Influenza-Associated Deaths Reported Among Children Aged <18 Years --- United States, 2003--04 Influenza Season

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From Morbidity & Mortality Weekly Report

Update: Influenza-Associated Deaths Reported Among Children Aged <18 Years

--- United States, 2003--04 Influenza Season

Since October, 42 influenza-associated deaths among children aged <18 years

have been reported to CDC. All patients had influenza virus infection

detected by rapid antigen testing or other laboratory testing methods. This

report describes preliminary findings based on data provided from multiple

states, as of December 17, 2003. To improve surveillance, CDC has requested

that all influenza-associated deaths of children aged <18 years be reported

to CDC through state health departments.

Among the 42 reported deaths, 20 (48%) patients were male, and 21 (50%)

were female; the sex of one patient was not reported. Twenty-three (55%) of

the children were aged <5 years, and 13 (31%) were aged 6--23 months (Table

1). The median age was 4 years (range: 9 weeks--17 years). Seventeen (40%)

of the children had underlying chronic medical conditions (Table 2); SEE

END OF ARTICLE FOR INSERTION OF THIS INFORMATION OR GO TO WEBSITE TO READ

TABLE

the previous medical status for four (10%) children was unknown. Among the

21 patients who had no underlying chronic medical condition, five had

invasive bacterial co-infections, including three caused by

methicillin-resistant Staphylococcus aureus (MRSA), one by Streptococcus

pneumoniae, and one by Group A streptococcus. Three children with

underlying chronic medical conditions had invasive bacterial co-infections,

including one caused by MRSA, one caused by Streptococcus pneumoniae, and

one caused by Neisseria menigitidis.

Influenza vaccination status was available for only seven patients; five

(aged 1 year, 14 months, 20 months, 3 years, and 8 years) were not

vaccinated; two (aged 21 months and 5 years) received 1 dose of influenza

vaccine; however, their previous vaccination history was unknown. Influenza

A viruses were isolated from 11 (26%) patients; 29 (69%) infections were

detected by rapid diagnostic testing or by direct fluorescent antibody

testing of respiratory specimens. In two (5%) patients, evidence of

influenza A virus infection was solely by immunohistochemical staining

(IHC) of postmortem tissue specimens at CDC (Figure). Five cases that were

positive by rapid antigen testing of respiratory specimens also were tested

by IHC; all five also had influenza A viral antigens detected in bronchial

epithelium tissues obtained at autopsy. CDC continues to work with state

health departments to collect additional information on all cases.

[COMMENTS BY DR. YAZBAK - The lack of information on the vaccination

status of 83% of the deceased children is disturbing and indicates a

further lowering of the bar. Positive viral cultures are more definitive

proofs of viral presence. The fact that viral cultures were positive in

only 26% of cases is important. On the other hand, a positive viral culture

is not absolute proof that influenza is the cause of death; without more

details, its significance is hard to determine.

http://www.redflagsweekly.com/conferences/vaccines/2004_jan12_2.html ]

Reported by: State and local health departments. Influenza Response Team, J

, DVM, A Likos, MD, N Bhat, MD, EIS officers, CDC.

Editorial Note:

Influenza-associated deaths are not reportable conditions in the United

States, and the average annual number of such deaths is unknown. However,

cases of sudden death associated with influenza in previously healthy

children in the United States have been reported (1; CDC, unpublished data,

2003). During 1990--1999, approximately 92 influenza-associated respiratory

and circulatory deaths were estimated to have occurred annually among

children aged <5 years (2). However, this estimate was based on

mathematical modeling and not on counting fatalities associated with

laboratory-confirmed influenza virus infection.

Among the 42 reported cases, laboratory-confirmed influenza virus infection

was found in all of the children. Influenza can be confirmed by various

methods, including commercially available rapid tests, viral culture,

direct fluorescent antibody, reverse transcriptase polymerase chain

reaction, IHC of tissues collected during autopsy (3), and paired serology.

CDC Request for Reports of Influenza-Associated Deaths Among Children

During the 2003--04 influenza season, CDC is requesting that all

influenza-associated deaths among children aged <18 years be reported to

CDC through state health departments. In addition, CDC is requesting

submission of postmortem tissue specimens and autopsy reports where

available. Influenza viral isolates in fatal cases also should be sent to

CDC for antigenic characterization.

To report the influenza-associated death of a child aged <18 years, state

health departments should contact CDC's Influenza Branch, telephone,

800-232-4636; e-mail, eocinfluenza@ cdc.gov. Case-reporting and

specimen-collection forms will be made available to state health

departments and medical examiners via the Epidemic Information Exchange,

available at http://www.cdc.gov/mmwr/epix/epix.html. When completed, the

forms should be sent with a cover sheet headed ATTN: Fatal Case Reporting

to CDC via fax, 888-232-1322.

References

CDC. Severe morbidity and mortality associated with influenza in children

and young adults---Michigan, 2003. MMWR 2003;52:837--40.

W, Shay D, Weintraub E, et al. Mortality associated with influenza

and respiratory syncytial virus in the United States. JAMA 2003;289:179--86.

Guarner J, Shieh WJ, Dawson J, et al. Immunohistochemical and in situ

hybridization studies of influenza A virus infection in human lungs. Am J

Clin Path 2000;114:227--33.

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fROM DR. YAZBAK FROM HERE

http://www.redflagsweekly.com/conferences/vaccines/2004_jan12_2.html

" One must wonder why in a review of national importance, an effort was not

made to identify the sex of one child and the past history of four others.

The underlying chronic conditions (some children had more than one) were:

Lupus 1, cerebral palsy 2, chromosomal abnormality 1, hypothyroidism 1,

gastroesophageal reflux 1 and biliary atresia 1. Two children were

developmentally delayed and 2 had mental retardation. Three children had

asthma, one had received a heart transplant, 3 had seizure disorders, one

had Pierre Robin Syndrome and the last one had the syndrome of Cornelia de

Lange. The available information is not enough to determine the role of the

influenza infection in the demise of these children. Eight (19%) of the 42

children had fulminating systemic infections. At least in these, influenza

was not the primary cause of death. [The immediate cause of death

is listed first on a death certificate. To its right, the physician must

enter the interval between onset and death. In the following three lines,

underlying and associated causes are listed in order of significance with

the intervals between onset and death.]

What may be tragic is the fact that, because of the continuous bombardment

with reports of the “epidemic”, some parents, believing that their children

just had the flu, may have waited too long to seek medical advice for

meningitis, septicemia or pneumonia. Similarly, a busy ER physician seeing

a multitude of children brought by parents concerned about the “major flu

epidemic” going on, may have thought that the child he was sending home,

simply had the flu, like all the others. Symptoms of early bacterial

meningitis are easily mistaken for the flu. This was evident in New

Hampshire around Christmas when an 18-year old co-ed was seen in an

Emergency Room, diagnosed with the flu and discharged without further

testing only to die of meningococcal meningitis a short time later. The

cases of the 5 children in the MMWR report, who died of invasive bacterial

illnesses, and who had no underlying condition, should be thoroughly

investigated. The fact that they “tested positive for the flu” may be

etiologically irrelevant.

AND

Lastly, the fact that the events that followed vaccination of seven

children were not made available for review is also of concern

Before December 2002, there were 12 reports to the Vaccine Adverse Events

Reporting System (VAERS) of children under 10, who expired shortly after

receiving the inactivated flu vaccine. It is accepted that only a small

percentage of actual reactions are ever reported to VAERS. In 11 cases, the

flu vaccine was the only vaccine administered. All children had serious

underlying chronic illnesses. Five children died within 24 hours of

vaccination and 2 within 72 hours.

for full comments SEE

http://www.redflagsweekly.com/conferences/vaccines/2004_jan12_2.html

HYPING VACCINES: AN INVESTIGATION

Chickenpox, Lyme, Rotavirus, And A Highly Revealing Analysis Of Flu Statistics

By RFD Columnist, Dr. F. Yazbak