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  • Cost-effectiveness of Strategies for Offering Influenza Vaccine in the Pediatric Emergency Department

    Abstract Full Text
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    JAMA Pediatr. 2017; :e173879. doi: 10.1001/jamapediatrics.2017.3879

    This cost-effectiveness analysis compares 4 strategies for pediatric emergency department–based influenza vaccine: offering vaccine to all patients, only to patients younger than 5 years, only to high-risk patients (all ages), or to no patients.

  • JAMA Pediatrics March 1, 2017

    Figure: Data on Prescribing Antivirals for Children Hospitalized With Influenza

    A, Temporal trends in prescribing antivirals for hospitalized children with influenza, 2009-2015. B, Variability by hospital in prescribing antivirals among all children hospitalized with influenza (gray bars) and those with high-risk conditions (orange line) from 2009 to 2015.
  • Limited and Variable Use of Antivirals for Children Hospitalized With Influenza

    Abstract Full Text
    JAMA Pediatr. 2017; 171(3):299-301. doi: 10.1001/jamapediatrics.2016.3484

    This study reports on the patterns of antiviral use among hospitalized children with influenza, including those with high-risk conditions.

  • Association Between Influenza Infection and Vaccination During Pregnancy and Risk of Autism Spectrum Disorder

    Abstract Full Text
    online only
    JAMA Pediatr. 2017; 171(1):e163609. doi: 10.1001/jamapediatrics.2016.3609

    This cohort study examines the association between maternal influenza infection and vaccination during pregnancy and risk for autism spectrum disorder in children.

  • Infant Protection Against Influenza Through Maternal Immunization: A Call for More Immunogenic Vaccines

    Abstract Full Text
    JAMA Pediatr. 2016; 170(9):832-833. doi: 10.1001/jamapediatrics.2016.1322
  • Duration of Infant Protection Against Influenza Illness Conferred by Maternal Immunization: Secondary Analysis of a Randomized Clinical Trial

    Abstract Full Text
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    JAMA Pediatr. 2016; 170(9):840-847. doi: 10.1001/jamapediatrics.2016.0921

    This secondary analysis of a vaccine efficacy trial evaluates the duration of infant protection against influenza conferred by maternal immunization.

  • JAMA Pediatrics September 1, 2016

    Figure 1: Flow Diagram Representing the Number of Infants Analyzed at the Different Immunogenicity Visits

    Participants were excluded from the analysis for the relevant strain from the current visit onward. A laboratory-confirmed episode of influenza illness (confirmed by serology or polymerase chain reaction) occurred in the interval between the previous visit and the current visit. IIV3 indicates trivalent inactivated influenza vaccine.
  • JAMA Pediatrics October 1, 2015

    Figure 1: Prevalence of Comorbid Conditions Among Patients Requiring Hospitalization for Influenza A Virus Infection During the 2012-2013 Influenza Season

    Children who were hospitalized with influenza were significantly less likely to have had a preexisting medical condition before their hospitalization compared with the adult population. Data are adapted from the Centers for Disease Control and Prevention FluView website.
  • JAMA Pediatrics October 1, 2015

    Figure 2: How The Innate Immune Response to Influenza A Virus (IAV) Infection May Differ Between Children and Adults

    Viral RNA is recognized by Toll-like receptors located in the endosome, primarily TLR3 and TLR7, which activate the adaptor proteins Toll/interleukin (IL)–1 receptor domain–containing adapter-inducing interferon β (TRIF) and myeloid differentiation primary response gene 88 (MyD88), respectively. Activated TRIF and MyD88 act downstream on interferon regulatory factor 3 (IRF3), IRF7, and nuclear factor κB (NF-κB). Activated IRF3 and IRF7 translocate to the nucleus, where they stimulate transcription of the type I interferons (IFN-α/β). Nuclear factor κB serves as a transcription factor promoting production of proinflammatory cytokines and chemokines, including pro–interleukin-1β (pro–IL-1β), IL-6, IL-10, and IL-12. Alternatively, cytosolic viral RNA is recognized by retinoic acid–inducible gene I (RIG-I), which binds to its adaptor mitochondrial antiviral signaling protein (MAVS), stimulating IRF3 and NF-κB and their downstream transcription products IFN-α/β and proinflammatory cytokines. Nuclear factor κB activation, in addition to a second signal indicating cellular stress (changes in intracellular ionic concentrations, reactive oxygen species [ROS], potassium flux, etc), induces assembly of the multimeric nucleotide-binding oligomerization domain (NOD)–like receptor family, pyrin domain–containing 3 (NLRP3) inflammasome protein complex. The NLRP3 inflammasome activates caspase 1, which cleaves the proinflammatory cytokines to release their mature forms. Upward and downward arrows indicate the relative cytokine response in the young pediatric population compared with adults. The overall consequence may move away from a helper T-cell subtype 1 (TH1) response and toward a TH2- and TH17-predominant response that is more effective against extracellular pathogen clearance, leaving the young host at risk for the intracellular influenza pathogen. dsRNA indicates double-stranded RNA; ssRNA, single-stranded RNA. Illustration by Jacqueline Schaffer, MS, medical illustrator.
  • When the Health Care Worker Is Sick: Primum Non Nocere

    Abstract Full Text
    JAMA Pediatr. 2015; 169(9):809-810. doi: 10.1001/jamapediatrics.2015.0994
  • JAMA Pediatrics March 1, 2014

    Figure 1: Study Flow Diagram

    In patients receiving TIV-1, 68% of TIV-1 doses are the first influenza dose the patient received in the 2011-2012 season but not necessarily the first dose that patient ever received. In patients receiving TIV1- and PCV13, 96% of TIV-1 and PVC13 doses are the first influenza dose the patient ever received. In patients receiving PCV13, 0.9% were receiving their first dose, 2.7% their second dose, 16.4% their third dose, and 80.0% their fourth dose. In patients receiving TIV and PVC13, 0.9% were receiving their first dose of PCV13, 5.7% their second dose, 65.6% their third dose, and 35.8% at least their fourth dose. In patients receiving TIV-1 and PCV13, 1.3% were receiving their first dose of PCV13, 6.4% their second dose, 81.5% their third dose, and 10.8% their fourth dose. In patients receiving TIV-2 and PCV13, 0% were receiving their first dose, 3.6% their second dose, 20.0% their third dose, and 76.3% at least their fourth dose. PCV13 indicates 13-valent pneumococcal conjugate vaccine; TIV, trivalent inactivated influenza vaccine; TIV-1, first influenza dose that season; and TIV-2, second influenza dose that season.
  • JAMA Pediatrics February 1, 2013

    Figure: Feasibility of Web-Based Self-Triage by Parents of Children With Influenza-Like Illness: A Cautionary Tale

    Figure 1. The 2009-2010 Centers for Disease Control and Prevention and American Academy of Pediatrics Influenza Season Triage Algorithm for Children (≤18 years) With Influenza-Like Illness.
  • Influenza Coinfection and Outcomes in Children With Complicated Pneumonia

    Abstract Full Text
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    Arch Pediatr Adolesc Med. 2011; 165(6):506-512. doi: 10.1001/archpediatrics.2010.295
    Objective

    To determine the impact of influenza coinfection on outcomes for children with complicated pneumonia.

    Design

    Retrospective cohort study.

    Setting

    Forty children's hospitals that contribute data to the Pediatric Health Information System.

    Participants

    Children discharged from participating hospitals between January 1, 2004, and June 30, 2009, with complicated pneumonia requiring a pleural drainage procedure.

    Main Exposure

    Influenza coinfection.

    Main Outcome Measures

    Intensive care unit admission, receipt of mechanical ventilation, receipt of vasoactive infusions, receipt of blood product transfusions, in-hospital death, readmission within 14 days of hospital discharge, hospital length of stay, and cost of hospitalization.

    Results

    Overall, 3382 of 9680 children with complicated pneumonia underwent pleural fluid drainage; 105 patients (3.1%) undergoing pleural drainage had influenza coinfection. A bacterial pathogen was identified in 1201 cases (35.5%); the most commonly identified bacteria were Staphylococcus aureus in children with influenza coinfection (22.9% of cases) and Streptococcus pneumoniae in children without coinfection (20.0% of cases). In multivariable analysis, influenza coinfection was associated with higher odds of intensive care unit admission and receipt of mechanical ventilation, vasoactive infusions, and blood product transfusions as well as higher costs and a longer hospital stay. Children with influenza coinfection were less likely to require readmission, although there was a trend toward higher odds of mortality for patients with coinfection. In a subanalysis stratified by bacteria, outcomes remained worse for coinfected children in the subgroups of children with S aureus and with no specified bacteria.

    Conclusions

    Influenza coinfection occurred in 3.1% of children with complicated pneumonia. Clinical outcomes for children with complicated pneumonia and influenza coinfection were more severe than for children without documented influenza coinfection.

  • JAMA Pediatrics February 1, 2011

    Figure: Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants

    Geometric mean titers of strain-specific influenza hemagglutinin inhibition antibodies by vaccination status of the mother. Bars around each point on each figure indicate 95% confidence intervals; * P < .001; †Circulating strain during 2002-2003 season; ‡Vaccine strains for the 2002-2003 and 2003-2004 seasons; §Vaccine strains for the 2004-2005 season;∥Predominating influenza A H3N2 virus for 2004-2005 season; ¶Predominanting influenza B virus for 2003-2004 season.
  • Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants

    Abstract Full Text
    free access
    Arch Pediatr Adolesc Med. 2011; 165(2):104-111. doi: 10.1001/archpediatrics.2010.192
    Objective

    To assess the effect of seasonal influenza vaccination during pregnancy on laboratory-confirmed influenza in infants to 6 months of age.

    Design

    Nonrandomized, prospective, observational cohort study.

    Setting

    Navajo and White Mountain Apache Indian reservations, including 6 hospitals on the Navajo reservation and 1 on the White Mountain Apache reservation.

    Participants

    A total of 1169 mother-infant pairs with mothers who delivered an infant during 1 of 3 influenza seasons.

    Main Exposure

    Maternal seasonal influenza vaccination.

    Main Outcome Measures

    In infants, laboratory-confirmed influenza, influenzalike illness (ILI), ILI hospitalization, and influenza hemagglutinin inhibition antibody titers.

    Results

    A total of 1160 mother-infant pairs had serum collected and were included in the analysis. Among infants, 193 (17%) had an ILI hospitalization, 412 (36%) had only an ILI outpatient visit, and 555 (48%) had no ILI episodes. The ILI incidence rate was 7.2 and 6.7 per 1000 person-days for infants born to unvaccinated and vaccinated women, respectively. There was a 41% reduction in the risk of laboratory-confirmed influenza virus infection (relative risk, 0.59; 95% confidence interval, 0.37-0.93) and a 39% reduction in the risk of ILI hospitalization (relative risk, 0.61; 95% confidence interval, 0.45-0.84) for infants born to influenza-vaccinated women compared with infants born to unvaccinated mothers. Infants born to influenza-vaccinated women had significantly higher hemagglutinin inhibition antibody titers at birth and at 2 to 3 months of age than infants of unvaccinated mothers for all 8 influenza virus strains investigated.

    Conclusions

    Maternal influenza vaccination was significantly associated with reduced risk of influenza virus infection and hospitalization for an ILI up to 6 months of age and increased influenza antibody titers in infants through 2 to 3 months of age.

  • JAMA Pediatrics February 1, 2011

    Figure: Effects of Adverse Events on the Projected Population Benefits and Cost-effectiveness of Using Live Attenuated Influenza Vaccine in Children Aged 6 Months to 4 Years

    Simplified schematic of influenza cost-effectiveness simulation model. *Injection site reaction for inactivated influenza vaccine only.
  • Effects of Adverse Events on the Projected Population Benefits and Cost-effectiveness of Using Live Attenuated Influenza Vaccine in Children Aged 6 Months to 4 Years

    Abstract Full Text
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    Arch Pediatr Adolesc Med. 2011; 165(2):112-118. doi: 10.1001/archpediatrics.2010.182
    Objective

    To evaluate the effect of adverse events associated with live attenuated influenza vaccine (LAIV) in children younger than 5 years on the cost-effectiveness of influenza vaccination.

    Design

    A decision analytic model was developed to predict costs and health effects of no vaccination, vaccination with LAIV, and vaccination with inactivated influenza vaccine (IIV). Probabilities, costs, and quality adjustments for uncomplicated influenza, outpatient visits, hospitalizations, deaths, vaccination, and vaccine adverse events were based on primary and published data. The analysis included the possible increased incidence of adverse events following vaccination with LAIV for children younger than 5 years, including fever, wheezing, and hospitalization. A societal perspective was used. Sensitivity analyses, including probabilistic sensitivity analysis, were conducted.

    Setting

    Vaccination in the physician office setting in the United States.

    Participants

    Hypothetical cohorts of healthy children aged 6 months to 4 years.

    Intervention

    Vaccination with LAIV or IIV.

    Main Outcome Measure

    Incremental cost-effectiveness ratio in dollars per quality-adjusted life-year (QALY).

    Results

    Cost-effectiveness ratios ranged from $20 000/QALY (age 6-23 months) to $33 000/QALY (age 3-4 years) for LAIV and from $21 000/QALY to $37 000/QALY for IIV for healthy children aged 6 months to 4 years. Inclusion of possible new adverse events for LAIV had varying effects on cost-effectiveness results. Results were not sensitive to the inclusion of wheezing as an adverse event but were sensitive to a possible increase in the probability of hospitalization.

    Conclusion

    Live attenuated influenza vaccine had comparable cost-effectiveness compared with IIV for children younger than 5 years under a wide range of assumptions about the incidence of adverse events.

  • The Promise of Maternal Vaccination to Prevent Influenza in Young Infants

    Abstract Full Text
    Arch Pediatr Adolesc Med. 2011; 165(2):179-180. doi: 10.1001/archpediatrics.2010.193
  • Hospitalization of Children With Influenza A(H1N1) Virus in Israel During the 2009 Outbreak in Israel: A Multicenter Survey

    Abstract Full Text
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    Arch Pediatr Adolesc Med. 2010; 164(11):1015-1022. doi: 10.1001/archpediatrics.2010.195
  • Children Hospitalized With 2009 Novel Influenza A(H1N1) in California

    Abstract Full Text
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    Arch Pediatr Adolesc Med. 2010; 164(11):1023-1031. doi: 10.1001/archpediatrics.2010.203