The assessment made by the President's Council of Advisors on Scientific and Technology on the potential impact of novel influenza A (H1N1) virus (swine flu) that became a fixture of news reports over the summer may be starting to appear accurate as we enter the autumn months. As of the week of September 7-11, 2009, the Centers for Disease Control and Prevention (CDC) reported that 11 states are experiencing widespread flu activity - a date much earlier than the start of a typical flu season - and in nearly all of those cases in which flu virus was tested for, H1N1 was confirmed.

The impact of H1N1 on pregnant women, children, and young adults earlier this year was recognized quickly by public health officials, and helped to inform the recommendations by the Advisory Committee on Immunization Practices (ACIP) on prioritization of H1N1 vaccination to these age groups. However, the Food and Drug Administration has only just announced approval of four vaccines for the prevention of H1N1, and it is currently estimated that vaccines will not be available and ready for use until the beginning of October at the earliest. While the need for protecting children for H1N1 is well understood, some of the tools that states will need to protect their citizens are still forthcoming.

One of the tools that is currently available is the use of antiviral drugs. The H1N1 virus strains currently circulating throughout the population are susceptible to both oseltamivir (Tamiflu) and zanamivir (Relenza), and the CDC has released recommendations on their use. While there are currently adequate supplies of both of these drugs, these recommendations may change as their supply diminishes and the virus becomes more prevalent. The Academy has included specific guidance on the use of the these drugs as well as vaccines in children in its 2009-2010 influenza policy statement, and highlights the critical need for providers to be aware of their local and state health department recommendations as more becomes known about H1N1, and consider signing up for your state or local Health Alert Network.

The effect of H1N1 on children with chronic medical conditions has just recently come to light. The September 4, 2009 Morbidity and Mortality Weekly Report reviewed deaths in 36 pediatric cases in which H1N1 influenza was confirmed, and found that the majority of those children (78%) whose deaths were associated with H1N1 were in at least one of two groups previously found to be at increased risk for complications from seasonal influenza (children aged <5 years and those with a high-risk chronic medical condition). Perhaps more alarming, among the children with at least one high-risk chronic medical condition, 92% of them also had existing neurodevelopmental conditions, such as cerebral palsy or developmental delay. These troubling findings highlight the importance of an aggressive public campaign to vaccinate children against seasonal flu and H1N1, in order to protect both healthy children and these more vulnerable populations as well.

The early efforts by states on H1N1 when the virus first began to emerge earlier this year were praised by the CDC, the US Department of Health and Human Services (HHS), and the US Department of Homeland Security (DHS), but much more difficult work remains as the fall approaches and the virus continues to spread. Not only are all of the details regarding the distribution of H1N1 vaccine still being worked out, but many existing state influenza pandemic preparedness plans were initially developed in the middle of this decade in response to H5N1 avian flu. As highlighted recently in the Washington Post, state public health officials will not only need to be flexible in their approach as they adapt to the challenges posed by H1N1, but must also ensure that emergency departments have the surge capacity and pediatric-specific equipment to handle an increased number of hospital visits by children. To that end, the Academy will soon release revised guidelines for care of children in the emergency department in a joint statement of the AAP, the American College of Emergency Physicians, and the Emergency Nurses Association, making recommendations for essential equipment, medications, personnel training and key policies necessary for optimal pediatric emergency care. Please check the"First Pages" of Pediatrics next week, or the AAP Policy site on the week of September 28th for the statement following its release.

Many concerns remain about the practical implications of pediatricians providing H1N1 vaccination within their offices. AAP President David Tayloe, Jr, MD, FAAP recently provided testimony to Congress, where he stated the Academy's recommendations on H1N1, the actions needed by the government to help pediatricians cope with the financial pressures created by the response to H1N1, and emphasized the importance of the medical home to the overall vaccination campaign. AAP chapters may find these comments useful as a basis for their negotiations on this issue with state Medicaid programs and other state agencies.

As we reported in the August 25 Advocacy Flash sent to AAP chapters, states are using preregistration to plan for the distribution of vaccine to pediatric clinics and other physicians' offices. Since that time, the CDC has created a contact listing of each state office coordinating H1N1 distribution and preregistration. Individual pediatricians, particularly those who are not currently participating in the Vaccines for Children (VFC) program, who want to provide H1N1 vaccine in the office setting should reach out to their state immunization program as soon as they can.

AAP chapters also have an important role to play in reinforcing the message on the involvement of pediatric clinics in the coming H1N1 vaccination program. Chapters are urged to maintain open lines of communication with public health departments for both the initial vaccination campaign and the ongoing effort to combat H1N1.

The AAP is dedicated to this critical public health issue, and has produced a number of resources for use by Academy members, parents, caregivers of children, and the public at large:
H1N1 Information for Health Care Professionals
H1N1 Information for Parents and Caregivers
Testimony to the US House Committee on Small Business by AAP President, David Tayloe, Jr, MD, FAAP on H1N1
2009-1010 Recommendations for Prevention and Control of Influenza in Children

Additional resources on H1N1:
CDC H1N1 Flu Page
CDC Social Media Tools
Flu.gov
National Conference of State Legislatures

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