Get Ready for Seasonal & Pandemic Flu: Strategies for Head Start & Child Care
Hello. Good morning, everyone. My name is Robin Yu and I am the Program Assistant for the National Center on Early Childhood Health and Wellness. I am pleased to welcome you to today's webinar. Before we begin the presentation, I have some announcements for you. All the participants will be muted throughout the presentation portion of the webinar. There is a slide presentation being shown through the webinar system.
If you have a technical question, please type in the top box on the right corner of your screen. There's a lot to cover within the next hour and a half. You may submit your questions at any time. We will answer them at the end of the webinar. The survey for feedback and instructions for your certificate will be sent to your email a couple days after the webinar. And we do want to remind you that the webinar is being recorded, and an archive version, along with the slides will be available later.
Now I'll turn it over to Dr. Shope and Dr. Munoz for the presentation.
OK. Good morning. My name is Flor Munoz and I will be discussing with you the initial part of this presentation. Our topic today is, Get Ready for Seasonal and Pandemic Flu, Strategies for Head Start and Child Care. And I am pleased to share this presentation with Dr. Timothy Shope.
The objectives of our webinar today is to update you on recommendations for influenza season, prevention and treatment of influenza, to emphasize the importance of universal immunization in everyone in child care and school, to share the strategies that we use in early care and education setting to prevent and control influenza spread. And also we will have the opportunity, towards the end, to review the importance of influenza pandemic preparedness.
So starting with our initial, just overview about influenza, this is a slide that shows you the 2017, 2018 influenza season, so the one that we just had last year. And it illustrates, based on the CDC reporting, how influenza A and B viruses can cause annual epidemics and really spread throughout the country so that you have different levels of activity as the season begins. And certainly at the time of the peak of this season, which last year it was around December, so this time of the year, you would have very high levels of activity throughout the country.
Last year in particular, as you can see, we had a predominance of influenza A H3N2 as the main cause of influenza disease in the United States. The reason that we worry about influenza is that annually, you can see how about 10% to 20% of the population can potentially get infected with influenza and have influenza illness. That translates into about 50 to 60 million people in the country, an d then results in millions of visits to the doctor, as well as hospitalization that average, depending on the season, between 100,000 to 800,000. And then mortality associated with influenza, that unfortunately occurs every year, and some years can be worse than others.
Last year, as a matter of fact, was deemed to be one of the highest severity seasons in the United States, even more severe than what we saw during the influenza pandemic of 2009, 2010. This is based on CDC criteria that consider the number of outpatient visits, the number of hospitalizations, and the number of reported deaths associated with influenza. And you can see that the reason this was a high severity season is because for all age groups-- so including children, adults, and older adults depicted in the graph and different colors on the bars-- they achieved high severity.
In the end, there were about 900,000 hospitalizations associated with influenza. And there were about 80,000 deaths associated with influenza, among which about 200 were pediatric deaths. So this is one reason why, of course, we do need to consider influenza prevention every year and planning for influenza prevention.
But let me ask you a quick question here in terms of describing influenza. If you were to describe what influenza presentation is common, would you say that it-- and please, if you have the opportunity to do this in your computer, you can go ahead and start answering now. Does it present with cough, chills, spots on the throat, red, itchy skin rash, chills, and headache? Does it present with headache, fever, vomiting, and diarrhea, or is it more commonly a cough, fever, sore throat and body aches illness?
So looking at the responses as they're coming through, everyone is doing really well. The answer to this question, as most of you have correct, 93%, is that the influenza presents usually as a febrile illness with cough. Those are the two main symptoms. Many times you do have a sore throat, and it's characteristically a systemic illness where you will have myalgias, headache, and other symptoms of systemic disease.
Influenza is actually a respiratory illness, so it infects initially the nose, the throat, but it can definitely go into the lungs. And as we mentioned, you will have systemic symptoms associated with it. It is more serious than the common cold. And as you can see, some of the additional symptoms you can have-- it wears you down. You have less energy than usual. You might have gastrointestinal symptoms with abdominal pain, nausea and vomiting, as well as diarrhea, especially in young children, and even other symptoms associated with, in some cases, encephalitis or mental status changes, which could be purely associated with influenza.
These are some of the complications that we see. And focusing in children, given the interest of this group, you know that influenza in and of itself can be a cause of pneumonia. So influenza pneumonia can present a lot like what you see with a common bacterial pneumonia in that you will have a sudden onset of fever, chills, and the other stomach symptoms-- headache, malaise, myalgaia, cough, and then sore throat and other symptoms. And you could have clearly an abnormal chest x-ray in some cases.
The common complications of influenza in children are otitis mydia, croup, bronchiolitis-type symptoms, and then again, pneumonia. But one of the main concerns that we have in cases of influenza in general is that you can have a secondary bacterial infection. And this is really the main cause of mortality for influenza every year.
Staph aureus, strep pneumonia, group A streptococcus, and other common bacterial pathogens, many of them that are colonizing the respiratory tract, find their way into the lungs and into the bloodstream causing sepsis and pneumonia, and really may cause a very prompt deterioration after a case of influenza occurs. And so this is unfortunately one of the main concerns that we have is the rapid progression after an influenza infection due to the bacterial infections is really a very important cause of death.
We also have complications associated with an inflammatory process. So myositis, myocarditis. As I mentioned before, encephalopathies and seizures. That could be either associated with fever-- so febrile seizures or seizures associated with an encephalitis type picture. We've seen post-influenza Guillain-Barre syndrome, sepsis-like syndrome in neonates, and then exacerbation of chronic lung and heart disease in other patients.
We know as well that we should not use aspirin during the flu season because if you have aspirin treatment in influenza, that could cause Reye syndrome. It's an old type of disease we don't see very much because we don't use aspirin. And certainly as we mentioned, mortality is clearly associated with flu.
So this is just a quick summary. A common cold is not the same as influenza. And so in addition to the fact that influenza is a more intense illness with more systemic symptoms, as we mentioned, we also know that unlike other common cold viruses, the flu can give you a higher risk of hospitalization and death. But we also have vaccines and treatments available, as well as testing available for it.
So what about the children and the groups of patients or subjects that you work with? So we're talking about young children here. And how contagious can they be? So let's remember that influenza virus is actually a very, very easily transmitted virus. This is because the incubation period is very short, so that it's about one to four days, but on average is about two days.
So when somebody starts having symptoms of the flu, unfortunately they've already had a chance to infect other people because the contagious period begins before the symptoms appear. This is because once you have the virus in your respiratory tract, in your nose and throat, it begins replicating and it can be shed even before you start having that little sore throat or you start coughing or you start having the fever.
And then you have shedding of the virus that can last up to a week, especially in young children, maybe a little bit shorter in older adults. But the viral shedding can be several days. And as long as there is shedding, there will be a risk for contagiousness in transmitting the virus. So children are really good at that.
So both adults and children can spread the virus when they're infected, but not showing symptoms yet. So that's that incubation period. And also when symptoms are present, and even when they're recovering-- even when they feel better but the viral shedding can continue. It's very important to keep that in mind.
And this is one comment that I would like to make is that you see children really have a very central role, a pivotal role in the transmission of influenza, not just within childcare, pre-school, and school settings, but also in families, so that they bring the illness to other family members, to other children, and then that is spread throughout the community with children really being some of the primary vectors. They're the first ones to get sick. They're the ones who are more likely to be exposed and bring the infection to the community.
So why is that? Well, we know that young children have immune systems that in many cases are still trying to figure out how to fight these infections. So they're more prone, sometimes, in early life to get new viruses. They do have many opportunities to share, as we know, especially in our group care settings.
And we don't always have the best hygiene or etiquette after of being infected and being ill, regarding just the common things. It's very hard even for adults to do, but especially for young children to remember to cover their cough and to do it correctly, and then to be able to wash their hands and not be touching their eyes and nose and mouth before playing or touching other children and other things they play with.
So essential then also to remember, they might be too young to be vaccinated. This is especially true for those under six months of age. And then many times we don't stay home. And so we can have many opportunities to share this virus.
I do want to mention to you that among children in general, who is at high risk for complications of influenza? So unlike adults, in this graph that is put out by the CDC, you see that adults who are depicted in the blue bars tend to have underlying medical conditions to have complications from influenza. Either [INAUDIBLE] disease, metabolic disorders like diabetes or obesity are common, as well as chronic lung disease, such as asthma.
But for children, who are shown here in green, the majority of them are previously healthy, so that about 50% of children every year who are hospitalized with influenza actually have no underlying medical conditions. And that's important to know as well when we're thinking about prevention.
Now among those who do have medical underlying conditions, you see that asthma-- so chronic lung diseases remain important, as well as neurologic disorders. So young children with any seizure disorder or cerebral palsy, anything that does not allow them to manage their secretions very well is at risk, as well as any other type of chronic lung disease.
The mortality associated with influenza in children is concerning. Of course any one death that could be prevented is an important death to prevent. But the numbers change year to year. And these are influenza-associated pediatric deaths. You see that during the 2017, 2018 season, the number reported to the CDC was about 185.
And every year, I would say on average there would be at least 100 deaths associated with influenza. The number already for this season, 2018, 2019-- you see we've already had some mortality associated with flu-- about five reported deaths so far. And keeping in mind that, as you will see, many of these deaths occur after hospitalization.
And we've already seen that hospitalization in children is not necessarily associated or complications there are not necessarily associated with underlying conditions, but rather healthy children. We do need to keep in mind that vaccinations-- so prevention is very important, because this is a vaccine-preventable outcome-- the mortality associated with influenza.
This is the tally of those deaths that occurred during the 2017, '18 season, just to emphasize the fact that both influenza A and B can cause mortality. Last year we had mostly aged three and two. And you can see that both H3N2 and H1N1-- so both influenza A viruses were associated with about 60% of the deaths. This year it's looking like we're having mostly A H1N1 so far, but it might be too early to know. And we'll have to just follow what the CDC shows us.
Influenza B can also be associated with mortality. And these are young children with a mean age of seven years, ranging from eight weeks to 17 years of age. You see that 2/3 almost died after admission to the hospital, and that half of them were not having any underlying conditions. The important message as well is that 78%-- so more than 2/3 were not vaccinated, almost 80% not vaccinated.
So this is a message that I would like to bring to all. And we'll review the recommendations in a moment. But vaccination is indeed the most important tool for influenza prevention that we have at our hands. The recommendations for influenza vaccine for 2018, 2019 are supported by various organizations. You have the American Academy of Pediatrics, the CDC with their ACIP group, the American Academy of Family Practitioners, and ACOG among others.
And we have a universal recommendation in the United States, so that everyone, starting at six months of age should be vaccinated. It's only children less than six months who could not receive the vaccine because we don't have licensed vaccines for them yet.
There are special populations that we do need to reach out to, and you can see here, it's certainly based on age, independently from underlying medical conditions. If you have children under five and persons over 65, they are going to be at greater risk of complications and mortality. So they need to be vaccinated.
Pregnant women, they do have more complications towards the end of gestation. So the third trimester is a high risk period, so they need to be vaccinated. And then at the center you have the list of various underlying medical conditions, among which we've already emphasized the importance of chronic lung diseases, including asthma, cardiovascular disease, but also those patients that have weakened immune systems for many reasons-- diabetes, hemoglobinopathies, and chronic renal neuromuscular diseases.
And here we have the healthy person now. And also, anybody who is in contact with these populations should also be vaccinated, not just for themselves, but also to protect those around them.
The recommendations for this year, in terms of [INAUDIBLE] dates-- we don't really have too many. Clearly for children this year and for the general population who is healthy, one of the updates is that both inactivated influenza vaccine-- so the IIV, given as a shot in the muscle, or the LAIV, which the alive attenuated influenza vaccine given as a nasal spray in the nose can be used in the 2018 and '19 season.
This is different from the last two seasons where the live intra-nasal vaccine was not utilized based on concerns for its effectiveness, especially young children. But as you can see, the LAIV can be used, although the American Academy of Pediatrics prefers that the flu shot is given as the primary vaccination for children, and that the live vaccine is used only for those children who are healthy, so who meet indications and who would otherwise not be receiving their flu shot.
There is no preference for either trivalent or quadrivalent vaccines. So we have both types and both are approved for administration. And really among contraindications for all the vaccines, regardless of which type it is, is having a severe allergic reaction to a component of the vaccine. We'll talk a little bit about the egg allergy in a second.
The precautions-- if you have a acute febrile illness you could delay so that you have a good immune response after the illness has resolved. And in some cases, history of Guillain-Barre syndrome could be a precaution to a vaccination if it's been associated in the past with the vaccine, not with the illness.
The rationale for the updated recommendations for influenza vaccine, in terms of the utilization of the live vaccine, which is different this year from before were published in two articles, one in the AAP News by the Committee of Infectious Diseases of the American Academy of Pediatrics, and then one in the MMWR Report by the ACIP.
And we have really no differences this year in terms of trivalent versus quadrivalent, as I mentioned. This is a list of just the different strains that are included, to indicate that the A H1N1 component of the vaccine is the same. But we have a new A H3N2 virus in the vaccine, and also a new B virus on the Victoria lineage. Those are the ones that change from last season.
All trivalent vaccines and all quadrivalent vaccines include these three strains. But quadrivalent vaccines will add one more, which is the B Yamagata. As you know with having both B's in the vaccine, you decrease the risk of miss the circulating B virus.
And I just wanted to share with you this table, which you can refer to the CDC or different other sources like the vaccination schedules at the CDC website and ACIP website to look at specific products. But this is a summary. We have about 10 different types of vaccines for influenza this year in the United States, but they all have different recommendations in terms of usage based on age and the type of vaccine it is.
So the one that we use the most is the quadrivalent inactivated vaccine, so IIV4. This is still an egg-based vaccine, meaning that the virus it is used to produce the vaccine is grown in eggs. And there are four products of this vaccine that have a presentation of pre-filled syringes that have 0.25 or 0.5 ml or multi-dose vials. These vaccines-- three of them are licensed and approved for use at six months of age and older, and one of them for children five years of age and older.
Probably the one update that I would like to share with you about this is that of these four products that have the pre-filled syringes, three of them are 0.5 ml and one is 0.25, which is the dose-- 0.25 is the dose that we would recommend for children six months to 36 months of age. However, the 0.5 is also recommended for children six months to 36 months of age for those specific products. So young children might be getting one of the two this year. And there's no preference for either one.
Other quadrivalent vaccines-- there is a cell culture-based vaccine that also comes in pre-filled syringes and multi-dose, only for four years and up. That can be an option as well. But the recombinant product is only available for adults, so 18 and up. As you can see, there's only one product of trivalent inactivated vaccine. And that is only approved for five years and up-- egg-based.
And then the high dose and the adjuvanted vaccines, which are trivalent still, are only for people over 65-years-of-age. And they can be used. So certainly advantages with using adjuvanted and high dose vaccine in an older population are such that they do have a better protection. And so those are the ones recommended for that age group. And then finally the quadrivalent live vaccine that is a quadrivalent, only for two to 49-years-of-age who are previously healthy, given as an intra-nasal spray.
Now I'm going to just briefly mentioned the effectiveness of the flu vaccines. As you know, we have concerns or questions every year regarding how effective the vaccine could be. However, we know that there is inherent variability on the effectiveness. The effectiveness means how well the vaccine will prevent medically attended influenza illness.
And for that we need to make sure that there is a good match between the vaccine strain and the circulating strain in the community. We have seen that the health status of the person can affect the effectiveness. So you have different responses, if you are healthy versus if you have underlying medical conditions. And that age also affects that, so that young children or older adults can have lower effectiveness as well, because they don't respond as well to the vaccine.
And then finally the timing of vaccination in relation to this season-- this is why it's recommended to start vaccinating early and to complete vaccination before influenza circulates because the effectiveness will decrease once the season has already started. And there is a lag of time needed for the vaccine to be immunogenic and protective.
So as you can see in this table, in a given year, the effectiveness can vary from as low as 10% in one year to as high as, you know, 60%, 70%, depending on the year and the population. Probably the most important point I want to make here is that it is very critical to understand that this is for medically attended illness, and that even if sometimes you do not get full protection against getting the flu, you will have other good effects and beneficial effects of vaccination.
This is shown in this particular slide where you have a summary of two important papers, one regarding prevention of ICU hospitalization in children, in vaccinated children compared to unvaccinated.
So this study shows that among cases that were admitted in the ICU that have influenza versus other patients who were admitted to the ICU with influenza-- and you compare their vaccination status, also comparing with community controls-- this is old children-- among 21 pediatric ICUs in the United States for 2010 to 2012, vaccinated children were 74% or 82% less likely to be admitted to the ICU, meaning having complications from influenza compared to other PICU children or community controls that were not vaccinated.
And so a very important message is that you can prevent severity of influenza through vaccination. Important though that for those children who need two doses, if they only receive one, that is not protective.
And then the second manuscript, the second publication that came out that is really relevant is also protection against mortality. So this looked, again, at influenza associated deaths among children up to 17-years-of-age and compared those who received vaccines versus those who didn't in a survey cohort. And the protection in this case was 65% against death. So that is true for children with high risk conditions about 50% and those without, about 65%. So prevention of complications and mortality is really one of the goals of vaccination.
All right. So a quick second quiz to move on. If you want to start in answering the quiz, as I read you the options. In terms of doses, you have an 18-month-old Jill who received two doses of the flu vaccine last year. How many doses of the flu does she need for this season? And that would be zero, one, two, given two weeks apart, or two given at least four weeks apart.
This is wonderful. I can see everyone's responses already. And we will proceed with the answer, which is one dose. OK. So 95% of you responded correctly. I will talk a little bit about that. So I'm sure most of you take care of children, because you know the answer to this question. And that is children six months to eight years.
So the younger children, they do have a lower immune responses to the influenza vaccine, so that indeed if one dose is given, they might reach a certain level of protection in terms of antibody levels and duration of protection that might not be sufficient. And so for them, two doses are recommended the first time they are ever vaccinated, and also when they have incomplete vaccination.
So for this year, you need to look at their status based on whether they have received any vaccine before July 1, 2018. If they received at least two or more total doses-- it doesn't have to be in the same year or in sequential years-- if they can receive at least two doses before July 1, 2018, they only need one dose, which is the answer you gave us. And then if you don't have that or you don't know, then two doses are needed with an interval of four weeks. This is really to ensure [INAUDIBLE].
And when should we get vaccinated? As I mentioned before, as soon as the vaccine is available, but certainly the ACIP and AAP recommendations are ideally by end of October, because, especially for young children, you need to get those two doses in. And as we have seen, especially this year, we've already started to have a few sporadic cases of influenza in November and December.
So the idea is to be protected before the flu season, and then continuing to vaccinate through the season, which tends to peak usually in February. But the reason we continue to vaccinate is because there could be a circulation of more than one strain, and then the vaccine could protect you against other strains as well.
Quiz number three-- in terms of recommendations for given or not given the vaccine. So for whom is influenza vaccine not recommended? A, health care personnel, B, pregnant women, C, women who are breastfeeding, D, infants under six months, E, household contacts of those under five or F, household contacts with children with high risk conditions?
So the intention of this is for you to recognize high risk conditions, right. And this is not a difficult question since we've talked about universal vaccination. So I can see already that pretty much almost 97% of you have responded. The correct answer is infants under six months of age because we don't have a vaccine for them. Everybody else in this group should be vaccinated.
So I have another question about usage of the vaccine. And this is to make the point about allergies. So in this case you have a three-year-old Jack who comes to get his flu vaccine, but he's allergic to eggs. And I've heard that the vaccine is made in eggs.
So what should you tell them about egg allergies? Should you say that actually Jack should not get the flu shot because of his egg allergy? Or he should only get a flu shot that is egg-free? You know we have recombinant and we have other egg-cell-based vaccines now. Or do you want to tell them that he should get the flu shot because egg allergic children can get it like any other routine vaccine? Or should you say that he can receive the flu shot, but it must be given by an allergist.
All right. This one is probably a little bit more tricky, and I can see some of you are already logging in their responses. The recommendation has changed in the last couple of years. So as you know we were concerned in the past of egg allergy and there was a specific question asked about egg allergy. And those that did have severe reactions would have to be referred to an allergist to get vaccinated.
However, the correct answer, as 2/3 of you have a selected, is that just because they have egg allergy is not a contraindication to get vaccine. Children with egg allergy can get routine influenza vaccine like any other vaccine. And this is based on evidence, actually. There was a collaboration and work done between the American Academy of Pediatrics and American Academy of Allergy and Immunology where several studies, a total of 28 studies were done and reviewed. And that included 4,300 egg allergic subjects, many of them, as you can see, over 600 with severe egg allergies, and who had received influenza vaccine.
And then you could see that even in those with confirmed allergies and severe allergies, there were no serious allergic reactions associated with influenza vaccine administration. So indeed, the recommendation was changed. And AAP now says that, as you can see, as a policy recommendation, all children with egg allergies can receive the influenza vaccine with no special precautions than those recommended for routine vaccines.
Of course it's important to ask about any reactions to previous vaccinations, just like you do with any vaccines. And most facilities-- and actually all facilities who will give vaccines should be ready to respond to any allergic reaction to any component of the vaccine. And so that is true now for influenza.
OK. So now almost wrapping up, the cocooning-- so the fact that we vaccinate everybody to protect young children, especially those under six months of age, but also young children who, even after they get one dose, might not be fully protected enough [INAUDIBLE] two doses have lower protection than adults. Does that make sense?
And the strategy here is that by vaccinating ourselves, of the caregivers, those that take care of young children and who we ourselves could get sick, if we get vaccinated we have fewer infections. And that means that we have a lower risk of exposing young children that we take care of to influenza. And that results in fewer infections in children. So that is really the goal of the community immunity, if you will.
And then if you look at some polls, and some of what the public perceives, in terms of health care providers and child care providers, regarding vaccination for influenza, I think there's very good information out there. And so most people, based on this study, more than 90% think that nurses, doctors, and child care providers-- actually we have an obligation to be vaccinated to protect their children.
I want to finish by just giving you a brief update regarding the treatment of influenza, because we do have a couple of very, very interesting and exciting findings. Just as a brief summary, remember that once someone actually gets the flu, and especially children, we don't necessarily need laboratory confirmation of the flu if we know that there is influenza in the community.
And clinically children or patients have fever, illness, with cough and the very typical presentation. And that there are data, in terms of prospective studies, but also for observational studies showing that treating influenza does shorten the duration of fever and symptoms. It can also reduce the complications of influenza, reduce the duration of hospitalization in children, and also the risk of death in those adults who are hospitalized.
So the recommendation from the CDC and the American Academy is that we should treat-- so offer treatment as soon as possible to anybody who is hospitalized for suspected or confirmed influenza, anyone who has severe, complicated, or progressive illness from influenza, and those with high risk conditions. But we can certainly also consider treatment for any child who has suspected or confirmed influenza, and especially if there are high risk people at home.
And then the quick updates are related to the fact that we have now three neuraminidase inhibitors. In addition to the oseltamivir, which is the oral treatment that we give over five days for young children even to any age, we can also use it for prophylaxis. We don't use too much zanamivir, but it's available. The reason is because it's inhaled, and it's not very easy for young children, but seven years and older can do it. And it also can have a little bit of wheezing side effects reactive airway disease side effects for people with chronic lung disease.
But the new one is called peramivir. And it also works against influenza A and B like the others. And it's given intravenously as a one dose. And that's all you need. And it actually is approved for children starting at two years, and then also for older adults.
And then lastly, just this last couple of weeks-- actually last month, maybe, we had approval in the United States of baloxavir, which is an oral antiviral. It's different from the newer amidase inhibitors. In this case it actually inhibits the replication of the virus. And it's used and approved for treatment starting at 12 years and older. Again, one single oral dose in this case. So this [INAUDIBLE] for treatment is much greater. OK.
This is my part. I will turn it over to Dr. Shope. Thank you so much.
Thank you very much, Dr. Munoz. And it's great to be with all of you this afternoon. I'm very impressed with your responses to the questions. It looks like a very engaged and smart audience.
So what I want to do is take everything that Dr. Munoz talked about and then apply it directly to the settings in which you work every day to try to improve your strategies for prevention and control of influenza. And as Dr. Munoz alluded to, you're in a really unique situation in early education and child care settings because you're caring for the most vulnerable population with respect to risk for influenza. Younger children are at higher risk, and children under six months are not immunized, so they're are at the very highest risk.
The typical methods that we use to prevent influenza in school-age children and older are difficult to apply in the early education and child care setting. What's often recommended is non-pharmaceutical interventions, NPIs. And one of those is social distancing-- staying at least three feet away from other people. Obviously young children will not follow that recommendation. Teaching them to wash their hands properly is very difficult, and usually requires you to do it for them. Coughing and sneezing in an elbow is obviously something difficult for young children to learn.
We recommend exclusion in some instances. Obviously we only want to apply that in certain incidences because that affects the parent's ability to work. And it has some limitations in terms of control of influenza that we'll go into in a moment. And infection control is something that we try to prevent influenza and other conditions. But because of the way influenza is spread, it's difficult to have a lot of influence with infection control. And we'll also cover that in more detail.
And as was alluded to, children bring influenza home into families and spread it into communities. So you're at a very important point-- situated in a very important point to prevent the spread into the community.
So let's start with a case here. And you are the director of a child care center. And last year during the flu season, two infants from your center were hospitalized with complications from influenza. Fortunately they recovered and did not suffer any long term health problems. However, this experience made you determined to do the best possible job to address this season's expected influenza outbreak.
So I want you to think about what you can do to try to control influenza in your settings. And I'm actually going to give you some of the answers. The possible answers are immunizing, infection control and prevention, and exclusion, which is denying admission of an ill child or staff member when they show up in the morning, or asking them to leave if they become ill after they're already present.
Now I know you're familiar with all three of these, but I want you to determine which is the most effective method. You can go ahead and start the poll right now. And I see the answers are streaming in. And once again, a very high rate is getting the correct answer. It looks like 86% of you have selected immunization as the most effective means. In second place came infection control and prevention, and then in last place came exclusions. And so we'll talk about each of these methods and describe why immunization is the most effective.
All right. So infection control-- obviously we've gone over what that involves. And it's good to do, but it's less effective than protection with the flu vaccine. And then exclusion may help, but it's less effective than the vaccine.
Let's go into some details. One of the reasons that I hear from a lot of adults-- parents of children as to why they don't get the influenza vaccine themselves or give it to their children is that we don't get the flu shot because we don't get the flu. So I think it's helpful to look at, what are the chances that a child might get the flu in a given year? And these data that I am giving you here are specific to children who are in child care programs.
Actually data show that as many as 50% of children in child care programs get infected with the flu each year. Now that's determined by actually drawing blood and looking for antibodies that show that they were infected. Children can get infected and not have symptoms of flu infection. So they can be asymptomatic. They're not sick. So the number of kids who actually get sick from the flu yearly is less than the number that get infected, and that's somewhere around 10% to 40%.
The influenza immunization, as Dr. Munoz presented will vary by year, and it will prevent anywhere from 10% to 60% of influenza. And that varies, obviously because the vaccine, as you may have picked up, has either three or four different viruses that we put into that vaccine ahead of time. We don't know which viruses are going to come each year, so we have to make that vaccine ahead of time. And it's not always a perfect match as to what actually happens. And in a flu season, three or four viruses may come through-- two A viruses, two B viruses.
So they try to predict, but they don't always get it perfect every year. But 60% doesn't sound great, but it's better than the other methods. And we'll go into some more details there. the intra-nasal vaccine was actually considered even better than the shot in young children, some years getting to 70% or 80% effectiveness, but then went through a period of time where it was not effective for three or four years. And it's being introduced after a little redesign this year. And we're hoping it will be effective again. But the point is that even though the vaccine isn't 100% effective, if you get vaccinated, you're much less likely to catch the flu or to get seriously ill or die.
So what's happening in the world of child care centers? We did a study in 2016, and this was of randomly selected child care centers who were licensed. We interviewed the directors about influenza requirement-- the vaccine requirement. And among children, for children, only 24% of the directors required the flu vaccine, and 60% of centers did not track the flu vaccine. And for adult caregivers, only 13% of directors required that they get the flu vaccination. And half of the centers did not even track flu vaccination in the adult caregivers.
So this is obviously much lower than we would like to see. In 2012 a study showed in Ohio, where there is not a requirement for adult caregivers to get the flu vaccine, 22% of caregivers actually did receive the vaccine. It's still very, very low. We need to do much better than that. OK.
So we're going to move now to infection control, and we're going to start right off with a survey here about, how does influenza spread? And there can be more than one correct answer here. So select all that are correct.
From hands that are dirty, from diaper changing, floats in the air, and goes into the lungs, by droplets landing on other people's faces, by touching contaminated surfaces, and then touching the face. You have to realize you may not be able to click more than one, but try it. So the answers are streaming in here. It does look like mostly you can click more than one because the totals are adding up more than the attendees.
And the correct answers are, by droplets landing on other people's faces, by touching contaminated surfaces, which the majority of you got those two answers. 2/3 of you thought that it floats in the air and goes into the lungs, and that's actually not quite true. And from dirty hands, 14%.
So this is the primary way that influenza spreads. These droplets that are forcibly expelled with a sneeze or a cough, they travel about three feet and then they normally fall to the ground, except in early child care settings, in which they land on their buddy's face and it goes in their tissues in their eyes and their nose and their mouth and they get infected that way. So sometimes those droplets land on surfaces, and to a lesser extent then individuals can touch those surfaces and then place their fingers in their mouth or up their nose and cause an infection that way.
So what we try to do to address that is hand hygiene, surface cleaning sanitizing and disinfecting, often sneeze etiquette. But you can see that if those droplets hit another child, we can't prevent that completely. Now these recommendations are covered extensively in Caring for Our Children, Third Edition. That's a free publication and you can search the database for any question on the link that I provided.
We also cover infection control measures in managing infectious child care in schools. This is available for purchase from the bookstore. I'm one of the editors. I don't make any money on this publication, just to be clear. We have looked at how commonly this reference is used. And it's used by almost a quarter of all childcare centers. So we're really happy to see that. It also has the exclusive recommendations about all different conditions, including influenza.
OK. So we're going to another question here. How effective is infection control in reducing the spread of influenza? To what extent can we reduce it? 100% reduction? 75% reduction? 50% reduction? 25% reduction? Now remember that immunization is somewhere around usually 50% or 60% effective.
And so I see the responses coming in. Most of you are choosing 75% effective. And the next most common response is 50% effective. Well it's a little depressing, but we're only about 25% effective at reducing influenza spread using infection control and prevention methods. And it's much better in older children, in school-aged children, where we get a better than 50% reduction.
But in younger children who you care for every day, it's around 17% to 35% reduction. And this is in research studies where they've used real rigorous programs and taught everybody and observed whether they were following the protocol. And the one study that was at the upper end of that showed that hourly hand sanitizer use actually was effective. Obviously that's not practical to do in your studies, but it's important information to keep in mind, that in the middle of flu season, you want to be washing your hands and using hand sanitizer as much as possible, because it may have some benefit.
Another study only showed a benefit in younger children, surprisingly, when we know that older children are more likely to have more effective interventions to school-aged children. I'm not sure why that study showed that. But when we look at absence, it's even less of an effect. Obviously the goal of preventing influenza is to prevent absences. And there's only a 10% decrease when you're using rigorous infection control.
So this is kind of depressing information. And it's definitely not as effective as immunization. But I don't want you to stop doing it. Keep doing it, because it helps prevent other infections. And infection control is effective at reducing diarrheal disease. And you shouldn't change your practices during flu season with the exception of maybe you want to wash your hands more often or reduce the alcohol-based hand sanitizer more often.
But I think the reason that it's less effective than we would like is because of that slide where you saw the child sneezing, those droplets go directly onto other children, and it's very difficult to stop that from happening using the methods that we have at our disposal for infection control.
OK, so let's go to another case. We have a teacher caregiver in a toddler room who sees reports in the media that it's flu season. She sees that Suzy has been flushed, laying on the floor for the past hour, and has a cough and runny nose and she wants to be held all the time. The caregiver takes Susy's temperature and it's 104.
When Susy's mother is called she's frustrated that she has to come and pick her up. When she arrives, she notes that Susy's classmate, Bobby, also has a runny nose. Why doesn't he need to be excluded, she asks? And Bobby is playful and running around with the other children. I'm sure you've seen this scenario play out in your own settings.
So the question for you is, why specifically is Suzy being excluded? And again, there may be more than one answer-- because Susy has a runny nose and cough, because Susy has a fever, she's requiring too much care, she can't participate in activities, or she has a fever and respiratory symptoms.
OK, I see your answers are streaming in. I do want to make an advertisement for asking questions on the chat portion, because I think we will have 10 minutes at the end of this presentation to address any questions that you have. And if you don't write any in, we won't know what to address.
So the answers are coming in, and I see that many of you have picked fever alone as a reason to exclude. And that's actually not correct. This was a bit of a trick question. A is not correct because runny nose and cough alone is not a reason to exclude. Fever alone without behavior change is also not a reason to exclude.
So we combine those two responses in E, where fever and respiratory symptoms is a reason to exclude. And obviously if she's requiring too much care and can't participate in activities, that's a reason for exclusion. And many of you-- actually only about 1/3 of you picked, requiring too much care. But that's the number one reason why you should exclude.
OK. So needing to be held all the time, can't participate in activities doesn't matter. Influenza or any other condition-- that's a reason to exclude. You have that in your wheelhouse to make those decisions. All right. Now Bobby is acting normal, and although he has a runny nose and doesn't have a fever, he does not need to be excluded.
All right, so the reason why exclusion might not be that effective for influenza-- part of it was shared by Dr. Munoz. And the kids are contagious, infectious the day before the symptoms develop. And they may spread or shed the virus for one, even in some cases up to two weeks. We can't keep kids out that long. Lots of children are infected, and some of those children are infectious, but they don't show symptoms. And we just don't know. We don't have any solid evidence that exclusion reduces the spread of influenza.
There's some other issues here. We can't actually tell which kids have influenza. Obviously, we immunize against influenza because it can cause the most feared disease, but some of influenza is mild. So there's a lot of overlap with the common cold. And, in fact, in the middle of flu season, when it's hitting your community for about a six to eight week period of time, when kids who look like they have influenza are tested, only 25% of them actually have influenza. The other 75% have other types of viruses that can mimic influenza.
And so we can't exclude everybody like Bobby who has a runny nose, because the chance of him having influenza are relatively low. So we have to exclude based on their activities and fever and respiratory symptoms.
Now we do know that when kids who do have influenza have fever, they have a very large concentration of that virus in their secretion. So that's one of the reasons why we target those. Then obviously if children meet any of the other exclusion criteria as outlined in managing infectious diseases. And our hope is that this approach may reduce some of the spread of a really bad disease, like influenza that kids can die from.
All right. So after looking at the effectiveness of all the options, you decide you're going to focus on immunizations, because that's the most effective. So we're going to talk a little bit about how you address a strategy for increasing immunizations against influenza in your program, for adults and for children.
So the first thing I think is that we all need to sort of change the way we talk about influenza. And we need to talk about influenza vaccine as a requirement. Now how does the vaccine become a requirement? Well there's an organization called the Advisory Committee on Immunization Practices, ACIP, that makes vaccine recommendation. And they have a recommendation for influenza, just like they have a recommendation for measles, and chicken pox, and diphtheria, and all these other immunizations. The same level of recommendation from this important organization.
It's the states and their legislatures that turn those recommendations from the ACIP into requirements. But there's a lag time. And most states haven't made this a law yet. But even though there's an absence of a legal requirement to immunize against influenza, there are no laws that prevent you from adopting a requirement in your own center for children or adults. And I really advocate that you do that.
But let's look at the rationale behind requiring influenza immunization in adults. Health care systems, many of them require flu vaccine as a condition of employment, just like you have to have a TB test and some other vaccines. And the reason is because adults with these diseases, with influenza, can infect the very people that they're charged with caring for, the vulnerable people-- patients in the hospital.
Well we went over a lot already in this talk of how children are vulnerable. And so child care settings should be no different. Those adults should be immunized to protect the children, especially the children under six months who don't have a choice. They cannot be immunized, and they're the most vulnerable. That's what Dr. Munoz referred to as cocooning. We want to protect them.
Two states do have adult influenza vaccination requirements for child care providers, and many other states recommend, but they don't require a flu vaccine yet. You do not need to wait until your state requires it. You can make a requirement in your own program right now.
Now regarding children, there are more states, but still not very many-- Connecticut, New Jersey, Ohio, Rhode Island, and New York City added it briefly in 2015. It went away and now it's back again. Again, don't wait for these laws. Start the requirements now.
Now there are also some financial arguments that you can make that might convince some people. Adults who get influenza, they need to stay at home if they're sick, and they lose wages. So that might convince some people. In the child care setting it may be difficult to find a substitute child care provider on short notice. So the caregivers end up having to take care of the same number of children with less people, and they have to work harder. And you want everybody on your team to be healthy and prevent illness when they can. So that may convince some.
Children, when they get influenza, can be sick with fever for five days in some cases. And obviously they need to be out of the program for that period of time. And a parent needs to take care of them. They're going to lose wages if they're on hourly wage. And they can spread it to other family members. Some of those family members may be very high risk or vulnerable. So this is a reason.
We have social consciousness. We've already touched upon this verbally. You have to protect the vulnerable children for whom you care. And you as a caregiver might spread influenza into your family, to your vulnerable family members also. I think we've hit these points pretty hard.
There are also barriers and health beliefs that we need to address and acknowledge in any strategy that you developed in your program. Common beliefs are that healthy people don't need the flu vaccine. They never get the flu. They're unlikely to get sick from the flu, not at risk for the flu. So education obviously has to address those issues.
Access is a concern. If people don't have the time to see doctors, they're not going to get adjusted to get the influenza vaccine. They're less likely to receive it.
Inconvenience or don't have time is often stated as a barrier, and sometimes physicians themselves don't recommend the flu vaccine. That's something we need to work on our side.
People are afraid of vaccine side effects. They're afraid they might get the flu from the vaccine, which is absolutely not true, but it's a common belief. They don't trust gov doctors or the government, and they're afraid of needles. So theses are all issues that we need to address. And they kind of all boil down to three basic strategies you can implement in your programs. And that's education about the flu vaccine, group access to immunizations, and eliminate costs or provide incentives. So let's go over those right now.
There's a lot of wonderful educational information available from the Centers for Disease Control. You will have access to all of these links. There's a 10-question quiz, which is kind of fun to get people engaged. You can use it for continuing education. You can put up posters and circulate frequently asked questions to staff and parents.
And these materials will try to address the common health beliefs, like, I don't ever get the flu. Well, most of the time you don't. But when you do, you can't predict when it's going to be and you could get really sick from it. And we have to keep in mind, 100 children on average die of the flu every year. That's more than all of the other things we immunize against that nobody has a problem with. And so influenza should be the number one disease that we're trying to prevent every year. And for some reason we place it at a lower priority, and I'm not sure why that it.
Obviously the flu vaccine does not cause the flu. The symptoms from the vaccine can cause a little local soreness, redness, maybe a low grade fever, a little achiness. That's it. It doesn't cause the runny nose, the cough, the pneumonia, the hospitalizations. It's not a secret plot by the government. I used to work for the government for 21 years. It's not a plot by the government. OK.
Now we also have letters that you could send home to parents. And there's the mailing that comes from the AAP messaging series that I'm sure many of you who are on this list already read.
What we can do in terms of addressing access-- if you can somehow manage to do on-site immunizations for children and staff, that is the single most effective intervention that you could do to increase flu vaccine rates. In some cases the health department may come out or a child care health consultant, if you have one, may be able to arrange on-site immunizations. There are certain companies like this Passport Health that actually will do immunizations on site for a fee.
But the most important thing is to make it convenient for staff to get it. And so you could, if you're a director, find information about local sites where immunizations could take place, make sure that staff have time off to go when these places are open, and make annual flu vaccine part of the routine. Make it a habit.
In terms of addressing some of the cost issues and incentives, studies show that employers save money with influenza immunization. And that's why they pay for it and make it free for employees. The same could be true if some in the audience run a large network of child care programs, for example. They might look into providing a flu vaccine to employees.
Adult caregivers-- one incentive, just a simple $5 gift card has been shown to increase the rate of immunizations. In fact the other day I was in Walmart, and the first sign when I walked in was, $5 off of your groceries if you get an influenza vaccine. So they've got that message. Maybe they're charging $5 more for the immunization. I'm not sure. But you can figure out how to do the finances in your own accounting.
And it's the psychological thing of getting $5 and getting the vaccine that I think causes a lot of people to-- it raises the rates. So just consider that. See how you might apply it creatively to your own cost structure. For children, obviously $5 isn't going to mean very much to them, but maybe a book might mean more to them.
And this is really interesting. This is for child care providers. The flu immunization rates increased from 20% to 50% to 60% when the flu vaccine was offered free and on-site-- so very effective strategies.
So I want you to think about what you've done in your programs and what you could do. That's really an important exercise and goal of this talk. But the take home points here are that influenza is the most common cause of vaccine preventable deaths in children in the United States-- the most important vaccination. Children spread influenza to caregivers, families, and communities. And we're in a position to stop that spread. Immunization is by far the best influenza prevention tactic. Protection control is also important, but not as effective as an immunization.
Exclusion should be used when needed, but not as a method to reduce spread primarily. And child care programs have an important role and an opportunity to improve immunization rates. And the seasonal flu plan should be reviewed and updated annually.
But at this point I'm going to turn it back over to Dr. Munoz and we're going to talk about pandemic influenza and how it's different from seasonal influenza, and how you should prepare.
Thank you, Dr. Shope. So this is really just a brief summary for all of you, because here's the thing. Influenza pandemics are likely to occur. And it is not if, but when they will happen. So it is important to prepare.
And how are influenza pandemics different from seasonal influenza? Well, very important differences are listed in this slide. And you can see that, as opposed to seasonal influenza, usually for pandemic flu, we have new viruses that emerge for which we have no immunity. We will usually see that this occurs rarely, but it can happen any time, as opposed to yearly epidemics.
But clearly we will not have a vaccine early on at the time of a pandemic. Everyone will be susceptible, not just high risk groups. There will be very rapid spread, as this is a new virus that can make very many people sick. And then we will have essentially, as we have seen before, an early limited ability to test and treat with antivirals, because we might not really know how well our current antivirals work, or these new strains that could be causing pandemics. More likely hospitalizations and deaths are going to be at higher levels than with seasonal influenza.
So this is what leads to a pandemic, just to give you a little bit of background about that. Pandemics are going to be usually caused by influenza A viruses, because they contain these surface proteins, hemagglutinin and neuraminidase, HA and NA, of which there are more and more types emerging.
There are now 18 HAs and 11 NA types, which really means that they could be combining, in many, many different subtypes. And these are form-based on mutations that occurred on these proteins through infection in animals-- usually birds and pigs where there is all these mixing and combining of genetic material that occurs, resulting in this new virus strain.
Once a new virus arises-- this is a novel strain-- you will see that it can be transmitted from animals to humans, and then many times it can be apt to be transmitted from human to human. And this is where a pandemic virus emerges. Once it has the ability to go from one person to another, and because we really have no previous immunity, we don't recognize it, so it can spread rapidly and globally, which is the definition of a pandemic.
As you can see, pandemics have occurred already. We had four in the 20th century, one so far this year in 2009. We have varied severity. 1918 was the worst. We had a very high mortality. Up to 1% to 3% of the world's population died. This is more than during wars or doing any other plagues that had occurred in the past. So we always worry about that possibility occurring.
Now 2009 was relatively mild, which less than 1% mortality as you can see there. But we don't really know how severe the pandemics will be until we start seeing what the causes or the effects of the epidemic is going to be.
So we know that those who are younger and healthy will be clearly affected more disproportionately, because they will not have previous immunity, as older people might have residual immunity from similar strains in the past. And then we've talked about different ways of doing this. But in this case for pandemics, actually these other interventions, such as hand hygiene, respiratory etiquette, distancing exclusion from day care, from schools from work, et cetera, is really what will be the first strategy to try to reduce the spread of a pandemic.
We will potentially have medications and vaccinations, but it's not going to be immediately available as we learn about the strains and how to protect ourselves against them. And we saw that during the 2009 pandemic, even with current methods of diagnosis and typing of these viruses, it could be a delay of a few weeks to months.
So clearly here, you can see how, for early indication and child care settings, we already have talked of how difficult it might be to enforce these particular interventions, such as hand hygiene, respiratory etiquette, and distancing, but that will be really important to consider as one of the first strategies. Right.
And certainly think about how this will impact running the business itself. What is the risk for the children, for the staff? The staff might not be able to come to work. There may be other closures necessary to contain the pandemic. And it's really important, then again, to be at tune and plan ahead.
How is pandemic different from other disasters that occur, which we unfortunately see our fair share every year. Here the issue is that we might not really know that it's going to happen until we start seeing circulation. And there has to be surveillance in place to realize that a pandemic is occurring.
Why is it necessary to plan? Obviously we would like to make sure that everyone considers this as a potential emergency, and that you protect your staff, you protect your children, the protection of your center, and generally will save lives and reduce all of the adverse events that are associated with these infections. And then thinking about the difficult decisions that might have to be implemented at the moment ahead of time is also very helpful. So this will eventually be beneficial for everyone.
What do you consider is, who's going to be in charge of the plan? How are you going to be updating yourself and know what is going on? You know, again, the CDC is a great resource, but there might be other surveillance systems in place. You might want to consider, obviously as we have seen before, that closure of childcare and school settings is going to be recommended, and that duration of closure is going to be depending on how the epidemic occurs in the particular community.
Having a communication plan is going to be key, because we have seen that with all of the disasters that we have experienced in many settings that having information available as early as possible and then announcing ahead of time what would be the consequences of the implementation of the plan is going to be key. So think about what will be your main form of communication. Having those trees of information that come out is going to be important. And then of course for child care settings and schools, having alternative care arrangements will be also important. And that needs to be considered ahead of time.
This is some of the different items that the plan should include. And so you see here, planning and coordination, trying to make sure you identify key staff that is going to review and develop this plan, and also keep identified at the different sites where you can have a tracking of what the situation is.
Talk about legal advice-- that might vary by state, depending on where you are. And then identify your partners. So who would be your other partners in the community and who will be helping you with coordinating this?
The second piece, as we discussed, is the communication plan. So who will be those key contacts and how you will be keeping in touch with staff and families? The third piece is infection control. Again, always used, but especially during a pandemic important. We've talked about this-- hand hygiene, cough hygiene, cleaning, disinfection, exclusion, and education about what is happening.
And then lastly, operations-- how do you deal with the closings, staff absences, and all the impacts that are associated with your program being unable to function?
And then just to finish this particular topic, I just want to say, there's always information about influenza, both within the state, within the United States, regional, and global information is always available. There are some resources available regarding how to plan for seasonal and pandemic influenza, as you can see in these two different resources that are provided for you, and as well as AAP who has other documents that will help you work with your staff and your group regarding pandemic preparedness. So these will be available to you.
And with that I would like to close and make sure that we do have some time for questions. So I'll pass it back on to organizers. Thank you so much.
Great. Thank you so much, Dr. Shope and Munoz for that great presentation. So we did have a lot of questions come through the chat box feature. So we'll try to get to a few of those today. If we don't have time to answer your question, we'll try to get back to you after the webinar concludes.
We had one participant ask-- they've had parents say that they don't get the influenza vaccine because it causes the flu. Is that true? And if not, do you have suggestions for talking with these parents?
I'll go ahead and address that. No, it's not true. And despite us saying that all the time, parents believe that. I don't really know what to do except keep giving them the answer that it's not true. The vaccine-- the inactivated vaccine causes local soreness, redness, maybe a little achiness and a low grade temperature in perhaps 10% of children.
So the reason that the flu vaccine can not cause the flu, just to add it and maybe give you another argument is, it cannot possibly cause the flu because a virus that causes the flu is not included in the vaccine. The vaccine is made out of a protein, as we discussed. It's made out of hemoglutinin mostly, and so there is no actual infective virus in the vaccine that can cause the flu, if that helps.
Great. Thank you so much. We had another question. Our program does not allow a hand sanitizer. Do you know of any resources that you can share with us to prove that it is safe?
Well, we do recommend actually washing with soap and water first, and hand sanitizer only if you don't have access to the sinks. This is in child care settings as opposed to health care settings, where hand sanitizer is used much more frequently. Hand sanitizers don't do a real good job-- the alcohol-- against norovirus and some other diarrhea-causing organisms like cryptosporidium. So it is a good idea that you wash with soap and water as frequently as you can. But if you're outside or doing water play or something where a sink is not available, then using alcohol-based sanitizers-- I know it's faster and easier, but it's not 100%.
Thank you so much. Another question-- should a primary care provider note be a requirement for a child to return to group care if they are sick?
I'll take this one. So the answer that is not always, and most of the time not. And we try to address that for each condition in managing infectious diseases, because it's a huge problem. It ends up taking up about 1/5 of all of the pediatrician's visits are kids that are kicked out of child care and the parents aren't worried about them. And usually there's no diagnosis or treatment. I mean, we can tell the child has a cold or the child has a viral diarrhea.
So we're not diagnosing really scary conditions. Scary conditions have vaccinations. That's why the vaccinations were invented to address those really harmful conditions. And for the most part we have vaccinations for most of the really harmful diseases in the United States.
So there's rarely a need for a diagnosis or treatment, therefore there's rarely a need for a health care provider visit. And for specific conditions we have them listed. There are some things like lice and the hand, foot, and mouth. But we're a little far from influenza here. So I'll just stop there.
Thank you so much, Dr. Shope. Another person asked, "I often hear providers, parents, et cetera, stating that they do not want to be vaccinated because of mercury content. Is the mercury containing preservative only in the multi-dose vials of the options listed for this flu season?
Yeah, I can take that one. So indeed all of the pre-filled syringe vaccines have no mercury content in them at all. So that's the 0.25 for young children, the 0.5 ml. And the majority of the vaccines, you know, you have this pre-filled syringe presentation. The multi-dose vials have a thimerosal content that is very, very minimal, which is used as a preservative, and also as a way to prevent infection. Every time that you enter the vial with drawing another dose, you can introduce infections, bacteria and so on. And so this is a way to prevent infection inside of the vial.
And as we all know, it is very clear and very strongly supported that thimerosal or mercury does not have any adverse events in terms of causing autism or any other neurological conditions. So it is not an issue for that type of side effect or concern.
Thank you so much, Dr. Munoz. It looks like we have time for about one more question. And again, if we don't have time to answer your question that came through the chat box feature, we will try to get back to you as soon as the webinar concludes, maybe in the next week or two.
This person asked if you can just explain a little bit further as to why egg allergies are no longer an issue for the vaccine.
Absolutely. Thank you for that. And I did see another question coming up in the chat, you know, just confirming that, indeed, egg allergic children can and should receive influenza vaccine. And the reason for that is because even though the vaccine is made in eggs, the strain of the virus that is used as the base strain if you will, is grown in eggs. That's the best media to grow flu viruses. It is then purified and changed so that, as we said, not the entire virus is included in the vaccine.
You only actually extract the hemoglutinin that is in the virus. And that is purified. And down the line you may or may not have a very, very small amount of egg protein in the form of ovalbumin, that it may be residual in the vaccine itself. But that amount is considered to be very, very, very small, so almost negligible.
And the initial concern was that, you know, older vaccines used to have full viruses and had more chance of having that content. The current manufacturing process, and the way the vaccines are made really reduce that amount of ovalbumin that could be present in the vaccines.
And in addition to that-- so that very minute amount as you have seen with the studies that were done and reviewed, given to egg allergic children, either in clinical trials or in an inadvertent administration where you looked at retrospectively what happened with those children who receive vaccine and they had egg allergies, you could see that it is not capable of resulting in an anaphylactic reaction or in a severe allergic reaction, just associated with the vaccine.
So it's similar to the measles vaccine, that also has a production in eggs at some point. There is no need to be worried about egg allergy as a contraindication, because children with egg allergy can tolerate well, these vaccines given the minimum amount of egg protein that could be present in them.
All right. It looks like that's all the time that we have for questions. I would like to thank Dr. Shope and Dr. Munoz for this very engaging presentation. If you want more information or have additional questions, please feel free to contact the National Center and Early Childhood Health and Wellness. Our contact info is on the slide currently.
And then just to remind you that a survey and instructions for your certificate will also be sent to your registered email a couple of days after the webinar. And a link to the recording of the webinar will also be included in that email. Please make sure to watch for it. If you don't receive it, check your spam mail as well.
That concludes this webinar, and thank you for your participation.Close
Children in group care settings are at increased risk for infectious diseases such as influenza (flu). Seasonal influenza affects many children each year. Simple prevention and control strategies can help to protect children and their caregivers from complications. This webinar will help Head Start staff and early care and education providers take steps to improve influenza prevention and control.