daily>2340 kg (>5188 lb) 60 mg twice daily 60 mg twice daily>40 kg (>88 lb) 75 mg twice daily 75 mg once dailyChildren 3 mo to

[Gaithersburg, MD]), in February 2012.However, this vaccine is not expectedto be available during the 20122013inuenza season. It will likely rst beused during the 20132014 inuenzaseason, when it is anticipated to replacethe current trivalent LAIV formulation. Inaddition, inactivated quadrivalent vac-cines are currently in development.

Manufacturers predict being able toprovide adequate supplies of vaccine.Efforts should be made to createadequate outreach and infrastructureto ensure an optimal distributionof vaccine so that more people areimmunized. Health care for childrenshould be provided in the childs med-ical home. However, medical homesmay have limited capacity to accom-modate all patients (and their fami-lies) seeking inuenza immunization.Because of the increased demand for

immunization during each inuenzaseason, the AAP and the CDC recom-mend vaccine administration at anyvisit to the medical home during in-uenza season when it is not contra-indicated, at specially arranged vaccine-only sessions, and through cooperationwith community sites, schools, andchild care centers to provide inuenzavaccine. If alternate venues are used,a system of patient record transfer isbenecial to ensuring maintenance ofaccurate immunization records. Immu-nization information systems should beused whenever available.

Cost-effectiveness and logistic feasi-bility of vaccinating everyone continueto be concerns. With universal immu-nization, particular attention is beingpaid to vaccine supply, distribution,implementation, and nancing. Poten-tial benets of more widespreadchildhood immunization among recip-ients, their contacts, and the commu-nity include fewer inuenza cases,fewer outpatient visits and hospital-izations for inuenza infection, anda decrease in the use of antimicrobialagents, absenteeism from school, andlost parent work time. To optimallyadminister antiviral therapy in hospi-talized patients with inuenza whocannot tolerate oral or inhaled anti-viral agents, intravenous neuramini-dase inhibitors for children also areneeded.

Continued evaluation of the safety,immunogenicity, and effectivenessof inuenza vaccine, especially forchildren aged

Joan Robinson, MDCanadian Pediatric SocietyMarco Aurelio Palazzi Safadi, MDSociedadLatinoamericana de Infectologia Pediatrica(SLIPE)Jane Seward, MBBS, MPHCenters for DiseaseControl and PreventionJeffrey R. Starke, MDAmerican Thoracic SocietyGeoffrey Simon, MDCommittee on PracticeAmbulatory MedicineTina Q. Tan, MDPediatric Infectious DiseasesSociety

EX OFFICIOCarol J. Baker, MDRed Book Associate EditorHenry H. Bernstein, DORed Book Online As-sociate Editor

David W. Kimberlin, MDRed Book AssociateEditorSarah S. Long, MDRed Book Associate EditorH. Cody Meissner, MDVisual Red Book Asso-ciate EditorLarry K. Pickering, MDRed Book Editor

CONSULTANTSLorry G. Rubin, MD

CONTRIBUTORSStuart T. Weinberg, MDPartnership for PolicyImplementationJenna Katz, BAResearch Assistant, CohenChildrens Medical Center of NYJohn M. Kelso, MD

STAFFJennifer Frantz, MPH

ACKNOWLEDGMENTSThis AAP policy statement was pre-pared in parallel with CDC recommen-dations and reports. Much of thisstatement is based on literaturereviews, analyses of unpublished data,and deliberations of CDC staff in collab-orations with the Advisory Committeeon Immunization Practices InuenzaWorking Group, with liaison from theAAP.

REFERENCES

1. Lessin HR, Edwards KM; Committee On PracticeAnd Ambulatory Medicine; Committee On In-fectious Diseases. Immunizing parents andother close family contacts in the pediatric of-ce setting. Pediatrics. 2012;129(1). Available at:www.pediatrics.org/cgi/content/full/129/1/e247

2. Frush K; American Academy of PediatricsCommittee on Pediatric Emergency Medi-cine. Preparation for emergencies in theofces of pediatricians and pediatric pri-mary care providers. Pediatrics. 2007;120(1):200212

3. Bernstein HH, Starke JR; American Academyof Pediatrics. Committee on Infectious Dis-eases. Policy statementrecommendationfor mandatory inuenza immunization of allhealth care personnel. Pediatrics. 2010;126(4):809815

ADDITIONAL RESOURCES

American Academy of Pediatrics Committeeon Infectious Diseases. Recommendationsfor prevention and control of inuenza inchildren, 2011-2012. Pediatrics. 2011;128(4):813825

American Academy of Pediatrics. Inuenza. In:Pickering LK, Baker CJ, Long SS, Kimberlin DW,eds. Red Book: 2012 Report of the Committeeon Infectious Diseases. 29th ed. Elk Grove Vil-lage, IL: American Academy of Pediatrics; 2012:439453. Available at: http://aapredbook.aap-publications.org/u. Accessed August 14, 2012

Fiore AE, Fry A, Shay D, Gubareva L, Bresee JS,Uyeki TM; Centers for Disease Control andPrevention (CDC). Antiviral agents for thetreatment and chemoprophylaxis of inuenza

recommendations of the Advisory Committeeon Immunization Practices (ACIP). MMWRRecomm Rep. 2011;60(1):124

Centers for Disease Control and Prevention.Prevention and control of seasonal inuenzawith vaccines: recommendations of the Advi-sory Committee on Immunization Practices(ACIP)United States, 20122013 inuenza sea-son. MMWR Recomm Rep. 2012;61(32):613618

Englund JA, Walter EB, Fairchok MP, Monto AS,Neuzil KM. A comparison of 2 inuenza vaccineschedules in 6- to 23-month-old children. Pedi-atrics. 2005;115(4):10391047

Harper SA, Bradley JS, Englund JA, et al; ExpertPanel of the Infectious Diseases Society of

America. Seasonal inuenza in adults andchildrendiagnosis, treatment, chemoprophy-laxis, and institutional outbreak management:clinical practice guidelines of the InfectiousDiseases Society of America. Clin Infect Dis.2009;48(8):10031032

Kelso JM, Greenhawt MJ, Li JT, et al. Adversereactions to vaccines practice parameter 2012update. J Allergy Clin Immunol. 2012;130(1):2543

Pickering LK, Baker CJ, Freed GL, et al; InfectiousDiseases Society of America. Immunization pro-grams for infants, children, adolescents, andadults: clinical practice guidelines by the In-fectious Diseases Society of America. Clin InfectDis. 2009;49(6):817840


Council on Sports Medicine and Fitness. Policy Statement: CheerleadingInjuries: Epidemiology and Recommendations for Prevention. Pediatrics.2012;130(5):966971

An error occurred in the American Academy of Pediatrics policy statement, titledCheerleading Injuries: Epidemiology and Recommendations for Preventionpublished in the November 2012 issue of Pediatrics (2012;130[5]:966971; origi-nally published online October 22, 2012; doi:10.1542/peds.2012-2480). In Table 1,the third column heading should read Catastrophic Injury Rate (per 100 000Participants). We regret the error.

doi:10.1542/peds.2012-3544

Committee on Adolescence. Policy Statement: Emergency Contraception.Pediatrics. 2012;130(6):11741182

An update is needed for the American Academy of Pediatrics policy statement,titled Emergency Contraception published in the December 2012 issue of Pe-diatrics (2012;130[6]:11741182; originally published online November 26, 2012;doi:10.1542/peds.2012-2962). Because of recent changes in prescription recom-mendations, both males and females 17 years and older can buy levonorgestrelemergency contraceptive pills without a prescription.

The online version of the article has been corrected accordingly. The print versionrequires the following changes:

Abstract: the sentence that starts with In all states should read: In allstates, both males and females 17 years or older can obtain emergencycontraception without a prescription.

Page 1175, second column: the third sentence beginning Male adolescentsyounger than 18 should read: As of the date of publication, males 17 yearsor older can also access Plan B with or without a prescription.

Page 1179, Recommendation 5: the last 2 sentences should be replaced with1 sentence reading: Both males and females 17 years or older may obtainlevonorgestrel without a prescription, but must show proof of age.

doi:10.1542/peds.2012-3675

Committee on Infectious Diseases. Policy Statement: Recommendationsfor Prevention and Control of Inuenza in Children, 20122013.Pediatrics. 2012;130(4):780792

Two errors occurred in the American Academy of Pediatrics policy statement,titled Recommendations for Prevention and Control of Inuenza in Children,20122013 published in the October 2012 issue of Pediatrics (2012;130[4]:780792; originally published online September 10, 2012; doi:10.1542/peds.2012-2308).In Table 4, page 790, the Chemoprophylaxis column for oseltamivir for childrenweighing.2340 kg (.5188 lb) should read: 60 mg once daily. Also in Table 4,footnote a, eighth line, the concentration should read: 6 mg/mL.

doi:10.1542/peds.2012-3821

362 ERRATA

DOI: 10.1542/peds.2012-2308; originally published online September 10, 2012; 2012;130;780Pediatrics

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Recommendations for Prevention and Control of Influenza in Children, 2012

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DOI: 10.1542/peds.2012-2308; originally published online September 10, 2012; 2012;130;780Pediatrics

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Recommendations for Prevention and Control of Influenza in Children, 2012

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