Socioeconomic impact of influenza on healthy children and their families

[Recommendations of the Vaccine Advisory Committee of the Spanish Association of Pediatrics: influenza vaccination campaign 2006-2007]

The recommendations of the Spanish Association of Pediatrics on influenza vaccination in the pediatric age group for the 2006-2007 season are presented. Influenza has special characteristics in children due to the high morbidity it carries. Moreover, children constitute the most frequent source of transmission. The risk factors supporting influenza vaccination in children and the need for immunization in persons living with high-risk children are discussed. The advisability of extending vaccination in health workers, and specifically to pediatricians and medical personnel in contact with sick children is stressed. The composition of the vaccine for the 2006-2007 seasons, the schedules and dosages in children depending on age, and the contraindications to vaccination are specified. Finally, the premises required to recommend universal vaccination in young children in Spain as a strategy to reduce morbidity due to this epidemic in children and adults are discussed.

Cost-effectiveness analysis of inactivated virosomal subunit influenza vaccination in children aged 3-14 years from the provider and societal perspectives

The costs and benefits of vaccinating a theoretical cohort of 1000 preschool and school age children (3-14 years) with one dose of inactivated virosomal subunit influenza vaccine in primary health care centers of the Catalan Health Service during the fall annual health examination were compared with the current strategy of no routine vaccination. The economic analysis was carried out from the provider perspective (cost-effectiveness analysis) and from the societal perspective (cost-effectiveness and cost-benefit analysis). The time horizon of the study was established at 6 months. In the base case (cost of vaccination of euro 9.425, cost of paediatric visit plus antibiotic and antipyretic treatment of euro 42.50, cost of 1 day of hospital stay of euro 454.25, cost of the work lost by the mother to take care of her ill child of euro 29.2 and cost of 1 year of quality adjusted life year lost of euro 10,662), the vaccination does not save money from the provider perspective (net present value=euro-1460.51), but the cost-effectiveness ratios are very reasonable (euro 5.80 per episode of acute febrile respiratory process avoided and euro 18.26 per quality adjusted life year saved). From the societal perspective, the vaccination saves money (net present value=euro+7587.03) and the benefit-cost ratio is 1.80, meaning that euro 0.80 is saved per euro invested. Our study shows that vaccination of children 3-14 years old with a single dose of inactivated subunit influenza vaccine in primary health care centers during the fall annual health examination provides socioeconomic benefits to the society in addition to substantial health benefits for the child.

Safety, efficacy, and effectiveness of cold-adapted influenza vaccine-trivalent against community-acquired, culture-confirmed influenza in young children attending day care

OBJECTIVE

The goal was to evaluate the safety, tolerability, and efficacy of an investigational, refrigerator-stable formulation of live attenuated influenza vaccine (cold-adapted influenza vaccine-trivalent) against culture-confirmed influenza, acute otitis media, and effectiveness outcomes in young children in day care over 2 consecutive influenza seasons.

METHODS

Children 6 to <36 months of age who were attending day care were assigned randomly in year 1 to receive 2 doses of vaccine or placebo intranasally, 35 +/- 7 days apart. In year 2, subjects received 1 dose of the same treatment as in year 1.

RESULTS

A total of 1616 subjects (vaccine: 951 subjects; placebo: 665 subjects) in year 1 and 1090 subjects (vaccine: 640 subjects; placebo: 450 subjects) in year 2 were able to be evaluated for efficacy. The mean age at first vaccination was 23.4 +/- 7.9 months. In year 1, the overall efficacy of the vaccine against influenza subtypes similar to the vaccine was 85.4%; efficacy was 91.8% against A/H1N1 and 72.6% against B. In year 2, the overall efficacy was 88.7%; efficacy was 90.0% against H1N1, 90.3% against A/H3N2, and 81.7% against B. Efficacy against all episodes of acute otitis media associated with culture-confirmed influenza was 90.6% in year 1 and 97.0% in year 2. Runny nose or nasal discharge after dose 1 in year 1 was the only reactogenicity event that was significantly more frequent with cold-adapted influenza vaccine-trivalent (82.3%) than placebo (75.4%).

CONCLUSIONS

Cold-adapted influenza vaccine-trivalent was well tolerated and effective in preventing culture-confirmed influenza illness in children as young as 6 months of age who attended day care.

Establishing the health and economic impact of influenza vaccination within the European Union 25 countries

BACKGROUND

In 2003, the World Health Assembly (WHA) issued a resolution for prevention and control of influenza pandemics and annual epidemics, which urges the European Union 25 (EU-25) Member States to (1) establish and implement strategies to increase vaccination coverage of all people at high risk, including the elderly and people with underlying disease, with the goal of attaining vaccination coverage of the elderly population of at least 50% by 2006 and 75% by 2010; (2) to assess the disease burden and economic impact of annual influenza epidemics as a basis for framing and implementing influenza prevention policies. This resolution was reinforced by the European Union (EU), where Member States agreed to make additional efforts to improve uptake on their territory in accordance with their own recommendations and to achieve the World Health Organisation (WHO) target of 75% in high risk groups before 2010. It was also noted that the changing demographic profile of the EU population would result in an increasing number of elderly people falling within the current target groups.

OBJECTIVES

To establish the number of people who may be eligible for influenza vaccination in the EU, and estimate the costs and consequences of not vaccinating this population for five EU Member States, France, Germany, Italy, Spain, and the UK.

METHODS

A mathematical model has previously been developed, in which vaccine distribution data are combined with demographic and health economics data to model the public health consequences of influenza and possible intervention strategies. We have extended that model using specific EU-25 demographic data on populations at risk of influenza during the inter-pandemic period. For each country, the total population and age breakdown was calculated to estimate the percentage of the population that falls under the WHA recommendations. Other target groups for influenza vaccination were identified by analysing estimating the proportion of the population with respiratory or cardiovascular related diseases, diabetes, AIDS or transplantation, as well as health care professionals. Target population size and possible vaccination coverage rates across the EU-25 Member States, along with the potential cost and health consequence impact is estimated.

RESULTS

For the EU-25, it was estimated that up to 49.1% of the population (or 223.4 million people) should be vaccinated against influenza. This ranged from 41.6% in Cyprus to 56.4% in the UK. There were, on average, 174 vaccine doses distributed per 1000 population within the EU-25, which leads to an average vaccination rate of the target population of 35.4% based on current supply constraints. As a consequence, up to 144.4 million people who could be considered "at risk" may not currently be vaccinated. Implementing a 100% vaccination rate programme for all risk groups across the EU-25 would lead to an estimated reduction of number of influenza cases of 7.22 million, 1.96 million reduced PCP visits for influenza treatment, 796,743 less hospital admissions and 68,537 fewer influenza related deaths for all EU-25 countries. The implementation of a 100% vaccination rate programme for all risk groups in France, Germany, Italy, Spain and UK would require an additional 1.52 billion Euro. This would result in estimated savings of 39.45 million Euro of reduced primary care visits and further savings of 1.59 billion Euro in reduced hospitalisations respectively in these countries.

CONCLUSIONS

There is a gap between current vaccination coverage and the EU recommendations. The public health consequences of low vaccination coverage include increased morbidity, hospitalisations and mortality associated with influenza-related complications. This model is a powerful tool to: (1) support EU public health officials in implementing recommendations; (2) to visualize the need for increased vaccination rates for better influenza control; (3) the consequences of low vaccine coverage.

Effectiveness of virosomal subunit influenza vaccine in preventing influenza-related illnesses and its social and economic consequences in children aged 3–14 years: A prospective cohort study

To evaluate the effectiveness of a virosomal subunit influenza vaccine in preventing influenza-related illnesses and its social and economic consequences in children aged 3-14 years, a prospective cohort study was carried out during the 2004-2005 influenza season in 11 private pediatric clinics in the Barcelona metropolitan area. One dose of a virosomal subunit inactivated influenza vaccine (Inflexal V Berna) was given during September and October 2004 to healthy children aged 3-14 years attended in 5 of the 11 clinics. Who comprised the vaccinated cohort (n=966). The non-vaccinated cohort (n=985) was comprised of children attended in the other six clinics. Informed consent was obtained from all parents. The follow up was performed between 1 November 2004 and 31 March 2005. Using a self-administered questionnaire, information was collected from parents or guardians on any type of acute, febrile respiratory illness suffered by their children during the study period, including antibiotic use, and absence from school or work-loss of parents as a result of the illness. RT-PCR (influenza A+B+C) was carried out on pharyngeal and nasal samples obtained from children attended by pediatricians during this period in these clinics with the following symptoms: fever> or =38.5 degrees lasting at least 72h, cough or sore throat (influenza-like illness). Adjusted vaccination effectiveness was 58.6% (95% CI 49.2-66.3) in preventing acute febrile respiratory illnesses, 75.1% (95% CI 61.0-84.1) in preventing cases of influenza-like illnesses and 88.4% (95% CI 49.2-97.3) in preventing laboratory-confirmed cases of influenza A. The adjusted vaccination effectiveness in reducing antibiotic use (18.6%, 95% CI -4.2 to 3.64), absence from school (57.8%, 95% CI 47.9-65.9) and work-loss of parents (33.3%, 95% CI 8.9-51.2) in children affected by an acute febrile respiratory illness was somewhat lower. Vaccination of children aged 3-14 years in pediatric practices with one dose of virosomal subunit inactivated influenza vaccine has the potential to considerably reduce the health and social burdens caused by influenza-related illnesses.

Influenza vaccination: the paediatric perspective

Influenza in young children represents a significant problem to families and to society, as this population is most susceptible to developing complications and is also a major route of disease spread within communities. However, there is a paucity of European data for the burden of disease in children and the health benefits and cost-effectiveness of vaccination, leading to a lack of awareness by governments, authorities, healthcare professionals and parents. The experience in elderly individuals and the paediatric experience in the US may provide some guidance in developing studies that will provide evidence for the creation of guidelines and educational strategies within Europe.

Should healthy children be vaccinated against influenza? A consensus report of the Summits of Independent European Vaccination Experts

Influenza is often regarded as an illness of the elderly portion of the population because most of the excess mortality associated with influenza epidemics occurs in that age group. However, evidence derived from a large number of clinical studies carried out in different countries and various settings has clearly demonstrated that the burden of influenza is also substantial in children. The attack rates of influenza during annual epidemics are consistently highest in children, and young children are hospitalized for influenza-related illnesses at rates comparable to those for adults with high-risk conditions. Especially among children younger than 3 years of age, influenza frequently predisposes the patient to bacterial complications such as acute otitis media. Children also serve as the main transmitters of influenza in the community. A safe and effective vaccine against influenza has been available for decades, but the vaccine is rarely used even for children with high-risk conditions. Despite several existing problems related to influenza vaccination of children, the current evidence indicates that the advantages of vaccinating young children would clearly outweigh the disadvantages. Considering the total burden of influenza in children, children younger than 3 years of age should be regarded as a high-risk group for influenza, analogously with the age-based definition of high risk among persons 65 years of age or older. Annual influenza vaccination should be recommended to all children from 6 months to 3 years of age.

Influenza vaccination coverage among children with high-risk medical conditions

We evaluated influenza vaccination coverage in children with chronic disease at high risk of influenza complications, and the need for methods to increase parents' and pediatricians' knowledge of influenza and its prevention. The 5286 children aged less than 14 years attending our Emergency Department on Wednesdays and Sundays between 1 January and 30 April 2003 included 274 (5.2%) high-risk patients. The use of influenza vaccine during the previous three seasons had been very low, but significantly increased in the last season (2000-2001, 5.1%; 2001-2002, 12.9%; 2002-2003, 26.3%; p<0.001). The children with asthma or cardiac disease showed the lowest vaccination rates; their parents and primary care pediatricians had only a marginal knowledge of influenza and the benefits of its prevention. In conclusion, the delivery of influenza vaccine to children with chronic disease at high risk of influenza complications is completely inadequate, and major efforts are urgently needed to increase parents' and pediatricians' knowledge of its importance.

Impact of rapid influenza testing at triage on management of febrile infants and young children

OBJECTIVE

To determine the impact of an emergency department (ED) triage protocol for rapid influenza testing of febrile infants and children on additional diagnostic testing, ED charges and patient time in the ED.

METHODS

A trial of triage-based rapid influenza A and B testing of febrile infants and children 3 to 36 months of age presenting to an urban ED during December 2002 to March 2003 was performed. Children with a temperature of 39 degrees C or higher or history of fever 102 degrees F or higher at home were included. Those with obvious focal infection, potential immunodeficiency, and indwelling medical devices were excluded. The intervention group, tested for influenza at triage (TT) was compared with a nonintervention group consisting of those receiving usual care (SP). A subanalysis comparing influenza-positive children was performed.

RESULTS

Of 1007 eligible subjects a total of 719 (71%) patients were in the SP group and 288 in the TT group. There were significant differences in respiratory syncytial virus rapid test (RSV; 18%-7%) and chest radiographs (CXRs; 26%-20%) tests in the TT group. In addition, significant increases in obtaining a complete blood count (relative risk [RR] 12.0; 95% confidence interval [CI] 2.9-49), blood culture (RR, 12.0; 95% CI, 3.0-51.0), RSV testing (RR, 0.9.2; 95% CI, 3.4-25.0), urinalysis (RR, 5.7; 95% CI, 2.0-16.0), CXR (RR, 2.2; 95% CI, 1.04-4.5), time in the ED (195 vs 156 minutes; 95% CI, of the difference 19-60), and medical charges ($666 vs $393; 95% CI, of the difference 153-392) were seen among those testing positive for influenza in the SP group.

CONCLUSIONS

A triage protocol for rapid influenza testing for febrile infants and children appears to significantly decrease additional testing, time in the ED, and charges in children testing positive for influenza.

Vaccines for preventing influenza in healthy children

BACKGROUND

In children and adults the consequences of influenza are mainly absences from school and work, however the risk of complications is greatest in children and people over 65 years old.

OBJECTIVES

To appraise all comparative studies evaluating the effects of influenza vaccines in healthy children; assess vaccine efficacy (prevention of confirmed influenza) and effectiveness (prevention of influenza-like illness) and document adverse events associated with receiving influenza vaccines.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); OLD MEDLINE (1966 to 1969); MEDLINE (1969 to December 2004); EMBASE (1974 to December 2004); Biological Abstracts (1969 to December 2004); and Science Citation Index (1974 to December 2004). We wrote to vaccine manufacturers and a number of corresponding authors of studies in the review.

SELECTION CRITERIA

Any randomised controlled trials (RCTs), cohort and case-control studies of any influenza vaccine in healthy children under 16 years old.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

Fifty-one studies involving 263,987 children were included. Seventeen papers were translated from Russian. Fourteen RCTs and 11 cohort studies were included in the analysis of vaccine efficacy and effectiveness. From RCTs, live vaccines showed an efficacy of 79% (95% confidence interval (CI) 48% to 92%) and an effectiveness of 33% (95% CI 28% to 38%) in children older than two years compared with placebo or no intervention. Inactivated vaccines had a lower efficacy of 59% (95% CI 41% to 71%) than live vaccines but similar effectiveness: 36% (95% CI 24% to 46%). In children under two, the efficacy of inactivated vaccine was similar to placebo. Thirty-four reports containing safety outcomes were included, 22 including live vaccines, 8 inactivated vaccines and 4 both types. The most commonly presented short-term outcomes were temperature and local reactions. The variability in design of studies and presentation of data was such that meta-analysis of safety outcome data was not feasible.

AUTHORS' CONCLUSIONS

Influenza vaccines are efficacious in children older than two years but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. That no safety comparisons could be carried out emphasizes the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given recent recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as public-health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required.

The cost of influenza in Thailand

The cost of influenza in less wealthy tropical countries is needed to inform national vaccine policy decisions. Between September 2003 and August 2004, we prospectively identified hospitalized pneumonia cases and outpatients with laboratory confirmed influenza in a Thai province. Disease incidence, patient interviews, medical record reviews, and data from a national health survey were used to calculate direct and indirect costs which were extrapolated to the Thai population. Influenza was identified in 80 (11%) of 761 hospitalized pneumonia inpatients with projected annual incidence of 18-111/100,000 population. Influenza was confirmed in 23% of 1092 outpatients with an estimated annual incidence of 1420/100,000 population. Influenza was estimated to cause between US dollar 23.4 and US dollar 62.9 million in economic losses with lost productivity accounting for 56% of all costs. The burden of influenza in Thailand is greater than previously appreciated, particularly in young children and the elderly. The impact and cost-effectiveness of influenza vaccination for high-risk groups merits further investigation.

Influenza related hospital admissions in children: evidence about the burden keeps growing but the route to policy change remains uncertain

Commentary on the paper by Beard et al (see page 20)

Clinical and socio-economic impact of influenza and respiratory syncytial virus infection on healthy children and their households

This prospective study compared the clinical and socio-economic impact of laboratory-confirmed influenza and respiratory syncytial virus (RSV) infection on healthy children and their families. Among 1,520 otherwise healthy children aged< 15 years attending the Emergency Department for acute conditions other than trauma, influenza viruses and RSV were found in 234 (15.4%) and 116 (7.6%; p<0.0001) patients, respectively. The fact that influenza has a similar global clinical impact on the community to that of RSV infection, but represents a greater socio-economic burden, may contribute to broadening the acceptance of influenza vaccination.

Clinical and economic impact of influenza vaccination on healthy children aged 2-5 years

This paper reports the data concerning the net economic cost savings attributable to influenza vaccination in healthy children aged 2-5 years, and may be useful when deciding the best recommendations for the use of influenza vaccine in pediatrics. A total of 303 previously unprimed healthy children aged 2-5 years (163 males; mean age+/-S.D.: 3.22+/-2.43 years) were prospectively, blindly randomised in a 2:1 ratio to receive two doses of an inactivated, trivalent, virosome-formulated subunit influenza vaccine (Inflexal V, Berna Biotech, Berne, Switzerland) or no vaccination. The results show that influenza vaccination of healthy children aged 2-5 years substantially reduces influenza-like illnesses and related costs in the children themselves and their families. However, larger and longer running study spanning multiple seasons may be warranted before suggesting the universal vaccination of this group of subjects.

Nuevas indicaciones de la vacuna inactivada antigripal en la población infantil (2004-2005)

Several epidemiological studies have indicated that, in all countries and in distinct epidemic years, the highest rates of influenza infection (between 15% and 42%) occur in the pediatric population, especially in school-aged children. Over various influenza seasons, the rates of annual outpatient visits attributable to influenza vary from 6-29% of children. Influenza and its complications have been reported to result in a 10-30% increase in the number of antibiotic courses prescribed to children during the influenza season. Current percentages of influenza vaccination in children are very low, although the hospitalization rates for infectious complications in children under 5 years are at least equal to those observed in individuals aged more than 65 years. The reasons for these low immunization rates are unknown, but many factors could be involved, especially the need for annual revaccination. In 2003 the Advisory Committee on Immunization Practices (ACIP) recommended influenza immunization only in children at high risk for influenza complications and in those living with someone in a high-risk group. However, they encouraged vaccination of all children aged 6-23 months old. After a review of various epidemiological studies, in 2004 both the ACIP and the American Academy of Pediatrics recommended systematic immunization of all healthy children within this age group. However, both institutions advise that before the routine introduction of influenza immunization in all children aged 6-23 months old, immunization programs in high-risk children need to be implemented.

Influenza burden of illness, diagnosis, treatment, and prevention: what is the evidence in children and where are the gaps?

Influenza is a disease of global public health significance. Traditionally the emphasis has been on adult disease because of the impact of influenza related mortality in the elderly and other high risk groups. However, it is becoming increasingly better recognised that young children suffer considerable morbidity from influenza. There are also potential consequences for siblings, parents, other carers, and extended family members in terms of secondary infections and carer leave. Influenza infection in childhood could be effectively prevented through vaccination. However, the United States is the only industrialised country currently recommending universal influenza vaccination for young children (between the ages of 6 and 23 months), as opposed to vaccinating only those with high risk conditions.

Impact of human metapneumovirus in childhood: comparison with respiratory syncytial virus and influenza viruses

This study evaluated the overall impact of human metapneumovirus (hMPV) infection in 1,505 children and their households, and compared it with infections due to respiratory syncytial virus (RSV) and influenza viruses. Nasopharyngeal swabs were used at enrollment to collect specimens for the detection of hMPV, RSV, and influenza virus RNA by reverse-transcriptase polymerase chain reaction (RT-PCR). hMPV was detected in 42 children (2.8%), RSV in 143 (9.5%; P < 0.0001 vs. hMPV), and influenza viruses in 230 (15.3%; P < 0.0001 vs. hMPV). Of the 42 hMPV-positive samples, one was also positive for RSV and six for influenza viruses, for a co-infection rate of 16.7%. Clinically, hMPV was identified only in patients with acute respiratory infection, whereas RSV and influenza viruses were also detected in patients with different clinical manifestations. Symptoms with statistically significant different proportions at presentation were fever (more frequent in the hMPV- and influenza-positive children) and wheezing with bronchiolitis or asthma exacerbation (more frequent among hMPV- and RSV-positive cases). The households of the hMPV- and the influenza-positive children had significantly more illnesses, needed significantly more medical visits, received more antipyretics, and missed significantly more work or school days than those of the RSV-positive children. Results show that hMPV is an emerging cause of acute respiratory infection in childhood, and may have a significant clinical and socioeconomic impact on children and their families.

Assessment of the efficacy and effectiveness of influenza vaccines in healthy children: systematic review

BACKGROUND

We aimed to assess evidence of efficacy and effectiveness of live attenuated and inactivated influenza vaccines in children up to 16 years of age.

METHODS

We searched the Cochrane Library, MEDLINE, EMBASE Biological Abstracts, and Science Citation Index to June, 2004, in any language, and contacted vaccine manufacturers and authors of relevant studies to identify additional data. We included randomised, cohort, and case-control studies comparing efficacy of vaccines against influenza (reduction in laboratory-confirmed cases), effectiveness of vaccines against influenza-like illness (reduction in symptomatic cases), or both, with placebo or no intervention. We analysed the following outcomes: influenza, influenza-like illness, admissions, school absences, complications, and secondary transmission.

FINDINGS

We included 14 randomised controlled trials, eight cohort studies, one case-control study, and one randomised controlled trial of intraepidemic use of the vaccines. Live attenuated influenza vaccines had 79% efficacy and 38% effectiveness in children older than 2 years compared with placebo or no immunisation. Inactivated vaccines had lower efficacy (65%) than live attenuated vaccines, and in children aged 2 years or younger they had similar effects to placebo. Effectiveness of inactivated vaccines was about 28% in children older than 2 years. Vaccines were effective in reducing long school absences (relative risk 0.14 [95% CI 0.07-0.27]). Studies assessing the effects of vaccines against secondary cases, lower-respiratory tract disease, acute otitis media, and hospital stay suggested no difference with placebo or standard care, but lacked statistical power.

INTERPRETATION

Influenza vaccines (especially two-dose live attenuated vaccines) are efficacious in children older than 2 years. Efficacy and effectiveness of the vaccines differed strikingly. Only two small studies assessed the effects of influenza vaccines on hospital admissions and no studies assessed reductions in mortality, serious complications, and community transmission of influenza. If influenza immunisation in children is to be recommended as public-health policy, large-scale studies assessing such important outcomes and undertaking direct comparisons of vaccines are urgently needed.

Immunizations, neonatal jaundice, and animal-induced injuries

PURPOSE OF REVIEW

Published studies during the past year about three topics important to the pediatric clinician-- immunizations, neonatal jaundice, and animal-induced injuries-are concisely reviewed.

RECENT FINDINGS

Recent updates regarding vaccines including the questionable link with autism, implementation of universal influenza vaccination for young children, the efficacy of pneumococcal vaccine against invasive disease, and new information on pertussis, varicella, hepatitis A, hepatitis B, measles, and rotavirus vaccination are discussed. No association between measles/mumps/rubella vaccine or thimerosal-containing pertussis vaccine and autism is evident. Universal influenza vaccination for children 6 to 23 months of age will be recommended for the 2004-2005 flu season, and this implementation should reduce significant school absenteeism as well as complications seen last year including encephalopathy, seizures, respiratory failure, and pneumonia. Pneumococcal vaccine significantly reduces rates of invasive pneumococcal vaccine in healthy and HIV-infected children, although it does not appear to greatly affect otitis media rates. A reduction in post-vaccine febrile seizures appears to be present since the introduction of acellular pertussis vaccine. Multiple outbreaks in varicella have been reported since the introduction of the varicella vaccine, and a booster vaccination may be necessary in the future. Methods for detecting and preventing severe neonatal hyperbilirubinemia are reviewed, as well as anticipated recommendations from the American Academy of Pediatrics for the detection and management of hyperbilirubinemia. High bilirubin levels in preterm infants may result in hearing dysfunction and developmental impairment. The American Academy of Pediatrics has recommended a higher level of monitoring for newborn jaundice and treatment of hyperbilirubinemia in an effort to prevent kernicterus and sequelae from elevated bilirubin levels, including post-discharge follow-up appointment by day 3 to 5 of age. Dog bites in children with resultant post-traumatic stress disorder, rabies, and salmonellosis from pet reptiles in the home are also addressed. Clinicians need to be aware of the risk for rabies bites, need to recognize that dog bites in children appear to cause post-traumatic stress disorder in more than half of cases, and need to know how to educate patients on how to prevent salmonellosis from pet reptiles and amphibians.

SUMMARY

Progress has been made in immunizations, especially immunization for influenza, pneumonia, and pertussis. It is recommended that monitoring for neonatal hyperbilirubinemia be more thorough to prevent the consequences of this condition. Rabies, post-traumatic stress disorder from dog bites, and salmonellosis associated with pet reptiles constitute an important area for patient education.

Features of patients with influenza virus infection examined in the emergency department of a university hospital in north-western Japan

We aimed to determine if there were any changes in the clinical features of patients infected with influenza during an influenza epidemic in north-western Japan. We retrospectively obtained data on influenza-infected patients from an electronic database set up in the emergency department. Patients were examined in the Department of Emergency Medicine, Kanazawa Medical University in 2001, 2002 or 2003. The information collected included age, sex, time of visiting the emergency department, visiting method, grade of emergency, where they were when their symptoms started to develop, influenza-related complication(s) and outcome. The retrospective data collected for the 3 years analysed (2001-2003) were similar despite the influenza epidemic in the winter of 2002/2003. These results allow us to estimate the influenza-related total medical costs and total work burden for staff in the emergency department of a university hospital during any future influenza epidemics.

Are we ready for universal influenza vaccination in paediatrics?

Recent studies have suggested that paediatric influenza is a greater medical problem than usually thought because it can cause excess hospitalisations, medical visits, and antibiotic prescriptions even in healthy children, especially those under 2 years. Furthermore, influenza in otherwise healthy children may have substantial socioeconomic consequences for the children and their household contacts. These findings have led many experts to encourage the more widespread use of influenza vaccine in childhood. Although the immunogenicity of the available vaccines is good and they are safe, well-tolerated, and highly effective in preventing influenza and its complications, economic data support universal vaccination only when indirect effectiveness is considered. However, infants aged 6-23 months, children with recurrent acute otitis media or respiratory-tract infections, and healthy children attending day-care centres or elementary schools should be included among the paediatric groups requiring vaccination.