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2011~2012关于在儿童中预防和控制流感的推

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2011~2012关于在儿童中预防和控制流感的推 DOI: 10.1542/peds.2011-2295 ; originally published online September 2, 2011;Pediatrics COMMITEE ON INFECTIOUS DISEASES 2012 −Recommendations for Prevention and Control of Influenza in Children, 2011 http://pediatrics.aappublications.org/content/early/20...
2011~2012关于在儿童中预防和控制流感的推
DOI: 10.1542/peds.2011-2295 ; originally published online September 2, 2011;Pediatrics COMMITEE ON INFECTIOUS DISEASES 2012 −Recommendations for Prevention and Control of Influenza in Children, 2011 http://pediatrics.aappublications.org/content/early/2011/08/30/peds.2011-2295 located on the World Wide Web at: The online version of this article, along with updated information and services, is of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point publication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly by guest on October 24, 2011pediatrics.aappublications.orgDownloaded from POLICY STATEMENT Recommendations for Prevention and Control of Influenza in Children, 2011–2012 abstract The purpose of this statement is to update recommendations for rou- tine use of trivalent seasonal influenza vaccine and antiviral medica- tions for the prevention and treatment of influenza in children. The key points for the upcoming 2011–2012 season are that (1) the influenza vaccine composition for the 2011–2012 season is unchanged from the 2010–2011 season, (2) annual universal influenza immunization is in- dicated, (3) a simplified dosing algorithm for administration of influ- enza vaccine to children 6 months through 8 years of age has been created, (4) most children presumed to have egg allergy can safely receive influenza vaccine in the office without need for an allergy con- sultation, and (5) an intradermal trivalent inactivated influenza vaccine has been licensed for the 2011–2012 season for use in people 18 through 64 years of age. Pediatricians, nurses, and all health care personnel have leadership roles in the prevention of influenza through vaccine use and public education. In addition, pediatricians should promptly identify influenza infections to enable rapid treatment, when indicated, to reduce childhood morbidity and mortality. Pediatrics 2011;128:000 INTRODUCTION The American Academy of Pediatrics (AAP) recommends annual triva- lent seasonal influenza immunization for all children and adolescents 6 months of age and older during the 2011–2012 influenza season. Spe- cial outreach efforts should be made to vaccinate people in the follow- ing groups: ● All children, including infants born prematurely, 6 months of age and older with conditions that increase the risk of complications from influenza. ● All household contacts and out-of-home care providers of ● children with high-risk conditions and ● children younger than 5 years. ● All health care personnel (HCP). ● All womenwho are pregnant, considering pregnancy, or breastfeed- ing during the influenza season. KEY POINTS RELEVANT FOR THE 2011–2012 INFLUENZA SEASON 1. All people 6 months of age and older should receive trivalent sea- sonal influenza vaccine each year, especially those who are at high COMMITTEE ON INFECTIOUS DISEASES KEY WORDS influenza, immunization, live-attenuated influenza vaccine, trivalent inactivated influenza vaccine, vaccine, children, pediatrics ABBREVIATIONS AAP—American Academy of Pediatrics HCP—health care personnel CDC—Centers for Disease Control and Prevention TIV—trivalent inactivated influenza vaccine LAIV—live-attenuated influenza vaccine This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2295 doi:10.1542/peds.2011-2295 All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children PEDIATRICS Volume 128, Number 4, October 2011 1 by guest on October 24, 2011pediatrics.aappublications.orgDownloaded from risk of influenza complications (eg, children with chronic medical conditions such as asthma, diabe- tes mellitus, immunosuppression, or neurologic disorders). In the United States, more than two- thirds of children younger than 6 years and almost all children older than 6 years spend signifi- cant time in child care and school settings outside the home. Expo- sure to groups of children in- creases the risk of infectious dis- eases. Children younger than 2 years are at an increased risk of hospitalization and complications attributable to influenza. School- aged children bear a large influ- enza disease burden and have a significantly higher chance of seeking influenza-related medical care compared with healthy adults. Therefore, reducing influ- enza transmission among chil- dren who attend child care or school should decrease the bur- den of childhood influenza and transmission of influenza to household contacts and commu- nity members. Most egg-allergic children can now receive influ- enza vaccine safely. 2. Annual trivalent seasonal influ- enza vaccine is recommended for household members and out-of- home care providers of children and adolescents at high risk of complications of influenza and healthy children younger than 5 years, especially infants younger than 6 months. Pediatric offices should consider serving as an al- ternate venue for parents and other adults who care for children to receive influenza vaccine, if this approach is acceptable to both the pediatrician and the adult to be immunized. Clinicians should still encourage adults to have a medi- cal home and communicate their immunization status to the pri- mary care provider. Immunization of close contacts of children at high risk of influenza-related com- plications is intended to reduce their risk of contagion (ie, “co- cooning”). The concept of cocoon- ing is particularly important for helping to protect infants younger than 6 months, because they are too young to be immunized with influenza vaccine. The risk of influenza-associated hospitaliza- tion in healthy children younger than 24months has been shown to be greater than the risk of hospi- talization in previously recognized high-risk groups such as the el- derly. Children 24 through 59 months of age have had increased rates of outpatient visits and anti- microbial use. 3. The 2009 pandemic influenza A (H1N1) virus emerged in March 2009 and was associated with 2 significant waves of influenza ac- tivity during 2009 and 2010, as de- fined by the World Health Organi- zation. This virus strain disproportionately affected the pediatric population compared with the usual seasonal influenza strains. It was 1 of 3 circulating influenza viruses during the 2010–2011 influenza season, and it is expected to circulate again during the 2011–2012 influenza season in combination with 1 or more of the other seasonal influ- enza strains. During the 2010– 2011 season, influenza A (H3N2) was the predominant circulating strain, but weekly virus subtype activity varied regionally. 4. Although the number of hospital- izations for younger persons and outpatient visits for influenza-like illness overall was lower during the 2010–2011 season compared with the influenza A (H1N1) pan- demic period, at least 114 laboratory-confirmed influenza- associated pediatric deaths were recorded during the 2010–2011 season. Seventy-one deaths were associated with influenza A virus subtypes: 30 influenza A (2009 H1N1), 21 influenza A (H3N2), and 20 undetermined subtypes. Forty- three deathswere associatedwith influenza B viruses. More than half of all hospitalized pediatric pa- tients (51.8%) did not have any known underlying conditions (Fig 1). Although children with certain conditions are at higher risk of complications, substantial pro- portions of seasonal influenza morbidity and mortality occur among healthy children. 5. The recommended trivalent vaccine for the 2011–2012 influenza season contains the following 3 virus strains: ● A/California/7/2009 (H1N1)–like antigen (derived from 2009 pan- demic influenza A [H1N1] virus); ● A/Perth/16/2009 (H3N2)–like antigen; and ● B/Brisbane/60/2008–like antigen. 6. On the basis of ongoing global surveillance data, for only the fourth time in 25 years there is no need to change any of the in- fluenza vaccine strains (Fig 2). The number of trivalent seasonal influenza vaccine doses to be ad- ministered this year depends on the child’s age at the time of the first administered dose and his or her vaccine history (Fig 3): ● Infants younger than 6 months are too young to be immunized with influenza vaccine. ● Children 9 years of age and older need only 1 dose. ● Children 6 months through 8 years of age should receive 2 doses of vaccine if they did not receive any dose of vaccine last 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on October 24, 2011pediatrics.aappublications.orgDownloaded from season. The second dose should be administered at least 4 weeks after the first dose. ● Children 6 months through 8 yearsof agewhoreceivedat least 1 dose of the 2010–2011 trivalent seasonal influenza vaccine last season need only 1 dose of the 2011–2012 influenza vaccine this season. In most influenza seasons, children who received influenza vaccine for the first time the previous season but who received only 1 dose are recom- mended to receive 2 doses of vaccine in the current season, because the first vaccine dose primes the immune system, but no significant protection against disease is achieved until 1 week after the second dose. How- ever, because the vaccine strains for the 2011–2012 season are un- changed from last season, 1 dose this season coupled with the 1 dose of last season will provide adequate protection (Fig 4). Previous recom- mendations for 2 doses of vaccine will resume for seasons inwhich 1 ormore of the vaccine strains change. 7. Optimal protection is achieved through annual immunization. An- tibody titers wane to 50% of their FIGURE 1 Selected underlying medical conditions in patients hospitalized with influenza, FluSurv-NET 2010–2011. Reprinted from: Centers for Disease Control and Prevention. FluView 2010–2011 influenza season week 15 ending April 16, 2010. Available at: www.cdc.gov/flu/weekly. H1N1-like strain H3N2-like strain B-like strain 1986-'87 A/Chile/1/83 and A/Singapore/6/86 A/Christchurch/4/85- A/Mississippi/1/85 B/Ann Arbor/1/86 1987-'88 A/Singapore/6/86 A/Leningrad/360/1986 B/Ann Arbor/1/86 1988-'89 A/Singapore/6/86 A/Sichuan/2/87 B/Beijing/1/87 1989-'90 A/Singapore/6/86 A/Shanghai/11/87 B/Yamagata/16/88 1990-'91 A/Singapore/6/86 A/Guizhou/54/89 B/Yamagata/16/88 1991-'92 A/Singapore/6/86 A/Beijing/353/89 B/Yamagata/16/88 1992-'93a A/Singapore/6/86 A/Beijing/353/89 B/Yamagata/16/88 1993-'94 A/Singapore/6/86 A/Beijing/32/92 B/Panama/45/90 1994-'95 A/Singapore/6/86 A/Shangdong/9/93 B/Panama/45/90 1995-'96 A/Singapore/6/86 A/Johannesburg/33/94 B/Beijing/184/93 1996-'97 A/Singapore/6/86 A/Wuhan/359/95 B/Beijing/184/93 1997-'98 A/Bayern/7/95 A/Wuhan/359/95 B/Beijing/184/93 1998-'99 A/Beijing/262/95 A/Sydney/5/97 B/Beijing/184/93 1999-2000a A/Beijing/262/95 A/Sydney/5/97 B/Beijing/184/93 2000-'01 A/New Caledonia/20/99 A/Moscow/10/99 B/Beijing/184/93 2001-'02 A/New Caledonia/20/99 A/Moscow/10/99 B/Sichuan/379/99 2002-'03 A/New Caledonia/20/99 A/Moscow/10/99 B/Hong Kong/330/2001 2003-'04a A/New Caledonia/20/99 A/Moscow/10/99 B/Hong Kong/330/2001 2004-'05 A/New Caledonia/20/99 A/Fujian/411/2002 B/Shanghai/361/2002 2005-'06 A/New Caledonia/20/99 A/California/7/2004 B/Shanghai/361/2002 2006-'07 A/New Caledonia/20/99 A/Wisconsin/67/2005 B/Malaysia/2506/2004 2007-'08 A/Solomon Islands/3/2006 A/Wisconsin/67/2005 B/Malaysia/2506/2004 2008-'09 A/Brisbane/59/2007 A/Brisbane/10/2007 B/Florida/4/2006 2009-'10 Pandemic A/Brisbane/59/2007 A/California/07/2009 A/Brisbane/10/2007 B/Brisbane/60/2008 2010-'11 A/California/07/2009 A/Perth/16/2009 B/Brisbane/60/2008 2011-'12a A/California/07/2009 A/Perth/16/2009 B/Brisbane/60/2008 FIGURE 2 World Health Organization vaccine composition recommendations 1986 to present. a No change in influenza vaccine strains from previous influenza season. Data source: World Health Organization, Global Alert and Response. Recommendations for influenza vaccine composition. Available at: www. who.int/csr/disease/influenza/vaccinerecommendations1/en/index.html (for data from 1998 to pres- ent; previous years’ data were obtained from Weekly Epidemiologic Record). FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 128, Number 4, October 2011 3 by guest on October 24, 2011pediatrics.aappublications.orgDownloaded from original levels 6 to 12months after vaccination. Because the vaccine strains for the 2011–2012 season are unchanged from last season, a repeat dose this season is critical for maintaining protection in all populations. 8. As soon as the trivalent seasonal influenza vaccine is available lo- cally, health care personnel (HCP) should be immunized, pub- licize vaccine availability to par- ents and caregivers, and begin immunization of all children 6 months of age and older, espe- cially children at high risk of complications from influenza. HCP endorsement plays a major role in vaccine uptake. A strong correlation exists between HCP endorsement of influenza vac- cine and patient acceptance. Pro- viders should continue to offer vac- cine through the vaccine expiration date. Protective immune responses persist throughout the influenza season, which can have �1 dis- ease peak and often extends into March or later. Prompt initiation of influenza immunization and continuance of immunization throughout the influenza season, regardless of whether influenza is circulating (or has circulated) in the community, are critical com- ponents of an effective immuniza- tion strategy. This approach pro- vides ample opportunity to administer a second dose of vac- cine, becausechildrenyounger than 9 years might require 2 doses to confer optimal protection. 9. HCP, influenza campaign organiz- ers, and public health agencies should collaborate to develop im- proved strategies for planning, communication, and administra- tion of vaccines. ● Plan to make trivalent seasonal influenza vaccine easily acces- sible for all children. Examples of such action include creating walk-in influenza clinics, ex- tending office hours beyond routine times during peak vac- cination periods, considering how to immunize parents and adult caregivers at the same time in the same office setting as children, and working with other institutions (eg, schools, child care centers, and reli- gious organizations) or alterna- tive care sites, such as emer- gency departments, to expand venues for administering vac- cine while providing appropri- ate documentation of immuni- zation for the child’s medical home. ● Concerted efforts among the aforementionedgroups, plus vac- cinemanufacturers, distributors, andpayers, are also necessary to FIGURE 3 Number of 2011–2012 seasonal influenza vaccine doses for children 6 months through 8 years of age. ● This simplified approach is only possible because the 2011–2012 influenza vaccine contains the identical 3 influenza virus strains used last year in the 2010–2011 vaccine. ● Thenumber of doses to be given is determinedon thebasis of the child’s age at the timeof the first dose. FIGURE 4 Percentage of childrenwith titers greater than 1:32 during seasonswith no change in vaccine antigen. * One dose administered in the spring; the second dose administered in the fall. ** Two doses administered 4 weeks apart in the fall. (Reprinted with permission from Englund JA, Fairchok MP, Monto AS, Neuzil KM. Pediatrics. 2005;115[4]:1039–1047.) 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on October 24, 2011pediatrics.aappublications.orgDownloaded from appropriately prioritize distribu- tion to theprimarycareofficeset- ting, especiallywhen vaccine sup- plies are delayed or limited. ● Vaccine safety, effectiveness, and indications must be com- municated properly to the pub- lic. HCP should act as role mod- els by receiving influenza immunization annually and rec- ommending annual immuniza- tions to both their colleagues and patients. 10. The neuraminidase inhibitors os- eltamivir (Tamiflu [Roche Labora- tories, Nutley, NJ]) and zanamivir (Relenza [GlaxoSmithKline, Re- search Triangle Park, NC]) are the only antiviral medications rou- tinely recommended for chemo- prophylaxis or treatment during the 2011–2012 season. All strains of influenza currently anticipated to circulate are susceptible to neuraminidase inhibitors but have high rates of resistance to aman- tadine and rimantadine (Table 1). Resistance characteristics might change rapidly; clinicians should verify susceptibility information at the start of the influenza seasonand monitor it during the season through either the AAP Web site (www.aap.org or http:// aapredbook.aappublications.org/ flu) or the Centers for Disease Control and Prevention (CDC) Web site (www.cdc.gov/flu/index.htm). 11. As the 2011–2012 influenza sea- son unfolds, it is critically impor- tant for HCP to be aware of new or changing recommendations from the CDC or their local and state health departments. Up-to-date infor- mation can be found on the AAP Web site (www.aap.org or http:// aapredbook.aappublications.org/flu), through state-specific AAP chapter Web sites, or on the CDC Web site (www.cdc.gov/flu/index.htm). TRIVALENT SEASONAL INFLUENZA VACCINES Tables 2 and 3 summarize information on the 2 types of 2011–2012 trivalent seasonal influenza vaccines licensed for immunization of children and adults: injectable trivalent inactivated influenza vaccine (TIV) and intrana- sally administered live-attenuated in- fluenza vaccine (LAIV). Both vaccines contain the identical strains of influ- enza A subtypes (ie, H1N1 and H3N2) and influenza B anticipated to circulate during the 2011–2012 influenza season. TIV is an inactivated vaccine that con- tains no live virus and cannot produce a viral infection. TIV formulations are now available for intramuscular and intradermal use. The intramuscular formulation of TIV is licensed and rec- ommended for children 6 months of age and older and adults, including people with and without chronic med- ical conditions. The most common ad- verse events after administration are local injection-site pain and tender- ness. Fever might occur within 24 hours after immunization in approxi- mately 10% to 35% of children younger than 2 years but rarely in older chil- dren and adults. Mild systemic symp- toms such as nausea, lethargy, head- ache, muscle aches, and chills might occur after administration of TIV. An intradermal formulation of TIV has been licensed for the 2011–2012 sea- son for use in people 18 through 64 years of age. This method of delivery involves a microinjection with a needle 90% shorter than needles used for in- tramuscular administration. The most common adverse events are redness, induration, swelling, pain, and itching at the site of administration at a slightly higher rate than occurs with the intramuscular formulation of TIV. Headache, myalgia, and malaise might occur and tend to occur at the same rate as that with the intramuscular formulation of TIV. There is no prefer- ence for intramuscular or intradermal immunization in people 18 years of age or older; therefore,
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