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Protecting Children at Highest Risk for Influenza Complications

Moderators:Leticia R. Davila and Georgina Peacock

Presenters:Seema Jain, MD, Henry H. Bernstein, DO, MHCM, FAAP, Georgina Peacock, MD, MPH, FAAP, and Renee M Turchi, MD, MPH FAAP

Date/Time:September 24, 2013 2:00 pm ET

NOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to

Welcome and thanks for standing by. All participants will be able to listen only until the question and answer portion of today’s conference. To ask a question, please press Star 1. Today’s conference is being recorded. If you have any objections, please disconnect at this time. I would now like to turn your conference over to Miss Leticia Davila. Ma’am you may begin.

Leticia Davila:
Thank you Julie. Good afternoon. I’m Leticia Davila and I’m representing the Clinician

Outreach and Communication Activity, COCA, with the Emergency Communications System at the Centers for Disease Control and Prevention.

During the month of September, we are recognizing National Preparedness Month. Clinicians play an important role in Emergency Preparedness and Response. CDC has several activities and resources that we want to share with you to help you focus on turning awareness into action, by encouraging all your members to make an Emergency Preparedness Plan.

Please visit I’m delighted to welcome you to today’s COCA Webinar, Protecting Children at Highest Risk for Influenza Complications. We are pleased to have with us today, Dr. Georgina Peacock and Dr. Seema Jain from the Centers for Disease Control and Prevention, along with Dr. Henry Bernstein and Dr. Renee Turchi from the American Academy of Pediatrics. They will discuss strategies that primary care providers and medical sub-specialists can use in partnership with parents to improve influenza prevention and control in children at highest risk.

You may participate in today’s presentation by audio only, via webinar or you may download the slides if you are unable to access the webinar. The PowerPoint slide set and the Webinar link can be found on our COCA Web site at Click on COCA calls. The webinar link and slide set are located under the call in number and call passcode.

At the conclusion of today’s session, the participant will be able to: 1) identify chronic medical conditions associated with the increased risk of hospitalization or influenza complications in children, 2) review caregiver and physician perceptions and practices about seasonal influenza immunization in children with neurologic and neurodevelopmental conditions, 3) discuss collaborative opportunities for medical subspecialists and primary care pediatricians to promote medical homes for children and increase influenza immunization. And lastly, 4) describe strategies and key messages to improve influenza prevention and control in children at highest risk for complications.

In compliance with Continuing Education Requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters, as well as, any use of an unlabeled product or products under investigational use. CDC, our planners and the presenters for this presentation do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or products under investigational use. There was no commercial support for this activity.

At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone dialing Star 1, will put you in the queue for questions. You may submit questions through the Webinar System at any time during the presentation by selecting the “Q&A” tab at the top of the Webinar Screen and typing in your questions.

Our moderator for this Webinar is Dr. Georgina Peacock. She’s the Medical Officer and Developmental Behavioral Pediatrician with the Division on Birth Defects and Developmental Disabilities at the CDC. She is currently working with CDC’s Office of Public Health Preparedness and Response on an initiative to enhance CDC’s Public Health Disaster Preparedness and Response for Children. At this time, please welcome today’s COCA call moderator, Dr. Peacock.

Georgina Peacock:
Hi. Thank you Leticia. I’m going to go ahead and introduce all of our speakers all at once and then the speakers will just go in from one presentation to the next, so that we can streamline that process.

So today’s first presenter is Dr. Jain. She’s a Medical Epidemiologist for the Epidemiology and Prevention Branch in the Influenza Division in the National Center for Immunization and Respiratory Diseases at CDC. Dr. Jain’s current research focuses on influenza and pneumonia, pediatric influenza, and influenza complications and includes work on understanding factors associated with being at high risk for influenza and its complications.

Our second presenter, Dr. Bernstein, is Associate Editor of the Red Book Online and recent member of the Committee on Infectious Diseases for the American Academy of Pediatrics or AAP whose responsibility it is to develop and revise guidelines of the AAP for Control of Infectious Diseases in children.

I will be the third presenter and then our final presenter today, is Dr. Renee Turchi. She is Associate Professor at Drexel University School of Public Health and Drexel University College of Medicine. In addition, she is Director of the Pennsylvania Medical Home Program, a statewide quality improvement program for pediatric practices across Pennsylvania. And so with that, I’m going to turn it over to our first speaker, Dr. Jain.

Seema Jain:
Good afternoon. It’s an honor to join you today and I’m just going go ahead and get right into it. So my first slide here, is a Flu View and I’m not sure how many folks are familiar with it, but this is our Web site that basically demonstrates all of our influenza surveillance activities.

So this Flu View Update that I’m going to go over in the next few slides, reports on flu activity for the week ending September 14th or week 37. This particular graph shows our weekly virologic surveillance, showing the number of influenza positive tests reported to CDC by 140 U.S. and WHO collaborating laboratories by week during the 2012-2013 Season.

Currently, the percentage of respiratory specimens testing positive for influenza in the United States remains low. As you can see from the inset on this slide, influenza A and B viruses are currently circulating at low levels. This includes both of the subtypes of influenza A viruses, H3N2, and 2009 H1N1.

For the week ending September 14th, 70 of the 73 influenza positive tests reported to CDC were influenza A and three were influenza B viruses. Among the 70 influenza A viruses identified that week, two were H3N2 viruses depicted here in red and 10 were 2009 H1N1 viruses depicted in orange. Subtyping was not performed on the remaining 58 influenza viruses which are depicted in yellow.

This next slide shows pneumonia and influenza mortality for 122 U.S. cities. These data are reported weekly from Vital Statistics and during the week 37, 5.8% of all deaths reported through the 122 city’s Mortality Reporting System, were due to pneumonia and influenza. This percentage was below the epidemic threshold of 6.1% for week 37. This next slide focuses on our Routine Pediatric Mortality Surveillance System which showed the number of influenza associated pediatric deaths by week of death from 2009 to present for children under 18 years old.

There were no new influenza-associated pediatrics deaths reported to CDC during week 37. A total of 164 influenza-associated pediatric deaths had been reported during the 2012 - 2013 season.

This slide shows our influenza-like illness or ILI syndromic surveillance that monitors the percentage of visits for ILI reported by U.S. outpatient ILI Surveillance Network or ILINet by week for several seasons.

This system is a network of approximately 4,000 physicians or clinics who record over 36 million patient visits a year. The current season is depicted in red. Nationwide during week 37, 0.9% of patient visits reported through ILINet were due to ILI. This percentage is below the national baseline of 2.2% that is shown by the dotted line. All ten U.S. regions reported ILI activity below the region specific baseline levels.

So in summary, overall flu activity in the United States is currently low. However, the timing and intensity of flu activity is unpredictable and can vary in different parts of the country. Most of the time, flu activity in the United States peaks in January or February, however, that peak could come earlier or could come later.

Localized or even more widespread outbreaks can occur in October, but they can also happen sooner than that. So here at CDC, we’ll continue to monitor activity through our National Surveillance to see how activity develops. Thank you for your attention.

Georgina Peacock:
Dr. Bernstein?

Henry Bernstein:
Yes. Hi. It’s an honor to be here and I’m excited about talking about influenza and the current recommendations for the 2013 - 2014 season.

Some of the key messages that I hope to convey, (are) that influenza vaccine is needed for everyone, every year. So anyone 6 months of age and older, should get the vaccine.

The vaccine strains this coming season have changed from last season, (which) emphasizes the importance of everyone getting an influenza vaccine this year.

For the first time ever, quadrivalent influenza vaccines are now available. Historically, we’ve always had trivalent vaccines, but we are transitioning toward quadrivalent, which would give coverage against four strains of influenza.

Because we have both trivalent and quadrivalent vaccines being manufactured this year, there (are) no vaccine product preferences. We really want to highlight the importance of everyone getting influenza vaccine and the more people that do, the better.

Along those lines, it’s important that egg allergic children be vaccinated. There’s no reason why they should not be vaccinated. In the past, there was always a concern, but the data suggests that this is not a concern anymore and so egg allergic children should receive the vaccine.

From this slide, you can see on the left-hand side are a number of diseases and at the top of the list is influenza and you can see that the number of annual cases is measured in the millions and the number of deaths on the right-hand side, can vary somewhere between 3,000 and almost 50,000 deaths a year.

That’s a lot of deaths from a disease that could be prevented by vaccine. Now how does influenza spread? It is spread person-to-person primarily by droplets created by coughing or sneezing as depicted in this slide.

People also can come in contact with the respiratory droplets that are contaminating surfaces and pick up the virus in that way. During community outbreaks of influenza, the highest attack rates occur amongst school age children who are very free in sharing their secretions and we all know that young preschoolers are the great transmitters to adults and teens.

Now this slide is an amazing slide, because it shows how influenza imposes a heavy disease burden on our society in an average year. Because influenza is so highly contagious (as an) acute respiratory disease, it’s responsible for an average of 50 to 60 million infections annually, which results in over 25 million healthcare visits, hundreds of thousands of hospitalizations and thousands of deaths.

You saw this slide before from Dr. Jain and I just wanted to point out, that not only does this keep track of the percentage of visits for influenza-like illness that are reported to the CDC, but if you look at the different color peaks, what you can see is that the first peak shows that the percentage of influenza-like illnesses came early in the flu season and that’s somewhere around November.

And then you’ll see the peak that we had last year was just around the New Year, the red bar and then the blue bar is the peak of activity in another influenza season and that came after January, well into February and March.

So what this highlights is, that flu can hit early, flu can hit in the middle, or flu can hit in the end of the season. So it’s important for everyone to get the flu vaccine as soon as possible, but even if they haven’t received it by January 1st, they should still get it (after the new year).

Now this slide, as you can see, depicts the underlying medical conditions for patients who are hospitalized with influenza and so you’ll see that there are problems in my friend, Dr. Turchi’s going to talk about a metabolic disorders, neurologic disorders, neuromuscular problems, etc.

But I also wanted to point out, that 45% of hospitalized children with influenza were actually perfectly healthy children without an underlying medical condition.

This is the same slide that Dr. Jain showed, and as you can see, there were 164 pediatric deaths due to influenza and that’s a problem because many of those deaths are preventable.

Now when we compare this to the 2011 - 2012 season, there were only 35 deaths due to influenza, so influenza can cause problems from one year to the next and it’s never predictable. Influenza virus is smarter than we are and it’s hard to know what each season’s going to be like.

And when we look at the past season, 2012 - 2013, and we compare it to the season before, we see that influenza A, the H3N2 was the most common strain. We see that the outpatient visits for influenza-like illness were higher. We see the rates of hospitalization were also higher, and the number of deaths from pneumonia and influenza were also higher last year.

So we certainly want to try to minimize the morbidity and mortality associated with influenza, and the number one way of doing that is by vaccinating everyone.

This year our influenza vaccine, as I mentioned earlier, comes in both a trivalent and a quadrivalent formulation. The trivalent has two A strains, the H1N1 that we’re familiar with from the pandemic in 2009 and the H3N2 virus, which is new this year in comparison to last year’s influenza vaccine. We also have a B strain of the virus, that’s in the trivalent and for the first time when we have a quadrivalent formulation, we have another B strain added.

So the quadrivalent has the same three strains as the trivalent and then it adds an additional B strain. So two or three strains are different from last season, and so again, it’s important that everyone receive the vaccine.

And when I mention that, that’s from 6 months of age and older and that’s important for all of us to recognize, that the American Academy of Pediatrics and the CDC both recommend vaccine for everyone 6 months of age and older.

And when we think about children and adults who we want to be sure get vaccinated, we look at all children, because as I mentioned earlier, there’s a degree of morbidity and mortality associated with the (disease), as well as children being great transmitters.

We also know that any household contact of young children, we want them to be vaccinated. Because if they’re vaccinated, they’re less likely to get the flu. If they’re less likely to get the flu, they’re less likely to give it to high-risk children and all children under the age of 5 who can have higher number of visits to the doctor and potentially complications from influenza, such as needing to be hospitalized.

All healthcare personnel should also receive the influenza vaccine each year. We go to the healthcare settings to help with our medical conditions and we expect to be helped. We don’t expect the people taking care of us to transmit influenza to us.

And it’s also critically important for all pregnant women to receive the influenza vaccine as well. There are 4 million births a year in this country, and it has been shown that if a pregnant woman receives influenza vaccine, she makes antibodies and then passes those antibodies onto her baby. And that, in fact, protects the baby against the flu during the first six months of life.

And as I mentioned earlier, children under 6 months of age, infants under 6 months of age cannot receive the flu vaccine, so it’s important to protect them in any way we can and certainly Mom who is pregnant, passing on her antibodies of protection is really very, very important.

Now we look closely and we’d say, “Gee we’d love for our immunization rates to be close to 100% and that’s an ideal,” but at the moment, as you can see, the coverage for children 6 months through 17 years is 55%, so it’s moving in the right direction and it’s certainly much better over the last several years since the pandemic in 2009. But as you can see in this slide, there’s a lot of room for improvement.

So it’s important that people start giving the vaccine as soon as possible, all healthcare providers, and for patients to be asking for it. And as I mentioned, sometimes flu can start early or it can come late. Sometimes a viral strain that causes a problem in November, a different viral strain can cause a problem in April.

So it’s important to continue to vaccinate people against the flu into April and May. We also want to be sure that the vaccine is accessible for all children, so we want to have influenza clinics. We’d like to extend office hours during peak vaccination periods, if at all possible, to administer vaccine during both well visits and sick visits and some consideration is being given to immunizing parents and adult caregiving and siblings of patients, so that they’re up-to-date as well.

We also want to make sure that people that are in other institutions and alternative care sites, if they work there and they can get the vaccine, that’s really helpful.

This is Cocooning and this is the concept that I mentioned earlier and the idea again, is if a young infant can’t get the vaccine, everyone who comes in contact with that young infant, should be vaccinated.

If you vaccinate the caregiver, they’re less likely to get infected with influenza. If they’re less likely to get infected, they’re less likely to have the disease and if they’re less likely to have the disease, they’re less likely to spread the infection to children.

And now in this slide you can see where (adults and) kids get their influenza vaccine. Two-thirds of kids get in a doctor’s office and another quarter of them get it in other medically related places, like hospitals, clinics or health centers and local health departments.

This is an algorithm that highlights how to administer vaccine to children 6 months through 8 years of age. Children in that age range need two doses the very first time they receive the vaccine, because their immune systems are not adequately primed to develop the right amount of protection.

So, this is a simple algorithm, when a child comes in, who is between 6 months and 8 years, we ask whether or not they received influenza vaccine in the past, if they haven’t, they get two doses.

If they have, then we need to know whether or not, they received two or more doses since July of 2010. If they didn’t, they need two doses. If they did receive (2) vaccine (doses) since July 2010, they only need one. When you give two doses to a child, you need to wait four weeks in between dose 1 and dose 2.

This algorithm is - looks complex, but it’s very straightforward. Again, almost all allergic kids with an allergy to egg, can receive the influenza vaccine. Basically, we ask a simple question, whether or not, they’re allergic reaction was mild or severe. If it was mild, like hives, then they certainly can get the influenza vaccine in that healthcare setting.

If in fact, they had a severe reaction, like a low blood pressure, trouble wheezing etc., then, the provider should consult with an allergy specialist to discuss how best to administer the vaccine.

The last slide that I have, talks about antiviral medications. Antiviral medications continue to play an important role in the management of influenza.

When used for treatment, we want to use the antivirals as soon after the onset of symptoms. The best effect is given within 48 hours of the onset of symptoms. And as you’ll see here in the red box, oseltamivir which is Tamiflu and zanamivir which is Relenza, are the only antiviral medications that are licensed and effective for the treatment of the various strains that can cause influenza.

And treatment should be considered for any otherwise healthy child with influenza infection, for whom a decrease in the clinical symptomatology is warranted. Of course, any child that gets hospitalized, any child that there’s concern for severe or complicated or progressive illness, should also be treated with antiviral medication. We should not wait for the test. We should treat them.

So in sum, the key messages again, are that everyone 6 months of age and older needs flu vaccine every year. The vaccine strains from last season’s vaccine have changed. For this season, there is now a quadrivalent influenza vaccine available, but we really have no vaccine product preferences and egg allergic children should be vaccinated. We want everyone to be protected against influenza. Thank you.

Georgina Peacock:
Thank you Dr. Bernstein and this is Georgina Peacock - and I’m going to talk to you just very briefly about an MMWR Morbidity and Mortality Weekly Report that came out recently, looking at vaccination practices of children with neurologic and neurodevelopmental conditions in the 2011 - 2012 influenza season.

And here’s just a picture of that MMWR. It came out, as you can see, September 13th and you can read a complete copy of that if you follow the link to - from the CDC Web site,

And what we did, with this study, is we surveyed parents and doctors who took care of children with neurologic or neurodevelopmental conditions, and we asked them about vaccination for the flu or their flu vaccination practices.

We did this by sending an online survey to parents or other caregivers on the Family Voices email listserv. We also did an online survey in partnership with the American Academy of Pediatrics to healthcare providers, in particular, to providers who were either subspecialists or primary care (pediatricians) who took care of children with special healthcare needs.

We asked them information about their vaccination practices and how they received information about vaccines.

What we found, was that one in two children with neurologic or neurodevelopmental conditions were vaccinated against the flu, which as you may recall from Dr. Bernstein’s slides is about the same as the whole pediatric population.

We also found that, three out of four parents reported that their child healthcare provider was their main source of information about vaccines.

When we talked to the healthcare providers who regularly cared for these children, they were mostly familiar with high risk conditions that caused flu illness, such as some neurodevelopmental conditions, such as cerebral palsy, epilepsy, asthma, diabetes and some other high risk conditions.

However, pediatricians did not recognize that intellectual disability was also a high risk condition for flu.

So, what - the conclusions from this, were that children with neurologic and neurodevelopmental conditions, were no more likely to be vaccinated for flu than the general pediatric populations, despite being at higher risk.

So as Dr. Bernstein said, everybody should be vaccinated against the flu, if they’re 6 months or older and in particular, we want to also have that message that these kids that are high risk absolutely should be vaccinated, keeping that message that everybody also should be vaccinated against the flu.

And that outreach to primary care providers and subspecialists about flu vaccination may be helpful and that’s part of the reason for doing this call today, is really to talk about how primary care physicians can partner with subspecialists to get that message out to families, because I think both the subspecialist and those primary care providers do have the ability to - have influence with parents to talk about the importance of vaccination against the flu and that if we do this, we really can make a difference and really reduce morbidity and mortality among these children.

And so with that, as just a brief introduction and with that, I’d like to turn it over to Dr. Turchi, whose going to really talk about how can we protect children at highest risk for flu - from flu complications. Thank you.

Renee Turchi:
Thank you Georgina and thank you CDC for inviting me to talk. It’s truly an honor to presenting here today and with my esteemed colleagues.

So, for my portion of the talk, I’m going to talking a bit about strategies for increasing influenza vaccinations for our most vulnerable children, those with special healthcare needs, partnership opportunities for primary care, team specialists and especially families and also identifying a few resources and Web sites here at the end, for families and providers that are caring, specifically for children with special healthcare needs.

So just so we’re all on the same page, I just wanted to provide for the Maternal and Child Healthcare Definition, of children and youth with special healthcare needs. This is a very broad definition is children who have or are at risk for, chronic physical developmental behavioral emotional conditions, and also require health or related services beyond that of children generally.

But when we really hone in on that definition, we think about specifically with children with influenza, who are we thinking about maybe warrants a special consideration?

Drs. Bernstein and Peacock already have mentioned some of these conditions, but specifically here we’re talking about either some of the more fragile children, those including children with neurologic condition, respiratory conditions, cardiac disorders, certainly endocrine and gastrointestinal issues, metabolic. For example, a child that has a metabolic condition, and also a child that might have genetic syndrome.

So why do these children warrant special consideration? Well, we know that children and youth with special healthcare needs have higher rates of morbidity and mortality than typically develop in children from influenza.

And certainly in the pandemic of H1N1 in 2009, when we looked at children who died, 64% of those had a neurologic condition. So again, thinking about, Dr. Bernstein’s sentiments. I think we should be striving to vaccinate all children over 6 months of age, However, I’m just really honing in on the fact that, when we think about your patients and our population of children with special healthcare needs, we really have to recognize and acknowledge that they’re at high risk for complication and have a the potential morbidity and mortality.

So thinking about strategies, Dr. Bernstein had a really nice slide that actually showed, if you recall, where children were actually getting their influenza vaccination and I want to say it was 62%, I think they were getting it or higher in their medical office.

But also, you know, he showed that there were other areas that the children could get influenza vaccinations. And so thinking about that high percentage of children receiving vaccinations in their medical offices, I think it’s prudent to talk about the role of the medical home.

And to just very briefly, remember the medical home is the standard for all children. And really we’re talking about fostering patient- and family-centered care, improved communication with families, and really emulating this partnership with families, specialists and community agencies.

And really start thinking about the role of our teams, it’s not just a physician. In fact, I would argue, that it’s way beyond the physician and when we talk about medical home, we should be thinking about everyone from our front desk staff, to nurses, to medical assistants, nurse practitioners, physician assistants and our whole team, that really are advocating for medical home, and in this case, specifically can help us get children vaccinated against influenza.

I’m not going spend a lot of time on this, I just wanted to highlight that if for folks who are interested in more information on medical home, if you Google “Joint Principle Core Statements of Medical Home,” you can come up with a nice three-page article that kind of talks about the key assets of medical home and sort of what we’re really focusing on that just sort of underscores what I talked about in my previous slide.

There’s certainly evidence supporting the role of medical home and that it improves patient and family satisfaction, quality of care, healthcare utilization, medical errors, certainly a better care coordination and efficiency in accessing care, and improves racial and ethnic disparities in care.

So when we think about this and vaccinating children with special healthcare needs and really trying to foster our vaccination rates, I think, you know, really looking at a medical home as an opportunity and some of the tools that I’ll talk about in a minute, that we provide within that medical home. We should be thinking about the coordination, the team, and the quality of care and really having these children cared for in a medical home, really as the hub of fostering vaccinations.

So how can we prepare better? Well one of the things the medical home (promotes) as a standard tool that we often talk about (is utilizing) a registry.

Certainly patient registries are accepted in quality improvement - you know, a standard in quality improvement. Most of us are electronic and some aren’t, so you certainly can run reports on,who’s gotten vaccinated if you have an electronic health record or pull out your children special healthcare needs, look at your children with highest risk. (Before we had an EHR when I practiced, I had a paper registry (in excel) which was helpful. You could certainly sort and use that as well as ways to outreach.)

For those of us that are getting ready or starting to vaccinate with flu, you certainly can use patient registries to identify children at highest risk.

And so with that registry, we can use it to contact families, and also facilitate working with specialists. When you think about that list of diagnoses that I shared earlier, certainly we’re going to have children who might be seeing a pulmonologist before they see their PCP in a medical home.

So how can we utilize the registry to say, “Hey, this child is going to get vaccinated in a specialty office or somewhere else.” You could certainly use that registry to track that information and most importantly ensure that the child actually gets vaccinated. We just want to make sure that we know that they are (getting vaccinated).

Certainly community partners are important, remember Dr. Bernstein’s slide, where he showed the place of vaccinations. Schools were listed on there as well. So the big thing in thinking about using the registry and collaborating with our partners, is really, you know, communication and just insuring that we’re able to track, so that children don’t get over vaccinated or under vaccinated in any way.

I do have here (a sample registry to help in) preparing the practice and thinking about that registry, you know, we can use it as emphasizing some of my points, (that the strategy for all patients or I talked about, you know, tracking them in their - in your EHR), certainly when you identify your team within the practice it doesn’t have to be the physician utilizing that registry or attracting patients, it certainly can be your front desk staff, nurses, or office managers helping you out.

Ultimately think about practice-wide education. So, you know, really looking at the practice and we actually in my own practice today, For example, we’re talking in staff meetings about strategies for additional opportunities for flu vaccination, how we were going to do outreach, having flyers and ways we could utilize our registry to foster vaccination. We really want to have everyone in the office have a stake in this and understand the importance and what their role is in helping families get access, know when influenza is available and understanding why this is so critically important.

You certainly can think about (opportunities for outreach), like anytime someone calls your office, even if it’s for a refill for medication or making an appointment. It is part of the medical home’s job- we do not just looking at things in a vacuum.

So really utilizing every opportunity, which is why I’m thinking about across the team to foster vaccinations.

Insuring and thinking about, you know, Dr. Bernstein also had a great graphic kind of showed how we’re making progress with influenza vaccination, but we certainly have a little ways to go.

We haven’t hit our ceiling. So, thinking about that graph (that he shared we’re up to 55%) that he share. We can think about utilizing some of our tools within a practice for a QI activity (utilizing some of the tools) to foster vaccination and really try to push those vaccination rates up, especially for our most vulnerable children.

Again sharing with you here an example of a patient registry that has, just some of the fields to begin thinking about how you might track your patients. Certainly a registry has wide-spanning utility beyond just influenza, but just wanted you to have an example of, some of the fields that one might use if they were to employ a registry in practice.

Another tool to think about that many of our practices use, that can foster influenza vaccination, is a care plan. Care plans, especially now with the advent of EHR can be very, easily created, prepopulated often from fields that you’re putting, filling in from your patient visit. (There are templates in the HER for care plans). You can include as I list here, a variety of fields that folks use on their care plan templates, that maybe you’re printing out and giving to a family. Often they’re in their EHR, so that a collaborator can see, but certainly including influenza vaccination and the date on there, would be a great thing, so that if that document is then shared, it can be as a communication tool, especially if a parent or caregiver isn’t available.

When thinking about care plans, remember we’re creating a care plan, updating it, certainly listing special community partners again in thinking about influenza, (and specialists) ( ie. if you have a child who does see that pulmonologist.) Perhaps if they’re like (tracheostomy-ventilator dependent) there may be a program they’re involved in. It’d be great to list some of those community partners on the care plan, you’re collaborating with them, maybe they’re having some influence in the influenza vaccination. Also, opportunities and those things can be included on that care plan.

If you’re interested in more on care plans, just wanted to highlight that you can access those in a variety of places, including AAP Web site. There’s some emergency information forms you can utilize as well.

And just so thinking about that care plan, is they should include family input at all times.

I talked a bit about earlier in my objectives about working with specialists and I certainly alluded we need to think about the most vulnerable children with special healthcare needs, the majority of them do have need for specialty care.

So it warrants consideration when we think about vaccinating in certain environments, as I’ve already mentioned, for example, pulmonary, where children may receive vaccinations, thinking about timing of appointments (with specialist and PCPs). Certainly thinking about children who might have let’s say physical (limitation) maybe need to be brought in on stretcher or are wheelchair-dependent. If the child is going to be seen in another practice or another area and you can have a handle on when those appointments are, certainly having folks go out or having them getting vaccinated at those appointments, would be prudent.

We just want to ensure vaccination (happens) and working with families to look at what’s convenient and what’s tenable given a child’s potential limitations based on their condition.

I talked a bit about care plans and utilizing those with specialists. So, if a specialist can either see the care plan or if, the parent actually has a copy, it’d be great to have on there whether the child was vaccinated for the season or is not vaccinated, it’s something you can put on there.

As I mentioned earlier, I just think a key point in my comments here today, is that communication is essential. It’s important across community partners, as well as, specialists to know that we need to understand what families need. How can we foster vaccination even hospital discharge. In certain hospital scenarios, children can get vaccinated. The key is documentation, as I mentioned and the role of registry. Families are key members of our team. It’s important to recognize that as we’re all talking about vaccinating and maximizing vaccination rates, we have to think about our families. These are, you know, understanding families and you know, understand the role of influenza vaccination and fostering family- centered care is critical. So if you’re talking with families about their care plans, including them in staff meetings.

Families are doing things like resource nights. They could - have one around (flu) season where parents are promoting to other parents vaccination and the role of that and the importance - reaching out via your medical home.

When can - when is your child vaccinated? Here’s why it’s important. And you know, utilizing parent partners if you have them in practice and have advertisements in newsletters that families can share.

Certainly if you’re part of a hospital system and there’s a parent advisory council. Take the time to educate those parents and have them partner with you to foster influenza vaccination rates and disseminate information on when practices are offering flu clinics and the importance of getting your child in.

Certainly community liaisons if you have those folks available, again partnering to spread the word.

So, I talked a bit about educating families. It’s important in practice, leading up to the flu season, to start talking to families, just seeing your child in April or May, you can, “Hey, influenza season’s coming. Remember we’re going to be having our vaccinations available in October. If you don’t hear from us, call us”, so that you can have parents be proactive.

Also, with the advent of electronic communication, if you’re in a position to have a patient portal or use social media for your practice, sending out blasts that, “Hey we got flu (vaccines) in.

Come set up your appointment. We’re having walk-in hours”. You can send blasts through your (patient portal in your EHR).

If you have email addresses, you can push that (communication) out. Certainly as I mentioned earlier, any time a family’s calling in for any type of request for referrals or appointments, those are opportunities.

Educate and try to schedule appointments. Certainly waiting room information -, if you have, you know, let’s say electronic pieces going, running in the televisions those are opportunities to let parents know, “Hey flu (vaccines) are going to be in soon. Here are the guidelines. Your child can get vaccinated if they’re this old, and if they have an egg allergy.” And certainly, even within the practice, you can have EHR prompts (for providers), so that, “Hey, my medical assistance is in there,” they’re weighing a child, they’re going to say, “Hey you know, we’re going to vaccinate Johnny against the flu today,” or “Hey next month we’re going to have the flu vaccine.”

You can never hear something too many times. So it’s important to think about ways that we can foster that. I’ve already mentioned community partners. I just wanted to highlight if you have home nursing agencies, your children that are receiving home nursing, you can certainly think about partnering with them to administer flu vaccine, again it’s about communication.

Children (with special health care needs) are going to medical daycare, so there’s nurses that can administer vaccines. There’s another place. We talked about schools, childcare centers, certainly if you have Medicaid or any type of insurance care manager, they can do education, help get patients in.

And you know, we’ve talked about the role of our community partners. So it’s important to think even beyond just the medical sector.

And I just want to end with a couple of Web sites that you can certainly partnering with Family Voices. Identifying your local to Family-to-Family Health Information Center. Every state and commonwealth has an F2F, so work with the F 2 F in your area.

Families are instrumental partners in helping us get some of these initiatives off the ground, and so working with them collaboratively to help them understand the importance, is important and also family citing flu and the CDC has, you know, wonderful information on influenza. So with that, I’m finished. Thank you very much.

Georgina Peacock:
Thank you Drs. Jain, Bernstein and Turchi for providing our COCA audience with such a wealth of information. Now we’re going to open up the lines for questions and answers, and please remember you can submit questions through the Webinar System as well. So I’ll turn it over, back to you Leticia.

Leticia Davila:

Thank you. If you would like to ask a question, please press Star 1 and you will be prompted to record your first and last name. Please unmute your phone when recording your name and to withdraw your question, press Star 2.

One moment please. Excuse me, we have a question from Dr. Norman Castle. Your line is open.

Norman Castle:
Dr. Bernstein, I’m hearing in my community, doctors advising people not to get the flu shot before the end of November, because the duration of immunity is low.

Can you comment on that?

Henry Bernstein:
Thank you for the question. There are some data that suggest immunity does wane in some individuals, but the clear recommendation is that when the vaccine’s available in someone’s community, they really ought to get it and as was seen on one of the slides. I tried to point out that sometimes influenza can rear its ugly head at the end of October into November, as you’ll recall in 2003 - 2004, that’s when the peak of activity was.

And that’s actually when (we started) to keep track of the number of pediatric deaths. So I would clearly recommend that people get it as soon as it’s available in their community.

Children 6 months through 8 years also may need two doses and it’s just important that people are protected. There’s lots of room for improvement when we look at our overall immunization rates.

Norman Castle:
kay, and also on the quadrivalent vaccine, I know the nasal mist is all quadrivalent, but I have been unable to find any injectable quadrivalent at any pharmacies, health departments. I searched the Internet. It doesn’t seem to be actually out there.

Henry Bernstein:
So, it is out there, but there is not a lot and as far as the inactivated is concerned, the majority of it is the trivalent. Certainly, Sanofi Pasteur has a quadrivalent and GSK, GlaskoSmithKline also has a quadrivalent, but from (when these vaccines were licensed) and how they’re distributed, it may vary geographically from one area to another.

Norman Castle:
Okay, thank you very much.

Henry Bernstein:
You’re welcome.

Once again, to ask a question, please press Star 1. One moment.

Leticia Davila:
As we wait for questions to queue up on the phone, we do have a question that has come through the Webinar System and the question is, “Some people with MS, multiple sclerosis, are afraid to get a flu shot, because they believe it will provoke an exacerbation of their disease, because of the immune response. And I’m just wondering, because I’ve never seen this recommendation?”

Georgina Peacock:
Dr. Bernstein or Dr. Jain, could you take that question?

Henry Bernstein:
Sure. I’ll take a stab to suggest that certainly when we’re looking at many different chronic health conditions, I can understand the concern that somebody would have with multiple sclerosis, but in general, that is not necessarily a contraindication to receiving the vaccine and in fact, it would be important that they receive it in order to be protected.

There are certainly some health conditions that we worry about, but in general, almost all of them, the benefits of receiving the vaccine and being protected against influenza outweigh any concerns such as this individual with multiple sclerosis.

Leticia Davila:
Thank you Dr. Bernstein.

We do have a question on line, if you’d like to take it?

Leticia Davila:
Yes please.

(Karen) your line is open.

Hi. You may have answered this question, but I missed it. If an infant gets the quadrivalent for their first dose, and then in four weeks is due for their second dose, can it be trivalent?

Henry Bernstein:
Yes, that’s a great question also. It certainly can be trivalent, with the understanding that, since the young infant needs two doses to be adequately primed, they may not be as adequately primed against that fourth strain that’s in the quadrivalent, but not in the trivalent.

Okay, thank you.

I’m showing no further phone questions.

Leticia Davila:
We do have another question that has come through the Webinar System and this question is for

Dr. Turchi. “What does QI stand for and QI activity?”

Renee Turchi:
I apologize that I used that acronym without defining it. Quality improvement, so quality improvement activities, you know, working with on small sets of change in practice, where you know, you might identify something in this case, increasing your influenza vaccination rates.

And doing a small quality improvement activity, where perhaps you utilize your registry, go through highest risk patients and maybe identify strategy where you’re going to have, you know, for the next two weeks, every patient that calls in for an appointment, let’s say a referral, be scheduled for your flu clinic.

You know, sort of a small test of change, where you know, within an office setting, you can identify your goal and something very brief and quick, that’d you want to do as an intervention and you’d want to measure before and after, sort of to see the success of your efforts.

But it’s meant to be something that can be very rapid cycle and can be planned in a couple of days and implemented pretty easily.

I apologize again for not defining that acronym.

Leticia Davila:
Thank you, Operator?

Yes, we did have another question come in. One moment. I believe his name is Mr. (Sulo).

(Sulo) yes. The question is what should be the interval, if a child has received a live vaccine, what is the interval that should take place before being able to deliver any of the influenza vaccines?

Henry Bernstein:
After administration of any live virus vaccine, at least four weeks should pass before another live virus vaccine is administered. And so, if you’re going to give two doses of LAIV Flu Mist to somebody, it’s four weeks apart.

Would it be okay to give the inactivated?

Henry Bernstein:
Yes. Do you mean perhaps, give one dose of Flu Mist and then four weeks later give the inactivated?

No, no I mean, just give the inactivated so you don’t have to wait for the four weeks before you immunize the child?

Georgina Peacock:
Are you meaning a different live virus, so like if you give MMR and then the flu vaccine...

Yeah, and then how long do you - let’s say the child has received that vaccine within the last month, and I want to know is it okay to immunize him, not with the live vaccine, but just with an inactivated influenza vaccine?

Henry Bernstein:
In general, once you give a live virus vaccine, you really should wait four weeks before administering (another) inactivated or a live (influenza) virus vaccine.

Okay. Good.

Henry Bernstein:
[Please note Current Guidance for this statement.]

They can certainly be given concurrently in - during this - at the same office visit, but once you give it, then I would not have them come back in a week for the inactivated, I would have them wait four weeks from when they received the live virus vaccine.

[Note: Current guidance from the Advisory Committee on Immunization Practices in Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2013–2014, MMWR Sep 20,2013/62(RR07); pg. 32 states that limited data are available on the concurrent administration of influenza vaccines with other live vaccines. Use of LAIV3 concurrently with measles, mumps, rubella (MMR) and varicella vaccine among children aged 12 through 15 months has been studied, and no interference with the immunogenicity to antigens in any of the vaccines was observed. Among adults aged ≥50 years, the safety and immunogenicity of zoster vaccine and IIV3 were similar whether administered simultaneously or sequentially spaced 4 weeks apart. In the absence of specific data indicating interference, following ACIP's general recommendations for vaccination is prudent. Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. Inactivated or live vaccines can be administered simultaneously with LAIV. However, after administration of a live vaccine (such as LAIV), at least 4 weeks should pass before another live vaccine is administered. Retrieved from paragraph: Concurrent Administration of Influenza Vaccine With Other Vaccines]

Thank you.

Leticia Davila:
We have another question that has come through the Webinar System. And this says, “Dr. Bernstein mentioned MS patients should go ahead and get the vaccine. Also presenters have stressed neurological conditions, but you did mention conditions concerning in which you might not or should not give the vaccine. Can you please share examples?”

Henry Bernstein:
So, in general, virtually everyone can receive the vaccine, but certainly, if in fact they’ve had a past reaction to the influenza vaccine that has raised significant concerns, they should at least discuss that with their particular doctor.

Certainly somebody who has a suspected immunodeficiency or other kinds of chronic health conditions, such as asthma or are pregnant, have diabetes should not receive the live attenuated influenza vaccine, but can receive the trivalent or quadrivalent injection.

So virtually everyone is eligible for the (injectable) influenza vaccine to be perfectly honest. The intranasal should only be (given to) those that are 2 through 49 years of age and they need to be considered healthy.

Leticia Davila:
Thank you Dr. Bernstein and also for a follow up to that question. “What about spinal injections of steroids?”

Henry Bernstein:
I’m sorry, spinal injections of steroids?

Leticia Davila:

Henry Bernstein:
So under special circumstances, I’m not sure if the suggestion is somebody perhaps has a condition with low back pain and is using steroids for reducing inflammation and relieving pain.

If there’s a concern about how competent they are immunologically, I would certainly have them speak with their particular doctor, so that they can individualize it. Many times they can still receive the injectable vaccine under most conditions and their physician can help guide them or their infectious disease specialist at their particular institution can help. But under most circumstance, patients can receive the injectable influenza vaccine.

Leticia Davila:
Thank you.

Henry Bernstein:
Obviously, I should mention that if people are on steroids or (are severely immunocompromised) or on cancer drugs or things of that nature where their immune systems are severely compromised, they should not necessarily receive the influenza vaccine. Certainly I would encourage all of their care providers and all the people that come in contact with them to receive the vaccine to decrease the chance that these (individuals will) be exposed.

Seema Jain:
Hi there. This is Dr. Jain. I know we’re running out of time, I just wanted to add one thing to that, which is that the recommendation focuses on (all children above the age of 6 months) for vaccination, but I will just add maybe perhaps semi-end here, on the fact that maternal immunization can give great benefits for those children who are under 6 months of age. So maternal immunization is and remains a real key.

Leticia Davila:
Operator we have time for one more question, please.

I’m showing no questions.

Leticia Davila:
Thank you, we do have one that has come through the Webinar System. “Is it safe to administer Flu Mist with children with asthma?”

Henry Bernstein:
So, Flu Mist is licensed for children and adults 2 years of age through 49 years, and it’s only licensed for people that are healthy. So therefore, anyone with chronic underlying medical conditions, including asthma, should get the injectable form, not the LAIV.

And as many in the audience knows, it’s very difficult to make the diagnosis of asthma in preschoolers and therefore, there are questions that we recommend that people ask for 2, 3, and 4 year olds, to find out whether indeed, they’ve had some recurrent wheezing or they’ve just had one bout of medically attended wheezing in the previous 12 months.

So if somebody does not carry the diagnosis of asthma and has really not had difficulty with wheezing in the previous 12 months, they certainly could, as a 2, 3 or 4 year old, receive the LAIV vaccine.

But in general, asthma’s a problem with the lungs. Influenza is a problem with the lungs. We would not want to give a live attenuated influenza vaccine into the respiratory system for somebody with a chronic condition such as asthma, especially knowing that there’s an injectable form that’s available.

We might feel differently if it wasn’t - if we didn’t have an alternative, but since we do, we do not recommend it for children with asthma.

Leticia Davila:
Thank you. On behalf of COCA I would like thank everyone for joining us today with a special thank you to our presenters, Drs. Jain, Bernstein, Peacock and Turchi. We invite you to communicate to our presenters after the Webinar. If you have additional questions for today’s presenters, please email us at Put “September 24th COCA Call” in the subject line of your email and we will insure that your question is forwarded to them for a response.

Again, that email address is The recording of this call and the transcript will be posted to the COCA Web site at within the next few days.

Free Continuing Education is available for this call. Those who participated in today’s COCA Conference Call and would like to receive Continuing Education should complete the Online Evaluation by October 25, 2013 using Course Code EC1648 that is E as in Echo, C as Charlie, and the numbers 1648.

For those who will complete the online evaluation between October 26, 2013 and September 23, 2014, use Course Code WD1648. All Continuing Education Credits and Contact Hours for COCA Conference Calls are issued online through TCE Online. The CDC Training and Continuing Education Online System at .

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