by Harry Goldhagen
First published October 9, 2002 in Medscape Pediatrics
A few of us were hanging out the other night in San Diego, during ICAAC (click here to read our coverage), watching the fireworks show from my balcony in Mission Bay. We were chatting about the usual things one chats about at an infectious disease meeting: antibiotic resistance, the best cities for great meals, our latest theories about the anthrax mailer, and favorite movies. One of the group, who grew up in India, told us that when he was young, the movies there were rather prim and never showed explicit sexuality, kind of like those wonderful Fred Astaire-Ginger Rogers films where you almost never saw them kiss on screen, or those Hitchcock classics where a train entering a tunnel or fireworks exploding over the French Riviera was as racy as it got. Indian movies used similar tricks to imply but never show a moment of intimacy — a door opening or a cow walking by, for example. In one especially memorable flick, he told us, a train huffed by at the critical moment, and by the time it passed, the lovers were done, busy smoothing their clothes and fixing their hair. An older fellow sitting nearby had seen this film 10 or 12 times before, and when our friend asked him why, he said, “I know one of these times that train is going to be late!”
As predictable as the phases of the moon or heartburn after chili, the winter influenza outbreak returns each year, as regular as a sine curve. We can count on this annual visit so reliably that most of the people developing syndromic surveillance systems to provide early warning of a bioterrorist attack use the annual flu outbreak to gauge the effectiveness of their algorithms. Nevertheless, for most physicians and others in healthcare, when it comes to influenza, each time is like the first time, which is great for romance but terrible for public health. Despite the fact that we can almost completely prevent mortality and most of the morbidity of influenza (when the vaccine strains match the circulating strains, which is generally the case), we still see 10,000 to 20,000 cases of “excess deaths” from influenza each year.
Now, granted, the majority of these fatal cases occur in the elderly. But a significant risk group for hospitalization is children 1 year of age and younger, who are especially targeted by the guidelines from the CDC and AAP.[1] For instance, children from newborn to 4 years old who have high-risk conditions have hospitalization rates of approximately 500/100,000 population (and only 100/100,000 population for those without high-risk conditions), and children in the first year of life have the highest rate of hospitalization, comparable with rates found among people older than 65 years. Those at highest risk include:
- children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma;
- children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or HIV); and
- children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for developing Reye syndrome after influenza infection.[1]
But how to protect the youngest children, those younger than 6 months, when the vaccine is not approved for this group? One strategy is to protect their families, the parents and older children as well as their nurses, baby-sitters, and others involved in their daily care. Though not proven to be protective, it seems a prudent and inexpensive way to keep the most vulnerable out of the hospital this winter. And as an unintended bonus, you can help save the elderly in your community. The Japanese experience with vaccinating schoolchildren had the added benefit of reducing mortality in the elderly.[2]
So go ahead, write a new ending for the annual script of missed vaccination opportunities. Sure, you’ll get tears from your patients and guff from their parents, arguments from insurers and pressure from your pharmacy and administrators. But is any intervention as clear as this one? You won’t even need subtitles to find the happy ending.
References
- Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2002;51(RR03);1-31. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5103a1.htm. Accessed October 3, 2002.
- Reichert TA. The Japanese program of vaccination of schoolchildren against influenza: implications for control of the disease. Semin Pediatr Infect Dis. 2002;13:104-111. Abstract available at: https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12122948&dopt=Abstract. Accessed October 3, 2002.
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