¹School of Medicine, Department of Pediatrics, Division of Neonatology, New York University, 20 Waterside Plaza, Suite 30K, New York, NY 10010, USA

Correspondence: Shetal Shah, MD, New York University, Neonatology, 20 Waterside Plaza, Suite 30K, New York, NY 10010, USA.

Abstract

The neonatal intensive care unit (NICU) team has traditionally invested itself in maintaining the health of its patients upon discharge from high-acuity care. Historically, this has included the administration of vaccinations to the patients and more recently, Palivizumab — a monoclonal antibody directed against respiratory synctial virus (RSV). With increasing awareness of the ill-effects associated with influenza virus and recommendations those in close contact with high-risk infants receive the vaccine, the NICU may be an ideal arena to capture parents of high-risk infants for vaccination. This would potentially decrease exposure of the neoatal patient group to influenza virus and may decrease morbidity and mortality associated with the disease. NICUs should work in concert with their associated Departments of Obstetrics to immunize pregnant mothers when appropriate, educate parents regarding influenza and its potential effects in infants and offer influenza vaccine in-season to parents as part of comprehensive care.

Influenza is a common infectious agent in the pediatric population, infecting 15 to 42% of preschool children with a fatality rate of 3.8 per 100,000.^1,2,3 Those with underlying respiratory and cardiac disease are at substantially higher risk of complications from influenza and are more likely to require hospitalization.^4,5,6,7 Trivalent inactivated influenza vaccine is a safe, cost-effective method of preventing influenza in children, with a sero-conversion rate of up to 89%.^8,9,10 Based on this information, both the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) recommended influenza vaccine for family members and close contacts of those at risk of serious influenza. (Table 1).¹¹ Included in this high-risk category are children with chronic respiratory and cardiac disease and healthy children below 23 months of age, particularly those younger than 6 months.⁸

Table 1 - Center for Disease Control (CDC) Recommendations for Influenza Vaccine of Relevance to the Neonatologist (abbreviated and adapted from www.cdc.gov).

Full table

Yet studies demonstrate the majority of adult patients who meet eligible criteria do not receive the influenza vaccine.¹² As all parents of NICU infants will inherit a high-risk patient upon discharge home — and in light of poor vaccine coverage rates for adults and children — NICUs appear to be unique, unexploited arenas to immunize parents of hospitalized neonates during the flu season. In an effort to maximize comprehensive care efforts, the neonatal team should work closely with OB/GYN to immunize mothers during or immediately after labor. Furthermore, since children are important vectors of harboring virus, discharge planning should also include, in season, education regarding influenza and a strong recommendation by the NICU team that sibling and children of neonates receive the flu vaccine.^13,14 It has also been shown that physician recommendations are the greatest single predictor of receiving vaccine and thus alone may strongly influence parental decision-making.¹⁵ For parents who cannot obtain the vaccine elsewhere, the NICU should endeavor to administer it to appropriately consented parents.

As the AAP recently expanded its guidelines for influenza immunization to include all healthy children between ages 6 to 23 months, several concerns regarding the logistics of distributing increased vaccine quantities to an expanded population have arisen (Table 2). Limited vaccine supply, an issue based on recent experience in which there has been an estimated 10 to 30 million shortage in vaccine supply, does not apply to this NICU initiative as in times of vaccine shortage, parents of high-risk infants would still be prioritized for receipt of vaccine under current vaccine rationing suggestions.¹⁶ The introduction of, intranasal trivalent, cold-adapted, live attenuated vaccine for those patients not in contact with infants or those at high risk of serious influenza should also ease the vaccine burden. Other concerns such as increased personnel demands, physician/nurse time and recall systems do not apply to the 24-hour staffing available in the intensive care setting and should therefore not remain an obstacle to comprehensive parental vaccination.

Table 2 - Logistic Constraints to Influenza Immunization (adapted from reference 8, Rennels et al.).

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The NICU with its readily available access to parents of high-risk neonates should be an ideal venue for administering influenza vaccine in season. Given the statistics for adult compliance with receiving the vaccine and the logistical constraints posed on primary caregivers to immunize all young healthy children, the NICU may help safeguard the future care of their discharged patients by providing this service. As an interdisciplinary subspecialty, neonatologists should work with OB/GYN and other relevant hospital divisions to ensure timely influenza vaccination to adults in close contact with their tiny and vulnerable patients.