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http://www.medpagetoday.com/InfectiousDisease/URItheFlu/15832

Healthy Kids Can Die from Swine Flu

By Todd Neale, Staff Writer, MedPage Today
Published: September 03, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit
for reading medical news
Action Points

* Explain to interested patients that the CDC’s Advisory Committee on Immunization Practices has recommended that all children 6 months and older — as well as caretakers of younger children — receive the H1N1 vaccine when it becomes available.

Even previously healthy children can develop severe illness and die from the 2009 H1N1 influenza (swine flu) virus, the CDC said.

Of 36 confirmed deaths in patients younger than 18, eight were in children who were 5 or older and had no chronic medical conditions, according to an article in the Sept. 4 issue of Morbidity and Mortality Weekly Report.

However, most of the children (67%) had underlying conditions that put them at risk for flu-related complications. More than 90% of these children had neurodevelopmental disorders, such as developmental delay or cerebral palsy.

The authors of the report re-emphasized the government’s recommendation that all children 6 months and older — as well as caretakers of younger children — receive the pandemic vaccine as soon as it becomes available, as stated in recent guidance from the Advisory Committee on Immunization Practices. Vaccination is also recommended for adults under 25. (See ACIP: Pregnant Women Among Top Priorities for Swine Flu Vaccine)

Vaccine is expected to be available in mid-October, CDC director Thomas Frieden, MD, MPH, said during a conference call discussing the pandemic.

He said that, as expected, cases of H1N1 infection have begun to rise with children and college students returning to school. The severity of the infections does not appear to have increased since the beginning of the outbreak in the spring, he said.

As of Aug. 8 there were 477 deaths attributed to the new H1N1 strain in the U.S., according to the MMWR report.

The median age of all fatal pediatric cases was 9 (range 2 months to 17 years), with 19% of deaths in children younger than 5.

Mortality among the youngest children was lower than that seen in recent years with seasonal influenza, according to an accompanying comment by the MMWR editors. Normally, about 40 percent of pediatric deaths caused by seasonal flu involve children under 5.

In addition, the authors said, the proportion of fatalities among children with chronic medical conditions is higher than seen with seasonal flu.

“Continued surveillance is needed to determine whether these and other differences between pediatric deaths from seasonal influenza and deaths from [new H1N1 virus] are important,” they said.

Overall, 61% of the children who died received antiviral treatment, but only four were treated within two days of illness onset.

The editors stressed that “evidence for benefits from antiviral treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset.”

Bacterial infections were common among the children who died, occurring in 43% of youngsters whose lab results were available — including all six who were older than 5 and were free from chronic medical conditions.

This suggests, according to the editors, “that bacterial infection, in combination with [infection with the pandemic virus], can result in severe disease in children who might be otherwise healthy.”

They noted that “empiric antibacterial therapy, when indicated, should be directed at likely pathogens associated with influenza, such as S. aureus, S. pneumoniae, and S. pyogene.”

They said the findings were subject to at least five limitations:

* Pandemic flu-related pediatric deaths might be underestimated because of low levels of testing and under-reporting of cases.
* Differences in case ascertainment limit the comparison of these findings with similar reports involving seasonal flu.
* Some chronic medical conditions might be under-reported because they are not listed specifically on the case report form.
* Some children could have been misclassified because of incomplete data on antiviral treatment and testing for bacteria.
* The severity of the neurodevelopmental conditions could not be determined because medical records were not reviewed.