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Running head: INFLUENZA IN THE PEDIATRIC POPULATION
Influenza in the Pediatric Population
Jessica Scharfenberg, RN-BSN
Concordia University Nebraska
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Abstract
Influenza is a viral infection, categorized by several strains, with an ever changing epidemiology.
The World Health Organization and Center for Disease Control and Prevention, work
collaboratively with state and local public health systems to monitor the spread and effects of the
virus. Children are particularly at risk of contracting the virus because of underdeveloped
immune systems, and close contact with others during the prime viral months. Research
continues to identify barriers that prevent children from getting immunized from the virus, while
governmental agencies fight to implement policies to protect children from influenza.
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Influenza is an infectious viral illness that follows a secular pattern, peaking between
December and March of any given year (Center for Disease Control and Prevention [CDC],
2009). There are 3 strains of the virus including A, B, and C. Influenza A is categorized as a
moderate to severe respiratory illness that affects people of all ages and animals (CDC, 2009). It
has numerous subtypes identified by surface antigens H and N. Influenza B is usually a milder
illness than A and affects mostly children (CDC, 2009). Lastly, influenza C is not reported often
as most cases are subclinical. All strains of the virus are spread through the respiratory
transmission route, and is spread for 5-10 days through respiratory secretions after infection of
the host (CDC, 2009). Both strains A and B of influenza are characterized by sudden onset of
symptoms which include fever, cough, sore throat, myalgia, headache, rhinitis, and malaise
(CDC, 2008). Specifically in children, symptoms are often accompanied by otitis media,
vomiting, and nausea.
It is theorized that pandemic influenza affects mostly school aged children because adults
have some immunity from exposure to prior strains of influenza, and because children have the
highest level of contact rate; meaning they are in contact with the most people throughout the
day (Bansal, Pourbohloul, Hupert, Grenfell, & Meyers, 2009). Most deaths from influenza are
caused by complications associated with the viral infection such as pneumonia, Reye syndrome,
and myocarditis (CDC, 2009). Any children with underlying respiratory conditions such as
asthma, are at higher risk of complications. Also, those children with diabetes, metabolic
disorders, cardiac disease, chromosomal abnormalities, and neurological diseases such as
cerebral palsy, intellectual disability, or epilepsys are at an increased risk of complications
(CDC, 2012).
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Children with neurological disorders sometimes have difficulties with lung function,
muscle function, swallowing, and clearing secretions from their airways; influenza can make
these conditions even more dangerous (CDC, 2012). According to the CDC’s 2012 press
release, the most common influenza associated complications in children with neurological
disorders were pneumonia and acute respiratory distress syndrome (CDC, 2012).
Current statistics reveal that children between 5 and 18 years of age are not at increased
risk of influenza based complications, but they usually have the highest infection rates during an
outbreak (CDC, 2014a). The theory behind this is that they are in school, where they are in close
contact with several people each day. The trajectory of a sneeze is 3 feet (CDC, 2014a). Since it
is spread through respiratory transmission, any child within the 3 foot radius of the child who
sneezed, is then exposed. Children 0 to 4 years of age are at higher risk of needing medical care
if they contract influenza, with those under the age of 2 facing the most severe of complications
because of immune systems that are not fully developed (CDC, 2009).
Epidemiologically, influenza can be transmitted from children to others for more than 10
days, usually starting one day before the start of symptoms (CDC, 2009). It can be spread
through airborne contact with infected respiratory secretions, usually from a cough or
sneeze. The influenza virus can also be spread by direct or indirect contact with a surface
contaminated with the virus (CDC, 2009). On average a person touches the face 16 times in an
hour (Painter, 2009). While touching one’s face a person may be transferring the virus from their
hands into their eyes, nose, and mouth.
Throughout history several pandemics and epidemics have been caused by the ever
mutating, influenza virus. Research dating back to the 1890s shows influenza as the causative
agent of a pandemic that killed many (United States Department of Health and Human Services
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[USDHHS], 2014). Beginning in 1918, the federal government started to require local health
departments to collect data on diseases present in their communities. That data was then
reported to the state, who in turn reported it to the federal government. During that same year,
1918, an influenza outbreak killed twenty million people worldwide, but influenza was not one
of the reportable disease (USDHHS, 2014).
On September 27, 1918, due to the pandemic outbreak, influenza was added to the list of
reportable diseases (Tumpey, 2006). Although, the first surveillance of the disease was crude, it
set forth the ground work of today’s influenza surveillance system. When the United States first
began collecting data on influenza, the disease was so wide spread it was difficult for accurate
data to be collected (USDHHS, 2014). It was also the start of World War I, so many public
health facilities were short of staff, leading to lack of data being submitted (USDHHS, 2014).
Today, influenza is still on the reportable disease list and the CDC, monitors the cases
closely (CDC, 2013b). The Epidemiology and Prevention Branch in the Influenza Division of
the CDC collects data year round to analyze current influenza trends. They then publish
Fluview, which is a weekly surveillance report, with hopes to paint a picture of national
influenza activity (CDC, 2013b).
The CDC influenza surveillance is broken down into five categories; virological,
outpatient illness, mortality, hospitalization, and geographic spread (CDC, 2013b). The
information collected from those categories allows epidemiologists with the CDC to locate areas
where influenza is tracking above endemic levels. It is also used to identify which strains of the
virus are spreading and the extent of the illness; including influenza related hospitalizations and
deaths (CDC, 2013b).
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Through virological surveillance, respiratory specimens are tested for influenza A and B
by laboratories located throughout the United States (CDC, 2013b). Each week the laboratories
then report to the CDC the number of specimens tested and the number of positive cases. There
are 85 World Health Organization Collaborating laboratories and 60 National Respiratory and
Enteric Virus Surveillance System laboratories located in the United States. Their collaborative
efforts to identify the number of positive cases and virus types are then published weekly in the
Fluview (CDC, 2013b).
Outpatient illness surveillance data is collected by over 2,900 outpatient care providers
located in all 50 states (CDC, 2013b). Providers report to the CDC the number of patients, based
on age, whom have influenza like illnesses. This specific data uses the following symptoms for
classification, fever of 100 degrees Fahrenheit or greater and a cough or sore throat with no other
known cause. The percentages reported by each facility are weighted and based off of the state’s
population, then compared to the national average of 2% (CDC, 2013b). There are 10 activity
levels that correspond to the number of standard deviations at, above, or below the mean for the
current week. The activity levels are as follows: levels 1-3 signify minimal influenza activity,
levels 4-5 correspond with low influenza activity, levels 6-7 correspond with moderate influenza
activity, and levels 8-10 correspond with high influenza activity (CDC, 2013b).
There are two systems in place that track influenza related mortality (CDC, 2013b). The
122 Cities Mortality Reporting System reports the number of influenza or pneumonia death cases
listed on death certificates as underlying or contributing causes (CDC, 2014b). This is broken
down further and reported based on age categories. The percentages are then compared with the
seasonal baseline and epidemic threshold. The CDC defines a standard deviation increase of
1.645 above the seasonal baseline as the epidemic threshold (CDC, 2013b). In 2004, a pediatric
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mortality surveillance system was added, in which any influenza related death of a person under
the age of 18 is reported. This was after 153 pediatric, influenza related deaths occurred in the
2003-2004 influenza season (CDC, 2013b). The goals of the pediatric system are to monitor and
describe the incidence, distribution, and basic epidemiology of deaths among children related to
the influenza virus (CDC, 2014b). This information is also used to guide further policy
development, as it allows for rapid recognition of a strain or season that is going to have a large
impact on children under 18 years of age (CDC, 2014b).
Hospitalization surveillance reports any lab confirmed, influenza hospitalizations in both
pediatric and adult patients (CDC, 2014b). The Influenza Hospitalization Network, also known
as FluSurv-Net, is located in 70 counties in 10 states (CDC, 2011). States were chosen based on
their emerging infection program status (New Mexico Department of Health, 2013). This data is
only reported during influenza season (CDC, 2013b).
Geographic spread is reported by state health departments and estimates the level of spread
in each state (CDC, 2014b). There are five different levels of spread that can be assigned (CDC,
2013b). The “no activity” level is defined as no lab confirmed cases and no increase in reported
influenza like illnesses. “Sporadic” means that there has been a small number of lab confirmed
cases, but no increase in influenza like illness reports. A “local” level is assigned when
outbreaks or influenza like illnesses are located in a specific region of a state. A “regional” level
indicates outbreaks and an increase in influenza like illnesses reported in at least two, but less
than half of the regions in a state. A “widespread” level occurs when at least half of the regions
of the state have an increase in lab confirmed cases and influenza like illnesses (CDC, 2013b).
Influenza monitoring efforts by collaborative organizations leads to early detection and
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prevention of epidemics. This is especially important to high risk populations, such as children,
as their immune systems are not fully developed (CDC, 2009).
Influenza is the most common respiratory infection in the world next to the common cold
(Florida State University [FSU], 2005). This highly contagious virus is most common during the
winter months because of the close indoor proximity with others during the colder months of the
year. It is transmitted to a susceptible host through airborne droplets (FSU, 2005).
The three known types of influenza, A, B, and C, comprise the viral family known as
Orthomyxoviridae (FSU, 2005; Hunt, 2010). The family is characterized by segmented,
negative-strand ribonucleic acid, RNA (Bouvier & Palese, 2008). Although there is a common
genetic ancestry between the strains, re-assortment of RNA does not occur between types, only
within the genus. Influenza A is further categorized by the subtype of surface glycoproteins
(Bouvier & Palese, 2008). The two surface glycoproteins are hemagglutinin (HA) and
neuraminidase (NA); HA has sixteen subtypes and NA has nine (National Center for
Biotechnology Information [NCBI], 2009; Todar, 2008). Only three of the HA and two of the
NA subtypes have caused human epidemics.
The nomenclature of the virus is determined by virus type, species it was isolated in,
isolate number, the year, and if it is influenza A the subtype (Bouvier & Palese, 2008).
For
example A/Panama/2007/1999(H3N2), is a human influenza A virus found on isolate number
2007, in Panama in the year 1999. It was then further categorized by the subtype H3N2, as it
was an influenza A virus.
Influenza A and B are spherical and filamentous in shape, and often times are
undistinguishable under the microscope (Bouvier & Palese, 2008; Todar, 2008). The virus is
enveloped in a lipid membrane with glycoprotein spikes that aid in the attachment to the host cell
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and the release of virus particles (Bouvier & Palese, 2008; Todar, 2008). The inner side of the
viral envelope contains an antigenic protein lining and seven to eight pieces of single stranded
RNA (FSU, 2005).
Mutations in the antigenic structure have led to numerous influenza subtypes and strains
and is known as antigenic shift (FSU, 2005). The re-assortment, or shift, can happen in cells
infected with both human and animal viruses, resulting in influenza viruses that humans have no
preexisting immunity to (Bouvier & Palese, 2008). This leads to pandemic influenzas, as the
human population does not have immunity to the strain created by the antigenic shift. Looking
back in history, the shift was the likely cause of the pandemic Spanish Flu in 1918-1919, as the
new genome was highly pathogenic and many were without immunity (NCBI, 2009).
While infecting a host, the influenza virus is searching for sialic acid, which is found on
the surface of the host cell (Bouvier & Palese, 2008; Hunt, 2010). Once found, the glycoprotein
spikes on the outer part of the viral envelope bind to it. Sialic acid is located on most mammal
cells, specifically on the epithelium of the respiratory tract (Bouvier & Palese, 2008).
Once attached to the host cell, it is endocytosed and released into the host cell cytoplasm
(Bouvier & Palese, 2008; Hunt, 2010). The virus is then transported into the host cell nucleus
where the viral RNA is transcribed and replicated. The synthesized viral RNA migrates back
into the cellular cytoplasm, and the new viral complexes bud from the infected cell (NCBI,
2009). The virus repeats this process with neighboring, susceptible host cells.
There are still many unknowns surrounding the viral replication and packaging process
(NCBI, 2009). It was originally thought that it was a random process, in which RNA segments
were randomly incorporated into viral particles (Bouvier & Palese, 2008). New research
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however, indicates that it is completed through a selective process to insure a full genome is
incorporated. Without a full genome, the virus is not as infectious (Bouvier & Palese, 2008).
Although all three influenza types have rather simple RNA with strong surface proteins,
it is difficult to produce a highly effective vaccine (Bouvier & Palese, 2008). They are
continually going through antigenic shifts, mutating the viral genomes, making it problematic for
researchers to match the vaccine to the virus (Hunter, 2008). It also impedes human immunity as
the strains continue to change. This is one reason that children are more susceptible to the virus,
because they have not been exposed to as many strains to gain immunity (FSU, 2005; Hunt,
2010). The other is because they are in closer quarters to others, in schools and daycares, during
the winter months.
The National Institute of Allergy and Infectious Disease, NIAID, began funding an
influenza genome sequencing project in 2009 with hopes that a better understanding of the
virus’s evolution, spread, and cause of disease would be gained (NIAID, 2009). The effort has
revealed thousands of complete influenza virus blue prints, of strains that can effect both humans
and birds. The goal is to provide researchers with the information needed to develop new
vaccines and help them understand the genetics that govern the virulence. If the genome project
is successful it should help lessen the impact of yearly influenza epidemics and provide guidance
to control pandemics (NIAID, 2009).
Children are considered a target group for the influenza vaccine due to their higher risks
related to less immunity and greater exposure to the disease (World Health Organization [WHO],
2000). The decision to vaccinate a child against influenza is left to the parents or guardians,
while the health care provider is to communicate the reasoning, benefits, and risks of the
immunization. It is also important for the health care provider to help parents understand that
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their children are at risk of contracting influenza, but that the vaccination will decrease that risk
(Schneider, 2014). By giving parents knowledge they are able to make educated decisions.
The CDC currently recommends that every child over 6 months of age receives an
influenza vaccine (CDC, 2014c). Special consideration should be given to those children who
have an egg allergy, history of Guillain-Barré Syndrome, and those who are currently ill.
Otherwise, only with rare exception, should the influenza vaccine not be given. Children under 7
years of age, who have not received the vaccine previously, should be given the vaccination
twice, four weeks a part (CDC, 2014c). Those who have had the vaccine in the past only need
one shot annually.
Several social and behavioral barriers exist that impede influenza vaccination rates
among children (SDDOH, 2013). Knowledge barriers fall into two categories (WHO, 2000).
The parents either have a lack of knowledge about the vaccine or inaccurate knowledge. There
are many groups and non-evidence based articles that convey influenza immunizations as
dangerous. One in particular from Sarah Clacher, a reporter for CNN health, warns of the low
efficacy and small risk of getting influenza in healthy people (Clacher, 2007), but not once does
she mention the benefits of getting vaccinated, such as less severe symptoms if you contract
influenza and have been vaccinated (CDC, 2013d). There are also many public forums in which
parents post personal opinions about the influenza vaccine. A study by the World Health
Organization revealed that 67% of parents expressed concerns about potential side effects
associated with vaccines, with most concerns being fostered by the media (WHO, 2000). The
most important aspect for health care providers is to educate parents with reliable, evidence
based resources of information like the CDC and American Academy of Pediatrics (WHO,
2000).
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Another set of barriers include environmental and logistic barriers (WHO, 2000).
Environmental barriers include geographical location and access to care. In rural areas there is a
lack of public transportation and poor road condition that make it difficult for parents to bring
their children to clinics to receive their influenza vaccines. The hours of clinic operations may
also be limited or inconvenient (WHO, 2000), creating challenges for parents to bring children in
during non-work hours. This ties into socioeconomic barriers, as some families have to work to
meet daily needs for survival and are unable to leave work to take their child to the clinic for the
influenza vaccine (WHO, 2000). Some states and local health departments have tried to alleviate
this barrier by offering influenza shot clinics at schools. To insure the influenza vaccine is
available to all children, no matter the socioeconomic status, some states like the state of South
Dakota provides the vaccine free of charge to anyone under 18 years of age (SDDOH, 2013).
Birth order and family size, along with family mobility, are other barriers identified by
WHO (WHO, 2000). Young children of large families are less likely to be vaccinated because of
increased family responsibilities that are not focused on health care needs (WHO, 2000).
Migrant families often do not have a strong relationship with a healthcare provider as they move
several times throughout the year, and may have language barriers within their current
community. The CDC and Immunization Action Coalition have developed an influenza vaccine
information statement that is available in 29 different languages (IAC, 2013). It is required that
the statement be handed out to parents whenever an immunization is given; and provides
information on why children should be vaccinated, the types of influenza vaccines available,
who should not be vaccinated, risks and side effects of the vaccine, and what to watch for in case
of a serious reaction (CDC, 2013d). This statement is updated yearly so the most current
information is available to parents.
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Health care provider’s attitudes towards the influenza vaccine can also be a barrier to
parents who are trying to decide whether they are going to give their children the immunization
(WHO, 2000). One provider bias includes not personally believing in childhood immunizations
and conveying that onto parents who are unsure about immunizations (SDDOH, 2013).
In best
practice scenarios, providers will only provide information to parents that can be substantiated.
Personal opinions and bias should not be shared with parents as the information can be
inaccurate (CDC, 2013d).
The ecological model of health behavior recognizes that individual beliefs and behaviors
occur in a social context (Schneider, 2014). If the social environment can be changed, health
promotion can be achieved. This specific model looks at health behavior factors at five different
levels that create the social environment (Schneider, 2014). The five levels include the
intrapersonal, interpersonal, institutional, community, and public policy levels.
The intrapersonal level focuses on the knowledge, attitude, and skill of an individual
(Schneider, 2014). The interpersonal level influences the intrapersonal level, as this level
includes friends, family member, and coworkers; those a person spends time with and learns
from. Families are the origin of most health behaviors, but as a person ages, friends begin to
provide a larger influence on those behaviors (Schneider, 2014). The third level is institutional;
these are setting such as schools and the workplace, where a person spend up to half of their time
(Schneider, 2014). Behaviors influenced at the institutional level are often identified as stress
and work place hazards, but sometimes are identified as positive behavior influences such as
workplace wellness programs. The fourth level, community, is where organizations work
together to promote healthy behaviors (Schneider, 2014). Community organizations include
churches, Lions clubs, and health facilities. The final level is public policy. This level brings
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together public health by setting regulations and limitations to improve health behaviors, such as
smoking restrictions, school entrance immunization regulations, and seat belt laws (Schneider,
2014).
The model has been successfully implemented in a variety of health promotion projects.
In 2013, the CDC used this model in the Colorectal Cancer Control Program, to promote early
screenings (CDC, 2013a). In the 1980s the ecological model of health behavior was used in San
Francisco to help control the AIDS epidemic (Schneider, 2014). The National Center of Injury
Prevention and Control also has implemented this model, based on WHO recommendations, to
prevent violence; whether it be in schools, workplaces, or homes (CDC, 2013c). The model has
been used to promote cardiovascular health of low income, Hispanics living along the United
States and Mexico border (Balcazar, et al., 2012). More importantly, it has been used as a
framework for past influenza pandemics, like the 2009 H1N1 pandemic (Kumar et al., 2012).
Since children are not able to make the decision whether or not to get the influenza vaccine,
the intrapersonal level of the ecological model focuses on the beliefs and attitude of the guardian
who will making the decision. To promote influenza vaccine rates intrapersonal determinants
are looked at, such as perceived risk, perceived vaccine safety, and past immunization experience
(Kumar et al., 2012). Guardians are known to base their decision on physician recommendations
and past experience. If health care providers can educate the guardian on the risk of influenza
and the safety of the vaccine, even if past experience has been bad, there is a greater probability
for vaccination (Kumar et al., 2012).
Children, under the age of 18, spend most of their time in close contact with others at
schools or daycare settings (Schneider, 2014). It is very important that the teachers, providers,
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and administration are aware of the dangers of influenza and promote the vaccine. They also
need to be aware of the exclusion recommendations if someone is influenza positive, to decrease
transmission among other (Kumar, et al., 2012). This institutional level, although causes spread
of influenza among children, provides an ideal setting for intervention (Schneider, 2014). Many
schools in South Dakota, have local public health nurses hold influenza immunization clinics
(SDDOH, 20113). Although the flu shot is not mandatory for students, there are less barriers
when a person can go into the school, rather than a parent bringing the child to a clinic (WHO,
2000).
The ecological model of health behavior identifies the interpersonal level and community
level as the origin of health behavior; and the two groups whom have the most influence on
change (Schneider, 2014). Since families and communities influence health behavior changes, it
is important that they are educated on the importance of children being vaccinated against
influenza (WHO, 2000). Education at both levels can come from local health professionals, but
also through capital campaigns like South Dakota Flu. South Dakota Flu is a media campaign
targeting numerous age groups to inform, educate, and promote the influenza vaccine (SDDOH,
2014). Aspects of the campaign include television commercials, radio ads, billboards along
highways, webpages, and social media pages. Recently the South Dakota Flu campaign added a
video clip to their social media page from the United States Department of Health and Human
Services (SDDOH, 2014). The clip shows an interview with Elmo after an episode of Sesame
Street, advertising to young children the importance of health during the flu season.
Lastly, the public policy level sets forth regulations and limitations to promote childhood
influenza vaccinations. It is done by offering the vaccine to children at little or no cost, and
providing services at locations of easy access for parents (Kumar et al, 2012). Public health
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officials strive to reduce the barriers that prevent children from getting influenza vaccines
(WHO, 2000). They also set up pediatric surveillance programs to monitor the spread and
epidemiology of each year’s viral strain; to protect children, whose immune systems are weak,
and as they are at higher risk of developing influenza related complications (CDC, 2014b).
Public policy allows for education of the public and providers, so the benefits of the vaccine and
risks of the viral infection can be conveyed.
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