The Pediatric Influenza Vaccine Playbook: Proven Paths to Prevention

Introduction

Dr. Ravi Jhaveri (Ann & Robert H. Lurie Children's Hospital of Chicago): Hello, everyone. Welcome to The Pediatric Influenza Vaccine Playbook: Proven Paths to Prevention. My name is Dr. Ravi Jhaveri. I'm at the Ann & Robert H. Lurie Children's Hospital of Chicago, and I'd like to introduce my colleagues, Dr. Tina Tan and Dr. Jennifer Walsh. Dr. Tan?

Dr. Tina Tan (Ann & Robert H. Lurie Children's Hospital of Chicago): Thank you. I'm Dr. Tina Tan. I am also at Ann & Robert H. Lurie Children's Hospital of Chicago.

Dr. Jhaveri: Dr. Walsh.

Dr. Jennifer Walsh (George Washington School of Nursing): Hi, there. My name is Jennifer Walsh. I'm an assistant professor at the George Washington School of Nursing. I'm also a certified pediatric nurse practitioner practicing in primary care in the D.C. area.

Dr. Jhaveri: All right. Wonderful. Thanks so much for joining us today. So we're going to first start out with a section we're calling “Assessing the field: trends in influenza activity”. And since everyone can relate to a case, we're going to start with a case that probably sounds very familiar to all of you. It's early December, and your pediatric hospital ward has started to fill with children presenting with respiratory distress. Among them is a seven year old girl, previously healthy except for some mild asthma, who presents with fever to 103 Fahrenheit or 39.5 Celsius. 

Cough and myalgia for two days, increasing shortness of breath and oxygen saturation of 89% on room air. Her nasopharyngeal PCR is positive for influenza A H1N1. She is not vaccinated this season, and you note that in the emergency department, there have been several other recent admissions, including a 15 month old with congenital heart disease, a 10 year old with obesity, and a six year old with cerebral palsy, all testing positive for influenza. All right. So, I'm going to ask both of you to just talk maybe a little bit about your perceptions and recommendations about those children who are at higher risk or at highest risk for severe influenza complications. So, Dr. Tan, maybe you can go first.

Dr. Tan: So the kids that are at highest risk for severe influenza complications need to be treated for their influenza, and they should be vaccinated and all their family members should be vaccinated.

Dr. Jhaveri: And so as we think about the sort of background of the patients we discussed, which of those clinical scenarios worry you the most, Dr. Walsh?

Dr. Walsh: I would say, honestly, all three. They all three have risk factors that put them at significant increased risk of complications, office visits, hospitalizations, and potentially death. So I would say all of them.

Dr. Jhaveri: Yeah, I would - I would definitely agree with that. And what about thinking the youngest infants, you know, we tend to think about them as being the most vulnerable for many reasons? Do you want to just maybe talk - either of you - talk a little bit about sort of the combination of factors that make young infants at highest risk for severe disease?

Dr. Tan: Well, anatomically as well as immature immunity basically puts them at much higher risk for complications.

Dr. Walsh: So, we know that children's immune systems, as well as their respiratory systems are not mature. They're continuing to develop. They're at much more risk of hypoxia and potential hospitalization. And we know that our body's response to pathogens is to send in mucus, increase inflammation, and that really has a much more significant impact on airways of children versus adults. So, definitely a concern for all of our pediatric patients because of those reasons.

Dr. Tan: Right.

Dr. Jhaveri: Yes, I completely agree. I think the – the - one other thing I might add, too, is when we think about those infants younger than six months who aren't eligible for any vaccine, right? We're really relying on perhaps some presence of maternal immunity that's passed on at delivery, which is why we vaccinate pregnant women during pregnancy. But also, obviously, the idea that we need to rely on others in the family caretakers to be vaccinated, to protect those youngest infants. And so it's a - I think a combination of all those factors that really make those youngest infants most vulnerable. What about sort of varying degrees of immune compromise? How do you - how does that factor into your thinking or decision making?

Dr. Tan: Well, the more immune compromised you are, the higher risk you are for complications, but it doesn't seem to matter. You need to be vaccinated and the people in the household need to be vaccinated.

Dr. Walsh: Completely concur, Dr. Tan.

Dr. Jhaveri: Yeah, I would just - I think I would just add a couple of things, which is that I think one, to highlight that when we think about the burden and particularly pediatric deaths. that most of the kids, in fact, don't have any risk factors. Underlying risk factors, right? So that's one of the things to remember. And I think, let's say, thinking about the scenario of those cases we ran through previously, I think we underestimate just how much immune dysfunction comes for patients who have significant obesity. I think the studies have been pretty clear about dysregulated immune system, whether they're infected with influenza or, frankly, any other virus. 

And so, I think we should be thinking about immune compromise really in the broadest sense. All right. Thanks so much for that discussion. All right. So let's just review a couple of the points that we went over. Certainly the patients we think about at highest risk, those young infants for the anatomic and immune factors we've already discussed. Varying degrees of immune compromise and really underlying medical disease for any reason. So, whether it's cardiac, neurologic, respiratory, diabetes, anything that gives you a systemic disease of any kind really can give you potential complications for - with influenza. 

As we think about the prior pandemic we had, which was back in 2009, I think it really opened our eyes to some of the factors - the risk factors that we think about now - particularly patients who have obesity of varying degrees. I think we - we saw a tremendous morbidity and mortality back in 2009. Same goes for pregnancy. I think that was really the impetus for us to want to vaccinate pregnant women is because we saw so many pregnant women dying, or needing to be on ECMO or on ventilators back in those days. And so it was really scary and very eye opening for us. 

And - and I think with every bad influenza season, we think about those patients that have underlying neurologic conditions that really interferes with their ability to clear secretions and all the things that also come with influenza. And I just want to highlight, I think many of us who were practicing in the last year knew that last year was a difficult flu year,  to say the least. So, just to quote the CDC, "Influenza activity in the United States during the '24/'25 season was classified at high severity, making - marking the most severe influenza season since 2017/2018.  High severity was reflected across multiple indicators, including influenza associated outpatient visits, hospitalizations, and deaths, underscoring the significant public health impact of the '24/'25 season. Flu activity began increasing in mid-November and peaked in early February 2025."

All right, so I'm not really a prognosticator, but I think all of us in practice are always asked to provide some thoughts about - about what to expect for the upcoming season. So, we're going to try to - to give us a little bit of a prediction. 

So first, I think we know that the isolates that we see in the Southern Hemisphere in their winter, which is our summer, can often be a preview of what we might expect. It's not a perfect indicator, but it's often highly correlated. And so this is data that was collected from a group of public health labs and collaborators across mostly South America, but some countries in parts of Africa, as well as in the Asian Pacific Area. And so, when you look at the breakdown of isolates that they saw, they had sort of a mixed season. 

Mostly H1N1 isolates, almost 60%, just shy of a third that was also flu A and H3N2. And then, a few cases that were flu A, but not further subtyped. And I would say that most of us assume there's a general breakdown that falls within the other A subtype. So you can probably add about, you know, 8% and 4% or a little more than that to the other - to the H1N1 and H3N2.  And then a smattering of B cases, about 5%, you'll see that late in their season, which is often what happens, we tend to see the B strains emerge.

And so, for us that tends to be in that February to sort of April window where we see most of the B cases. I do just want to point out that we're primarily now seeing just the - one of the B strains, the B/Victoria family of isolates. For whatever reason, since the COVID pandemic, we have not been seeing any Yamagata B strains. And so, that's actually the main reason why our vaccines have gone from the prior quadrivalent vaccines we had several years ago, to now just a trivalent with an H1N1 A strain, an H3N2 A strain, and a B/Victoria strain included in vaccine. 

When we look at the estimates of vaccine effectiveness, the flu vaccine actually did pretty well in these countries The estimates ranged anywhere between 45% to 77%. As is often the case, the efficacy - the effectiveness - was higher against H1N1 and predicted to be a little bit lower with H3N2. There weren't enough strains in cases for them to do proper estimates here. You'll see that the estimates against B strains, even though they're very, very small, were closer in that 60% to 70%. So, on average I would say, that's a pretty good year. And so that actually does bode well for us as we head into this season.

All right. So, this is going out on a very short limb. I'm not going way out there. But I think we're going to have an active flu season this year.  It's unclear what the distribution is going to be, but I would expect it's going to be a mix of H1N1 and H3N2, probably in that two thirds one third range. And I think one of the patterns that we've seen over the last couple of years and that we're going to talk about is that we're seeing fewer - fewer people seeking vaccine, particularly amongst the children and young adult populations.  

And there's, I think, many reasons for that. I think some of the delivery changes that we've seen since the pandemic, shifting from traditional office based vaccination to pharmacy and other delivery. And then certainly I think many, what many of us would call the headwinds of vaccine hesitancy and misinformation that have really prompted patients to seek additional input or maybe to continue to be apprehensive and to defer vaccine to either some future point or to not opt to do it at all. All right. So, now I'm going to pivot to Dr. Tan, and she's going to walk us through some of our vaccine options for children.

Dr. Tan: Thank you.

Dr. Jhaveri: Dr. Tan.

Dr. Tan: So basically, the ACIP does recommend that all individuals six months of age and older should receive an influenza vaccine on an annual basis. And basically, the CDC does recommend the use of any licensed age appropriate flu vaccine. And this would include the trivalent inactivated vaccine that could either be egg based or cell culture based, the recombinant influenza vaccine, or the live attenuated influenza vaccine. And, as Dr. Jhaveri pointed out, the trivalent flu vaccines protect against two influenza A strains, H1N1 and H3N2, and then one B strain of the Victoria lineage. And the shift, as he pointed out, was due to the fact that we really did not see circulation of the other B strain that used to be in the vaccine, which is the Yamagata strain. 

Now, this basically shows you the available trivalent flu vaccination formulations. You have egg produced for six months of age and older, cell culture produced for six months of age and older, and then the egg produced live attenuated for those individuals between two and 49 years of age that are completely healthy with no underlying conditions. And if you look at the way these different vaccines are produced, we know that the egg produced vaccines use embryonated hens’ eggs, and it's estimated that four eggs are required for each dose of the vaccine produced. 

Now, the vaccine does induce antibodies that bind egg adapted viruses well, but binding to circulating viruses is less effective. And then, when you look at the cell culture or the recombinant hemagglutinin flu vaccines, these vaccines basically induce antibodies that bind both cell adapted and circulating viruses as well. And this basically shows you the different strains that are contained in the egg based vaccines, as well as the cell or recombinant based vaccine. 

And this shows you the different available trivalent inactivated - trivalent influenza vaccines that are either egg based, cell culture based or recombinant. So, when you look at the differences among these vaccines, we know that the inactivated influenza vaccines are made from killed influenza viruses, so they cannot cause a flu infection. And, as we mentioned, they contain two different A strains and one B strain and is administered as an injection. 

The live attenuated influenza vaccines are made from attenuated or weakened influenza viruses. And they definitely should not cause infection. And they contain the same strains that are contained in the inactivated vaccine and is administered as a nasal spray. And then when you look at the recombinant influenza vaccines, these are made by only cloning the viruses hemagglutinin gene, which is then combined with the baculovirus, resulting in a recombinant baculovirus. And this virus then delivers genetic instructions for making flu haemagglutinin antigen into the host cell. The recombinant virus then instructs the cells to rapidly produce the haemagglutinin antigen. This is also administered by injection, and this particular vaccine never, ever uses the actual virus, but only a portion of the virus, and it contains three times the antigen content compared to just regular or standard influenza vaccine. And basically, this basically improved its vaccine effectiveness compared with the inactivated vaccines.

So, the question that always comes up is, do cell based vaccines work better? And this only shows you information from the quadrivalent vaccines. We don't have information on the trivalent vaccines. 

But this is looking at effectiveness against influenza related medical encounters between 2019 and 2020, looking at cell based quadrivalent versus egg based. And you can see that for any influenza related medical event, or for outpatient influenza related medical encounters, the cell based vaccines tend to have a better effectiveness. And this is another study that - or it should be the same study - but basically explains some of the different factors that were looked at to basically determine that the cell culture based vaccines actually function better. 

And then this was another study looking at the quadrivalent vaccines over three different consecutive influenza seasons. And, basically, what they found was that if they looked at the cases and the controls for those individuals that either got cell culture based or egg based vaccine, the cell culture based vaccines did tend to have a better effectiveness compared to the egg based vaccines. But again, these are all quadrivalent. We don't have information yet on the trivalent. 

And basically, if you look at the cell culture based influenza vaccine and the effectiveness against the different strains, you can see that it's most effective against H1N1. And has a little bit less effectiveness against influenza B and H3N2. So, the thing to remember about the inactivated influenza vaccines is, you can administer this vaccine with all other routinely recommended vaccines and COVID 19 vaccine, with absolutely no immune interference with any of the vaccines.

These vaccines have an excellent safety profile. Most common adverse reactions are mild fever, irritability, pain, and mild swelling and redness at the injection site. And all these reactions tend to basically resolve very quickly. And studies have shown that vaccine effectiveness does vary depending upon the year and the fitness of the strain match between those contained in the vaccine and those circulating in the community. 

So basically, you can see that there's a wide range there. But in general, vaccine efficacy for the inactivated influenza vaccines is about 50% to 60% against influenza caused by any A or B strain. And if you look at the live attenuated influenza vaccines, again, these can also be administered with all other routinely recommended vaccines and COVID 19 vaccine with no immune interference. These are very safe vaccines, with the most common adverse reactions being nasal congestion, cough, malaise and fever given that this is a nasal spray. 

And studies have shown that the live attenuated influenza vaccine effectiveness does differ depending on the vaccine strain, with multiple years of poor effectiveness against the H1N1 A strain and several years of poor effectiveness against the H3N2 A strain. And the factors underlying the decrease of effectiveness included reduced thermostability of the vaccine virus and reduced replication fitness of the H1N1 strain in the vaccine. So, by changing the strain of the virus to a more thermal stable strain and one with increased replication fitness, it really stabilized and increased the effectiveness of LAIV. 

And even though you can see that vaccine effectiveness was very wide ranging, in general the estimated effectiveness is 60% to 70% against any influenza A or B virus. And so, to Dr. Jhaveri and Dr. Walsh, how do you select among the various influenza vaccines for your patients? And how can clinicians explain why influenza shots vary in effectiveness while still reinforcing their value in preventing hospitalization and death? Dr. Jhaveri, let's start with you.

Dr. Jhaveri: Yeah. I think - you know, I've been a firm believer that the more options we can give patients, the better off we are. And it's amazing to me sometimes when I talk to patients and families like, what really resonates with them, what they're most concerned about. And so I try to talk about the multiple options that they have. And so it's not just a question of flu vaccine, yes or no. There's different types. And, depending on what their concerns might be, whether their child, you know, does well with - with vaccines or whether there's a big huge battle, in which case sometimes the - the intranasal works well. Some people have concerns about egg allergy, even though that's not a true contraindication, in which case, then, you know, discussion about cell based vaccine becomes a very easy one. And - and then we all know that patients have sort of what I would say concerns or issues that comes up that - that aren't necessarily, like a direct logic based, let's say. 

And there's sort of some specific flew thinking that happens, and so sort of talking your way through that. One of the points that I like to just highlight, too, is when we think about vaccine effectiveness that's not the whole story. And one of the points that I like to make that I know we're going to reinforce is the idea that the vaccine has a really powerful effect in - in modifying disease. So, even if you do get infected, you're much less likely to be - to get severely ill. And so, obviously, there's a huge benefit to that. So, Dr. Walsh.

Dr. Walsh: Thank you. I would say, first of all, it's important to recognize that, as care providers for pediatric patients, we really rely on expert panels, expert organizations to help guide us with this. Those, you know, looking at developing the new vaccines. What was the prior year? What do they anticipate this year? But also really science based evidence practice studies as well. And really look to that. So, I really hope that - that continues into our future, that we've got those reliable entities to - to focus on. 

And I know, you know, definitely the American Academy of Pediatrics is definitely on top of that, as well as many other NAPNAP and immune and infectious disease organizations as well. And I think, when I think about vaccines, it's not so much the vaccines that save lives, but it's vaccination that does. We can have a vaccine that's 100% effective at preventing disease. But if we don't get it into our patients and we don't get it in in time, it really - it doesn't make a difference. 

So, I think thinking about what is going to be the best to cover the most amount of people for your particular practice, and that can really vary. And if you have the luxury of selecting several different options, I agree that's best for patients, it's not always possible depending upon what type of delivery is - is giving that. You know, what type of practice or what type of organization has access to that. So, those are just some things that I think about when I think about selecting influenza vaccines. 

And again, I cannot agree enough that - that we really need to reframe that flu is still possible even with the vaccination. But we have excellent data, year after year after year, that it really reduces the risk significantly. Reduces the office visits, missed school, missed work, reduces ER visits, reduces hospitalization, and reduces death. So, it's really an effective and powerful tool that we have.

Dr. Tan: Excellent. And if we had combination vaccines, so flu and COVID, flu and RSV, or flu - flu, COVID and RSV, what role would these vaccines play in improving coverage rates or addressing vaccine fatigue? And, Dr. Walsh, you want to take that one?

Dr. Walsh: Sure. I'd say that, you know, the number of vaccinations definitely is something that's on parents’ minds and on children's minds as well. So, if we have a safe and effective combination vaccine that's cost effective and works, I think that's awesome, something to look for - for the future. The less - the less vaccines we have, the greater the chance of - of getting those administered.

Dr. Jhaveri: Yeah. I mean, I certainly agree, I think that it's - there's a little bit of nuance that obviously has to come with it. We'd be thinking about that mostly for older children and young, healthy adults, where the combination would give us the most bang for the buck. I think we see that for older adults over 65, that's actually the one group where we've actually maintained pretty high vaccination rates, surprisingly. And so - and we offer those specialized enhanced vaccines for that age group.  And obviously we think about the - the need for additional vaccines,  and perhaps modified dosing in younger children.  

But - but in those groups where they're eligible and should receive all three,  or two of the three, whichever, I think combination vaccines we've shown always tends to enhance that patient convenience. And - and obviously it makes it more efficient for providers too. We shouldn't forget that efficiency of inventory is a really powerful motivator for pharmacies and practices when they're thinking about how much room is in their fridge.

Dr. Tan: I know Dr. Walsh and Dr. Jhaveri all brought this up, but these are some of the practical considerations that practices use for selecting pediatric influenza vaccines. And the bottom line is that practices generally select vaccines that are applicable to the largest number of patients that they've seen. And one thing too to consider is that if you have a lot of patients that have a fear of needles, you may want to consider using the LAIV because you can get more people vaccinated. And with that, I'm going to turn over to Dr. Walsh.

Dr. Walsh: Thank you, Dr. Tan. So, I'm going to focus on uptake of influenza vaccines in children, reversing the trends that we've seen, especially recently. So, we talked about that case at the beginning. That seven year old girl who presented, ended up being hospitalized, requiring oxygen support. And it's important to reflect what if she had been vaccinated? So, imagine this alternative scenario. She received her influenza vaccine in October in line with the recommendations for asthma and other chronic conditions. Two months later, she developed similar flu like symptoms: fever 104 Fahrenheit, cough, congestion, mild fatigue, no respiratory distress. 

Her pulse ox is excellent 96% on room air. Testing again shows influenza A H1N1, but she recovers at home with supportive care and no complications. So, that brings us to the fact that the flu vaccine is very impactful for reducing those complications and the hospitalization and the burden of illness on the child and the family. So really, a totally different scenario in a vaccinated child versus a non-vaccinated or partially vaccinated child. So, I have some questions. What signs suggest a vaccine modified illness? What do you think of when you think of a vaccine modified illness?

Dr. Tan: It's definitely milder. And these kids, even though they might have fever and other symptoms, the symptoms are definitely much milder and they don't last as long. And basically they do recover faster and don't require hospitalization.

Dr. Jhaveri: Yeah, I might just build on that. And think about that it depends on who we're talking about, you know. And if we're talking about an otherwise healthy kid, who has vaccinated and gets the flu, it might mean that they either miss no school or maybe miss just one day when they're feeling the worst, but they get back to school pretty quickly. They're back to playing basketball or soccer or softball or volleyball or whatever their sport of choice is, which often is really important for the kid and the family.  

For our patients with more severe underlying conditions, severe asthma or the kids maybe who are technology dependent, it's really a life or death scenario where they might survive an illness that - that - that could be fatal. And so, I think we - we - it can look different. But you, you go from what could be the worst case scenario to something that's far better and that's a win in every - in every situation.

Dr. Walsh: Excellent. How can we ensure children like this get vaccinated?

Dr. Tan: Well, it brings up the same point as everything else. I mean, you know, everyone should be vaccinated so that they don't get severe disease. And the other thing to point out, is that there's more than one strain circulating. So even if they got flu, they probably still should get the vaccine after that to protect them against the other circulating strains.

Dr. Jhaveri: Yeah. Yeah, I would - I think I would also add that perhaps we, as providers, the broader medical community, I think we need to do a better job to expecting that - or sort of bringing vaccine to patients-  instead of expecting that they're going to come to us. And so I think pharmacies is only one answer. I think we could do better about providing vaccines in schools and community centers. Certainly our institution has worked hard for kids who are hospitalized for other conditions to offer vaccine when they show up, either in the ED or at our specialty clinics or on the inpatient wards.  

Other colleagues around the country are doing it when children have procedures. And, you know, now there's even potentially, the - the option to get certain flu vaccines delivered to your home. So, I think just the idea that any - there are many options. And the point is we should be aware of those options and help share them with the patients so that we can just - we're far better off when more kids get a not perfect vaccine, than waiting around for a few kids to get some perfect vaccine.

Dr. Walsh: Excellent. I totally agree. So, pivoting just a bit, when should children receive antivirals or even chemoprophylaxis for influenza, Dr. Tan?

Dr. Tan: Well, I mean, you know, if kids have underlying conditions and they get flu, they definitely should be treated so that it basically decreases the amount of virus that's there, and, you know, allows them to maybe recover faster. However, there really is no criteria for kids in the outpatient setting to get antivirals. So, if you have someone who comes in who seems to be fairly sick, you may want to treat them so that they're not shedding as much virus, especially if they're living in a household with a lot of other individuals that may be at increased risk for influenza.

Dr. Jhaveri: Yeah. I - you know, I certainly agree. I think we also probably need to work hard with providers to sort of convince them that these antivirals do have a positive effect. I think there's probably a lot of lore and a lot of belief amongst providers that influenza virals aren't worth the trouble and you're going to vomit and have diarrhea, and instead of focusing on that. And so there's a lot more talk about the potential side effects. Again, they're not perfect. But I would say, if you look at the studies and if you start them as early as possible, if you told somebody, "Hey, if you take this antiviral, you might - you might still feel crummy, but instead of going from feeling like you got hit by a truck to feeling like you're about 80%”, I think all of us, when the question is framed that way, would say, "Yeah, sure, I'll take something that is going to get better a little more quickly and where my symptoms are less severe”. 

And so - and then I think we also need to make people more aware that there's more than one option for treating influenza. And there's now one dose option that is oral and actually has a terrific safety profile. Yes, it's a little more expensive, but - but if you can get your patients to take it and it makes them feel better, then the - the sort of cost and value equation is very different. And so, I think we also need to do a better job at distributing the message, talking about options, and being timely with our diagnostics.

Dr. Walsh: Excellent. I know that we have a much better track record in hospitalizations for antivirals, but the outpatient, you're right., it's definitely lacking. So, there's many opportunities for improved patient care. All right, so I think this is a very important slide. It just shows how pediatric vaccination rates in all ages are decreasing over the past, you know, years. So, we're seeing a significant - that lowest line that's the pinkish red - is our most recent, and, as we mentioned, our most severe influenza year we had. But it was also the lowest vaccination rate we had as well, which really creates a perfect storm that is not a pretty one. So, keys to improve vaccination in children, prioritizing vaccination, especially our high risk children which honestly, based on age, based on underlying conditions, prioritizing their caregivers, their household contacts, etc., using every opportunity. 

So, well-child visits, acute care visits, we're going to talk a little bit about opportunities in other settings as well. And then educating all office providers and staff. I think it's really important that everyone's on the same page, that we - from the office staff that's scheduling to the nurses to the providers seeing the patients - that we're all on the same page, we're all recommending vaccination, we're all taking a proactive stand for it. Other, and there's many script templates that AAP [inaudible 00:41:12] has as well, training exercises, etc., for effective communication.  Because sometimes that communication occurs when the patient calls up to schedule the visit before they even see a healthcare provider. So, it's really important that we're all on the same page.

And then other considerations as Dr. Jhaveri mentioned, school vaccinations, daycare vaccinations, community vaccinations. I think about all of the fall festivals we have in Northern Virginia can be an excellent place. Those pumpkin patches, etc., really great places to capture children. And then considering setting up a sensory - sensitive spot in the clinic for patients as well. I know my practice does a drive through nurse influenza clinic on the weekends, which is very effective and very - very popular.

So, systems to improve vaccination rates. There's a lot of opportunity with electronic medical records as well as AI to really help us get better at vaccination. So updating the EMR, it should prompt healthcare providers. It should also be able to gather those children under the age of five, those that will be six months and on when they come in to visit, those that have underlying health conditions, etc., to really capture those, to set up systems to help facilitate that vaccination. So, text messages, letters, postcards, messages from portals, telephone messages, also social media. I know lots of - lots of families get information on social media. And seeing that, "Hey, it's time for the flu vaccine. Hey, did you know this? You know, this helps reduce hospitalization, reduces missed school, etc.."  

So, lots of ways to kind of reach those patients. It's always important to remember effective communication, which is really what it all comes down to with our parents. So supporting parent autonomy, right? We're partners in keeping your child healthy. That's our job to keep your child as healthy and safe as possible. And then I can provide you, we can provide you with the evidence to make that decision easier. And the messages should be strong and personalized. So, this is what I chose for my child, this is what I chose for my family, and I would recommend this vaccine for children in my family. 

As we mentioned earlier, presumptive recommendations are really key. So, your child needs his or her flu vaccine today. And this as well, as I mentioned, with all of the office practice or the hospital practice as well. Instead of “are you interested in getting this vaccine at your appointment?”, having that presumptive recommendation really clearly helps increase vaccine acceptance, and helps set up that conversation as well.

As Dr. Tan mentioned, influenza, we've got multiple different types of influenza vaccination. But one thing that we need to keep an eye on is making sure that children get effectively vaccinated with two doses if they are under the age of eight. So, any children from six months to eight years need two vaccines spaced out by at least four weeks in order to move on to that one dose annually at that point. And I think this - this slide does a great - great way of discussing this.

And so, vaccination uptake, best practices. We like to think of kind of a Gantt chart or some other policy, pardon me practice type of algorithm that really has it broken down into the steps and the timing that we're going to be administering some of these best practices. So, as I mentioned earlier, run - run the report of the electronic health record for the ages, prioritizing patients with asthma, diabetes, chronic health conditions, as Dr. Jhaveri mentioned, including obesity, etc., and include all active patients. Sometimes you can exclude those that have well-child visits from August to October because you know you're going to capture them as well.  But begin advertising as soon as possible with all those different message vehicles that I mentioned. Offering the vaccine to family members, siblings, parents, caregivers when they come in as well. And then nurse run clinics, as I mentioned, these can be very, very effective. So, having a designated nurse to administer the influenza vaccines. They're shorter visits, they don't need a provider,  they're billable. And then also setting up nurse run clinics for after hours or weekends. Scheduling children that need a second dose on the day that you schedule the first dose, or the day that they receive it. So we've got it in the books. We know that they're coming back. 

And then continuing to vaccinate through the season. One thing that is important is sometimes we think of August/September, maybe not quite - we're thinking about flu yet. Most of us think, you know, flu definitely October, flu by boo, or flu by Halloween kind of-  kind of saying. But a lot of those, especially older children, might come in for heir sports or their school physicals in August/September, and that might be an excellent opportunity to catch them where you might not get them back, right? Kids and families are extremely busy, and if that's not a priority for them, they can get lost in the shuffle. So, if you have it available in your practice, trying to capture those children as well.

So, now I have some commonly asked questions that we all get from patients. So, Dr. Tan and Dr. Jhaveri, my child's healthy, why do they need the flu vaccine?

Dr. Tan: Because anyone can get influenza and they can get very sick. Not, you know, because - because you're healthy doesn't mean that you won't get severe illness. And, if you look at last year, the vast majority of the children that passed away were normal, healthy children. So that is not a reason to not vaccinate.

Dr. Jhaveri: Yeah, I would - I certainly echo that. And I think the other thing that I would say is we often know that flu will run through families and, inevitably, people may not care about Joe next door or down the street, but they care about their close family, their good friends and neighbors. And if you say, "Hey, your child might be healthy, but their best friend might be getting treated for leukemia or might have diabetes or so on." And you want them to play together and be safe. And so I think there - there are a lot of other reasons that you can offer people where the flu vaccine just has that broad appeal.

Dr. Walsh: So, patients often ask as well, or families, the flu isn't that bad. The vaccine carries more risk or the vaccine actually causes the flu. What do you say to those families?

Dr. Tan: Basically, explain to them that the vaccine cannot cause flu, and that flu vaccine will prevent the child if they got flu from getting very sick. You know, there is this misperception that flu isn't that bad, but unfortunately, some people can get extraordinarily ill and we can't predict among the healthy population who's going to get ill.

Dr. Jhaveri: Yeah, I would kind of for patients sometimes use the analogy of like a seatbelt. Yeah, a seatbelt might be annoying and uncomfortable if you have to sit in the car for a couple of hours. But the reality is you might need it once in your life and it's going to save your life. And so, thinking about the idea that you don't want to take that chance, it's not necessary to take that chance. And a lot of people take that chance every year, and unfortunately it doesn't work out. They pay the ultimate price. And so, just thinking about that.

Dr. Walsh: Great analogy. So, my child got the vaccine last year. They still got the flu. I don't think it worked. How do you address that?

Dr. Tan: Again, getting the vaccine, it's not 100%, but it will protect you and you know, others in the family if they get vaccinated from getting severe disease and being hospitalized.

Dr. Jhaveri: Yeah. And I - what I often try to do is, you know, discuss that obviously around the time that people are getting vaccinated in the fall, there's still plenty of other sort of flu copycat viruses that are out there. And that more likely they got one of the other viruses and - but never got tested for the flu. They just sort of assumed. But there's a lot of viruses that fall into that similar bucket. And so the vaccine gets blamed because they're like, "Oh, yeah, I got my vaccine, you know, three days ago."

Dr. Walsh: And also if they have, you know, a mild fever or a little soreness or achiness, that's their immune system doing what it's supposed to do. And a lot of people think, "Oh, that gave it. That vaccine gave me the flu. I felt horrible”, or not so much horrible, but, you know, the side effects.  And so the last question, why does the flu shot need to be given every year when other child vaccines do not?

Dr. Tan: Well, I think that you need to explain that, you know, there are different strains that circulate, and the flu vaccine is basically made to protect against the circulating strains.

Dr. Jhaveri: Yeah. I would also just remind them that pretty much every vaccine that we give needs some kind of boosting. And so, there's no vaccine where you just get one and you're done for your entire lifetime. And the fact is, is that for all the reasons we talked about seasonal variation year over year, and the fact that the immunity just doesn't last beyond the - the sort of season that we need to do, the annual boosting. And everybody's trying to make the perfect flu vaccine, but we're not there yet.

Dr. Walsh: Thank you so much. So, I just want to also point out to our participants that the AAP has a flu toolkit with excellent - excellent resources for providers, patients, families, etc. that is available. So, make sure to take a look at that. And then now I believe we move on to the post - the posttest questions.

Quentin (CCO): Yeah. You actually don't have to read those. Those are going to be just available for the learners.

Dr. Walsh: Okay. So how do we wrap it up?

Quentin: I'd say, however - however you - you want to wrap it up, uh.

Dr. Jhaveri: Maybe we'll just - we'll invite everyone to make a few closing comments. All right. So I'll - I can start the segue.

Dr. Walsh: Great.

Dr. Jhaveri: Dr. Walsh, thanks for that discussion. That was really a terrific overview about how we can all do better. Let's maybe move to close with some final thoughts. So, Dr. Tan, do you want to just share any last thoughts?

Dr. Tan: So, I think people just need to understand that influenza occurs every year. It can be severe in healthy individuals. And everyone, whether you're healthy or have an underlying condition, you should be vaccinated and your family should be vaccinated to protect individuals. And the vaccines that we have are safe and effective.

Dr. Jhaveri: Dr. Walsh.

Dr. Walsh: Yeah, she took the words right out of my mouth. They're very safe vaccines. Everybody deserves an opportunity to protect themselves and their family against illness and possible complications.  And they are the greatest tool that we have to keep our population, especially those with underlying conditions, but as we mentioned, those that are completely healthy and have nothing in their history, to keep them safe out of the hospital and away from harm. So vaccinate, vaccinate, vaccinate.

Dr. Tan: I agree.

Dr. Jhaveri: Awesome. That was great. I might just finish with a closing thought or maybe a challenge perhaps to those providers who are out there to maybe choose one thing that you, your practice, your group can do to - to change how you're vaccinating flu - against flu. So, maybe it's including one different option of vaccine. Maybe it's working on a communication strategy. Maybe it's thinking about one of the outreach campaigns that Dr. Walsh mentioned in your community at the pumpkin patch or the apple orchard, or at a school event or whatever it is. Just thinking about one additional thing you could do beyond just obviously doing what you can in the office, in the hospital setting, wherever you practice. And if we can all do a little bit of those things, I think we would go a long way. All right. I think with that we'll - I appreciate Dr. Tan, Dr. Walsh, really appreciate you sharing your expertise with all of us today. My name is Ravi Jhaveri. Thank you all so much for joining us.

Dr. Walsh: Thank you.

Dr. Tan: Thank you.

Dr. Jhaveri: Is that good?

Quentin: I was not expecting it to all be one take. That was great. Yeah, that was perfect. Thank you. Yeah. Nothing more to add but-

Dr. Walsh: Excellent. So, Quentin, you'll just add, like, a closing slide that Dr. Jhaveri when he does kind of the wrap up for that.

Quentin: Yeah. Yeah. There'll be one kind of slide that's like a wrap up slide. Yeah.

Dr. Walsh: Super.

Dr. Jhaveri: It'll show us riding off into the sunset.

Quentin: Exactly. Exactly. Well, I'm looking forward to emailing Taryn and telling her that actually there are no edits, so this should be posted, actually pretty soon.

Dr. Jhaveri: Awesome. Okay.

Quentin: Yeah.

Dr. Jhaveri: Quentin, thanks to you. Tammy, thanks to you, Tina and Jennifer. Thanks so much. Really appreciate it.

Quentin: Thank you so much.

Dr. Walsh: Thanks for the opportunity.

Dr. Tan: Yeah. Thank you.

Dr. Jhaveri: All right.

Tammy (CCO): Thank you all.

Dr. Jhaveri: Take care all. I'll see you later.

Dr. Walsh: Bye.

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