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Management and Prevention of Pediatric Influenza in Healthcare Settings

Moderator: Leticia R. Davila

Presenters: Joseph Bresee, MD, FAAP, Henry (Hank) Bernstein, DO, MHCM, FAAP, Brent Kaziny, MD, FAAP

Date/Time: September 18, 2014 2:00 pm ET

Welcome and thank you for standing by. At this time all participants are in a listen-only mode. After the presentation we will conduct a question and answer session. If you would like to ask a question you may press star 1. Today's conference is being recorded. If you have any objections you may disconnect at this time. Your host of today's call is Leticia Davila. Thank you, you may begin.

Leticia Davila:
Thank you, (Trish). Good afternoon. I am Leticia Davila and I am representing the Clinician Outreach and Communication Activity, COCA, with the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention. I am delighted to welcome you to today's COCA Webinar: Management and Prevention of Pediatric Influenza in Healthcare Settings. We are pleased to have with us today Dr. Joseph Bresee, Dr. Hank Bernstein and Dr. Brent Kaziny.

They will discuss strategies to improve influenza prevention and control in children and will describe ways to leverage season influenza planning to improve pandemic preparedness.

You may participate in today's presentation by audio only or via webinar. The webinar link can be found on our COCA Website at Click on COCA calls. The webinar link is located under the call-in number and call passcode. The slides will be available a few days after today's call.

At the conclusion of today's session, the participant will be able to: discuss strategies to assist clinicians in preparing for the 2014-2015 influenza season; identify approaches to reduce influenza disease burden in children; and describe how to leverage seasonal influenza action plans to address annual flu surge.

In compliance with Continuing Education requirements, CDC, our planners, presenters and their spouses and partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. Planners have reviewed content to ensure there is no bias. The presentation will not include any discussion of the unlabeled use of a product or products under investigational use. CDC does not accept commercial support.

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 question.

Our first presenter, Dr. Bresee, is Chief of the Epidemiology and Prevention Branch in the Influenza Division at CDC. His branch is responsible for conducting influenza surveillance, working to understand influenza disease burden, helping to derive appropriate vaccine and antiviral use policies to prevent seasonal influenza, detecting and preventing avian influenza and pandemic influenza and providing technical expertise to global public health partners. Dr. Bresee is a pediatrician and is a Captain in the US Public Health Service.

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

Our final presenter, Dr. Brent Kaziny, is a pediatric emergency medicine-trained physician and former Utah State Representative for disaster preparedness for the state of Utah's chapter of the American Academy of Pediatrics. He is also an assistant professor in the Department of Pediatrics at Baylor College of Medicine and he serves as a physician liaison for Texas Children's Hospital Emergency Management Committee.

Again, the PowerPoint slide set and webinar link are available from our COCA webpage at At this time, please welcome Dr. Bresee.

Joseph Bresee:
Hey, everybody. This is Joe Bresee. And thanks for having me on the call. I'm going to spend maybe 10 minutes just to set the stage for Brent and Hank to talk about some of the specific recommendations for this year. And what I want to do is spend a few minutes talking about the surveillance systems in the United States and what's happening now with flu and what we're watching with flu using last year as a sort of jumping-off point for that.

And last, I want to spend a few minutes talking about why flu vaccines are so unique and how we think about changing strains each year and what goes into those decisions and why we think it's a very complex procedure.

And so let me start here. And many of you know this, and I apologize if I'm saying simple things. But the way the influenza surveillance systems work in the United States, CDC houses between 8-10 different influenza (systems) depending on if you're a lumper or a splitter. And those systems measure a variety of outcomes of influenza from laboratory positives to mild illness to outpatient illness, hospitalization, deaths and novel influenza, (a development).

So a variety of types and parts of flu are surveyed for each week during the year through a variety of systems. And what's happened is the data comes into CDC from these 8-10 systems, usually each Monday, Tuesday and Wednesday morning of each week.

We compile the data, clean it and look at it and publish our report called Flu View, which this picture shows, every Friday usually around 10 o'clock depending on how down to the wire we are, 10:00 to 10:30 this is usually posted on our Website and describes what's happening with flu in a very updated and we think very comprehensive way.

Thinking about these systems looking at last year's flu season, as you recall, there was last year we thought was a moderate flu season. Here's a - oh, passed it by. Here's a slide of what we call the influenza ILI net which measures clinic-based influenza-like-illness over time and what this system does is measure the proportion positive. So of all the patients you see in your office what fraction have influenza like illnesses. This is a pretty good way to monitor influenza in the country.

And what you see is this and multicolored line slide is the last six seasons or so. Last season was the one in the red and I want to say two things about last season based on this slide, first is it was an early season. It was, in fact, the second early season in a row where we had a December peak. Usually we have about a March peak in influenza disease.

And second, if you look at the height of the curve in the red, again, you see it was a pretty moderate season; not the worst season we've seen in the last six years but certainly more severe than some. So a moderate season that had an early peak of disease.

And this is a slide that shows the last 30 or so seasons when we usually see peaks in the influenza season. And you'll see that in February is the most common month we see and about 80% of the season’s peak somewhere between January and March and so to have two seasons in a row with December peaks is relatively unusual.

So the next slide is a slide of our laboratory data from last year. And the main point I want to make here is also you see the early peak in December of the laboratory data which mirrors the disease data. But mostly I want to show that the color is orange and what that means to us is that it was an H1 - influenza A H1 predominant year. This is actually quite unusual; about 90% or 85% of the islets were A’s last year and most of those were H1 disease.

This is the first time we've seen much H1 since the pandemic year of 2009. And if you look at this you see that only in the last 20 or so years have we had six - we've only had six of those 21 years where H1 was the dominant virus and again only one in the past five years. So a relatively unusual year for that reason as well.

Trying to change the slide, let's see if it works? Yes, there it goes. And finally we have a few ways to look at how severe the disease was last year. This is one that's relevant for you all. This is - if you die of influenza and you have a lab-confirmed illness in the United States and you're 18 years old or below you - it's meant to be a nationally notifiable disease.

If you look at the far right side here we had 107 deaths - 107 up top is the true number - 107 deaths reported as of last year. And this is a - again, a moderate severe season. We've had more deaths reported in some years and fewer deaths in some years.

Notably that last year, like the previous years, is about 90% or 80% of the kids who die have not been vaccinated the year before. So this is another way to look at the efficacy of influenza vaccine and the need to get all our kids vaccinated.

Let me just say a brief word about how well the vaccine worked last year. This is a slide that shows the vaccine effectiveness by age group. And again if you look at the far right side you see that overall we had about 52% effectiveness last year of the flu vaccine. And in kids, if you can scroll down the right-hand column, you see it was about 50%-60% for kids. This was about what we normally see each year in the United States, about a 50%, 60% or 70% effectiveness rate of the vaccine.

I do want to make one point though, over the last couple of years there's been a host of studies that look at the more severe outcomes and how well the vaccine protects against that. We published a study where the data are summarized in this slide looking at how well the vaccine protected against ICU admissions among children. And you see that in the two years, 2010 and 2012, there was a 74% effectiveness against ICU admissions for influenza.

And so while flu does protect 50%-60% of the time for office visits it may well protect against severe disease in a greater - to a greater extent. And that's something worth communicating to our patients.

Finally and increasingly we're transforming these data on vaccine effectiveness and vaccine coverage in the US to try to estimate the total annual disease burden averted by influenza vaccine. There's maybe an easier way to communicate the value of influenza vaccines.

We did this, we published a couple of papers this last year. Look at the bottom left box here and that shows in the 2012-13 year, which is the last year for which we had good data, influenza vaccination in the United States prevented 3 million cases of influenza, almost 2 million cases of clinic visits and about 15,000 hospitalizations that otherwise would have occurred.

We'll present the data for this last season in the next week or two, so you'll have something to talk about with your patients to show the substantial benefit - beneficial impact of influenza vaccine.

Finally, I'll say while we're monitoring season influenza we're still monitoring a variety of other things including the avian influenzas in China, the swine origin influenzas in the United States. The development - hopefully - lack of development of oseltamivir resistance and the variety of new treatments and universal vaccine developments that are ongoing.

There's lots of things happening with flu right now both in terms of viruses and in terms of treatment and prevention strategies. And so I think the landscape has changed very quickly over the last few years and will continue to change very quickly over the next few years.

And let me just finish with a couple words about strain selection, how we decide whether to change a strain in the vaccine for the annual vaccine or not. If you look at the next slide, there it is, influenza is unique for a couple of reasons. First, the virus - the vaccine induces strain-specific immunity and that requires a multivalent vaccine, either a three or a four valent vaccine rather than just a single strain.

Second, the vaccine targets are multiple. Not only do we have three or four season vaccines to protect against, we have the emergence continuously of a variety of pandemic - or potentially pandemic strains all of which deserve and require vaccine preparation or at least vaccine development so a very robust and very ever-changing and active field.

Third is that each sub type and type of flu changes all the time so we need an annual vaccine that's updated every year to keep up with the changing extremes. And finally, all that has to be done every year, so we monitor vaccines year around. We recommend which strains will go in the vaccine in February. The manufacturers make the vaccine over the ensuing five or six months. We distribute the vaccine in August and September and October, and do most of our vaccination in the fall - so all on a very tight timeline.

Oops, let me skip this slide. There we go. And the way this is done is a variety of laboratories around the world are looking for flu all the time. If you look at this slide in the top left box there's 136 laboratories and 106 countries around the world that do the surveillance, find the flu positives. They take those data, they send them to WHO every week.

They take the samples they get, the flu positives, and send them to one of five international laboratories and one of which is at CDC in Atlanta. Those laboratories look at the strains, they look at the antigens, the protein (that surface) the genetic characteristics, the antiviral resistance. They come up with whether they think this - whether - if the strains are changing or not.

And then they develop the vaccines against the strains and send those vaccine candidates to all the manufactures in the world free of charge for vaccine development. All this is coordinated by the World Health Organization.

And so each year, as all the data come in to CDC and the other four labs of all the different strains that are circulating, we look at the data and we ask four questions. And this will determine whether the strains are updated or whether they remain the same from year to year.

And usually, again, one strain or two strains changes every year. It's fairly uncommon to have all strains stay the same, which has happened in the last year.

First is, are there new antigen variants developing for an H3 or an H1 or are they changing? Second is, are they changing in a way that's concerning? Are they becoming more common? Are they becoming more geographically widespread?

Third is, do the current vaccines protect against them? If we vaccinate a (ferret), for instance, with the current vaccine, will it protect against the new emerging strains or not? If not we think we might need to change the strain in the vaccine.

And finally, among the new variants, is there one we could make a vaccine from? It often happens, or sometimes happens, that there are new variants but there's no good - there's no individual virus that grows well enough in eggs or is a good enough vaccine candidate that we can't change the vaccine.

And so not only is - do we need to know if it's changing but we have to find the right virus that actually grows well enough in eggs to make a vaccine (unintelligible). And again, all this has to be done on a time clock between - in the fall, make the decision in February and the vaccines are all made in the next five months.

And so in summary, I'll say that there's a bunch of new data to indicate that the vaccines are beneficial to kids. And increasingly there's been data on showing the vaccine is beneficial against severe outcomes in kids, which are most important.

Second is that influenza, our communication plan at the Influenza Division at CDC will increasingly focus on disease - severe disease prevention and the annual substantial impact of influenza vaccines in this country.

And third is that all this, the benefits of vaccine, is predicated on being able to make a vaccine each year and to remind you that the vaccine production is a complex beast and it's time sensitive, annually updated. And hopefully each year we make a pretty good prediction on what's going to circulate that following year. And we get good enough (effectiveness at the lot) of the disease that will occur actually. And I'll stop there and turn it over to Hank Bernstein for the rest of the talk.

Hank Bernstein:
Great. Thank you, Joe. Great job. And let me try and advance the slides here. Oh that didn't work. Can somebody advance the slides?

Leticia Davila:

Hank Bernstein:
I have lost the slide. There we go. Got it. Thank you. Sorry for the technical difficulty. So I'm going to talk about the influenza recommendations for 2014-2015. And there are six key messages that I hope to convey.

One is that influenza vaccine is needed annually including this year, even though the strains haven't changed. Everyone six months of age and older should get the vaccine.

As I mentioned, and Joe mentioned earlier, the vaccine strains are identical to the ones last year and which is pretty unusual but usually there's antigenic changes, but not between last year's vaccine and this year's vaccine.

There are both tri and quadrivalent influenza vaccines available throughout the country. And when readily available, LAIV should be considered for healthy children 2-8 years of age. There's a dosing algorithm that's produced by the American Academy of Pediatrics and the CDC. And it's for children 6 months through 8 years and it does reflect the fact that the vaccine strains have not changed. And egg allergic children should be vaccinated.

As you can see in this slide, influenza is a common and serious public health problem contributing significantly to patient morbidity and mortality. And it creates a huge financial burden on our healthcare systems. You can see the notable impact of influenza each year in comparison with other vaccine preventable diseases.

Influenza is spread from person to person quite easily and primarily by respiratory droplets created by coughing and sneezing. Contact with those droplets that are contaminating surfaces is another probable mode of transmission.

During community outbreaks of influenza, the highest attack rates occur among school-age children. Secondary spread to adults and other children within a family is quite common, as we're all aware.

From this slide you can see that influenza imposes a heavy disease burden on our society in the US every year. Because it's a highly contagious acute respiratory disease, influenza is responsible for an average of 50 million to 60 million infections annually which result in 25 million healthcare visits, hundreds of thousands of hospitalizations and thousands of deaths of all ages. In pediatrics, as you heard it was only 107 but many of them are preventable by vaccine.

This is a slide that you saw from Joe as well. And I'll only comment that in the 2013-2014 season, the weekly percentage of outpatient visits for influenza-like illness to outpatient network facilities exceeded the national baseline of 2% for 14 weeks. So it really was a moderate season. And it was an early peak.

Children with certain medical conditions are at higher risk of complications. And as you can see here asthma is number one and neurologic disorders are number two.

Among children hospitalized with laboratory confirmed influenza, almost half, 43%, were perfectly healthy and did not have any underlying medical condition. So it's important for us to not just earmark those at higher risk, but all people 6 months of age and older should be getting the vaccine.

This slide also Joe showed. And, again, there were 103 deaths, pediatric deaths, and back during the pandemic there were 348 deaths. Prior to the pandemic it was usually under 100 so it is very unpredictable and many of these - this morbidity and mortality is preventable by vaccine.

Last year, as you also heard, that influenza A, the pandemic, H1N1, was the most common strain. Compared with the 2012-2013 season, there were less outpatient visits, less hospitalizations and less deaths.

This highlights that both trivalent and quadrivalent vaccines will be available in the 2014-2015 influenza season. The quadrivalent vaccines contain the same three strains as the trivalent vaccine but they add an additional B strain which is the opposite lineage. There are two lineages, so B and then the quadrivalent have both of those B lineages. And again, all the strains are unchanged from those included in last year's vaccine.

All people, 6 months of age and older, should get the flu vaccine. Because the circulating flu viruses often change from year to year, annual vaccination against the flu is necessary even when the vaccine strains have not changed.

This is the number of seasonal influenza doses for children 6 months through 8 years of age. Infants younger than 6 months of age are too young to be immunized with influenza vaccine, and children 9 years of age and older need only one dose.

It's those children 6 months through 8 years where we need to determine how many doses they need each year. And the number of doses needed depends upon the patient's flu vaccine history and their age.

This dosing algorithm reflects that the virus strains in the vaccine have not changed from last year, so a number of children who may have routinely needed two vaccine doses, if the vaccine strains had changed, only will need one dose this season.

There are special populations that we need to reach. Each year seasonal flu places a large burden on children. And they commonly need medical care because of influenza especially those children under 5 years of age. Each year an average of 20,000 children under the age of 5 are hospitalized because of influenza complications.

Although immunization is the best way to prevent outbreaks, vaccination rates among healthcare personnel remain well below the expected targets. And influenza vaccination coverage among healthcare personnel is important for patient safety. We know that mandatory annual influenza immunization has been recommended by the AAP and has been implemented successfully at a number of pediatric institutions.

Annual season influenza vaccine is especially important for household members and out of home caregivers of children and adolescents at high risk of complications of influenza and then again children - all children, including healthy ones, under the age of 5 and especially infants under the age of 6 months, because they cannot get immunized themselves.

And the fourth group on this slide are pregnant women. We know that pregnant women are at increased risk for hospitalization and death from influenza. And it has been found and documented that maternal vaccination during pregnancy, at any time during pregnancy, can protect newborns against influenza during their first few months of life.

This slide is talking about LAIV, which is given intranasal versus the inactivated influenza vaccine given by injection. And using the G.R.A.D.E. framework, the CDC Advisory Committee on Immunization Practices systematically reviewed the evidence pertaining to the efficacy of LAIV and IIV for healthy children.

It concluded that there seemed to be an increased relative efficacy of LAIV as compared with IIV against laboratory confirmed influenza amongst younger children up through 6 years of age. Therefore, LAIV should be considered for healthy children 2-8 years of age who have no contraindications or precautions to the intranasal vaccine.

However, if LAIV is not available at that particular visit, IIV should be used. Vaccination should never be delayed in order to obtain LAIV down the road. We know that patients tend not to come back; they go unimmunized or (eligible) for it but end up getting influenza at an early age.

G.R.A.D.E. is that systematic review of the literature. It takes into account the quality of evidence, strength of recommendations, health impact and multiple other elements.

This is one of the studies that supported the G.R.A.D.E. analysis and this is a study of about 8000 children. The top line are those children that received inactivated vaccine; the bottom line in red is those that received the live attenuated vaccine. And you can see that the proportion of children with influenza who got inactivated vaccine was 8.5%, versus around 4%-4.5%, for those that received live attenuated influenza vaccine.

This is another study that, again, suggests the same finding that it appears that LAIV is more efficacious especially into - through 8 years of age. In this study, there were 53% fewer cases of influenza in those that received LAIV in comparison to IIV.

This slide highlights for us that the age specific influenza vaccine coverage really does vary by age but you can see that children 2-8 years of age, in particular, have low rates of vaccine coverage and would benefit and have lots of notable room for improvement.


Hank Bernstein:
Full vaccine coverage, which is two doses, is...

I mean, I'm sorry, but, you know, as the years have gone on...

Hank Bernstein:

Leticia Davila:
Excuse me, speakers, please mute your phones. Go ahead, Dr. Bernstein.

Hank Bernstein:
Yes, thank you. So as you can see from full coverage data there is notable room for improvement. And this next slide gives us the vaccine coverage and - although the right hand side of the slide for the 2013-2014 the data was literally just released this week. And it has improved. It moved from 57% up to 59% for children 6 months through 18 years. So we're making headway, but there is still lots of room for improvement.

This slide is intended to highlight that as soon as the vaccine is available, pediatricians and vaccine administrators should start giving the vaccine as soon as possible and offer it throughout the season.

Protective immune responses persist during the influenza season. And as we know, influenza can actually have more than one peak of activity in any particular geographic area and may extend, as you saw from the earlier slides that Joe presented, can extend throughout and well into March, April and May.

These are ideas in order to make vaccine easily accessible to families: we should email or text or use patient portals, create influenza clinics, extend our office hours during peak vaccination periods, administer it during well as well as sick visits if at all possible, consider immunizing parents and adult caregivers and siblings of children and work with other institutions or alternate care sites in order to make vaccine available. (There are) going to be anticipated to be close to 165 million doses available around the country this year from the manufacturers.

Recent data has shown that IIV administered as a single age-appropriate dose is well tolerated by nearly all recipients who have egg allergy. So this slide that gives an approach to children with presumed egg allergy is something that we should be aware of, but understand that egg allergy is not a contraindication for giving influenza vaccine.

We also know that cocooning is a vaccination strategy that aims to reduce infection in children by immunizing those around the children. If the people that are around the children, the close contacts of children, are protected by the vaccine, then they're less likely to get influenza and they're less likely then to expose their children.

This concept of cocooning is particularly important to help infants under 6 months of age, because they're too young to be immunized with influenza vaccine.

According to the data from the 2013-2014 season, the most common place for vaccinating adults and children was the doctor's office. So you can see two-thirds of all children were vaccinated in the doctor's office and about one-third of adults were vaccinated there.

Adults and children have used other alternate venues, like pharmacies or stores or workplaces, and even some schools have offered influenza vaccine. This is just intended to remind us that antivirals are very important in the control of influenza. And when used for treatment, antivirals can lessen the symptoms and shorten the duration of the flu by 1-2 days.

Neuraminidase inhibitors, specifically oseltamivir, Tamiflu or Zanamivir, Relenza, are used for treatment or prophylaxis. This slide shows that both of these neuraminidase - not both of them - only oseltamivir, because Relenza is inhaled - oseltamivir can be given to infants under a year of age right down to birth. And this includes both term and preterm infants. The dose varies based upon their post-menstrual age.

So in conclusion, I just want to remind everyone that everyone 6 months of age and older needs vaccine. The strains have not changed. Tri and quadrivalent vaccines are available this season. When available in your office, LAIV should be considered for healthy children 2 through 8 years of age.

There is a dosing algorithm to be sure that children 6 months through 8 years are adequately primed. And egg allergy is nothing that we should really be concerned about anymore. All those children should also receive the vaccine, or essentially all of them. Thanks and I'll pass the presentation over to Brent Kaziny.

Brent Kaziny:
Hi. Thank you, guys. Thank you for having me on the call. I just am going to try to rush through some of this just because I want us to end on time at 45 minutes past the hour, so that we have plenty of time for questions. I do have a lot of slides but I'm going to try to get through it here.

As somebody that's emergency department–based, I have a little bit of a different view on things, but I think that I've got some strategies that will hopefully be helpful for the general pediatrician, the physician in the community hospital as well as those in the tertiary and quaternary pediatric facilities.

I think, you know, why should we care about this issue? In general, I think we wouldn't be on this call if we didn't know the answer to this question. But, you know, H1N1, looking at some of the numbers then are nothing new or crazy but, you know, a disproportionate number of children were affected with 3/4 of the - almost 3/4 of the hospitalizations - sorry - cases - being in children age 0-24 and over half of hospitalizations affecting children.

And we also know that our hospitals in the United States tend to not be specifically focused on pediatric preparedness. CDC survey in 2008 showing that only about 1/3 of hospitals had guidelines for increasing pediatric surge capacity.

And while hospitals don't seem to be particularly prepared for this, we do know that the community at large does think that it's an important thing. If you look at Marist College of Institute Public Opinion Poll that they conducted for the AAP in October of 2010, we saw that a majority of people surveyed thought that not only should there be, you know, some consideration given to preparedness for children but it really should be a higher priority for children's preparedness over the needs of adults.

So in Texas we see a lot of hurricanes, especially here in Houston, and so we kind of tend to view things in kind of analogies related to the storm - the coming storm. And I think, you know, you'll hear me kind of talk in these analogies throughout the rest of my talk.

But I think what's really important is to kind of have that eye on preparedness prior to the arrival of the surge, so kind of preparing for the storm before it's coming. And some really, you know, starting at the institution and while I'm talking about a hospital this could apply to a pediatric office or what have you - I think a key that we've heard over and over again is the importance of vaccination.

And I think in particular the importance of vaccination like healthcare workers could be improved upon. And when you look at some of the numbers only about 2/3 of healthcare workers have received influenza vaccine despite some mandating it at various institutions.

There are definitely some tried and true strategies for improving vaccination rates and these include improving education for healthcare workers as well as just making it easier for them to access these vaccines, so giving it to them in the workplace, in the unit, not making them go to employee health, etcetera, to receive these.

In addition, working with healthcare workers who refuse to vaccine, putting them in lower risk areas of work, making them wear a mask, etcetera, some - may be some things that kind of discourage them from not wanting to get that vaccine.

I think another thing that's important to look at and focus on is the fact that you really should anticipate about 20% absenteeism should there be a significant flu event. You know, given individuals getting sick and/or having to care for children of theirs at home that are sick, really beefing up your staffing prior to a potential flu surge can really be helpful in the long run.

In addition to just protecting your healthcare workers through, you know, employing good hand hygiene initiatives as well as having the appropriate PPE available for them.

Now it's not just about preparing the institution but obviously preparing those at risk. And Dr. Bernstein and Dr. Bresee have touched a bit on this but I think, you know, it's really important to look at these at risk patients and recognize that as an emergency department physician whether it be in a pediatric facility and/or a community hospital, you're really touching these patients quite a bit.

They're coming into your ER for asthma exacerbations, fever, etcetera. And I think talking to them when they have these visits can be very helpful, and kind of encouraging them to get the vaccine if they haven't already gotten it and hopefully improving some of these vaccination rates among these at-risk patients.

And then from the emergency department standpoint, I think it's also important to look at partnering with our primary care partner - physicians out there in the community, identifying networks of primary care physicians whether they be within your home hospital network and/or outside of that.

And really showing yourself as an institution to be kind of an institution that vets some of this information that's being passed down from the CDC and AAP. And opening two-way communication among yourselves as well as these primary care physicians to share information regarding strategies for testing, treating, and when to refer to the emergency department.

And I can say first hand, as a physician that works in the emergency department, it's extremely important for parents to have kind of the appropriate expectations for their emergency department visit if it is a patient that you decide to refer to the emergency department. This can improve I think their experience as well as the timeliness of their visit, allowing them that tertiary quaternary care center to see more patients and kind of offload some of the burden.

In addition to preparing our kind of primary care partners I think creating relationships with outside hospitals is also beneficial. And you can work on that through kind of hopefully the creation of some coalitions in your region.

I think it's mostly about sharing that similar information you'd be sharing with the primary care physicians but also about just finding a pediatric champion at each of these facilities so finding somebody, whether it's a nurse manager or an emergency department physician, or just one of the hospitalists that works there that really has taken it upon, you know, kind of as their - they're kind of carrying the mantle as the pediatric champion for that facility allowing you somebody to communicate directly with that can then disseminate that information to the rest of their staff.

And I think this coalition-building goes beyond seasonal flu surge, but I do think that the annual nature of the flu surge really provides a good way to test these relationships, to work on these avenues of communication and improve them.

Because they can provide beneficial in multiple different scenarios whether that be mass casualty, pandemic, etcetera. But I think this annual nature really helps build this nice relationship.

So we've talked a little bit about things that you can do before the surge occurs, but how do you know when the surge is coming? And I think this is something that obviously the CDC does a very good job of working towards - as we've seen in Dr. Bresee's presentation. And I think they provide kind of the big view, the big picture view.

And I think their flu site can provide you with kind of the National Weather Service version of flu surge and when to expect that impending surge. And this Website can be very helpful for that. But I think what are some things that you can do in your region a little bit more close to home to try and figure out when that surge is going to come?

I think some things that you can do, you know, I like to think about these - our community hospitals in our region as well as our primary care physician providers and partners as kind of buoys out in the water. As that storm approaches, you know, they're going to be the first people to see some of this action.

And something that we're working on at Texas Children's this year is actually trying to survey flu tests that are being sent by primary care physicians within our network of pediatricians as well as prescriptions of oseltamivir to see if we're getting kind of an increase in the rate of those tests being sent and prescriptions being sent off, to potentially identify when that surge might occur.

In the hospital, random surveillance testing as flu season approaches can be very helpful in identifying when we're going to see the flu hit us in a major way, and monitoring that percentage of positive tests in our lab can be very helpful as well.

Some other things that you can do is just, in a hospital level, look at overcrowding in your emergency department. We've utilized the NEDOCS system too a bit, which is an emergency department overcrowding scale that can really show you in real time when you're getting to a point where things are getting too crowded for you to deal with and need some additional help.

And so what does that additional help look like? And I think when looking at surge response there's kind of two things that are really important; making something that's going to be scalable as well as sustainable.

And we're going to talk kind of small to large with regards to how to effectively initiate some action plans that can help you during the course of flu season.

I think on the small end of things is utilizing your available resources that you have day to day but in a very different way. And the way that you can do that is restructuring your current resources to allow for improved efficiency and patient throughput.

Some things that have been done in the past are triage-based screening tools for patients with ILI; separate waiting rooms as well as streamlined charting. I think providing a checkbox type paper chart or electronic tablet-based charting tool for patients with ILI can really improve throughput and increase efficiency of that provider that's seeing a large number of patients very quickly. And this is has been shown to work in the past.

In addition, I know that my former partners and colleagues at the University of Utah utilize a discharge video reviewing flu basics. And when you think about the 3 to 5 minutes that an emergency department physician spends with a family reviewing the basics of the flu as they go about their discharge, if you could cut that out completely, allow them to watch a video and then answer questions that could save a tremendous amount of time over the course of an entire shift.

So that's just using things that you have at your disposal every day, but kind of restructuring them to improve throughput. Now obviously you get to a point where you need some extra help.

And something that we've done here at Texas Children's, and it's been done at some other facilities as well with varying degrees of success, is having surge staffing so having the presence of an additional physician in the emergency department that's on call as well as nurses that are on call because you need both to really effectively see patients in a timely manner and have some hospital-based metrics that identify when you should trigger that person to come in and start helping see patients.

Now obviously that's an additional resource but we've seen at Texas Children's that that has improved significantly the number of our patients leaving without being seen and it's something that the administration has really bought into because they see the number of patients that are leaving, and then after the implementation of this program they see that those patients are not leaving without being seen, and that's something they really want to improve upon.

Again, going back to these coalitions that I've discussed earlier, I think it really needs to - you really need to focus on these surge type situations but this is a two-way street.

So hopefully, you know, if there were to be some type of pandemic or kind of a harsh flu season you're working with these outside facilities, providing them with the expertise that you have as a pediatric center but at the same time they should really be working at trying to buffer that pediatric tertiary or quaternary care facility from seeing these large numbers of worried well and noncritical patients.

And I think that kind of relationship and that back and forth is very important to build hopefully building that prior to flu season, so that you've got some of these kind of networks as well as the infrastructure for that network in place.

And then we get to kind of the big - the big response when things are really going crazy in the emergency department and you have vast number of resources. And here we've used - and similar things have been studied at other institutions. We refer to it as our mobile pediatric emergency response team which we used post-Katrina in the Reliant Stadium shelter and also during H1N1.

For H1N1 that looked - and it can look like a variety of different things - but for H1N1 it looked like a kind of mobile emergency department that was put up in a parking lot, basically, and so it's a creation of an additional resource, a resource that you don't usually have in your day-to-day that requires a mobilization of a lot of resources.

But it has been shown to work as far as improving throughput of patients, and it's also been shown to be something that families don't mind doing. So families and caregivers both can be amenable to care in this nontraditional setting as long as they're being seen and helped out in their time of need.

So what are some available resources out there to both the general pediatrician as well as the hospital-based doc in the emergency department who's interested in improving the response at their facility.

I think one of these things would be - is put out by the AAP which is terrific resource, the Pediatric Preparedness Resource Kit. It was a product developed out of the Enhancing Pediatric Partnerships to Promote Pandemic Preparedness meeting in 2011. I challenge you to say that five times quickly. There's a lot of Ps there!

But there was really a key emphasis placed on improving communication and information flow, which I think we've touched on previously in this talk, as well as identifying those pediatric experts - I think experts is maybe the wrong word - I think it's that pediatric champion in every community that you can rely on. And then just prioritizing pediatric preparedness and improvement in general, as we know that it needs to be improved upon in our country.

And it's available online as a PDF. Here's a picture of the cover page of it. And you can reach it via going to the AAP's Website and looking at their children and disasters site. And I think it's a terrific resource.

In addition, there was recently a three-day workshop that was presented by the CDC, multiple children's hospitals applied to participate in this workshop and Primary Children's Medical Center and the University of Utah was selected. They did a three-day workshop with the CDC and Primary Children's looking at ways to improve response in surge planning.

And I think there was a significant focus during the talk on coalition building, but there's a lot more to come from them down the road; I think they've got a lot of interesting stuff that came out of that three-day workshop that be on the horizon, so keep an eye out for that.

So I think in summary, you know, there are some available resources out there already for the emergency department and/or general pediatrician doc to look at. I think it's mostly about preparing the institution, looking at ways to know when the surge is coming and then obviously keying in on scalable and sustainable methods to deal with the surge when it occurs.

So thank you very much for your time. And I guess now I'll pass it over to Leticia.

Leticia Davila:
Thank you. Thank you, Dr. Bresee, Dr. Bernstein and Dr. Kaziny for providing our COCA audience with such a wealth of information. We will now open up the lines for the Q&A answer session. And also remember, you can send in questions through the webinar system. Operator.

Thank you. At this time we will begin the question and answer session. To ask a question, please press star 1 and record your first and last name. If you wish to withdraw your question, please press star 2. One moment please for your first question. We have no questions on the phone at this time.

Leticia Davila:
Okay, we do have some that have come through the webinar system. The first one is, "The flu vaccine supply to our office has been delayed. What do we need to know about the situation overall at this time?"

Joseph Bresee:
This is Joe Bresee. I can take a crack at that if you want me to, Leticia. The - I think the - I don't know the true answer to the question. I can relate that in fact we should have plenty of supply this year. We're expected to have plenty of supply this year of the flu vaccine, as Hank had said earlier. And so, talk to the place that you ordered it from to see what the delay is about. But we think that there should be - all the vaccine should be available that you ordered well ahead of the influenza season this year. Again, if you look at the right side of my slide, we're not seeing much influenza circulation right now so it looks like we have a few more weeks now before we start seeing an uptick in influenza disease hopefully. So hopefully plenty of time still left to vaccinate even if your supply is delayed.

Leticia Davila:
Thank you. We do have another one that has come in. It says, "Could you suggest some YouTube videos or other short videos for education of families?"

Brent Kaziny:
So, I can speak on that since I did mention some. I don't know of any - sorry this is Brent Kaziny. I don't know of any YouTube videos that might be out there. And I - and please, Dr. Bresee and Dr. Bernstein, chime in if you know of any. I know that the University of Utah produced their own video and utilized that in their emergency department to, I think, quite effectively. But I don't know of any YouTube videos that might be helpful. Does anybody else have any ideas?


Hank Bernstein:
Yes, hi, this is Hank. You might also look at or I don't know that they're specific to - they have specific YouTube videos per se, but there's a wealth of information about influenza for families on both of those Websites. And they're wonderful and the information is top notch so I would encourage - I know there's some videos on the Website which is the National Foundation for Infectious Diseases.

Joseph Bresee:
And finally, this is Joe, there's also some video clips available on the CDC Website; if you go to the CDC influenza Website you should be able to find those fairly easily, and they relate to vaccine and antiviral recommendations and influenza fact sheets.

Leticia Davila:
Thank you. The next question is, "What populations of patients are recommended to receive the quadrivalent over the trivalent vaccine?"

Joseph Bresee:
Hank you want to...

Hank Bernstein:
Yes, so currently - this is Hank - so currently the American Academy of Pediatrics and the CDC, there's no preference for one over the other. Logistically it would make sense that being protected against four vaccine strains, both lineages of influenza B, would be a preference over the trivalent. But we don't have full - a full analysis of the use of quadrivalent has - which is being studied by the CDC and data being gathered.

We don't have that information, and we also know that the manufacturers have not totally shifted to producing only quadrivalent. So the recommendation in general is immunize as many children as you can with influenza vaccine, either tri or quadrivalent. If quadrivalent is available certainly that - understandably might be a choice. I should mention that the intranasal vaccine, the live attenuated influenza vaccine is only - comes only as quadrivalent.

Leticia Davila:
Thank you. The next question is, "How would you best explain to a patient who asks, 'If I received my flu vaccine last year and the strain hasn't changed this year, why do I need to receive a vaccination this year?'"

Hank Bernstein:
I can take a, early crack at this, and then maybe Joe wants to chime in. That's a common question that people ask about vaccines in general and especially flu vaccine. The reason is, first of all we know that the vaccine is not - the vaccine effectiveness is not 100%. We also know that the protection that all of us develops that there's a concept of waning immunity and that over time the vaccine immunity in a particular individual may diminish or by as much as 50% over 6-8 months.

And so, getting the vaccine again the following year, even though the vaccine strains haven't changed, will boost that protection and ensure that there's better protection for that individual and the population at large. So it really is important knowing that the concept of waning immunity does happen over time.

Joseph Bresee:
Yes, nothing to add from me, Hank, that's exactly what I would have said.

Leticia Davila:
Perfect. The next question is, "A frequent question I get is why do we start to give the vaccine in September if the flu is worse in February and March? What is the length of time the vaccine is effective?"

Joseph Bresee:
Yes, this is Joe. I'm happy to take that. That's a great question. And the reason we give vaccines starting really in August, but a lot in September and October, is because we know each year flu is going to circulate some time in the fall and winter but we don't exactly know when it's going to start.

And so we want to get the vaccine - ahead of the vaccine - of the influenza season far enough ahead that where we develop enough immunity. Remember, it takes about two weeks after you get the vaccine to develop full immunity in most kids. And so, we want to make sure we have time ahead of the season, ahead of the risk period to get the vaccine in.

And while the vaccine does - the vaccine antibodies do wane over time, vaccinating children who are generally immunologically pretty robust even a few months before the circulation of the influenza vaccine, they should have plenty of immunity during the influenza circulation period well into April and May.

And so September, August, October vaccination certainly - good timing because you get ahead of the season, and not too early to where you'd worry about waning immunity in this population.

Leticia Davila:
Operator, we can take two questions from the phone lines.

Thank you. You have one question in queue right now, and it's from (Erin Colis). Go ahead your line is open.

Hi, actually it's (Karen). Thank you. I just had a follow up question. The ACIP also just changed the LAIV use recommendation for immunocompetent children with chronic disease, so those with asthma, those with diabetes, those with seizures can all receive LAIV; it's no longer a contradiction but a precaution. And I believe their statement is that providers should determine if it's okay to use.

A question that I had is that because of the ACIP guidelines, they stated their preference for LAIV use in 2-8 year olds in healthy children. As I understand it, it can be used in 2-8 year olds who are immunocompetent even if they have asthma or another chronic illness because that is now just a precaution. Am I correct with my interpretation? Thank you.

Joseph Bresee:
Hank, you want to take that one?

Hank Bernstein:
Sure. So I think that you're thinking is correct that there is a point - the ACIP recommendation has pointed out that in fact children with chronic medical conditions whether or not to use LAIV for those children, is not a contraindication but actually a precaution. But the ACIP and the AAP specifically did not intend to make the recommendation that LAIV should be used for children with chronic medical conditions this year.

There really is not enough data, especially for children who have chronic respiratory problems, and obviously influenza causes respiratory disease, so the recommendation really is for LAIV for children 2-8 years of age who are healthy, not those with chronic medical conditions.

A precaution by definition is such that if the provider feels that the benefit of using a product or vaccine product or otherwise far outweighs the benefit of not giving it, then certainly that decision can be made by the provider. But the recommendation is for LAIV to be used only in healthy children 2-8 years of age.

Thank you.

Leticia Davila:
Operator, we'll take one more from the phone if there is one.

There is one, just a moment. The next question comes from (unintelligible). Go ahead, your line is open.

Yes, hello. Two questions, why are egg allergies no longer a contraindication? And, number two, we're seeing a surge of the enterovirus, and I find that families with children in the hospital are very poorly compliant with precautions. And I thought when the flu season coming are the - do you - of course it's a droplet, but how important do you feel gowns are in addition to the masks and good hand hygiene? Thank you.

Hank Bernstein:
I'll start with the egg allergy. The data to date really suggests that people with egg allergy, it's safe product to be able to be used - the influenza vaccine, in virtually all children with egg allergy. At the moment our recommendation is to - is to consider whether or not someone who has had anaphylaxis, a serious allergic reaction associated with egg, should receive the vaccine and our - most of our allergy colleagues suggest to us that even those individuals can receive the vaccine. I should say that we're talking about the inactivated vaccine by injection. LAIV is under studied, but has not been fully studied in giving it to children who are presumed to be egg allergic.

And then I - the enterovirus D68 issue I think is continuing to sort itself out thanks to the CDC, which has provided lots of information - your recommendations as far as trying to decrease transmission and droplet and standard precautions is very appropriate and should be emphasized just as we do every year with influenza, and certainly in the outpatient setting we're going to see lots of children coming in with ILI and needing to try to decrease the transmission as best we can. I don't know, Joe, if you wanted to add to that?

Joseph Bresee:
Not a bit. I think that - I think - and just to say that on the AAP main Website and the CDC main webpage if you go to or, you'll see links to information about the new enterovirus as well.

Leticia Davila:
Thank you. We have one final quick question. "We are also having a delay with flu vaccine; however, I have been able to obtain both LAIV and IIV for my family practice office. We have been directed to not administer the vaccines until October 1 this year. Usual go date is September 1. Is there any CDC recommendation or information that would support this delay?"

Joseph Bresee:
No. The - our recommendations generally are the ACIP recommendations, and AAP’s is to administer the vaccines when they become available. And, again, we want to make sure we get the vaccines in at the first opportunity to reach a kid. We don't want to miss those opportunities, lest kids remain unvaccinated when flu starts to circulate. So if you have vaccine and you have kids who want the vaccine, it's a good time to go ahead and start.

Leticia Davila:
Thank you. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to Dr. Bresee, Dr. Bernstein and Dr. Kaziny. 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 18 COCA call in the subject line of your email, and we will ensure that your question is forwarded to the presenters for response. Again that email address is

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