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A Good Shot 

Vaccinating school children is one of the best ways to avoid the flu.

It's an early fall evening at the AMC Palace 20 movie theater in Harahan, and six teenage girls — all polished lips and shiny hair — squish together on a metal bench in the parking lot. The young women are seniors at Eleanor McMain High School in New Orleans and the air around them smells of popcorn and perfume. As they wait for their ride to pick them up, they pass a soda back and forth and occasionally erupt into giggles.

Ask them if they've had their flu shot this year and they get quiet just long enough to look at each other before looking up and answering in chorus:

"No, no."

"We've heard about it."

"We haven't gotten it."

"I got mine already, after Katrina. I got sick."

"It makes you sick."

"It has the virus in it."

With the 2008-2009 flu season about to kick off in full, miserable swing, the Centers for Disease Control and Prevention (CDC) released its most expansive recommendation to date for who should get the influenza vaccine this year. The guidelines cover everyone ages 6 months to 19 years. This is the first time all kids and teenagers — not just small children and youngsters with asthma or other risk factors — are being told to get vaccinated. The young women sitting outside the theater are exactly the target at whom the CDC aimed its recommendation. And like the rest of their cohort, they are one of the most difficult populations to vaccinate.

"That's the biggest change in the area this year," says Dr. Frank Welch, the medical director of state immunization for the Louisiana Office of Public Health (OPH).

The CDC still recommends the vaccine for risk groups previously identified: adults over 50, pregnant women, patients with chronic illnesses, residents of nursing homes, anyone who is high-risk for complications from the flu and people who have contact with any of these groups. But with the new guidelines, 28 million more kids should get vaccinated this year than in the past.

It's not quite a universal recommendation, CDC spokesperson Curtis Allen says, but "we're almost moving in that direction about 81 percent of the population is covered by the recommendation."

Allen says the only people who shouldn't get the shot are babies younger than 6 months, people with chicken egg allergies and anyone who's had a bad reaction to the shots in the past. "Or if you're a hermit," the only population without exposure to anyone who is high-risk for flu, he jokes. "Most people have contacts with someone who is high risk."

The contact issue is at the heart of the new recommendations for adolescents and teenagers. "Schools are essentially a reservoir of influenza," Allen says.

"The reason is because most of those people in that age group are in a school environment," Welch says. Large groups of kids in close quarters with less than ideal hygiene practices is a recipe for breeding the flu. "You pick it up and get sick, not too bad, but you take it home to get someone else sick."

A Harvard study published in July shows a link between the proportion of children under 18 living in a set of zip codes and the rate of adult hospitalization for flu and respiratory complications. For every percent increase in proportion of kids living in a zip code, researchers found a 4 percent increase in adult hospital visits.

Public health officials have long known that older children and young adults get the flu in similar and often higher rates compared to other age groups. What's different is how they react. While small children are about as likely to be hospitalized with flu as people over the age of 65, older kids and teenagers don't get as sick when they get infected. Most older kids who get the flu feel wretched for a few days, but they're seven times less likely to be hospitalized because of complications like pneumonia. They're also much more likely to survive the virus than traditionally vulnerable populations. Last year, 42 children between the ages of 5 and 18 died from complications of the flu. By comparison, about 36,000 Americans die annually from the disease.

Because this age group tends to fare better and vaccine production has been limited, these youngsters haven't been included in past vaccine recommendations. This year, however, the CDC announced there will be record production of the influenza vaccine — upwards of 146 million doses. The increase in availability of the vaccine means the CDC can recommend people get it not just to protect themselves, but to protect others.

In fact, Welch and the OPH regularly use school attendance records as indicators of the severity of a flu season in a region. "We monitor school attendance and absenteeism," Welch says. "It's a great marker of community illness." It can take weeks for lab samples to come back and confirm exactly what bug is going around. But attendance reports are known as real-time indicators of who's sick and where.

"I really like to look at my attendance report," says Maria Vibandor, a math and science teacher at L.W. Higgins High School in Jefferson Parish. She says it's obvious when an infection is burning through the school. "I've never seen such a large number of students be absent for so many days in a row because of sickness," she says. In talking about the new flu vaccine recommendations, she and her friend Jenny Katz, a fourth-grade teacher at Joshua Butler Elementary School in Westwego, agree that it makes sense to target these students.

"A lot of them live with their grandparents and live with their parents and have siblings," Katz says, "and then they come to school and they're surrounded by a lot of kids. You just get sick a lot."

Joshua Butler and a few other schools have offered the vaccine to students on campus this year, but getting this age group vaccinated is notoriously difficult. Less than 20 percent of children get the vaccine. Part of the disconnect has to do with how youngsters visit doctors. Most kids only go to the doctor when they're already sick, and they shouldn't get the flu vaccine while they have a fever. If a child does see a pediatrician for a check-up when they are well, it tends to happen in late August or early September — before school starts and before the vaccine is distributed.

"The younger people are generally more difficult because they are young and healthy," says Dr. Kevin Stephens, director of the New Orleans Health Department. He and his staff are in the process of procuring vaccines for city health clinics. "Right now they're feeling great. But you take [a flu shot] while you're feeling great."

Misconceptions also keep people from getting the vaccine.

When Vibandor came back to work after a bout of what she's pretty sure was the flu this fall, her high school students had a million questions about the virus.

"They asked, "How come when you get the flu shot you don't get sick?'" Vibandor says. "I had them research it." She had them visit the CDC Web site, then they discussed the mechanics of the vaccine.

There are two ways to get vaccinated against the flu. The first and most widely used is a flu immunization that contains killed influenza virus. The second method is a nasal spray containing a live, attenuated flu virus that has been weakened enough to not cause illness. Both vaccines contain the three most widely circulated flu strands expected to hit North America in the current season, and both elicit a response from the body's immune cells, allowing them to develop a resistance to the virus without actually getting sick from it.

"There could be a tendency towards a little fever or a tendency towards a little muscle ache, but that's rare," says Dr. Joseph Sejud, a family physician at Touro Hospital. He has heard people young and old discuss fears they will get the flu from the shot, but he says the uncommon side effects are nothing compared to a full flu infection. "By the time you see it in the [emergency room], it's too late because they haven't had the shot," Sejud says. "The take-home point is that nothing is as effective as the vaccine."

Of course, the vaccine is ineffective if it's not delivered to the desired population. The general feeling is that it's still going to be hard to vaccinate local children if parents don't know how important it is to do so.

"I think definitely they need to be educated about the pros and cons," Vibandor says. "I think everyone needs to be on board it should be a family education."

Vaccinations already have started in the city, and it's never too late in the season to get a flu shot. New Orleans "flu season usually peaks much later than other parts of the country because the weather stays warmer longer, though Welch points out "the only thing you can predict with the flu is that it's unpredictable." Until then, Welch, Vibandor and others will keep an eye on the attendance rolls and continue spreading the word out about flu vaccines.

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