Report: Pandemic plans need more focus on children

Oct 17, 2007 (CIDRAP News) – The US government's pandemic influenza preparedness plans need to pay more attention to children, especially their need for antiviral drugs and the effects of prolonged school closings, according to a report released today by public health and pediatrics experts.

The groups recommend that the federal government vastly increase its stockpile of antiviral medication for children, do more testing of pandemic vaccines for children, and increase efforts to understand and deal with the effects of school closings in a country where half of workers can't use sick leave to take time to care for sick children, among other steps.

"Children should be a priority, not an afterthought," said Jeffrey Levi, PhD, executive director of the nonprofit advocacy group Trust for America's Health (TFAH), at a news conference today. TFAH issued the 31-page report in collaboration with the American Academy of Pediatrics (AAP).

The report notes that almost 46% of the fatal human cases of H5N1 avian influenza, the strain considered the leading candidate to trigger a pandemic, have involved children and teenagers.

"The fact that H5N1 has been disproportionately impacting children and adolescents should give us pause," Levi said in a TFAH news release.

Planning gaps and problems cited in the report, titled "Pandemic Influenza: Warning, Children at-Risk," include the following:

  • The US Strategic National Stockpile currently contains only 100,000 doses of oseltamivir (Tamiflu) formulated for children, though the country has 73.6 million children.
  • Neither of the two antiviral drugs that are considered effective against H5N1—oseltamivir and zanamivir (Relenza)—is licensed for children younger than 1 year.
  • About 30 million children rely on the National School Lunch Program, and many rely on schools nurses for healthcare, but there are no plans for providing these services if schools close during a pandemic.
  • The Centers for Disease Control and Prevention (CDC) recommends using N95 respirators in certain circumstances in a pandemic, but no such respirators are available in children's sizes.

The report makes a series of recommendations to address these and other problems. Among them:

  • The government should stockpile enough pediatric doses of antiviral drugs to treat 25% of the nation's children and adolescents—about 18.4 million youngsters.
  • The Department of Health and Human Services (HHS) should conduct more studies on the feasibility of extended closings of school and child care centers, including a closer assessment of the interruption of school meals programs.
  • Educators and public health officials should plan for special "influenza-free" daycare centers to allow parents in essential jobs to continue to work. Such centers should be equipped to provide point-of-care rapid testing for sick children.
  • HHS should conduct more studies on H5N1 vaccine efficacy in young children, support the development of more flu vaccines, and do more studies of antiviral drugs for infants.
  • HHS should set up an independent task force to study and make recommendations on the use of surgical masks, N95 respirators, and other personal protective equipment for children.
  • All schools should teach children about communicable diseases and infection control, including cough etiquette, handwashing, and measures that might be taken during a pandemic, such as school closings.
  • Teachers and school administrators should be encouraged to get flu shots and should remind families about flu vaccination recommendations.
  • Educators and public health officials should prepare to make psychologists and grief counselors available to help students cope with illness and the loss of family members and friends.

At the news conference, Levi said federal officials are aware of many of the problems cited in the report but need to do more about them. "The purpose of this report is to try to push people from recognizing the problem to actually addressing the problem," he said.

Much of the news conference focused on the likely effects of school closings and the idea of setting up special daycare centers to allow parents to keep working.

John S. Bradley, MD, a member of the AAP Committee on Infectious Disease, asserted that the CDC recommended closing schools and daycare centers to help combat a pandemic "without ever having talked to anyone in pediatrics to realize that closing these is not as easy as it sounds. The idea of the planners was that if you close schools and daycare you stop the spread of disease. . . . But there are unlicensed daycare centers that operate under the radar, which is where all these kids would be going."

"We're now connecting more with the CDC, but we still don't know if they get how critical it is to address these issues," Bradley added.

Reporters questioned the concept of influenza-free daycare centers, noting that people infected with a flu virus can spread it to others even before having any symptoms. Bradley and Henry H. Bernstein, DO, also a member of the AAP Committee on Infectious Disease, acknowledged that keeping a daycare center free of flu would be difficult but said it would be worth trying.

"Whether it's a realistic goal or not, it should be our ideal goal. We should move as close to it as we can," said Bernstein.

Bradley agreed that children can shed flu virus before becoming symptomatic but said they are far more contagious later. "Symptomatic disease, when they begin to have a runny nose, correlates with a dramatic increase in infectivity and contagiousness," he said. Contagiousness during the incubation period "is probably extremely low compared with that of the child who has the runny nose."

Levi said that though the problems concerning pandemic planning and children are complicated, certain policy changes could make a difference.

"Half of all workers in the US do not have any sick leave at all," he said. "That tends to be concentrated in poorer families. And they are more likely to have the kinds of jobs where you can't telecommute." Measures to allow parents to use sick leave to care for sick children would help that situation, he suggested.

For another example, he said, "The government is recommending that people have an extra month of routine medication" for conditions such as asthma, 'but we don't have policies in Medicaid or SCHIP [the State Children's Health Insurance Program] to allow for that kind of stockpiling."

See also:

TFAH news release
http://healthyamericans.org/newsroom/releases/release101707.pdf

TFAH report "Pandemic Influenza: Warning, Children at-Risk"
http://healthyamericans.org/reports/fluchildren/KidsPandemicFlu.pdf

Feb 1 CIDRAP News story "HHS ties pandemic mitigation advice to severity"

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