Influenza vaccination in children with neurologic or neurodevelopmental disorders

doi:10.1016/j.vaccine.2015.03.050

Vaccine

Volume 33, Issue 20, 11 May 2015, Pages 2322-2327

https://doi.org/10.1016/j.vaccine.2015.03.050 Get rights and content

Abstract

Background

Children with neurologic or neurodevelopmental disorders (NNDDs) are at increased risk of complications from influenza. Although the Advisory Committee on Immunization Practices (ACIP) has recognized NNDDs as high-risk conditions for influenza complications since 2005, little is known about influenza vaccination practices in this population.

Methods

CDC collaborated with Family Voices, a national advocacy group for children with special healthcare needs, to recruit parents of children with chronic medical conditions. Parents were surveyed about their knowledge, attitudes, and practices surrounding influenza vaccination. The primary outcome of interest was parental report of vaccination, or intent to vaccinate, at the time of survey participation. CDC also collaborated with the American Academy of Pediatrics to recruit primary care and specialty physicians who provide care for high-risk children, specifically those with neurologic conditions. The primary outcome was physician recognition of ACIP high-risk influenza conditions.

Results

2138 surveys were completed by parents of children with high-risk conditions, including 1143 with at least one NNDD. Overall, 50% of children with an NNDD were vaccinated, or their parents planned to have them vaccinated against influenza. Among all 2138 children, in multivariable analysis, the presence of a respiratory condition and prior seasonal influenza vaccination was significantly associated with receipt or planned current season influenza vaccination, but the presence of an NNDD was not. 412 pediatricians completed the provider survey. Cerebral palsy was recognized as a high-risk influenza condition by 74% of physician respondents, but epilepsy (51%) and intellectual disability (46%) were less commonly identified.

Conclusions

Our estimates of influenza vaccination in children with NNDDs are comparable to published reports of vaccination in healthy children, which continue to be suboptimal. Education of parents of children with NNDDs and healthcare providers about influenza and the benefit of annual influenza vaccination is needed.

Introduction

Seasonal influenza epidemics are associated with an estimated average of more than 200,000 hospitalizations and 3400–49,000 deaths among all age groups in the U.S. annually [1], [2] The burden of disease is especially high among young children and those with certain chronic medical conditions. Since 2005, the Advisory Committee on Immunization Practices (ACIP) has included cognitive dysfunction, spinal cord injuries, seizure disorders, and other neuromuscular disorders as high-risk conditions for complications associated with influenza [3]. Such neurologic and neurodevelopmental conditions are associated with higher rates of influenza-associated respiratory failure and death [4], [5]. One-third of reported pediatric influenza-associated deaths among children with documented medical histories between 2004 and 2012 in the U.S. occurred in children with neurologic disorders [6]. This was even more evident during the 2009 H1N1 influenza pandemic; of 343 pediatric deaths associated with laboratory-confirmed 2009 H1N1 virus infection in the U.S., 146 (43%) had at least one known underlying neurologic or neurodevelopmental disorder (NNDD) [7]. Among these 146 children, neurodevelopmental disorders – specifically intellectual disability (111, 76%) and cerebral palsy (51, 35%) – and epilepsy (74, 51%) predominated.

While several studies have focused on influenza vaccination practices among high-risk children and their healthcare providers, most have focused on children with asthma and have not included those with NNDDs [8], [9], [10], [11]. To better understand influenza vaccination practices among these children, the Centers for Disease Control and Prevention (CDC) conducted surveys of parents of children with NNDDs and healthcare providers who care for children with NNDDs. To our knowledge, this is the first study of influenza vaccination among children with NNDDs.

Section snippets

Parent survey

CDC collaborated with Family Voices (FV) (www.familyvoices.org), a national advocacy group for children with special healthcare needs, to recruit parents of children with chronic medical conditions. An on-line survey was distributed to members of the FV listservs and administered from September 6 to October 24, 2011 in both English and Spanish. Surveys were disseminated by individual FV chapters in all 50 states and the District of Columbia. Parents or other caregivers were queried about their

Child characteristics

2138 surveys were completed by parents of children with 4045 high-risk conditions for a median of one condition per child. 1143 (53%) children had at least one NNDD; 516 had more than one. Specific diagnoses included 950 children with intellectual disability (ID), 359 with epilepsy (EP), and 271 with cerebral palsy (CP). 524/2138 (25%) children had at least one underlying chronic respiratory condition including 455 with asthma, 60 with bronchopulmonary dysplasia, and 85 with other chronic lung

Discussion

Annual influenza vaccination is recommended for all children aged ≥6 months in the U.S, with emphasis on those children in certain high-risk groups [13]. However, influenza vaccine coverage among children has been modest – with approximately half of all eligible children vaccinated during the 2011–2012 influenza season [12]. Our data from the same influenza season suggest similar vaccine uptake among children with NNDDs despite the fact that they are at increased risk for poor outcomes from

Conclusions

We present the first estimates of seasonal influenza vaccination among children with NNDDs, and a preliminary view of the influenza vaccine-related attitudes, beliefs, and practices of parents and healthcare providers of these children. Although children with NNDDs are at increased risk of influenza complications, our estimates of influenza vaccination are similar to published reports of vaccine coverage in healthy children. Education of parents and healthcare providers about influenza and the

Funding

This research was performed in cooperation with the Oak Ridge Institute for Science and Education (ORISE) through an interagency agreement between the U.S. Department of Energy and the Centers for Disease Control and Prevention.

Acknowledgment

The authors would like to thank Dick Tardif, Janice Watkins and Adina de Coteau from ORISE for their assistance in survey design and preliminary data analyses. The authors also thank staff from Family Voices and the American Academy of Pediatrics for their assistance in survey distribution.

Conflict of interest: M.J.S. has received research support for vaccine clinical trials from Sanofi and Novartis. All authors have no conflict of interest.

References (16)

C. Brown et al.
Validity of parental report of influenza vaccination in young children seeking medical care
Vaccine
(2011)
Estimates of deaths associated with seasonal influenza – United States, 1976–2007
MMWR Morb Mortal Wkly Rep
(2010)
W.W. Thompson et al.
Influenza-associated hospitalizations in the United States
J Am Med Assoc
(2004)
S.A. Harper et al.
Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP)
MMWR Recomm Rep
(2005)
R. Keren et al.
Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection
J Am Med Assoc
(2005)
C.O. Eriksson et al.
Risk factors for mechanical ventilation in US children hospitalized with seasonal influenza and 2009 pandemic influenza A
Pediatr Crit Care Med
(2012)
K.K. Wong et al.
Influenza-associated pediatric deaths in the United States, 2004–2012
Pediatrics
(2013)
L. Blanton et al.
Neurologic disorders among pediatric deaths associated with the 2009 pandemic influenza
Pediatrics
(2012)

There are more references available in the full text version of this article.

Cited by (26)

Vaccine Preventable Diseases in Pediatric Palliative Care – A Multicenter Cross-Sectional Study
2023, Journal of Pain and Symptom Management
Citation Excerpt :
To our knowledge there were no studies on the frequency or burden of vaccine preventable diseases and immunization rates in pediatric palliative home care. A small body of research has examined vaccination among chronically ill children, but mostly include patients without life-limiting disease.1-6 Compared to the general population vaccination gaps were seen in children with neurodevelopmental diseases,1-4 cerebral palsy,7 spina bifida,8 or cystic fibrosis.9
Vaccine preventable diseases lead to distressful symptoms and complications among pediatric patients receiving specialized home palliative care. There was no data on the vaccination compliance.
The objective was to determine the vaccination coverage, discuss the relevance of vaccinations and provide vaccination recommendations in pediatric palliative care.
Vaccination data were compared in a multicenter cross-sectional study. Expert interviews were conducted to evaluate symptom burden. The vaccination status of patients treated by six German pediatric specialized home palliative care teams was recorded from January 2019 to December 2019. The data were compared to the national immunization schedule and the vaccination rate of a representative German pediatric cohort. Onset of missed vaccination was compared to the date of diagnosis of the life-limiting condition. A risk score was calculated to evaluate the relevance of each individual vaccinations.
Vaccination rates of Tdpa, haemophilus influenzae type B, poliomyelitis, hepatitis B, pneumococcal disease, meningococcal diseases type C, and MMR were lower compared to healthy controls. There were no significant differences in varicella. In most cases the discontinuation of recommended immunizations occurred after diagnosis of the palliative condition. Influenza had the highest risk score and was the most frequent vaccine preventable disease in retrospective data. This paper includes a pragmatic proposal for the management of vaccination in this vulnerable population.
Children and adolescents with life-limiting conditions are at increased risk of vaccine preventable diseases. Individual vaccination counselling is recommended.
Seasonal influenza vaccine uptake among adults with disabilities in Korea
2023, Disability and Health Journal
Previous research on vaccination among people with disabilities has focused on children or adolescents.
To examine variations in seasonal influenza vaccination (SIV) uptake according to disability type and age group and explore the vulnerable groups and risk factors of non-vaccination to identify areas of policy support in Korea.
This pooled cross-sectional study included adults who participated in the 2011, 2014, and 2017 National Survey of Persons with Disabilities. The dependent variable was SIV uptake. Age-stratified multivariate logistic regression was conducted to assess its relationship with disability characteristics.
Among 18,069 adults with disabilities, the overall SIV uptake rate increased with age (33.8%, 50.1%, and 85.3% in 20–49, 50–65, and ≥65 years, respectively). In the multivariate analyses (reporting the adjusted odds ratio and 95% confidence interval), severe disability was associated with lower and higher SIV uptake rates in older adults and younger age-groups (0.88, 0.76–1.01; 1.62, 1.42–1.86; and 1.54, 1.24–1.92 in those aged ≥65; 50–64; and 20–49 years), respectively. Health behaviors (regular doctor visits, general health examinations, and non-smoking) were significantly associated with higher odds of SIV uptake. After adjusting for covariates (age, medical conditions, functional ability, and behavioral factors), individuals with brain, epileptic, and psychiatric disabilities showed lower odds of SIV uptake compared to those with internal organ disabilities across all age groups.
Policy initiatives that can improve the health behaviors of people with disabilities (especially the elderly and people with intellectual, brain, epilepsy, and psychiatric disabilities) to promote SIV uptake are needed.
Movement disorders, cerebral palsy and vaccination
2022, European Journal of Paediatric Neurology
Citation Excerpt :
There are a limited number of studies about vaccination in patients with neurological disabilities [4,12–14]. In addition, usually only a subgroup of children with cerebral palsy, is mentioned in these studies, while other neurological conditions leading to movement disorders are not differentiated [2,15,16]. Several studies have shown that children with cerebral palsy do not receive age-appropriate childhood vaccinations [2,15,17].
This review focused on vaccination in children with movement disorders, including cerebral palsy and the movement disorders triggered by vaccination in children with and without neurological disabilities. The following clinical questions were addressed: 1) Can children with movement disorders be vaccinated? 2) Can vaccination trigger movement disorders in children without neurological disabilities? 3) Can vaccination trigger movement disorders in children with neurological disabilities? and 4) Is there any consensus of care concerning vaccination in children with movement disorders? Following the PRISMA reporting guidelines, 1096 records were identified and 34 relevant papers were included. No evidence that vaccinations are contraindicated for children with movement disorders was noticed. Several reports of neurological adverse events, including movement disorders in children without neurological disabilities after various types of vaccination, were found. The reporting rates were low, the causality was controversial, and patient outcomes were mostly favourable. There was limited (if any) evidence in our search that any vaccination leads to any movement disorder exacerbation. Finally, no generally accepted consensus or standards of care concerning vaccination in patients with movement disorders were found. In summary, we found few precautions for vaccination in this group of patients and concluded that general best practice guidelines for immunization should be followed. In addition, influenza and pneumococcal vaccines are recommended because they can reduce morbidity and mortality in individuals severely affected by movement restrictions.
Crisis of confidence in vaccination and the role of social media
2022, European Journal of Paediatric Neurology
Citation Excerpt :
The immunization status of children with neurological disorders has not received sufficient attention, this being reflected in the scarcity of publications on this topic. A few papers the search retrieved on this subject revealed that vaccination rate among children with epilepsy and other chronic neurological diseases was significantly lower than in healthy children [49–56]. Only one study showed similar vaccination coverage between children with chronic neurological disorders and the population of healthy children, but most of the patients were incompletely immunized [57].
The aim of this paper is to review the current situation of vaccine hesitancy, with emphasis on children with neurological disorders, and to present the role social media plays in this situation.
A literature review using the following search words was performed: vaccine∗ OR immune∗ AND hesitancy OR confidence AND social media.
The search retrieved 277 results; 17 duplicates and 234 irrelevant articles were excluded. 43 articles were fully analyzed.
An increasing number of parents are becoming vaccine hesitant. Their motives are complex and nuanced and involve factors related to vaccine safety and efficiency, perceived personal risks and benefits, socio-demographic and psychological characteristics. Attitudes toward vaccination differ in adolescents from their parents. In children with neurological disorders, factors involved in vaccination decision included physicians' knowledge of neurological diseases and parents’ concerns that vaccination would exacerbate the chronic disorder. Unfortunately, the current pandemic is associated with an increase in vaccine hesitancy and brought forward unique determinants. The social media platforms can be a tool for the anti-vaccine movement to spread misinformation, but it can also be valued as a way for promoting health and pro-vaccine information.
Status epilepticus outcomes among vaccinated and unvaccinated children: A population-based study
2022, Epilepsy and Behavior
To determine the proportion of first status epilepticus (SE) cases that are vaccine-proximate (VP-) and compare clinical outcomes to non-vaccine-proximate (NVP-) cases.
Birth records for 1,440,807 Australian children born in 1998–2012, were probabilistically linked to hospitalizations, deaths, and vaccination history available to 2013. First SE coded hospitalizations were categorized as VP-SE or NVP-SE; clinical severity and post-SE vaccination coverage were compared. SE rates were calculated.
Of 867 first SE cases (7.9 per 100,000 person-years), 31 (3.6%) were VP-SE; 16 followed dose-1 measles vaccine (1.2 SE per 100,000 doses). Compared with NVP-SE, VP-SE cases were younger (1.0 vs 2.6 years, P < 0.0001) and had longer hospitalizations (4 vs 3 days, P = 0.005). There was no difference in the proportion of VP-SE cases with a coinfection diagnosis compared to NVP-SE (25.8% vs 19.9%, P = 0.42). Controlling for age and history of hospitalization for a neurological condition, intensive care unit (ICU) admission had a stronger association with coinfection (aOR 2.52 (95%CI 1.78–3.57)) than having VP-SE (aOR 1.41 (0.66–3.01)). Groups had similar SE recurrence rates at 12-months (12.9% VP vs 16.9% NVP, P = 0.56) and reduced vaccine uptake following initial SE (from 93.5% to 56.3%).
Proportionally few first SE cases were VP-SE, with higher ICU admission rates mostly explained by younger age and higher coinfection rates. Vaccination plans are needed to improve vaccine uptake following SE.
Prevalence, Risk Factors, and Outcomes of Influenza-Associated Neurologic Complications in Children
2021, Journal of Pediatrics
Citation Excerpt :
Our findings emphasizing the strategic importance of influenza immunization and treatment in this high-risk population40 provide targets for immediate, actionable changes in clinical practice.
To determine the frequency of neurologic complications associated with influenza in hospitalized children.
We performed a cross-sectional study of children (2 months through 17 years of age) with influenza discharged from 49 children's hospitals in the Pediatric Health Information System during the influenza seasons of 2015-2020. Neurologic complications were defined as encephalopathy, encephalitis, aseptic meningitis, febrile seizure, nonfebrile seizure, brain abscess and bacterial meningitis, Reye syndrome, and cerebral infarction. We assessed length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, 30-day hospital readmissions, deaths, and hospital costs associated with these events. Patient-level risk factors associated with neurologic complications were identified using multivariable logistic regression.
Of 29 676 children hospitalized with influenza, 2246 (7.6%) had a concurrent diagnosis of a neurologic complication; the most frequent were febrile seizures (5.0%), encephalopathy (1.7%), and nonfebrile seizures (1.2%). Hospital LOS, ICU admission, ICU LOS, deaths, and hospital costs were greater in children with neurologic complications compared with those without complications. Risk factors associated with neurologic complications included male sex (aOR 1.1, 95% CI 1.02-1.21), Asian race/ethnicity (aOR 1.7, 95% CI 1.4-2.1) (compared with non-Hispanic White), and the presence of a chronic neurologic condition (aOR 3.7, 95% CI 3.1-4.2).
Neurologic complications are common in children hospitalized with influenza, especially among those with chronic neurologic conditions, and are associated with worse outcomes compared with children without neurologic complications. These findings emphasize the strategic importance of influenza immunization and treatment, especially in high-risk populations.

View all citing articles on Scopus

^☆: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

View full text

Influenza vaccination in children with neurologic or neurodevelopmental disorders☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Parent survey

Child characteristics

Discussion

Conclusions

Funding

Acknowledgment

Vaccine

Estimates of deaths associated with seasonal influenza – United States, 1976–2007

MMWR Morb Mortal Wkly Rep

Influenza-associated hospitalizations in the United States

J Am Med Assoc

Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Recomm Rep

Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection

J Am Med Assoc

Risk factors for mechanical ventilation in US children hospitalized with seasonal influenza and 2009 pandemic influenza A

Pediatr Crit Care Med

Influenza-associated pediatric deaths in the United States, 2004–2012

Pediatrics

Neurologic disorders among pediatric deaths associated with the 2009 pandemic influenza

Pediatrics