DISCUSSION: Prioritization in the General Population (GP) Group

COMMENT THREAD

• where do infants fall in the Tiers?
  

  Submitted by Brant Goode   on 12/5/07 07:39 AM

  Hi Timaly,
  
  I believe infants and pregant women are currently in Tier 1 of the General Population group. See pp7-12 of the draft guidance.
  
  Brant

  • Infants
    

    Submitted by Timaly Shepherd-Miller on 12/5/07 08:37 AM

    Thanks Brant for the information.
    

  • infants
    

    Submitted by Catherine Jackie Mitchell on 12/5/07 08:40 AM

    A quick question....is there some protection afforded to breastfeeding infants if the mothers have taken anti-virals and/or vaccines?
    

    • infant protection via breastfeeding if mom is vaccinated?
      

      Submitted by Brant Goode   on 12/5/07 09:01 AM

      I can't speak to the specific issue of antibodies or drugs in breastmilk--no testing has been conducted that I'm aware of.
      
      We recommend vaccines for pregnant women because they're at higher risk of complications/death. A vaccinated mom may provide some antibodies--there is at least some animal model evidence supporting this--but I'll let others address that specific question.
      
      The risk of exposure to an infant if the mom is ill remains...should the mom be moved up in line? The moms of infants under 6 months old (and other family members) are currently in Tier 2.
      
      Brant

    • Breast feeding immunity for Infants
      

      Submitted by MoMos Mom on 12/5/07 02:49 PM

      Hi, Catherine, everything that you ingest is passed through your milk to your breast feeding baby. In the awesomeness of nature, the mother's and baby's immune systems are hormonally in synch. For instance, there have been studies that show that a sick child will cause a mother's immune system to create antibodies against a disease that the baby has if the mother has already had the disease. Based on that, the mother's body may produce antibodies that will attack the babies illness. As for the anti-virals being passed to the baby, they would be, but we wouldn't know the level of the anti-virals being passed or how much protection it would actually afford.
      
      Still, it would probably be better than nothing at all for an infant under 6 months of age.

      • I disagree MoMosmom
        

        Submitted by Mirine Dye on 12/5/07 05:02 PM

        Hi , I am a lactation consultant and research in this area and so far find nothing to support any theory that breastfed infants will receive protection from a novel strain of virus. Part of the miracle of antibody protection in breastfeeding is previous passive or active immunity, of which women will have neither for a pandemic. ( Unless mom and baby survive the first wave, but there is no evidence of this so far).
        
        With that said there should be no question that breastfeeding should remain the first line of defense for all infants in any public health crisis including pandemics.
        

        • thank you
          

          Submitted by Catherine Jackie Mitchell on 12/6/07 12:42 AM

          Now if we can only tell new moms before they start on formula.

• Babies under 6 months of age
  

  Submitted by MoMos Mom on 12/5/07 07:43 AM

  It is my understanding that babies under the age of 6 months are not recommended to get the current seasonal flu vaccine because it has never been tested for this age group. Pregnant women are encouraged to get a flu shot because it would protect the baby too until they reached 6 months of age and could get the regular seasonal flu vaccine. Would the pandemic vaccine work in the same way?

  • infants under 6 months
    

    Submitted by Terry Adirim   on 12/5/07 08:00 AM

    That's right. Infants under 6 months could not get the vaccine. And it is household contacts of infants less than 6 months who are in tier 2, not the actual infants.

    • adjuvants are a concern
      

      Submitted by Ellen Rice on 12/5/07 03:53 PM

      Another unknown is what adjuvant (chemical booster) might be used in a pandemic vaccine. Some adjuvants have a murky history and may not be suitable for infants.
      

  • Thanks Momos Mom
    

    Submitted by Timaly Shepherd-Miller on 12/5/07 08:35 AM

    Hi Momos Mom, you are definitely right. I am aware of the fact that infants below the age of 6 months do not receive the flu vaccine. My primary concern for the babies of that age group is the fact that they are already immunocompromised and reside with both parent(s) and other siblings who has the greatest possibilty of exposure from outsiders. Thanks
    

• Vaccinating the youngest isn't such a good idea.
  

  Submitted by Dani Adams on 12/5/07 08:35 AM

  I don't want to sound heartless, but young children aren't going to contribute to keeping society safe and running during the crisis. It seems that immunizing the youngest would be done purely for sentimental, rather than practical reasons. Older children, who would be very difficult to keep away from other kids (how many 9 year olds would tolerate being cooped up for weeks without any interaction with other kids?) and who would then pass on any infection should be a priority.
  

  • School aged vectors
    

    Submitted by Karen Rose on 12/5/07 09:16 AM

    I agree that school aged children are more likely to be spreading the flu virus than infants, and should therefore have a higher priority for vaccination. They are very efficient "vectors." I heard a speaker recently state that school aged children shed influenza virus 6-7 days before showing symptoms, whereas for adults this is about 1 day prior to onset of symptoms, from what I understand. If our priorities are to prevent death and illness, we can make a huge impact through social distancing, PI's, and then vaccination of this segment of our population.

    • kids as vectors
      

      Submitted by Terry Adirim   on 12/5/07 11:25 AM

      Hi,
      You are right that preschoolers and school age kids are vectors for viruses. This has been shown in research studies and has been a consideration in modeling.
      
      However, consider that there are 75 million children and unless you are able to immunize all of them at about the same time, this strategy does not work. This is why school closure is a part of the community mitigation guidance. The committee that drafted the vaccine guidelines seriously considered this issue, but there will not be enough vaccine produced to implement a strategy like this. So for the general population column, it was decided to immunize the group most vulnerable (likely to die, pregnant women with possibly a 50% mortality rate) and who we could get more "bang for the buck". Immunizing a pregnant woman protects 2 people and the littlest children, 6 months to 35 months need 1/2 the dose of older children and adults.
      
      Regarding prioritizing children in general, this sentiment was expressed in the public engagements that have been held to date. The public wants children vaccinated near the top. Critical infrastructure was one of the top "values" expressed by the public along with protecting children.

      • Why we can't vaccinate all those vectors
        

        Submitted by Karen Rose on 12/5/07 12:42 PM

        Terry,
        Thank you for this response. I appreciate the explanation of the rationale here.

      • demoralizing effects
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 02:25 PM

        There are effects on the overall psyche of a society when that society fails to protect its most vulnerable citizens.
        

        • Society's most vulnerable
          

          Submitted by John Carney on 12/5/07 03:23 PM

          I know this is about vaccines and not ventilators, but are we willing to say the same thing if a pregnant woman contracts the virus and then needs a respirator and the only one left is keeping a person in vegetative state alive? Most ventilators in this country are already assigned to the most vulnerable patients. Vulnerable populations is a hard category to define and defend in a severe pandemic. All of a sudden someone's instrumental value takes on a whole new meaning. If my child was in need of a respirator and would likely recover from the virus, I'm not sure how I'd feel about someone who was more vulnerable getting first dibs.

      • Vaccinating kids and the public's priority for babies
        

        Submitted by John Carney on 12/5/07 03:42 PM

        Terry - I'm not sure I understand why you would need to have 75 million doses all ready at once for the kids. If you closed all schools in a pre-emptive fashion before there was any exposure in some communities why would all the kids need to be immunized - because they belong to a particular class?
        
        Also, I know the pbulic engagement phase of the pandemic response received feedback about the importance of saving children but the definition of critcial infrastructure is important to examine. Depending on how the pandemic unfolds and who is most susceptible, I hope there is an adjustment factor that allows for "critical" to include the folks who keep the lights and water running if higher than projected rates (50-70%) are unable to work and the AR exceeds 40%.

• Babies are born with immunities
  

  Submitted by Diana Tolladay on 12/5/07 12:42 PM

  Babies from birth to 5 months are not immunocompromised, and are not at a greater risk. They have natural immunities, and can be isolated and protected from exposure far more easily than other members of the general population. For example: the garbage collector, grocery store clerk,..
  
  http://www.immunize.org/nslt.d/n...
  http://www.ahealthyme.com/topic/...
  http://www.2coolbaby.com/Documen...
  

  • Natural Immunities
    

    Submitted by Catherine Jackie Mitchell on 12/5/07 12:53 PM

    If the mother had no immunity would the child? This is a "novel" strain.

    • Natural Immunities
      

      Submitted by Jeffrey Duchin   on 12/5/07 02:16 PM

      With a new pandemic virus it is assumed that all persons are susceptible. Neither mother nor child would be expected to have pre-existing immunity.
      

      • Vulnerable Infants
        

        Submitted by Karen Rose on 12/5/07 02:36 PM

        And, with any influenza virus, infants and young children are considered high risk groups, as they are more likely than older children and young adults to experience complications of flu. Also, the infection rate/attack rate for seasonal flu, at least, is much higher among the young (ages 0-18 yrs.) than the older groups.

        • vaccine complications
          

          Submitted by Catherine Jackie Mitchell on 12/5/07 03:10 PM

          There must also be some discussion of the effects of SOME vaccines on SOME children. Personally, I would leave this up to the parents discretion but from a public health standpoint we are also looking for herd immunity.
          
          There may be many parents who decide to opt out.

• Infants in Tier 2 because....
  

  Submitted by Mirine Dye on 12/5/07 04:55 PM

  If the pregnant woman receives the flu vax in her 3rd trimester there is evidence the fetus receives protection for the first 6 months of life.
  Breastfeeding will not be projected to be of much help because breastfeeding and human milk antibodies are most helpful when there is previous antibody production. There is not going to be any genetic memory in women to produce antibodies for H5N1 and pass along to nursing babies.