AAP Guidelines Updated for Influenza Vaccination in 2008-2009 Season

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

Release Date: October 14, 2008


October 14, 2008 — The American Academy of Pediatrics (AAP) has issued updated guidelines for routine use of influenza vaccine in children and adolescents in the 2008 to 2009 influenza season, according to a statement reported in the October 1 Early Release issue of Pediatrics. This update revises guidelines originally published in a comprehensive format in Pediatrics in April 2008.


The AAP recommends annual influenza immunization for all children aged 6 months through 18 years, including those who are healthy and those who have high-risk conditions; for household contacts and out-of-home care providers of children with high-risk conditions or of healthy children younger than 5 years; for any woman who will be pregnant during influenza season; and for healthcare professionals.

Since the April 2008 guidelines, the recommended age range of children for annual influenza immunization has been expanded in these updated guidelines to include all children aged 6 months through 18 years.

“This expansion targets all school-aged children, the population that bears the greatest disease burden and is at significantly higher risk of needing influenza-related medical care compared with healthy adults,” write AAP chairperson Joseph A. Bocchini, Jr, MD, and colleagues. “In addition, reducing influenza transmission among school-aged children will, in turn, reduce transmission of influenza to household contacts and community members.”

This expanded indication now means that the following groups should be vaccinated:


  • All children who are at greater risk for influenza complications, such as those who are immunosuppressed or who have chronic medical conditions.

  • All healthy children aged 6 through 59 months.

  • If feasible, all children aged 5 through 18 years should be vaccinated in the 2008 to 2009 influenza season. If not, these children should be routinely vaccinated no later than the 2009 to 2010 season.

  • Household members and out-of-home care providers of all children at high risk and adolescents and all healthy children younger than 5 years should also receive influenza vaccine annually to lower the risk for exposure to influenza for these young children, who are at serious risk for influenza infection, hospitalization, and sequelae. In healthy children younger than 24 months, the risk for influenza-associated hospitalization is at least as great as the risk in previously recognized high-risk groups. Furthermore, children aged 24 through 59 months have greater morbidity and higher rates of outpatient visits and antibiotic use related to influenza illness.


Influenza vaccine has not been approved for use in infants younger than 6 months. Clinicians should identify all children aged 6 months through 18 years, especially those at increased risk for complications related to influenza, and should inform their parents when annual influenza immunization is due.

All 3 strains in the 2008 to 2009 influenza vaccines are different from the 2007 to 2008 vaccine strains on the basis of global surveillance of circulating influenza strains.

Healthy children aged 2 through 18 years can receive either trivalent inactivated influenza vaccine (TIV) or live-attenuated influenza vaccine (LAIV).

Age determines the number of influenza vaccine dose(s) to be administered, as follows:


  • Children aged at least 9 years who have not previously received the influenza vaccine require only 1 dose in their first season of immunization.

  • Any child younger than 9 years who is vaccinated against influenza for the first time should receive a second dose at least 4 weeks after the first.

  • Children younger than 9 years who received only 1 dose of influenza vaccine in the first season they were vaccinated should receive 2 doses of influenza vaccine the following season. This recommendation applies only to the influenza season after the first year that a child younger than 9 years is vaccinated against influenza.


For the 2008 to 2009 influenza season, oseltamivir or zanamivir are still the antiviral medications recommended for chemoprophylaxis or treatment. Because of widespread resistance among some circulating influenza A virus strains, and lack of efficacy against influenza B strains, amantadine or rimantadine should not be prescribed for treatment or chemoprophylaxis of influenza. Oseltamivir resistance has been reported but it is still very limited, so current antiviral treatment recommendations have not changed.

As soon as the influenza vaccine is available, it should be offered to all children, and immunization efforts should continue throughout the entire influenza season, even after influenza activity has been documented in a community. There may be more than 1 peak of activity during the same influenza season, which often extends into March and beyond. Immunization through May 1 can still protect vaccinees during that season and facilitates administration of a second dose of vaccine to children who require 2 doses during that season.

“Health care professionals, influenza campaign organizers, and public health agencies should cooperate to develop plans for expanding outreach and infrastructure to achieve the target immunization of all children 6 months through 18 years of age, beginning no later than the 2009-2010 influenza season,” the guidelines authors conclude. “Concerted effort among the aforementioned groups, plus vaccine manufacturers, distributors, and payers, also is necessary to appropriately prioritize administration of influenza vaccine whenever vaccine supplies are delayed or limited.”

Pediatrics. Published online October 1, 2008.

Clinical Context

The 2007 to 2008 guidelines for influenza immunization of children were published in the April 2008 issue of Pediatrics by the AAP Committee on Infectious Diseases. This statement from the AAP updates the recommendations for influenza immunization in children and adolescents for the 2008 to 2009 season.

Study Highlights


  • The 2008-2009 influenza vaccine contains H1N1 and H3N2 influenza A subtype strains and 1 influenza B strain, which are different from last year’s strains.

  • Annual influenza immunization is recommended for the following:



    • Children with chronic medical conditions or immunosuppression

    • Healthy children aged 6 through 59 months

    • Healthy children aged 5 to 18 years (at least by 2009-2010 season)

    • Household contacts and out-of-home care providers of healthy children younger than 5 years and children with high-risk conditions

    • Any woman who will be pregnant during influenza season

    • Healthcare professionals



  • Healthy children younger than 24 months have same or greater risk for influenza-associated hospitalization vs children with high-risk conditions.

  • Children aged 24 to 59 months have increased outpatient visits and antibiotic use from influenza.

  • Children younger than 9 years receiving their first influenza vaccine should receive a second influenza vaccine after a 4-week interval.

  • Children younger than 9 years who only received 1 influenza vaccine in the first season should get 2 doses in the second season.

  • The recommended medications for influenza prophylaxis or treatment are oseltamivir or zanamivir.

  • Amantadine or rimantadine treatment is not recommended because of resistance.

  • Influenza season begins in November, peaks in February, and extends through May.

  • Influenza vaccine can be given through May 1.

  • Preparation of both TIV and LAIV involves eggs.

  • TIV, a split-virus vaccine, is given intramuscularly to persons aged at least 6 months.

  • The most common TIV symptoms are injection site soreness, fever usually within 24 hours, and mild systemic symptoms.

  • LAIV is given in each nostril to persons aged 2 through 49 years who do not have excessive nasal congestion.

  • LAIV symptoms include mild influenza-related signs and symptoms.

  • One study found LAIV vs TIV had better efficacy in infants and young children without severe asthma or recent wheezing.

  • The incidence of autism spectrum disorders has not been found to be related to thimerosal-containing vaccines.

  • Thimerosal is not present in LAIV and some types of TIV.

  • Contraindications to both TIV and LAIV include moderate to severe febrile illness; a history of hypersensitivity to any vaccine component, including eggs; and a history of Guillain-Barré syndrome.

  • Contraindications to LAIV include live vaccine administration in the past 4 weeks; chronic pulmonary or cardiovascular disorders, including asthma and reactive airways disease; medical conditions, including metabolic disease, diabetes, renal dysfunction, and hemoglobinopathy; immunodeficiency; salicylate use; pregnant adolescents; and conditions that affect respiratory function, handling of secretions, or aspiration risk, including cognitive dysfunction, spinal cord injury, and seizures.

  • The following precautions should be taken:



    • Children younger than 5 years with recurrent wheezing or wheezing in the past 12 months should not receive LAIV.

    • Children with immunocompromised contacts should receive TIV or restrict contact up to 7 days after LAIV.





Pearls for Practice


  • Influenza immunization is recommended for all children from ages 6 months to 18 years, household contacts and out-of-home care providers of healthy children younger than 5 years and children with high-risk conditions, any woman who will be pregnant during influenza season, and healthcare professionals.

  • Contraindications to influenza vaccine are moderate to severe febrile illness, hypersensitivity to eggs or any components of the vaccine, and a history of Guillain-Barré syndrome. TIV is contraindicated in children younger than 6 months. Contraindications to LAIV include children younger than 2 years, live vaccine within past 4 weeks, chronic pulmonary or cardiovascular disorders including asthma, underlying medical conditions, immunodeficiency, aspirin use, pregnant adolescents, and conditions that compromise handling of secretions or aspiration risk.


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