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Influenza Vaccine: An Updated Position Statement of the Society for Adolescent Health and Medicine

  • Society for Adolescent Health and Medicine
      Globally each year, 5%–10% of adults and 20%–30% of children experience influenza infections [
      Vaccines against influenza WHO position paper—November 2012.
      ]. During the 2009–2010 H1N1 influenza pandemic, these rates were higher and children and adolescents were disproportionately affected [
      • Shrestha S.S.
      • Swerdlow D.L.
      • Borse R.H.
      • et al.
      Estimating the burden of 2009 pandemic influenza A (H1N1) in the United States (April 2009-April 2010).
      ]. Specifically, in the United States this pandemic was estimated to have caused 86,000 hospitalizations and 1,280 deaths among children 0–17 years of age [
      • Shrestha S.S.
      • Swerdlow D.L.
      • Borse R.H.
      • et al.
      Estimating the burden of 2009 pandemic influenza A (H1N1) in the United States (April 2009-April 2010).
      ]. Worldwide, it is estimated that there were 44,500 deaths among youth 0–17 years attributable to pandemic influenza infection [
      • Dawood F.S.
      • Iuliano A.D.
      • Reed C.
      • et al.
      Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: A modelling study.
      ].
      Most adolescents with influenza experience a self-limited illness characterized by fever, cough, headache, sore throat, and body aches. However, among adolescents who are pregnant or morbidly obese, as well as those with chronic medical problems, including asthma and diabetes, influenza can result in a more severe disease course. In addition, school-aged children and adolescents serve as reservoirs for spreading influenza within their communities. The economic burden of influenza infection (during pandemic and non-pandemic years) has been substantial owing to days missed from school, parental absenteeism from work, and costs associated with over-the-counter medications, clinician visits, and hospitalizations. Furthermore, for young adults, other important benefits of influenza vaccination include preventing absenteeism from college, training, and work.
      Initially, influenza vaccination policy used a targeted approach, focusing on populations at higher risk for influenza-related morbidity and mortality. However, these strategies were not effective in preventing widespread disease. In 2008, the Advisory Committee on Immunization Practices (ACIP) recommended that all adolescents up through age 18 years receive annual influenza vaccination. Starting in 2009, these recommendations were further expanded to include vaccination of everyone ≥ 6 months of age [
      Prevention and control of seasonal influenza with vaccines.
      ]. The Society for Adolescent Health and Medicine (SAHM) suggests that health care providers adhere to their country-specific policies or the broader World Health Organization guidelines regarding influenza [
      Vaccines against influenza WHO position paper—November 2012.
      ]. SAHM strongly supports the broad ACIP recommendations and urges all United States–based providers to recommend and offer yearly influenza immunization to all adolescent and young adult patients before and throughout the influenza season. In addition, SAHM strongly supports vaccination of health care workers to further prevent transmission and protect vulnerable populations.
      Vaccination remains the most effective method for reducing influenza-related illness and outbreaks, even in years in which the vaccine is not well matched to circulating viral strains [
      • Neuzil K.M.
      • Dupont W.D.
      • Wright P.F.
      • Edwards K.M.
      Efficacy of inactivated and cold-adapted vaccines against influenza A infection, 1985 to 1990: The pediatric experience.
      ,
      • Belshe R.B.
      • Nichol K.L.
      • Black S.B.
      • et al.
      Safety, efficacy, and effectiveness of live, attenuated, cold-adapted influenza vaccine in an indicated population aged 5-49 years.
      ,
      • Treanor J.J.
      • Talbot H.K.
      • Ohmit S.E.
      • et al.
      Effectiveness of seasonal influenza vaccines in the United States during a season with circulation of all three vaccine strains.
      ]. Both inactivated and live attenuated influenza vaccines are licensed and available for use in adolescents and young adults. However, only the inactivated influenza vaccine is recommended for pregnant adolescents and young adults, a high-priority group for vaccination efforts. The inactivated vaccine is given primarily as an intramuscular injection and can be administered to all adolescents and young adults, with the exception of those with a previous, severe allergic reaction to the influenza vaccine. The Advisory Committee on Immunization Practices has modified recommendations regarding the safety of influenza vaccines for patients with egg allergies [
      Prevention and control of seasonal influenza with vaccines.
      ]. These guidelines should be reviewed before administering the inactivated influenza vaccine to a patient with egg allergy.
      Over time, several new influenza vaccines have been developed. In 2013, quadrivalent inactivated and live attenuated influenza vaccines were introduced. The quadrivalent vaccines provide protection against two influenza A strains and two influenza B strains. An intradermal inactivated influenza vaccine was introduced in 2011 that uses a small needle, and thus may be preferred by patients ≥18 years of age who are needle-phobic. The live, attenuated vaccine is administered intranasally and is ideal for youth who do not want an injection. Use of the live attenuated influenza vaccine should be limited to healthy, nonpregnant adolescents and young adults. Please review ACIP guidelines for the full list of indications and contraindications related to specific influenza vaccines, because these may change over time [
      Prevention and control of seasonal influenza with vaccines.
      ].
      To improve influenza immunization rates among teens, the Society for Adolescent Health and Medicine strongly encourages the following strategies:
      • The use of standing orders for influenza vaccine
      • Vaccine reminder/recall systems
      • The use of alternative sites for immunization delivery, including schools
      • Offering extended office hours during the influenza season
      Along with administering the influenza vaccine, clinical providers should remind patients and their parents or guardians that washing hands, staying home when ill, and covering the nose and mouth with a tissue when coughing or sneezing are important ways to reduce further the spread of influenza. Please consult http://www.cdc.gov for the most current information regarding the appropriate use of antiviral medications and to track influenza activity. For additional information regarding implementation of adolescent immunizations, please see “Adolescent Immunizations: A Position Paper of the Society for Adolescent Medicine” http://www.adolescenthealth.org/PositionPaper_Immunization.pdf.

      Author Disclosures

      Amy B. Middleman, M.D., M.S.Ed., M.P.H. is Principal Investigator on a public demonstration grant from the Society for Adolescent Health and Medicine that originates from Merck. In addition, Dr. Middleman has a subcontract on an education grant that SAHM has received from Novartis . Vaughn I. Rickert, Psy.D. has research funding and serves as a member of the United States Human Papillomavirus Advisory Board for Merck and Company, Inc. In addition, Dr. Rickert has served as a domestic and international member of the Adolescent Health and Wellness Advisory Board for Pfizer, Inc. Gregory D. Zimet, Ph.D. has been a co-investigator on investigator-initiated grants funded by Merck & Co., Inc. related to human papillomavirus vaccination. In addition, Dr. Zimet has been the recipient of an unrestricted cervical cancer prevention program development grant from GlaxoSmithKline.
      Prepared by:
      Elyse Olshen Kharbanda, M.D., M.P.H.
      HealthPartners Institute for Education and Research, Minneapolis, Minnesota
      Lisa S. Ipp, M.D.
      Weill Cornell Medical College, New York, New York
      Jennifer Maehr, M.D.
      Maryland Department of Juvenile Services, Baltimore, Maryland
      Amy B. Middleman, M.D., M.S.Ed., M.P.H.
      Baylor College of Medicine, Houston, Texas
      Vaughn I. Rickert, Psy.D.
      Indiana University School of Medicine, Indianapolis, Indiana
      Gregory D. Zimet, Ph.D.
      Indiana University School of Medicine, Indianapolis, Indiana

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