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
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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
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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
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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
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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
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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,