Pediatric Influenza Medication

  • Author: Itzhak Brook, MD, MSc; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 15, 2012
 

Medication Summary

The following 4 antiviral agents are approved for preventing or treating influenza: amantadine, rimantadine, zanamivir, and oseltamivir.[60] Vaccines against seasonal influenza are reformulated annually in order to contain the most recently circulating strains, usually one or more subtypes of influenza A virus and a subtype of influenza B virus.

The 2011-2012 seasonal influenza vaccine for the Northern Hemisphere contains A/California/7/2009 (H1N1)–like virus (the same strain as was used for 2009 H1N1 monovalent vaccines), A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens.[61]

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Antiviral agents

Class Summary

Use of influenza-specific antiviral drugs for chemoprophylaxis or treatment of influenza is an important adjunct to vaccination, particularly for controlling outbreaks in closed populations. Amantadine and rimantadine are effective against type A influenza virus only. They are approved by the US Food and Drug Administration (FDA) for prophylaxis of influenza type A in patients older than 1 year. Amantadine is also FDA-approved for treatment in children.

Since the 2005-2006 influenza season, amantadine and rimantadine are no longer recommended by the Centers for Disease Control and Prevention (CDC) because circulating strains of influenza virus have proved resistant.

Zanamivir and oseltamivir are members of a class of drugs termed neuraminidase inhibitors and are active against both influenza virus type A and type B. They are approved for both prophylaxis and treatment of influenza. When used for treatment, these agents should be started as soon as possible after the onset of symptoms, but no later than 2 days after onset.

Oseltamivir (Tamiflu) resistance emerged in the United States during the 2008-2009 influenza season, and the CDC issued revised interim recommendations for antiviral treatment and prophylaxis of influenza. Similarly, during the 2009-2010 novel influenza A H1N1 pandemic, preliminary data from a limited number of states indicated a high prevalence of virus strains resistant to oseltamivir. Because of this, zanamivir was recommended as the initial choice for antiviral prophylaxis or treatment when influenza A infection or exposure was suspected.

A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.

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Amantadine (Symmetrel)

 

Amantadine prevents penetration of virus into host by inhibiting uncoating of influenza A. This agent is no longer recommended by the CDC because of resistance in the predominant strains of influenza (H3N2) in the United States.

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Rimantadine (Flumadine)

 

Rimantadine inhibits viral replication of influenza A virus subtypes H1N1, H2N2, and H3N2. It prevents penetration of the virus into the host by inhibiting uncoating of influenza A. This agent is no longer recommended by the CDC because of resistance in the predominant strains of influenza (H3N2) in the United States.

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Oseltamivir (Tamiflu)

 

Oseltamivir is an inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Oseltamivir is effective against influenza virus types A and B.

Oseltamivir is approved for use in persons older than 1 year, for prevention of influenza and for treatment of influenza A or B in patients who have been symptomatic for no more than 2 days. It is available as capsules and as an oral suspension. During the 2009-2010 novel influenza A (H1N1) pandemic, the CDC issued an emergency use authorization for oseltamivir prophylaxis in patients younger than 1 year.[62]

As resistance to oseltamivir may occur, physicians should maintain awareness of current CDC recommendations for antiviral treatment and prophylaxis of influenza. In addition, local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice. A second-line alternative is a combination of oseltamivir plus rimantadine, rather than oseltamivir alone.

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Zanamivir (Relenza)

 

Zanamivir is an inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Zanamivir is effective against both influenza types A and B.

Zanamivir is approved for the treatment of uncomplicated acute influenza A or B in persons aged 7 years and older who have been symptomatic for no more than 2 days, and for prophylaxis of influenza in adults and pediatric patients aged 5 years and older. This agent is inhaled through a Diskhaler PO inhalation device. Circular foil disks containing 5-mg blisters of drug are inserted into a supplied inhalation device.

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Vaccines

Class Summary

These agents elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Current seasonal influenza vaccines provide no protection against human infection with highly pathogenic avian influenza type A viruses, including H5N1. However, reducing seasonal influenza risk through influenza vaccination of persons who might be exposed to nonhuman influenza viruses (eg, H5N1 viruses) might reduce the theoretical risk for recombination of an avian influenza type A virus and human influenza type A virus by preventing seasonal influenza virus infection within a human host. The CDC has recommended that persons who are charged with responding to avian influenza outbreaks among poultry receive seasonal influenza vaccination.

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Influenza virus vaccine (Afluria, Agriflu, FluLaval, Fluarix, Fluvirin, Fluzone)

 

Influenza vaccine is indicated for active immunization to prevent infection from influenza A and B viruses. The vaccine induces antibodies specific to virus strains contained in the vaccine. The US Public Health Service determines influenza vaccine contents annually. Typically, 3 live attenuated virus strains, which antigenically represent the influenza strains likely to circulate the next flu season, are included in the formulation each year. Fluzone is approved for children as young as age 6 months, whereas Fluvirin is approved for children aged 4 years or older.

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Influenza virus vaccine, intranasal (FluMist, FluMist Quadrivalent)

 

Intranasal influenza vaccine is indicated for active immunization to prevent influenza A and B viruses in healthy children, adolescents, and adults. The vaccine induces antibodies specific to virus strains contained in vaccine. The US Public Health Service determines influenza vaccine contents annually. Typically, 3 live attenuated virus strains, which antigenically represent the influenza strains likely to circulate the next flu season, are included in the formulation each year.

The FDA approved a quadrivalent form of the vaccine (FluMist Quadrivalent) in March 2012. Like the already approved FluMist (trivalent), the quadrivalent vaccine contains weakened forms of the virus strains and is administered as a spray into the nose. However, this new formulation includes a second B strain, which increases the likelihood of adequate protection against circulating influenza B strains.

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Influenza virus vaccine (H5N1)

 

The H5N1 inactivated virus vaccine induces antibodies against viral hemagglutinin, thereby blocking viral attachment to human respiratory tract epithelial cells. The vaccine is estimated to reduce the risk of contracting avian influenza by 45%. This vaccine is indicated for active immunization of adults at increased risk of exposure to the H5N1 influenza virus subtype.

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Contributor Information and Disclosures
Author

Itzhak Brook, MD, MSc  Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Coauthor(s)

Hakan Leblebicioglu, MD  Chairman, Professor, Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Turkey

Hakan Leblebicioglu, MD is a member of the following medical societies: American Society for Microbiology and European Society of Clinical Microbiology and Infectious Diseases

Disclosure: Nothing to disclose.

Anthony R Sambol, MA, SM, (NRM), SV(ASCP)  Assistant Professor, Department of Pathology and Microbiology, University of Nebraska Medical Center; Assistant Professor, Division of Clinical Laboratory Science, School of Allied Health Professions, University of Nebraska Medical Center; Assistant Director of Nebraska Public Health Laboratory; Manager of Special Pathogens/Biosecurity Preparedness Lab for Biological, Chemical, and Radiological Preparedness

Disclosure: Nothing to disclose.

Meera Varman, MD  Associate Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center

Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: phamaceutical companies Honoraria speaker; phamaceutical companies Grant/research funds clinical trials research

Specialty Editor Board

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Swine influenza virus. Colorized transmission electron micrograph (37,800X) of the A/New Jersey/76 (Hsw1N1) virus under plate magnification. Image taken during the virus' first developmental passage through a chicken egg. Courtesy of the CDC/Dr. E. Palmer; R.E. Bates.
Colorized transmission electron micrograph shows avian influenza A/H5N1 viruses (gold) grown in Madin-Darby canine kidney (MDCK) cells (green). Image courtesy of Centers for Disease Control and Prevention.
Transmission electron micrograph (original magnification X 150,000) shows ultrastructural details of an avian influenza A/H5N1 virion, a subtype of avian influenza A. Note the stippled appearance of the roughened surface of the proteinaceous coat encasing the virion. Image courtesy of Centers for Disease Control and Prevention.
 
 
 
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