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Influenza-Associated Deaths among Children To the Editor: Bhat et al. (Dec. 15 issue) 1 report on influenza-related deaths among children during the 2003–2004 influenza season. Combining medical records, autopsy reports, and analyses of virus isolates, their timely study provides estimates of the deaths that may have been caused by influenza. However, we question the authors’ recommendation that vaccine coverage should be improved among children, for several reasons. First, a considerable proportion of the reported deaths were among children under six months of age, for whom influenza vaccination is not approved. Second, about 12 percent of the children who died had been vaccinated. Furthermore, the efficacy of influenza vaccination is far from optimal and, in specific patient groups, even doubtful.2,3 In the season that was studied, efficacy was diminished because of a mismatch between wild virus and vaccine strains. If one combines these arguments with the fact that the number of cases in the 2003–2004 influenza epidemic was above average, millions of children would have to be vaccinated each year in order to prevent one influenza-related death. We conclude that universal vaccination of children is not justified. Johannes C. van der Wouden, Ph.D. Herman J. Bueving, M.D., Ph.D. Siep Thomas, M.D., Ph.D. Erasmus University Medical Center Rotterdam 3000 DR Rotterdam, Netherlands
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this week’s letters 1317 Influenza-Associated Deaths among Children 1318 Beta-Blockers to Prevent Gastroesophageal Varices in Cirrhosis 1320 Artificial Nutrition and Hydration 1322 Lentigo Maligna and Radiotherapy
1. Bhat N, Wright JG, Broder KR, et al. Influenza-associated
deaths among children in the United States, 2003–2004. N Engl J Med 2005;353:2559-67. 2. van der Wouden JC, Bueving HJ, Poole P. Preventing influenza: an overview of systematic reviews. Respir Med 2005;99: 1341-9. 3. Cates CJ, Jefferson TO, Bara AI, Rowe BH. Vaccines for preventing influenza in people with asthma. Cochrane Database Syst Rev 2004;2:CD000364.
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To the Editor: Bhat and colleagues describe 153 influenza-associated deaths among children in the United States during the 2003–2004 influenza season. However, data regarding the use of antiviral medications was omitted. Antiviral therapy has been shown to reduce symptoms and complications requiring antibiotics in children.1 In an analysis of data from two national surveys, my colleagues and I found that physicians prescribed antiviral medications to patients in whom they diagnosed influenza only 19 percent of the time.2 Adults received antiviral medications more frequently than children. We suggested that the lower rate of prescribing for children was due to the labeling of antiviral drugs and a reluctance to expose children to newer medicines.2 The series of influenza-related deaths reported by Bhat and colleagues cannot be used for a definitive assessment of efficacy. However, it would be interesting to know what proportion of the children received antiviral therapy, a fact that would
1322 Treatment for Rheumatic Disorders 1323 Antibodies Neutralizing Peginterferon Alfa during Retreatment of Hepatitis C 1325 Human Streptococcus suis Meningitis in the United States
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shed light on the activity of these medications dren under the age of six months, the ACIP recin this setting. ommends immunization of household contacts to reduce transmission to this vulnerable group. Jeffrey A. Linder, M.D., M.P.H. We were unable to assess the effectiveness of Brigham and Women’s Hospital Boston, MA 02115 influenza vaccine from our surveillance data,
[email protected] cause all cases were defined by outcome, without 1. Cooper NJ, Sutton AJ, Abrams KR, Wailoo A, Turner D, Nich- a comparison group. Younger age and antigenic olson KG. Effectiveness of neuraminidase inhibitors in treatment mismatch may affect the effectiveness of vaccinaand prevention of influenza A and B: systematic review and 1 meta-analyses of randomised controlled trials. BMJ 2003;326: tion. However, some protection is expected. There1235. fore, influenza vaccination should be provided 2. Linder JA, Bates DW, Platt R. Antivirals and antibiotics for to high-risk populations, in whom protection is influenza in the United States, 1995-2002. Pharmacoepidemiol most needed. Drug Saf 2005;14:531-6. With regard to the comments by Dr. Linder: our study found medical-record documentation The authors reply: With regard to the com- of the presence or absence of antiviral therapy in ments by Dr. van der Wouden and colleagues: the 73 of the 153 children reported to have died (48 U.S. Advisory Committee on Immunization Prac- percent) (data not previously reported). Among tices (ACIP) currently does not recommend influ- these 73, 10 patients received adamantanes and enza vaccination for all children but does recom- 18 received oseltamivir, and treatment within 48 mend annual influenza vaccination for specific hours after the onset of illness was documented groups on the basis of their increased risk of in- in 15 cases. Without a comparison control popufluenza-related morbidity. In 2004, annual vacci- lation, it is not possible to draw any conclusions nation was recommended for all children 6 to 23 from these data. months of age. Data from our surveillance led Niranjan Bhat, M.D. the ACIP in 2005 to expand its recommendations David K. Shay, M.D., M.P.H. to include persons with conditions that compro- Timothy M. Uyeki, M.D., M.P.H. mise respiratory function, such as neuromuscu- Centers for Disease Control and Prevention lar disorders.1 In February 2006, the ACIP voted Atlanta, GA 30333 to expand annual vaccine recommendations to in-
[email protected] clude all children 6 to 59 months of age.2 This 1. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prelast recommendation will be published in the vention and control of influenza: recommendations of the Advi2006 recommendations of the ACIP on the pre- sory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2005;54(RR-8):1-40. [Erratum, MMWR Morb Morvention and control of influenza.2 tal Wkly Rep 2005;54:750.] Influenza-related death may be rare in relation 2. Meeting of the Advisory Committee on Immunization Practo the number of children targeted for vaccination, tices, Atlanta, Georgia, February 21–22, 2006. Meeting minutes but improvements in vaccine coverage among will be posted at www.cdc.gov/nip/ACIP. Official recommendations will be available at www.cdc.gov/mmwr/index.html. children may also reduce the substantial burden 3. Thompson WW, Shay DK, Weintraub E, et al. Influenzaof morbidity due to influenza that leads to school associated hospitalizations in the United States. JAMA 2004; absenteeism, hospitalization, and lost work due 292:1333-40. 4. Neuzil KM, Hohlbein C, Zhu Y. Illness among schoolchildren to child care.3-5 Further work to quantify the re- during influenza season: effect on school absenteeism, parental ductions that are possible in all of these outcomes absenteeism from work, and secondary illness in families. Arch is needed to frame the debate regarding univer- Pediatr Adolesc Med 2002;156:986-91. 5. O’Brien MA, Uyeki TM, Shay DK, et al. Incidence of outpasal pediatric vaccination. Because antiviral drugs tient visits and hospitalizations related to influenza in infants and influenza vaccine are not approved for chil- and young children. Pediatrics 2004;113:585-93.
Beta-Blockers to Prevent Gastroesophageal Varices in Cirrhosis To the Editor: The report by Groszmann et al. (Nov. 24 issue)1 answers a question my colleagues and I first raised several years ago2 — namely, that of the potential value of nonselective betablockade in the treatment of unselected patients 1318
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with cirrhosis. We hypothesized that the use of nonselective beta-blockers would lead to a lower rate of esophageal variceal hemorrhage, death, or both, if these agents were given to all such patients.
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