As the 2020/21 influenza season is poised to collide with a cold-weather surge in COVID-19 transmission, the American Academy of Pediatrics (AAP) strongly recommends that all eligible children 6 months of age and older receive their flu vaccinations by the end of October.

Immunization with any licensed, age-appropriate influenza vaccine — intranasal or injectable — is acceptable, the AAP's Committee on Infectious Diseases states in the updated recommendations. The policy statement is published online today in Pediatrics.

"We are concerned that children have their protection in place before the flu season gets underway, which usually happens after Halloween, especially since we need to be prepared for some challenges in accessing doctors' offices and hospital beds this year. We have no good sense of what will be happening in communities or what the winter will look like in terms of other seasonal viruses," lead author Flor Munoz, MD, an associate professor of pediatrics (infectious diseases) at Baylor College of Medicine in Houston, Texas, told Medscape Medical News.

"This year's recommendations are in accord with those of the Centers for Disease Control and Prevention and are very similar to last year's, but the vaccines themselves have changed," Munoz said.

Among changes for the 2020-2021 season:

• All pediatric vaccines are now quadrivalent.

• Three of the strains are new, including the recommended influenza A(H1N1)pdm09 and A(H3N2) components and the influenza B/Victoria component. The B/Yamagata component remains unchanged from 2019-2020.

• Formulations available for children ages 6 months to 35 months have been updated. Afluria Quadrivalent will be the only vaccine for children in that age range, with a dosing volume of 0.25 mL. Fluzone Quadrivalent, licensed in 0.25-mL and 0.5-mL dosing volumes, will likely be available only in a 0.5-mL dosing volume for this age group. The dosing volume for Fluarix and FluLaval, the two other vaccines available for this age group, is 0.5 mL.

• The AAP does not recommend one product over another but advises pediatricians to give whichever formulation is available in their communities to ensure the greatest possible coverage for the influenza season.

• Children ages 6 months to 8 years of age receiving influenza vaccine for the first time, who have had only one dose ever before July 1, 2020, or whose vaccination status is unknown, should be immunized as soon as vaccines become available. They should receive two doses, ideally by the end of October. Regardless of age, those needing only one dose should also be vaccinated by the end of October.

• The contraindications for live attenuated influenza vaccine (LAIV) have been updated to align with recommendations from the CDC's Advisory Committee on Immunization Practices. Although no additional safety risks have been reported with LAIV among children with immunodeficiencies, anatomic or functional asplenia (absence of spleen), cochlear implants, or active cerebrospinal fluid leaks, the LAIV is not recommended for these groups.

According to the CDC, 188 children and adolescents under age 19 years died of influenza complications during last year's flu season. Typically, approximately 80% of children who die from influenza were unvaccinated.

Munoz notes that as with other infections, once a child has recovered from COVID-19, there would be no contraindication to receiving the influenza vaccine.

But the two infections can initially be indistinguishable based on clinical symptoms alone. "Indeed, this is why testing and treating for influenza is important as soon as symptoms begin, and this is why preventing flu by vaccination is so important as well," Munoz said.

In the unfortunate event that a child contracts both viruses at the same time, she added,  "Lots of things can happen, but none of them good. Having them at the same time or one after another is potentially seriously damaging to the lungs."

On a positive note, Munoz said, the masking, distancing, and sanitization precautions taken to ward off COVID-19 may reduce the incidence of other winter infections, such as flu, colds, and gastroenteritis. "Countries in the Southern Hemisphere, like Argentina, Chile, South Africa, and also Australia and New Zealand, that have already had their winter season, have noticed a very substantial decrease in infections over last year," she said.

However, Munoz says she is less optimistic about the capacity of such infection-control measures to curb infection rates in the United States because of its geographical size and diverse population.

This policy statement received no specific funding. Munoz has reported a royalties relationship with Up to Date, Pfizer, and Moderna as well as ties to Biocyst, the European Society of Pediatric Infectious Diseases, and the International Neonatal and Maternal Immunization Symposium.

Pediatrics. Published online September 8, 2020. Full text

Diana Swift is a medical journalist based in Toronto, Canada. dianaswift@rogers.com

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Cite this: AAP: Kids Should Receive Flu Vaccinations By the End of October - Medscape - Sep 08, 2020.