TY - JOUR AU - Shang, Mei AU - Blanton, Lenee AU - Olsen, Sonja AU - Fry, Alicia AU - Brammer, Lynnette PY - 2017/05/02 Y2 - 2024/03/28 TI - Influenza-Associated Pediatric Deaths in the United States, 2010–2015 JF - Online Journal of Public Health Informatics JA - OJPHI VL - 9 IS - 1 SE - Data Sharing and Collaboration Strategies Across Jurisdictions DO - 10.5210/ojphi.v9i1.7656 UR - https://ojphi.org/ojs/index.php/ojphi/article/view/7656 SP - AB - <div style="left: 82.0909px; top: 292.57px; font-size: 12.9217px; font-family: sans-serif; transform: scaleX(1.08129);" data-canvas-width="58.17357070707071">Objective</div><div style="left: 95.7727px; top: 306.208px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00861);" data-canvas-width="345.3807017676767">To characterize and describe influenza-associated pediatric deaths</div><div style="left: 82.0909px; top: 321.41px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.965235);" data-canvas-width="360.3220833333336">in the United States over five influenza seasons, 2010–11 through</div><div style="left: 82.0909px; top: 336.612px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00186);" data-canvas-width="48.45643939393939">2014–15.</div><div style="left: 82.0909px; top: 365.54px; font-size: 12.9217px; font-family: sans-serif; transform: scaleX(1.11718);" data-canvas-width="75.37237626262626">Introduction</div><div style="left: 95.7727px; top: 379.177px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02239);" data-canvas-width="346.0629684343434">Community influenza infection rates are highest among children.</div><div style="left: 82.0909px; top: 394.379px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.987966);" data-canvas-width="360.60765328282866">In children, influenza can cause severe illness and complications</div><div style="left: 82.0909px; top: 409.581px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.990929);" data-canvas-width="358.43551262626266">including, respiratory failure and death. Annual influenza vaccination</div><div style="left: 82.0909px; top: 424.783px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00028);" data-canvas-width="192.7532550505051">is recommended for all persons aged</div><div style="left: 274.853px; top: 427.238px; font-size: 12.9217px; font-family: sans-serif;">≥</div><div style="left: 281.945px; top: 424.783px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00459);" data-canvas-width="155.86175252525257">6 months. In 2004, influenza-</div><div style="left: 82.0909px; top: 439.985px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.0045);" data-canvas-width="307.9115984848484">associated deaths in children became a notifiable condition.</div><div style="left: 82.0909px; top: 468.914px; font-size: 12.9217px; font-family: sans-serif; transform: scaleX(1.07279);" data-canvas-width="53.12117929292929">Methods</div><div style="left: 95.7727px; top: 482.551px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02596);" data-canvas-width="342.2252184343435">Deaths that occurred in children aged &lt;18 years with laboratory-</div><div style="left: 82.0909px; top: 497.753px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.974956);" data-canvas-width="360.49006565656555">confirmed influenza virus infection were reported from states and</div><div style="left: 82.0909px; top: 512.955px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.963164);" data-canvas-width="360.319498989899">territories to the Centers for Disease Control and Prevention on a</div><div style="left: 82.0909px; top: 528.157px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.963244);" data-canvas-width="360.33371287878805">standard case report form. We used population estimates from the</div><div style="left: 82.0909px; top: 543.359px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.03311);" data-canvas-width="359.9512300505049">U.S. Census Bureau, 2011 to 2015, to calculate age group-adjusted</div><div style="left: 82.0909px; top: 558.561px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.997667);" data-canvas-width="358.62804621212115">incidence. We used Wilcoxon-rank-sum test to compare medians and</div><div style="left: 82.0909px; top: 573.763px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.03404);" data-canvas-width="360.0171308080806">chi-square and Mantel-Haenszel chi-square to compare differences</div><div style="left: 82.0909px; top: 588.965px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00168);" data-canvas-width="184.10862626262625">between proportions of two groups.</div><div style="left: 82.0909px; top: 617.893px; font-size: 12.9217px; font-family: sans-serif; transform: scaleX(1.08458);" data-canvas-width="46.67324242424243">Results</div><div style="left: 95.7727px; top: 631.531px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01924);" data-canvas-width="342.24460101010095">From October 2010 through September 2015, 590 influenza-</div><div style="left: 82.0909px; top: 646.733px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.960714);" data-canvas-width="360.26781212121216">associated pediatric deaths were reported. The median age at time</div><div style="left: 82.0909px; top: 661.935px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.950445);" data-canvas-width="360.2820260101012">of death was 6 years (interquartile range, 1–12 years). Half of the</div><div style="left: 82.0909px; top: 677.137px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.97358);" data-canvas-width="360.32208333333324">children (285/572) had at least one underlying medical condition.</div><div style="left: 82.0909px; top: 692.339px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.985161);" data-canvas-width="360.73299393939385">Neurologic conditions (26%) and development delay (21%) were</div><div style="left: 82.0909px; top: 707.541px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.980425);" data-canvas-width="360.66580101010084">most commonly reported. The average annual incidence rate was</div><div style="left: 82.0909px; top: 722.743px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00751);" data-canvas-width="359.1281166666667">0.16 per 100,000 children (95% confidence interval [CI]: 0.15–0.17)</div><div style="left: 82.0909px; top: 737.945px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.974066);" data-canvas-width="360.69681313131343">and was highest among children aged &lt;6 months (0.75, 95% CI,</div><div style="left: 82.0909px; top: 753.147px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.07815);" data-canvas-width="363.12092727272733">0.60–0.94 per 100,000 children), followed by children aged</div><div style="left: 82.0909px; top: 768.349px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02337);" data-canvas-width="359.7147626262625">6–23 months (0.34, 95% CI, 0.28–0.41 per 100,000 children). Only</div><div style="left: 82.0909px; top: 783.551px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.994698);" data-canvas-width="230.5544464646465">21% (87/409) of pediatric deaths in children</div><div style="left: 312.642px; top: 786.005px; font-size: 12.9217px; font-family: sans-serif;">≥</div><div style="left: 319.734px; top: 783.551px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.994302);" data-canvas-width="121.08941161616164">6 months had evidence</div><div style="left: 82.0909px; top: 798.753px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.991741);" data-canvas-width="360.58051767676784">of full influenza vaccination. Vaccination coverage was lower in</div><div style="left: 82.0909px; top: 813.955px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.956791);" data-canvas-width="360.04038989898976">children aged 6–23 months (15%) and 5–8 years (17%) than with</div><div style="left: 82.0909px; top: 829.157px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.04653);" data-canvas-width="360.02488383838374">those aged 2–4 years and 9–17 years (25%, p&lt;0.01). The majority</div><div style="left: 82.0909px; top: 844.359px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.997404);" data-canvas-width="361.07671161616156">of children aged &lt;2 years who died had no underlying medical</div><div style="left: 82.0909px; top: 859.561px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.0257);" data-canvas-width="359.8142598484845">conditions (63%, 105/167); this proportion was significantly higher</div><div style="left: 82.0909px; top: 874.763px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00196);" data-canvas-width="134.57968434343437">than that in children aged</div><div style="left: 216.646px; top: 877.217px; font-size: 12.9217px; font-family: sans-serif;">≥</div><div style="left: 223.738px; top: 874.763px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00169);" data-canvas-width="167.34915909090907">2 years (45%, 182/405, p&lt;0.01).</div><div style="left: 95.7727px; top: 889.965px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.0083);" data-canvas-width="347.57739368686856">Overall 65% (383) of pediatric deaths had influenza A virus</div><div style="left: 82.0909px; top: 905.167px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01567);" data-canvas-width="359.3762136363637">detected, and 33% had influenza B virus detected. Children infected</div><div style="left: 82.0909px; top: 920.369px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02404);" data-canvas-width="361.8119573232317">with influenza B virus had a higher frequency of sepsis/shock</div><div style="left: 82.0909px; top: 935.571px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.980975);" data-canvas-width="360.6554636363635">(41%, 72/174), acute respiratory distress syndrome (ARDS, 33%,</div><div style="left: 82.0909px; top: 950.773px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.992133);" data-canvas-width="358.62287752525236">58/174), and hemorrhagic pneumonia/pneumonitis (8%, 14/174) than</div><div style="left: 82.0909px; top: 965.975px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00959);" data-canvas-width="359.12811666666676">children infected with either influenza A(H1N1) pdm09 or influenza</div><div style="left: 82.0909px; top: 981.177px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00181);" data-canvas-width="257.06464141414136">A(H3N2) virus (p=0.01, 0.03, 0.03, respectively).</div><div style="left: 95.7727px; top: 996.379px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.982307);" data-canvas-width="346.99979292929277">Overall 81% (421/521) of children had an influenza-associated</div><div style="left: 82.0909px; top: 1011.58px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01729);" data-canvas-width="359.66178358585864">complication; the most commonly reported were pneumonia (40%),</div><div style="left: 82.0909px; top: 1026.78px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.983517);" data-canvas-width="360.6063611111113">sepsis/shock (31%) and ARDS (29%). Among those with testing</div><div style="left: 82.0909px; top: 1041.99px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.027);" data-canvas-width="361.6400984848487">reported, invasive bacteria coinfections were identified in 43%</div><div style="left: 82.0909px; top: 1057.19px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02711);" data-canvas-width="59.26416363636365">(139/322);</div><div style="left: 143.354px; top: 1059.64px; font-size: 12.9217px; font-family: sans-serif;">β</div><div style="left: 150.594px; top: 1057.19px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02689);" data-canvas-width="60.68942904040405">-hemolytic</div><div style="left: 213.283px; top: 1057.19px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.02885);" data-canvas-width="74.42004570707071">Streptococcus</div><div style="left: 287.692px; top: 1057.19px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.965396);" data-canvas-width="67.83513863636367">(20%) and</div><div style="left: 355.516px; top: 1057.19px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01623);" data-canvas-width="85.5327224747475">Staphylococcus</div><div style="left: 82.0909px; top: 1072.39px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.04526);" data-canvas-width="35.17291414141415">aureus</div><div style="left: 117.266px; top: 1072.39px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00598);" data-canvas-width="198.07700252525257">(17%) were reported most frequently.</div><div style="left: 95.7727px; top: 1087.59px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.97697);" data-canvas-width="347.035973737374">Most children (39%, 212/548) died within 3 days of symptom</div><div style="left: 82.0909px; top: 1102.79px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.943151);" data-canvas-width="285.2559517676766">onset, 28% died 4–7 days after onset, and 34% died</div><div style="left: 367.362px; top: 1105.25px; font-size: 12.9217px; font-family: sans-serif;">≥</div><div style="left: 374.538px; top: 1102.79px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.92522);" data-canvas-width="67.63355984848485">8 days after</div><div style="left: 465.182px; top: 291.005px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01421);" data-canvas-width="359.3335719696969">onset. The median days from illness onset to death for children with</div><div style="left: 465.182px; top: 306.208px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.963007);" data-canvas-width="360.27685732323215">an underlying condition was significantly longer than the time for</div><div style="left: 465.182px; top: 321.41px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.00182);" data-canvas-width="278.6051439393939">previously healthy children (7 versus 4 days, p&lt;0.01).</div><div style="left: 465.182px; top: 350.338px; font-size: 12.9217px; font-family: sans-serif; transform: scaleX(1.10277);" data-canvas-width="77.54322474747475">Conclusions</div><div style="left: 478.864px; top: 363.975px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.989263);" data-canvas-width="347.099290151515">Each year, a substantial number of influenza-associated deaths</div><div style="left: 465.182px; top: 379.177px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.980247);" data-canvas-width="360.6981053030307">occur among U.S. children, with rates highest among those aged</div><div style="left: 465.182px; top: 394.379px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.03005);" data-canvas-width="362.18281060606057">&lt;2 years. While half of the deaths were among children with</div><div style="left: 465.182px; top: 409.581px; font-size: 12.9217px; font-family: serif; transform: scaleX(0.959988);" data-canvas-width="360.2833181818182">underlying conditions, the majority of children &lt;2 years who died</div><div style="left: 465.182px; top: 424.783px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.05492);" data-canvas-width="362.50585353535337">were previously healthy. Vaccination coverage was very low.</div><div style="left: 465.182px; top: 439.985px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.03453);" data-canvas-width="359.7922929292929">Influenza vaccination among pregnant women, young children and</div><div style="left: 465.182px; top: 455.187px; font-size: 12.9217px; font-family: serif; transform: scaleX(1.01831);" data-canvas-width="359.70184090909083">children with high-risk underlying conditions should be encouraged</div>and could reduce influenza-associated mortality among children. ER -