Children and the winter flu vaccine

In May 2016, the Department of Health (DOH) and Public Health England (PHE) set out the national ‘flu immunisation programme for 2016/17.¹ The joint letter advised flu vaccination for the following groups:

• All children aged two to seven (but not eight years or older) on 31 August 2016
• All primary school-aged children in former primary school pilot areas in a cross-section of urban, rural and inner city settings
• Those aged six months to under 65 years in clinical risk groups:
• Chronic liver disease
• Immunosuppression
• Chronic neurological disease
• Chronic renal disease
• Chronic heart disease
• Chronic respiratory disease
• Diabetes
• Pregnant women
• Those aged 65 years and over
• Those in long-stay residential care homes
• Carers
• Disease risk groups (as listed above).

Flu vaccination should be offered to all children aged six months and over

Although most children with influenza will recover in one-two weeks, children under the age of five years are most likely to suffer complications,² including viral pneumonia, secondary bacterial pneumonia, otitis media, respiratory failure, encephalopathy, seizures, prolonged hospitalisation, and death. Children with conditions listed in the risk groups above are at highest risk, and the annual flu vaccine should be offered to all children over the age of six months with these conditions. In addition it has been shown³ that transmission by children is a major factor in ‘flu transmission throughout the population. Annual vaccination of children is therefore likely to reduce transmission of infection in all age groups.

The DOH and PHE joint letter states that ‘flu vaccine will be delivered in the 2016/17 programme as follows:

• Two, three and four year olds (but not five years or older on 31 August 2016) will receive the vaccine from GPs
• Children of appropriate age for school years one, two and three will have a service commissioned by NHS England, in schools in the majority of areas
• All children of primary school years one to six in former pilot areas will continue to be offered vaccination in schools.

The vaccine to be used for children over the age of two years is the live attenuated influenza virus (LAIV) vaccine delivered by nasal spray, which is more effective in children than the injectable vaccine. The vaccine contains gelatine derived from pigs and may not be acceptable to some faith groups, though some faith groups that normally ban the consumption of pork products may accept porcine products for medicinal use. If the intranasal vaccine is refused on cultural or religious grounds, the injectable vaccine should be offered to children in high-risk categories.

Nasal vaccine should not be given to all children

Conditions in which children should not be given the nasal vaccine include:

• Being under two years, as there is an increased risk of adverse effects in this age group. Children under the age of two years in high-risk categories should be given the injectable vaccine
• Current wheezing or wheezing in the past three days
• Severe immunosuppression or the presence of someone in the household who needs isolation because of severe immunosuppression, as children may shed live virus
• Severe egg allergy (anaphylaxis). Most children with egg allergy can be safely immunised with nasal ‘flu vaccine, but children with a history of severe egg allergy require specialist advice
• Allergy to any other components of the vaccine.

Full information on the intranasal vaccine, including adverse effects, is available on the EMC website.⁴

Case study: flu vaccination

A 39-year-old pregnant woman attends surgery with her 2-year-old child asking if they should both receive the ‘flu vaccine. She states that the child is allergic to eggs. What actions would you take and what advice would you give?

Answers

Mother

Advise her to have the injectable ‘flu vaccine. If she has ‘flu during pregnancy, she is more prone to complications of ‘flu such as pneumonia, sepsis or even meningoencephalitis. Her baby may be born prematurely or be of low birthweight, and ‘flu makes stillbirth or neonatal death more likely.

Child

First of all ask what the mother means by ‘allergic to eggs’. Some mothers may mean simply that the child will not eat eggs or that eggs cause symptoms such as a gastrointestinal upset; these do not constitute allergy and you should advise the use of the intranasal ‘flu vaccine. If the reaction to eggs suggests a mild allergy such as a skin rash, advise the mother that the intranasal ‘flu vaccine can safely be given; if she is unhappy with this advice it would be wise to refer her child to a paediatrician for further advice. If eggs have been associated with more severe symptoms, such as wheezing or angioedema suggesting an anaphylactic reaction, withhold the vaccine and refer the child to a paediatrician.

References

1. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529954/Annual_flu_letter_2016_2017.pdf2. Stokowski, L. A., Medscape Pediatrics Oct 20143. Glass L.M., Glass R., BMC Public Health 2008 8:61 DOI:10.1186/1471-2458-8-614. http://www.medicines.org.uk/emc/medicine/29112

Mike Townend MB ChB (Hons), Dip Trav Med, FFTM RCPS (Glasg), Hon Fellow BGTHA Hon Clinical Senior Lecturer, University of Glasgow