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Arch Dis Child. Jul 2007; 92(7): 644–645.
PMCID: PMC2083801
Archimedes
Is there any evidence for influenza vaccination in children with asthma?
Report by Will Carroll, Derby Children's Hospital, Uttoxeter Road, Derby DE22 3NE, UK; will.carroll@nhs.net
Richard Burkimsher, University of Nottingham, Medical School Nottingham, Nottingham NG7 2UH, UK
A 12 year old boy presents for a routine asthma follow‐up appointment during the autumn. He takes 200 μg per day of inhaled budesonide and uses his salbutamol 3–4 times per week. His mother asks if the flu vaccine will make it less likely that he will have an asthma exacerbation over the winter.
Structured clinical question
In children with asthma [patient] does influenza vaccination [intervention] reduce the number of asthma exacerbations associated with influenza [outcome]?
Search strategy and outcome
Primary sources: Medline 1966–April week 3 2006 using the OVID interface: {exp Infant/ or exp Child/ or exp Adolescent/ or exp Child, Preschool/} AND {exp Influenza Vaccines/ or {exp Vaccination/ and exp Influenza, Human/}} AND {exp Asthma/}.
PubMed and EMBASE: No further relevant articles were found.
Secondary sources: The references of relevant papers found by this method revealed one further relevant paper which was included in the analysis (Kramarz et al1).
Search outcome
117 papers were found of which four were relevant (see table 1).
Commentary
Current Department of Health guidance suggests that influenza vaccination should be offered to all children with “asthma requiring continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission”.5 This type of “umbrella advice” therefore extends to many children with mild and/or well‐controlled asthma. It is not unusual to be asked by parents of children with asthma whether influenza vaccine is necessary. Historically, rates of influenza vaccine uptake amongst children with asthma are known to be low (25% of eligible children).6 One of the key barriers to influenza vaccination is lack of physician endorsement of national recommendations7 with many doctors remaining ambivalent about the need for influenza vaccination in children with mild or moderate asthma. This view seems to be supported by the lack of convincing benefit shown in the published literature.
Table thumbnail
Table 1 Evidence for the use of influenza vaccine in children with asthma
We identified only one randomised placebo controlled trial of influenza vaccination in children with asthma.4 The primary endpoint of this study was the number of influenza‐attributable asthma exacerbations during the study period. The authors found that the vaccine did not significantly reduce the number of exacerbations. In fact, in this study there were more asthma exacerbations in the vaccine group, but this was not statistically significant. A secondary analysis suggested that the duration of exacerbations may be longer in unvaccinated children, but again this difference failed to reach statistical significance.
Clinical bottom line
  • National guidelines continue to recommend influenza vaccination for all children with asthma receiving inhaled corticosteroids. (Grade D)
  • On the basis of the published evidence, there are few data to suggest a benefit of influenza vaccination in children with asthma. (Grade B)
  • The need for vaccination in children with asthma should be assessed on a case‐by‐case basis. Younger children may be more likely to benefit from vaccination. (Grade B)
Two out of the three cohort studies show an increased number of exacerbations in children who received the influenza vaccine,1–3 but as inclusion was not randomised these studies may be subject to considerable bias. Hence children with more severe asthma may be more likely to attend primary care and to be vaccinated. Although no study shows convincing evidence of benefit overall, Smits et al demonstrated statistically significant beneficial effects in children under 6 years of age (crude odds ratio of acute respiratory disease 0.52 (95% CI 0.29 to 0.93, p = 0.018)).2 Thus young children may be more likely to benefit from vaccination.
1. Kramarz P, Destefano F, Gargiullo P M. et al. Does influenza vaccination prevent asthma exacerbations in children? J Pediatr 2001;138:306-10.
2. Smits A J, Hak E, Stalman W AB. et al. Clinical effectiveness of conventional influenza vaccination in asthmatic children. Epidemiol Infect 2002;128:205-11.
3. Christy C, Aligne C A, Auinger P. et al. Effectiveness of influenza vaccine for the prevention of asthma exacerbations. Arch Dis Child 2004;89:734-5.
4. Bueving H J, Bernsen R MD, de Jongste J C. et al. Influenza vaccination in children with asthma. Am J Respir Crit Care Med 2004;169:488-93.
5. Department of Health. 2005. The influenza immunization programme. http://www.dh.gov.uk/assetroot/04/11/65/17/04116517.pdf (accessed 3 April 2007).
6. Chung E K, Casey R, Pinto-Martin J A. et al. Routine and influenza vaccination rates in children with asthma. Ann Allergy Asthma Immunol 1998;80:318-22.
7. Rickert D, Santoli J, Shefer A. et al. Influenza vaccination of high-risk children: what the providers say. Am J Prev Med 2006;30:111-18.
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