Yale-New Haven Hospital: HealthLINK: Pediatrics, November 2001

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November 27, 2001

News this month
The cost of getting the flu

While millions of adults each fall roll up their sleeves to get flu shots, far fewer children receive immunization for influenza. For years, pediatricians have recommended that children with asthma and other chronic conditions get the vaccine, but what about the millions of healthy children?

Pediatricians have recommended that children with asthma and other chronic conditions get the vaccine, but what about the millions of healthy children?

These children sometimes do get the flu at rates higher than adults. While serious complications are uncommon, children with the flu miss school, parents miss work and the entire family is affected. In some cases, the illness is serious enough to cause hospitalization. Also, most experts believe that schools and day care centers are significant harbors of a spreading flu virus epidemic. Does that mean all children should get a flu shot?

Getting a handle on the debate
Recently, a flood of studies have attempted to examine the issue from all angles. These studies have shown that:

Healthy children younger than five years have two to four times the rate of influenza-related hospitalizations as older children
Influenza and influenza co-infections account for a substantial number of outpatient visits and courses of antibiotics in children of all ages.
Children infected with influenza are twice as likely to have a febrile seizure.
Of the five million children in the U.S. with asthma, only about 39 percent receive the flu vaccine.
Age-based strategies (vaccinating all children age five and under) are more effective than risk-based strategies (vaccinating all children with asthma).
Lack of knowledge or lack of a physician recommendation are main reasons parents cite for not vaccinating their high-risk children.

Looking at the financial costs
Two recent studies in Pediatrics examined the economic impact of flu on young children. These types of studies are important because when national vaccine policies are formulated, they take into account “cost-effectiveness.”

Intranasal vaccine studied
The first study, published in August 2001, looked at whether it was cost-effective to administer an intranasal vaccine to young children. The researchers conducted a cost-effective analysis of data collected between 1996 and 1998 during a prospective two-year efficacy trial of intranasal influenza vaccine. The analysis included both direct and indirect costs.

Vaccinated children had an average of 1.2 fewer [influenza-like illness] days per child than unvaccinated children did.

About 1,600 healthy children age 15 to 71 months were enrolled in the study during the first year; from this group 1,358 were enrolled the second year. One or two doses of intranasal influenza vaccine or placebo were given to measure the cost per influenza-like illness (ILI) day avoided. During the two-year study, vaccinated children had an average of 1.2 fewer ILI fever days per child than unvaccinated children did.

Costs measured
Lost productivity was measured by using the average hourly U.S. wage rate multiplied by the amount of hours of missed activity. Direct medical costs included the cost of the vaccine plus the charge to have it administered while nonmedical costs included transportation to get the vaccine.

The data suggested that vaccination of young children has the potential for economic benefits to society, which can be maximized if vaccination is performed in group-based settings, such as at child care or in elementary schools.

Economic impact study
An earlier study, published in Pediatrics in November 2000, looked at the use of the inactivated injectable form of the vaccine, which is the one currently used, on children age six months to five years old. They looked specifically at what would be the best setting in which to administer the vaccine—a flexible setting in which the vaccine was available outside work hours versus a restricted setting that limited availability to usual work hours. Interestingly, vaccination resulted in a net cost savings in both settings, although the savings was greater in the flexible setting because there was no loss in work productivity.

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Should your child get a flu shot?

There's a ton of information blossoming on the subject of whether kids should get flu shots. But there have been zero recommendations from the major health organizations, such as the U.S. Centers for Disease Control and Prevention, the American Academy of Pediatrics and the American College of Immunization Practices. Among pediatricians, some immunize children at high risk, some attempt to immunize many more, while others don't actively recommend vaccination at all. So there's a wide range of attitudes and practices, which doesn't help confused parents.

"Among pediatricians… there's a wide range of attitudes and practices…."

Children at high risk
So let's first look at the areas where there is agreement—the children at high risk of complications from the flu. In my practice, I would recommend a flu shot for children who have:

congenital heart disease
asthma and other chronic lung conditions
immune system deficiencies, such as those created by HIV or chemotherapy or those who lack the ability to fight off infection
diabetes—while not as high a risk, it still causes concern

Gray zone debated
Then there is a huge grey zone of kids, where you might be more likely to immunize than the general healthy population. These would include premature infants who are now older than six months and even kids in day care or nursery schools. These children represent major avenues by which flu infections spread to other children and adults they come in contact with.

But how about for a healthy one-year-old who is not in day care? Do the benefits outweigh the drawbacks? Even in those cases, I'd have to say “probably so.”

Weighing the risks of the vaccine
The vaccine itself has very little downside. It should be avoided by anyone who has an allergy to eggs. In very rare cases, it's been associated with Guillain-Barr� syndrome. And probably the greatest deterrent is that it's one more shot that children have to get each year, which isn't pleasant for anyone.

Shot vs. nasal spray
In 1998, an intranasal vaccine was available for use in this country, but then the federal government required strict and costly testing for all the strains of flu that might be included in the vaccine. Since there are so many different potential viral strains, performing all the necessary clinical trials wasn't cost effective for the manufacturer. Therefore, this form of the vaccine was never produced and we are left with giving the injectable form of the vaccine.

Infants age six months to three years get a half dose, while children three and older get a full dose. Children under nine who get their first flu shot will need a booster four weeks later.

Limited supply
Of course, this all has to be put into the proper context. There's a limited amount of the vaccine produced each year and the doses should go first to adults and children at high risk for complications, including the diseases we touched on earlier, but also anyone over age 65. Breastfeeding moms are also encouraged to get a flu shot.

“The cost of the shot is relatively low…and…it prevents such major illnesses that it's hard for me not to recommend it broadly.”

Flu shots need to be given in the fall or early winter so the body has enough time to produce antibodies to the flu virus before outbreaks occur, usually beginning in January. The cost of the shot is relatively low—about $15—and as this study points out, it prevents such major illnesses that it's hard for me not to recommend it broadly.

Complications from flu
In an average year, 20 to 30 percent of children will be infected with influenza. The complications that flu can cause in children are incredibly diverse. It's commonly associated with fever and will cause benign febrile seizures in about 5 percent of all children, who often end up in the hospital emergency room.

In some cases, babies with the flu have stopped breathing and ended up in intensive care. Babies can also become very irritable, prompting pediatricians to launch major medical work-ups looking for the source of their crankiness.

So in the end, it's really a decision to be made between parent and pediatrician in a very rational way, weighing all the pros and the cons and how they apply to your family.

Dr. Germain is a pediatrician on the attending staff of Yale-New Haven Children's Hospital and an assistant clinical professor of pediatrics at Yale University School of Medicine.