Mary Anne Jackson

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

It’s hard to believe that it is time to ring in the New Year already!

In 2010, we did indeed learn valuable lessons from H1N1 influenza. In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?.

For the upcoming year, I think we will be seriously talking about the following topics:

• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).

My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.

• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).

Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.

• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.

If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.

• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.

There is a lot of upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.

• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.

• Is a new cholera vaccine is needed? The devastating effect of the ongoing cholera outbreak in Haiti has raised discussion regarding the need for a more efficacious and readily available cholera vaccine. As of late December, 58,190 hospitalizations and 2,535 deaths have been reported in Haiti. Check out an eloquently written commentary by Dr. Peter J. Hotez, president of the American Society of Tropical Medicine and Hygiene, coauthored with Dr. Matthew K. Waldor and Dr. John D. Clemens, detailing the potential role of the United States in stockpiling and distributing cholera vaccine in cholera-distressed regions of the world (N. Engl. J. Med. 2010; 363:2279-82).

• Will we have pertussis outbreaks because of reduced vaccine efficacy related to improper storage? Baylor College of Medicine researchers have confirmed that inadvertent freezing of DTaP vaccine (which inactivates the acellular pertussis component) occurred frequently when 54 refrigerators that were used in the Texas county health system were evaluated. Typically, this occurred on weekends and at night when the appliances became excessively cold because they were not being opened for retrieval of doses. Investigators were able to correlate the risk of frozen vaccine with increased pertussis rates in specific regions of the community (Am. J. Public Health 2011;101:46-7).

These findings actually confirm information that has been known for many years, but the study is the first to outline the potential scope of the problem in the United States. Currently, we require only twice-daily measurements of refrigerator temperatures. Could tackling the problem of continued pertussis outbreaks be as simple as better temperature regulation?

• Could standard-dose amoxicillin return for treating otitis media? The epidemiology of pneumococcal disease will continue to evolve following implementation of PCV13. In a few more years, we could potentially see eradication of multidrug resistant serotype 19A with replacement by other serotypes that are penicillin susceptible. Dr. Doug Swanson from my section has been serotyping our strains for several years, and now is seeing previously uncommon types that are nearly all penicillin susceptible.

• IDSA guidelines for treatment of pediatric community-acquired pneumonia are coming your way soon. They are evidence based and have been formulated specifically for the pediatric patient. Look for highlights to include guidance regarding situations in which to obtain blood culture and chest radiography, the first-line agent of choice, and how to identify and handle the patient with complicated disease.

• More complicated Clostridium difficile–associated diarrhea (CDAD) makes its way to the pediatric patient. About 2 years ago, we looked at several years of data to document the epidemiology of CDAD in our pediatric population, and found that most were in patients with underlying comorbid conditions and an association with antecedent beta-lactam antibiotics – the more conventional epidemiologic features. At that point, we had not encountered many cases of severe CDAD that was associated with increased mortality and a reduced effectiveness of metronidazole, as have been seen by adult practitioners in previously healthy outpatients who had not received antecedent antibiotics.

But recently, we cared for an otherwise-healthy child with fulminant colitis who was referred for concern that her disease would necessitate emergency colectomy. Fortunately, she recovered without surgery. I fully suspect that this diagnosis will increase in incidence, and that community-acquired CDAD without prior antibiotic use will become more familiar to the pediatric practitioner.

My best wishes to you all for a year filled with goodness and peace!

This column, "ID Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson said she had no relevant financial disclosures to make.

[email protected]

As physicians who vaccinate children, we are becoming too complacent about polio. The risk has not disappeared. On the contrary, it's just a plane ride away.

Of recent concern, an ongoing outbreak of polio in Tajikistan and possibly Uzbekistan represents the first importation of polio in the World Health Organization European Region since it was certified polio free in 2002. I find this alarming, and I believe that the media has not given it enough attention.

As of this spring, the Tajikistan Ministry of Health has reported 432 cases of acute flaccid paralysis, of which 129 were confirmed as polio. Of the confirmed cases, 107 were children aged 5 years or younger. Twelve deaths were reported.

In Uzbekistan, several cases of acute flaccid paralysis have been reported near the border with Tajikistan, according to the Centers for Disease Control and Prevention (CDC). The recent flooding in nearby Pakistan is also cause for concern, because the disease remains endemic there and may be easily spread in the unsanitary conditions that exist now.

Indeed, Pakistan is one of four countries in which wild poliovirus circulation has never been interrupted. The other three are India, Afghanistan, and Nigeria. But since 2005, imported poliovirus has been reported in a long list of countries. In the past year, those have included Angola, Chad, Ethiopia, Indonesia, Nepal, Somalia, and Uganda.

We had been doing well prior to 2005. Between 1988 and 2004, global eradication efforts—in particular, the Global Polio Eradication Initiative —reduced the number of polio cases from 350,000 annually to a low of 1,189 cases. But in 2005, the number of cases rose again to 1,831 from an epidemic that originated in northern Nigeria and spread to 21 previously polio-free countries.

Here in the United States in 2005, the Minnesota Department of Health identified four cases of poliovirus infections in unvaccinated children who were members of an Amish community. The index case, a 7-month-old girl who was confirmed to have severe combined immune deficiency following admission for failure to thrive and pneumonia, was found to have poliovirus in her stool culture, which was confirmed to be vaccine derived. Neither the index patient nor her family had any history of international travel. The CDC determined that the source of the virus was most likely a person who had received the oral poliovirus vaccine (OPV) in another country.

This report was the first identification of a vaccine-derived poliovirus in the United States and the first occurrence of transmission in a community since OPV vaccinations were discontinued in 2000 (MMWR 2005;54:1053–5). None of those children developed paralytic disease, but the CDC issued a warning nonetheless, pointing out that the virus is considered to have potential for wider transmission and for causing paralytic disease.

Since 2005, while cases have been reported elsewhere in the world, we've not heard about any in the United States. I fear that with many parents now requesting that some vaccinations be delayed or skipped entirely, it will be tempting for clinicians to select out the polio vaccine simply because they haven't seen polio and therefore perceive it as less of a threat.

But it isn't. Families travel to all parts of the world with their children. Teenagers travel on educational and charitable missions. And of course, people from all over the world visit the United States. Polio could easily return here if we become complacent about vaccinating.

We must continue providing the inactivated polio vaccine (IPV) to children at ages 2 months, 4 months, 6–18 months, and 4–6 years. Travelers who have incomplete or unknown immunization status should also receive three doses of IPV (two doses at 4- to 8-week intervals).

We succeeded in eradicating smallpox, and now polio is slated to be next on the list. This is no time to let our guard down.

[email protected]

As physicians who vaccinate children, we are becoming too complacent about polio. The risk has not disappeared. On the contrary, it's just a plane ride away.

Of recent concern, an ongoing outbreak of polio in Tajikistan and possibly Uzbekistan represents the first importation of polio in the World Health Organization European Region since it was certified polio free in 2002. I find this alarming, and I believe that the media has not given it enough attention.

As of this spring, the Tajikistan Ministry of Health has reported 432 cases of acute flaccid paralysis, of which 129 were confirmed as polio. Of the confirmed cases, 107 were children aged 5 years or younger. Twelve deaths were reported.

In Uzbekistan, several cases of acute flaccid paralysis have been reported near the border with Tajikistan, according to the Centers for Disease Control and Prevention (CDC). The recent flooding in nearby Pakistan is also cause for concern, because the disease remains endemic there and may be easily spread in the unsanitary conditions that exist now.

Indeed, Pakistan is one of four countries in which wild poliovirus circulation has never been interrupted. The other three are India, Afghanistan, and Nigeria. But since 2005, imported poliovirus has been reported in a long list of countries. In the past year, those have included Angola, Chad, Ethiopia, Indonesia, Nepal, Somalia, and Uganda.

We had been doing well prior to 2005. Between 1988 and 2004, global eradication efforts—in particular, the Global Polio Eradication Initiative —reduced the number of polio cases from 350,000 annually to a low of 1,189 cases. But in 2005, the number of cases rose again to 1,831 from an epidemic that originated in northern Nigeria and spread to 21 previously polio-free countries.

Here in the United States in 2005, the Minnesota Department of Health identified four cases of poliovirus infections in unvaccinated children who were members of an Amish community. The index case, a 7-month-old girl who was confirmed to have severe combined immune deficiency following admission for failure to thrive and pneumonia, was found to have poliovirus in her stool culture, which was confirmed to be vaccine derived. Neither the index patient nor her family had any history of international travel. The CDC determined that the source of the virus was most likely a person who had received the oral poliovirus vaccine (OPV) in another country.

This report was the first identification of a vaccine-derived poliovirus in the United States and the first occurrence of transmission in a community since OPV vaccinations were discontinued in 2000 (MMWR 2005;54:1053–5). None of those children developed paralytic disease, but the CDC issued a warning nonetheless, pointing out that the virus is considered to have potential for wider transmission and for causing paralytic disease.

Since 2005, while cases have been reported elsewhere in the world, we've not heard about any in the United States. I fear that with many parents now requesting that some vaccinations be delayed or skipped entirely, it will be tempting for clinicians to select out the polio vaccine simply because they haven't seen polio and therefore perceive it as less of a threat.

But it isn't. Families travel to all parts of the world with their children. Teenagers travel on educational and charitable missions. And of course, people from all over the world visit the United States. Polio could easily return here if we become complacent about vaccinating.

We must continue providing the inactivated polio vaccine (IPV) to children at ages 2 months, 4 months, 6–18 months, and 4–6 years. Travelers who have incomplete or unknown immunization status should also receive three doses of IPV (two doses at 4- to 8-week intervals).

We succeeded in eradicating smallpox, and now polio is slated to be next on the list. This is no time to let our guard down.

[email protected]

As physicians who vaccinate children, we are becoming too complacent about polio. The risk has not disappeared. On the contrary, it's just a plane ride away.

Of recent concern, an ongoing outbreak of polio in Tajikistan and possibly Uzbekistan represents the first importation of polio in the World Health Organization European Region since it was certified polio free in 2002. I find this alarming, and I believe that the media has not given it enough attention.

As of this spring, the Tajikistan Ministry of Health has reported 432 cases of acute flaccid paralysis, of which 129 were confirmed as polio. Of the confirmed cases, 107 were children aged 5 years or younger. Twelve deaths were reported.

In Uzbekistan, several cases of acute flaccid paralysis have been reported near the border with Tajikistan, according to the Centers for Disease Control and Prevention (CDC). The recent flooding in nearby Pakistan is also cause for concern, because the disease remains endemic there and may be easily spread in the unsanitary conditions that exist now.

Indeed, Pakistan is one of four countries in which wild poliovirus circulation has never been interrupted. The other three are India, Afghanistan, and Nigeria. But since 2005, imported poliovirus has been reported in a long list of countries. In the past year, those have included Angola, Chad, Ethiopia, Indonesia, Nepal, Somalia, and Uganda.

We had been doing well prior to 2005. Between 1988 and 2004, global eradication efforts—in particular, the Global Polio Eradication Initiative —reduced the number of polio cases from 350,000 annually to a low of 1,189 cases. But in 2005, the number of cases rose again to 1,831 from an epidemic that originated in northern Nigeria and spread to 21 previously polio-free countries.

Here in the United States in 2005, the Minnesota Department of Health identified four cases of poliovirus infections in unvaccinated children who were members of an Amish community. The index case, a 7-month-old girl who was confirmed to have severe combined immune deficiency following admission for failure to thrive and pneumonia, was found to have poliovirus in her stool culture, which was confirmed to be vaccine derived. Neither the index patient nor her family had any history of international travel. The CDC determined that the source of the virus was most likely a person who had received the oral poliovirus vaccine (OPV) in another country.

This report was the first identification of a vaccine-derived poliovirus in the United States and the first occurrence of transmission in a community since OPV vaccinations were discontinued in 2000 (MMWR 2005;54:1053–5). None of those children developed paralytic disease, but the CDC issued a warning nonetheless, pointing out that the virus is considered to have potential for wider transmission and for causing paralytic disease.

Since 2005, while cases have been reported elsewhere in the world, we've not heard about any in the United States. I fear that with many parents now requesting that some vaccinations be delayed or skipped entirely, it will be tempting for clinicians to select out the polio vaccine simply because they haven't seen polio and therefore perceive it as less of a threat.

But it isn't. Families travel to all parts of the world with their children. Teenagers travel on educational and charitable missions. And of course, people from all over the world visit the United States. Polio could easily return here if we become complacent about vaccinating.

We must continue providing the inactivated polio vaccine (IPV) to children at ages 2 months, 4 months, 6–18 months, and 4–6 years. Travelers who have incomplete or unknown immunization status should also receive three doses of IPV (two doses at 4- to 8-week intervals).

We succeeded in eradicating smallpox, and now polio is slated to be next on the list. This is no time to let our guard down.

[email protected]

As my community battles another large Shigella outbreak, I wanted to point out a few aspects of the infection that are often overlooked.

An estimated 450,000 cases of shigellosis occur every year in the United States, the majority among children who are not yet toilet trained. Here in the Kansas City area, we've had an ongoing Shigella sonnei outbreak since November 2009, with more than 250 cases diagnosed to date.

While the diarrhea is usually mild and self-limited, it is highly contagious through the fecal-oral route. Treatment is recommended for confirmed cases, both to stem transmission and to shorten disease duration. Of concern, resistance to trimethoprim-sulfamethoxazole has risen dramatically, from 47% in 1999–2003 to 89% in 2006. Ampicillin resistance also jumped, from 80% to 86%, while strains resistant to both drugs rose from 38% to 89% (MMWR 2006;55:1068–71).

However, azithromycin remains a good choice for treatment and is recommended in the Red Book as a potential treatment option for shigellosis. Dosing is 10 mg/kg one time on day 1 and then 5 mg/kg once a day for 4 more days (maximum 500 mg on day 1 and 250 mg thereafter). Microbiology labs do not routinely report azithromycin-susceptibility data, but randomly selected isolates have been tested during our current outbreak and thus far all are susceptible.

Most isolates are also susceptible to both ceftriaxone and ciprofloxacin, but both of those drugs are approximately five times more expensive than azithromycin is, and fluoroquinolones aren't approved for treating shigellosis in children younger than 18 years of age unless there are no other choices.

Some data also support the use of oral cephalosporins, but eradication rates are lower than with other drugs, so they currently are not recommended.

The last Shigella outbreak in Kansas City, in 2005, involved more than 400 cases over a period of 6 months and also featured a multidrug-resistant strain. Most children had mild disease, but we encountered an obstacle in that Missouri state law requires two negative stool cultures after treatment before the child can return to school or day care, which typically took 2–3 weeks to achieve. Appropriate treatment was often delayed because of empiric therapy with drugs to which strains were resistant and/or preauthorization requirements for using alternative drugs. Getting the families to come back for the repeat culture also was often a challenge.

There are few data to support exclusion policies that mandate two negative cultures. In contrast, some data suggest that such policies prolong the outbreak, in part because some parents will simply move their child to another day care center without mentioning the infection or drop them off at the local water park.

In some states, children with a single negative stool culture may attend child care but are excluded from interacting with other children. Such “cohorting” of convalescing children is better than excluding them entirely. This makes sense because data suggest that if the first convalescent stool culture is negative, the second one almost always is as well (Pediatr. Infect. Dis. J. 2010 May [doi:10.1097/INF.0b013e3181e4ee6e]). I would like to see a change in the regulations that would allow children to re-enter day care sooner.

Of course, it isn't surprising that day care attendance could facilitate transmission of Shigella. Ingestion of as few as 10 organisms is sufficient to produce infection. In a study a few years back, Dr. Andi Shane, a pediatric infectious disease specialist at Emory University, Atlanta, identified several risk factors for prolonged transmission in such settings, many of which are modifiable: soiled diapers accessible to children, water activities involving kiddie pools, volunteers who diapered infants, employed staff who had not received formal hand-washing education, hand-washing supplies that were kept out of the reach of children (and presumably the adults too!), and no adult supervision provided for hand washing in young children (Arch. Pediatr. Adolesc. Med. 2003;157:601–3).

The key to minimizing the transmission of shigellosis in day care centers is clear. Appropriate hand washing and diapering practices must be adhered to. This should include scheduled hand washing for everyone on arrival at the day care center, before meals, or after playing outdoors, along with supervised hand washing for young children. Banning kiddie pools could go a long way too but may not be a good idea on these hot summer days

Just to note: Shigellosis isn't exclusive to children. After our last day care outbreak, I alerted our community to the history related to the Rainbow Family Gathering, a national event orchestrated by a group promoting world peace. Poor sanitation coupled with common sources for food and water facilitated person-to-person spread and one of the largest outbreaks ever reported (J. Infect. Dis. 1990;162:1324–8).

[email protected]

As my community battles another large Shigella outbreak, I wanted to point out a few aspects of the infection that are often overlooked.

An estimated 450,000 cases of shigellosis occur every year in the United States, the majority among children who are not yet toilet trained. Here in the Kansas City area, we've had an ongoing Shigella sonnei outbreak since November 2009, with more than 250 cases diagnosed to date.

While the diarrhea is usually mild and self-limited, it is highly contagious through the fecal-oral route. Treatment is recommended for confirmed cases, both to stem transmission and to shorten disease duration. Of concern, resistance to trimethoprim-sulfamethoxazole has risen dramatically, from 47% in 1999–2003 to 89% in 2006. Ampicillin resistance also jumped, from 80% to 86%, while strains resistant to both drugs rose from 38% to 89% (MMWR 2006;55:1068–71).

However, azithromycin remains a good choice for treatment and is recommended in the Red Book as a potential treatment option for shigellosis. Dosing is 10 mg/kg one time on day 1 and then 5 mg/kg once a day for 4 more days (maximum 500 mg on day 1 and 250 mg thereafter). Microbiology labs do not routinely report azithromycin-susceptibility data, but randomly selected isolates have been tested during our current outbreak and thus far all are susceptible.

Most isolates are also susceptible to both ceftriaxone and ciprofloxacin, but both of those drugs are approximately five times more expensive than azithromycin is, and fluoroquinolones aren't approved for treating shigellosis in children younger than 18 years of age unless there are no other choices.

Some data also support the use of oral cephalosporins, but eradication rates are lower than with other drugs, so they currently are not recommended.

The last Shigella outbreak in Kansas City, in 2005, involved more than 400 cases over a period of 6 months and also featured a multidrug-resistant strain. Most children had mild disease, but we encountered an obstacle in that Missouri state law requires two negative stool cultures after treatment before the child can return to school or day care, which typically took 2–3 weeks to achieve. Appropriate treatment was often delayed because of empiric therapy with drugs to which strains were resistant and/or preauthorization requirements for using alternative drugs. Getting the families to come back for the repeat culture also was often a challenge.

There are few data to support exclusion policies that mandate two negative cultures. In contrast, some data suggest that such policies prolong the outbreak, in part because some parents will simply move their child to another day care center without mentioning the infection or drop them off at the local water park.

In some states, children with a single negative stool culture may attend child care but are excluded from interacting with other children. Such “cohorting” of convalescing children is better than excluding them entirely. This makes sense because data suggest that if the first convalescent stool culture is negative, the second one almost always is as well (Pediatr. Infect. Dis. J. 2010 May [doi:10.1097/INF.0b013e3181e4ee6e]). I would like to see a change in the regulations that would allow children to re-enter day care sooner.

Of course, it isn't surprising that day care attendance could facilitate transmission of Shigella. Ingestion of as few as 10 organisms is sufficient to produce infection. In a study a few years back, Dr. Andi Shane, a pediatric infectious disease specialist at Emory University, Atlanta, identified several risk factors for prolonged transmission in such settings, many of which are modifiable: soiled diapers accessible to children, water activities involving kiddie pools, volunteers who diapered infants, employed staff who had not received formal hand-washing education, hand-washing supplies that were kept out of the reach of children (and presumably the adults too!), and no adult supervision provided for hand washing in young children (Arch. Pediatr. Adolesc. Med. 2003;157:601–3).

The key to minimizing the transmission of shigellosis in day care centers is clear. Appropriate hand washing and diapering practices must be adhered to. This should include scheduled hand washing for everyone on arrival at the day care center, before meals, or after playing outdoors, along with supervised hand washing for young children. Banning kiddie pools could go a long way too but may not be a good idea on these hot summer days

Just to note: Shigellosis isn't exclusive to children. After our last day care outbreak, I alerted our community to the history related to the Rainbow Family Gathering, a national event orchestrated by a group promoting world peace. Poor sanitation coupled with common sources for food and water facilitated person-to-person spread and one of the largest outbreaks ever reported (J. Infect. Dis. 1990;162:1324–8).

[email protected]

As my community battles another large Shigella outbreak, I wanted to point out a few aspects of the infection that are often overlooked.

An estimated 450,000 cases of shigellosis occur every year in the United States, the majority among children who are not yet toilet trained. Here in the Kansas City area, we've had an ongoing Shigella sonnei outbreak since November 2009, with more than 250 cases diagnosed to date.

While the diarrhea is usually mild and self-limited, it is highly contagious through the fecal-oral route. Treatment is recommended for confirmed cases, both to stem transmission and to shorten disease duration. Of concern, resistance to trimethoprim-sulfamethoxazole has risen dramatically, from 47% in 1999–2003 to 89% in 2006. Ampicillin resistance also jumped, from 80% to 86%, while strains resistant to both drugs rose from 38% to 89% (MMWR 2006;55:1068–71).

However, azithromycin remains a good choice for treatment and is recommended in the Red Book as a potential treatment option for shigellosis. Dosing is 10 mg/kg one time on day 1 and then 5 mg/kg once a day for 4 more days (maximum 500 mg on day 1 and 250 mg thereafter). Microbiology labs do not routinely report azithromycin-susceptibility data, but randomly selected isolates have been tested during our current outbreak and thus far all are susceptible.

Most isolates are also susceptible to both ceftriaxone and ciprofloxacin, but both of those drugs are approximately five times more expensive than azithromycin is, and fluoroquinolones aren't approved for treating shigellosis in children younger than 18 years of age unless there are no other choices.

Some data also support the use of oral cephalosporins, but eradication rates are lower than with other drugs, so they currently are not recommended.

The last Shigella outbreak in Kansas City, in 2005, involved more than 400 cases over a period of 6 months and also featured a multidrug-resistant strain. Most children had mild disease, but we encountered an obstacle in that Missouri state law requires two negative stool cultures after treatment before the child can return to school or day care, which typically took 2–3 weeks to achieve. Appropriate treatment was often delayed because of empiric therapy with drugs to which strains were resistant and/or preauthorization requirements for using alternative drugs. Getting the families to come back for the repeat culture also was often a challenge.

There are few data to support exclusion policies that mandate two negative cultures. In contrast, some data suggest that such policies prolong the outbreak, in part because some parents will simply move their child to another day care center without mentioning the infection or drop them off at the local water park.

In some states, children with a single negative stool culture may attend child care but are excluded from interacting with other children. Such “cohorting” of convalescing children is better than excluding them entirely. This makes sense because data suggest that if the first convalescent stool culture is negative, the second one almost always is as well (Pediatr. Infect. Dis. J. 2010 May [doi:10.1097/INF.0b013e3181e4ee6e]). I would like to see a change in the regulations that would allow children to re-enter day care sooner.

Of course, it isn't surprising that day care attendance could facilitate transmission of Shigella. Ingestion of as few as 10 organisms is sufficient to produce infection. In a study a few years back, Dr. Andi Shane, a pediatric infectious disease specialist at Emory University, Atlanta, identified several risk factors for prolonged transmission in such settings, many of which are modifiable: soiled diapers accessible to children, water activities involving kiddie pools, volunteers who diapered infants, employed staff who had not received formal hand-washing education, hand-washing supplies that were kept out of the reach of children (and presumably the adults too!), and no adult supervision provided for hand washing in young children (Arch. Pediatr. Adolesc. Med. 2003;157:601–3).

The key to minimizing the transmission of shigellosis in day care centers is clear. Appropriate hand washing and diapering practices must be adhered to. This should include scheduled hand washing for everyone on arrival at the day care center, before meals, or after playing outdoors, along with supervised hand washing for young children. Banning kiddie pools could go a long way too but may not be a good idea on these hot summer days

Just to note: Shigellosis isn't exclusive to children. After our last day care outbreak, I alerted our community to the history related to the Rainbow Family Gathering, a national event orchestrated by a group promoting world peace. Poor sanitation coupled with common sources for food and water facilitated person-to-person spread and one of the largest outbreaks ever reported (J. Infect. Dis. 1990;162:1324–8).

[email protected]

It's springtime, and that means you'll be seeing more children in your office with animal bites. Are you up to date on the latest treatment guidelines?

One of our community practitioners recently told me that he estimated that in the summer, at least once a week, they fielded a phone call or saw a child with an animal bite injury.

Most such injuries are minor, and usually inflicted by the family pet (dogs 80% of the time), but a recent review in our institution suggested that for children who come to the emergency department (ED) following an animal bite, nearly 7% have a serious injury resulting in hospitalization.

Nationally, it is estimated that millions of bites occur each year, and approximately 1% of all ED visits by children are related to animal bite injuries, so this is a substantial number of children. Practitioners should ensure that they have a standardized practice for caring for such children.

Ricky Ogden, a PharmD in our emergency department, presented a poster at the Infectious Diseases Society of America meeting in 2009 in Philadelphia detailing the epidemiology of animal bite injuries seen in our children's hospital ED from 2005 to 2008. He along with my ID colleagues reviewed a randomly selected subset of 400 patients; some of the interesting findings included that encounters occurred most often in April, May, and June, with Sunday being the most common day for an ED visit. Injuries to the face (50.7%) topped the list, and dogs (84%) were the most likely culprits.

In looking at animal bite prophylaxis, we were surprised to find that most prescriptions were given for an inappropriately long duration (7–10 days rather than the 2- to 3-day recommendation). If our experience is typical, this is a significant issue. Given that there are about 4.7 million bite wounds every year, that is a lot of unnecessary antibiotics..

Provision of care for the child with an animal bite is well outlined in the Red Book, but careful attention to all steps may be overlooked, particularly if the child is not cared for in his/her medical home or by a pediatric provider.

Documentation of the child's age, underlying diseases, and the bite encounter (animal, circumstances, and time of injury before health care provider visit) is key. In young infants or immunocompromised hosts, the risk of infection and serious outcome associated with animal bites increases. Wounds that are fresh (less than 12 hours old) and superficial require nothing more than cleansing and assessment of the need for a tetanus shot.

Assuming the child was previously healthy and is medically stable, your first order of business is to assess and characterize the wound and to provide cleansing, irrigation, and debridement. In the case of penetrating trauma, consider the possibility of occult fracture or damage to tendons or joints. For children with extensive wounds, surgical consultation may be necessary for certain types of hand injuries (potential compartment syndromes or artery, tendon, or ligament injuries) or in the case of cranial injuries.

The assessment of tetanus immunization status (and the need for rabies vaccine/immunoglobulin) is important; a notation that vaccines are “up to date” is not sufficient. We have noted that in children attending urgent care or walk-in retail clinics, the documentation of vaccine status is often overlooked or parents are simply asked if vaccines are “up to date.” This is an instance when it is particularly important to document the precise date when the last tetanus-containing vaccine was given in order to decide whether an additional dose of vaccine is necessary.

The decision to offer antibiotic prophylaxis in the child with an animal bite injury is guided by the assessment of several key pieces of information. You need to know when to initiate therapy, the correct drug to administer (amoxicillin-clavulanate), and the correct duration of therapy (2–3 days). For those with mild injuries and superficial abrasions, prophylaxis is not indicated. Wounds associated with devitalized tissue—especially crush injuries, puncture wounds, and bites to the face, hands or feet, or genitals—have a greater risk of complications, including infections.

For the child with an overtly infected wound, treatment is 10 days (and in those with wounds involving tendons, joints, or other deeper tissues, intravenous therapy should be utilized). The most common infecting organism with both dog and cat bites has always been Pasteurella multocida, but Staphylococcus aureus, Eikenella corrodens, Capnocytophaga species, some anaerobes, and some gram-negative organisms have been reported.

It is interesting to note that among infected wounds at our hospital, we found no methicillin-resistant Staphylococcus aureus despite that 70% of the children we see with skin abscesses (and we see a lot) are caused by this pathogen. For now, we are still recommending amoxicillin-clavulanate, but of course, culture the draining wound and carefully follow up. For those with true penicillin allergy, the combination of clindamycin plus trimethoprim-sulfamethoxazole can be used for nonreptile animal and human bites.

Stay tuned and enjoy the springtime weather and all of the fun it brings with it.

[email protected]

It's springtime, and that means you'll be seeing more children in your office with animal bites. Are you up to date on the latest treatment guidelines?

One of our community practitioners recently told me that he estimated that in the summer, at least once a week, they fielded a phone call or saw a child with an animal bite injury.

Most such injuries are minor, and usually inflicted by the family pet (dogs 80% of the time), but a recent review in our institution suggested that for children who come to the emergency department (ED) following an animal bite, nearly 7% have a serious injury resulting in hospitalization.

Nationally, it is estimated that millions of bites occur each year, and approximately 1% of all ED visits by children are related to animal bite injuries, so this is a substantial number of children. Practitioners should ensure that they have a standardized practice for caring for such children.

Ricky Ogden, a PharmD in our emergency department, presented a poster at the Infectious Diseases Society of America meeting in 2009 in Philadelphia detailing the epidemiology of animal bite injuries seen in our children's hospital ED from 2005 to 2008. He along with my ID colleagues reviewed a randomly selected subset of 400 patients; some of the interesting findings included that encounters occurred most often in April, May, and June, with Sunday being the most common day for an ED visit. Injuries to the face (50.7%) topped the list, and dogs (84%) were the most likely culprits.

In looking at animal bite prophylaxis, we were surprised to find that most prescriptions were given for an inappropriately long duration (7–10 days rather than the 2- to 3-day recommendation). If our experience is typical, this is a significant issue. Given that there are about 4.7 million bite wounds every year, that is a lot of unnecessary antibiotics..

Provision of care for the child with an animal bite is well outlined in the Red Book, but careful attention to all steps may be overlooked, particularly if the child is not cared for in his/her medical home or by a pediatric provider.

Documentation of the child's age, underlying diseases, and the bite encounter (animal, circumstances, and time of injury before health care provider visit) is key. In young infants or immunocompromised hosts, the risk of infection and serious outcome associated with animal bites increases. Wounds that are fresh (less than 12 hours old) and superficial require nothing more than cleansing and assessment of the need for a tetanus shot.

Assuming the child was previously healthy and is medically stable, your first order of business is to assess and characterize the wound and to provide cleansing, irrigation, and debridement. In the case of penetrating trauma, consider the possibility of occult fracture or damage to tendons or joints. For children with extensive wounds, surgical consultation may be necessary for certain types of hand injuries (potential compartment syndromes or artery, tendon, or ligament injuries) or in the case of cranial injuries.

The assessment of tetanus immunization status (and the need for rabies vaccine/immunoglobulin) is important; a notation that vaccines are “up to date” is not sufficient. We have noted that in children attending urgent care or walk-in retail clinics, the documentation of vaccine status is often overlooked or parents are simply asked if vaccines are “up to date.” This is an instance when it is particularly important to document the precise date when the last tetanus-containing vaccine was given in order to decide whether an additional dose of vaccine is necessary.

The decision to offer antibiotic prophylaxis in the child with an animal bite injury is guided by the assessment of several key pieces of information. You need to know when to initiate therapy, the correct drug to administer (amoxicillin-clavulanate), and the correct duration of therapy (2–3 days). For those with mild injuries and superficial abrasions, prophylaxis is not indicated. Wounds associated with devitalized tissue—especially crush injuries, puncture wounds, and bites to the face, hands or feet, or genitals—have a greater risk of complications, including infections.

For the child with an overtly infected wound, treatment is 10 days (and in those with wounds involving tendons, joints, or other deeper tissues, intravenous therapy should be utilized). The most common infecting organism with both dog and cat bites has always been Pasteurella multocida, but Staphylococcus aureus, Eikenella corrodens, Capnocytophaga species, some anaerobes, and some gram-negative organisms have been reported.

It is interesting to note that among infected wounds at our hospital, we found no methicillin-resistant Staphylococcus aureus despite that 70% of the children we see with skin abscesses (and we see a lot) are caused by this pathogen. For now, we are still recommending amoxicillin-clavulanate, but of course, culture the draining wound and carefully follow up. For those with true penicillin allergy, the combination of clindamycin plus trimethoprim-sulfamethoxazole can be used for nonreptile animal and human bites.

Stay tuned and enjoy the springtime weather and all of the fun it brings with it.

[email protected]

It's springtime, and that means you'll be seeing more children in your office with animal bites. Are you up to date on the latest treatment guidelines?

One of our community practitioners recently told me that he estimated that in the summer, at least once a week, they fielded a phone call or saw a child with an animal bite injury.

Most such injuries are minor, and usually inflicted by the family pet (dogs 80% of the time), but a recent review in our institution suggested that for children who come to the emergency department (ED) following an animal bite, nearly 7% have a serious injury resulting in hospitalization.

Nationally, it is estimated that millions of bites occur each year, and approximately 1% of all ED visits by children are related to animal bite injuries, so this is a substantial number of children. Practitioners should ensure that they have a standardized practice for caring for such children.

Ricky Ogden, a PharmD in our emergency department, presented a poster at the Infectious Diseases Society of America meeting in 2009 in Philadelphia detailing the epidemiology of animal bite injuries seen in our children's hospital ED from 2005 to 2008. He along with my ID colleagues reviewed a randomly selected subset of 400 patients; some of the interesting findings included that encounters occurred most often in April, May, and June, with Sunday being the most common day for an ED visit. Injuries to the face (50.7%) topped the list, and dogs (84%) were the most likely culprits.

In looking at animal bite prophylaxis, we were surprised to find that most prescriptions were given for an inappropriately long duration (7–10 days rather than the 2- to 3-day recommendation). If our experience is typical, this is a significant issue. Given that there are about 4.7 million bite wounds every year, that is a lot of unnecessary antibiotics..

Provision of care for the child with an animal bite is well outlined in the Red Book, but careful attention to all steps may be overlooked, particularly if the child is not cared for in his/her medical home or by a pediatric provider.

Documentation of the child's age, underlying diseases, and the bite encounter (animal, circumstances, and time of injury before health care provider visit) is key. In young infants or immunocompromised hosts, the risk of infection and serious outcome associated with animal bites increases. Wounds that are fresh (less than 12 hours old) and superficial require nothing more than cleansing and assessment of the need for a tetanus shot.

Assuming the child was previously healthy and is medically stable, your first order of business is to assess and characterize the wound and to provide cleansing, irrigation, and debridement. In the case of penetrating trauma, consider the possibility of occult fracture or damage to tendons or joints. For children with extensive wounds, surgical consultation may be necessary for certain types of hand injuries (potential compartment syndromes or artery, tendon, or ligament injuries) or in the case of cranial injuries.

The assessment of tetanus immunization status (and the need for rabies vaccine/immunoglobulin) is important; a notation that vaccines are “up to date” is not sufficient. We have noted that in children attending urgent care or walk-in retail clinics, the documentation of vaccine status is often overlooked or parents are simply asked if vaccines are “up to date.” This is an instance when it is particularly important to document the precise date when the last tetanus-containing vaccine was given in order to decide whether an additional dose of vaccine is necessary.

The decision to offer antibiotic prophylaxis in the child with an animal bite injury is guided by the assessment of several key pieces of information. You need to know when to initiate therapy, the correct drug to administer (amoxicillin-clavulanate), and the correct duration of therapy (2–3 days). For those with mild injuries and superficial abrasions, prophylaxis is not indicated. Wounds associated with devitalized tissue—especially crush injuries, puncture wounds, and bites to the face, hands or feet, or genitals—have a greater risk of complications, including infections.

For the child with an overtly infected wound, treatment is 10 days (and in those with wounds involving tendons, joints, or other deeper tissues, intravenous therapy should be utilized). The most common infecting organism with both dog and cat bites has always been Pasteurella multocida, but Staphylococcus aureus, Eikenella corrodens, Capnocytophaga species, some anaerobes, and some gram-negative organisms have been reported.

It is interesting to note that among infected wounds at our hospital, we found no methicillin-resistant Staphylococcus aureus despite that 70% of the children we see with skin abscesses (and we see a lot) are caused by this pathogen. For now, we are still recommending amoxicillin-clavulanate, but of course, culture the draining wound and carefully follow up. For those with true penicillin allergy, the combination of clindamycin plus trimethoprim-sulfamethoxazole can be used for nonreptile animal and human bites.

Stay tuned and enjoy the springtime weather and all of the fun it brings with it.

[email protected]

It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!

Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.

In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.

Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.

Here are my predictions, with the first two based on our influenza experience:

1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).

2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.

3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.

4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.

5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.

6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.

7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?

8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.

9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.

10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.

Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all

[email protected]

It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!

Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.

In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.

Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.

Here are my predictions, with the first two based on our influenza experience:

1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).

2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.

3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.

4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.

5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.

6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.

7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?

8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.

9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.

10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.

Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all

[email protected]

It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!

Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.

In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.

Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.

Here are my predictions, with the first two based on our influenza experience:

1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).

2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.

3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.

4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.

5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.

6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.

7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?

8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.

9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.

10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.

Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all

[email protected]

We are facing an unprecedented influenza season with the confluence of seasonal influenza and pandemic influenza A(H1N1).

Health care workers are morally and ethically—if not legally—bound to be immunized against influenza, especially this year.

The scenario is still unfolding, and there are many things we do not know about how it will play out. But we do know one thing: Health care workers (HCWs) are a high-risk group. Not only do they have a greater chance than ordinary citizens of becoming infected, they can also transmit the virus to patients even if they themselves aren't exhibiting symptoms. Yet, despite the wide availability of free and convenient immunization for influenza at many hospitals and other health institutions, health care workers traditionally have been one of the least well immunized of all high-risk groups.

Part of the problem may be that health care workers don't perceive themselves at high risk—after all, we're the healers, not the sick. But in a survey conducted at my hospital—led by my colleagues, Dr. Angela L. Myers and Dr. John Lantos—we found that health care providers, even in a large freestanding children's hospital, harbor some of the same misconceptions about the flu vaccine as does the general public: that you can get the flu from the vaccine, that it doesn't work, or that it isn't important. Many nurses and allied health professionals are young women of childbearing age and are fearful of receiving the flu vaccine while pregnant, even though the risk to them from the pandemic H1N1 influenza appears particularly high and the risk of getting the flu is much higher than the risk of getting the flu shot. And of course, even health care workers can have a fear of needles.

Some states, including Alabama, Arkansas, California, and Kentucky, have passed laws mandating influenza immunizations. These laws have resulted in increased participation by health care workers, but there still isn't 100% compliance. In many places, the mandate has been extended to include vaccination against the pandemic H1N1 influenza when that vaccine becomes available. However, these state laws all allow exemptions for employees who sign a special written declination, with or without a physician's note providing a medical reason for the refusal.

These requirements may soon become even stricter. Recently, there has been discussion by some health departments that a more stringent regulation be adopted. They recommend that all health care workers in inpatient, outpatient, and home health care settings be required to be vaccinated against both the seasonal and pandemic H1N1 strains of influenza or face dismissal from their jobs. The only exemption would be for a defined medical reason. There would be no religious or philosophical exemptions.

To evaluate health care worker attitudes regarding influenza vaccine, we surveyed about 1,000 employees at our 317-bed children's hospital. We got responses from 62 physicians, 177 nurses, and 346 other employees, a group that included nonclinical staff such as researchers, maintenance, security, and cafeteria workers, as well as care assistants and phlebotomists. The study was initiated in the spring of 2009, and the last surveys were completed 2 weeks after the onset of the pandemic H1N1 flu outbreak.

Physicians and nurses were significantly more likely to receive influenza vaccine than other employees. The physicians were more knowledgeable than other groups regarding immunization recommendations, communicability, high-risk groups, effectiveness, and vaccine safety. Physicians and nurses were more likely than other employees to understand the risk of severe influenza illness in patients with comorbidities.

No group scored well on questions about disease communicability prior to symptom onset. One-third of physicians and two-thirds of other employees did not know that the disease could be spread before the onset of symptoms. If these people are not immunized, and think that they could protect patients by simply not coming in to work if they are sick, they could spread influenza to patients during the presymptomatic phase of their illness. Fewer than two-thirds of physician and nurse respondents and fewer than half of other employee respondents answered this question correctly.

Physicians were more likely than nurses or other employees to agree that a hospital should mandate influenza vaccine for all employees. Overall, 2% of employee respondents reported that they would rather quit their job than comply with a policy that mandated yearly influenza vaccine. There were no physicians in this group.

Attitudes about influenza vaccine were correlated with attitudes about childhood vaccines. Physicians were more likely than nurses and others to agree with the statement: “Children should be required to get all currently recommended childhood vaccines, unless they have a medical reason not to.” When asked to agree or disagree with the statement, “I think parents should be free to decide which vaccines, if any, their children receive,” other employees and nurses were much more likely than physicians to agree or strongly agree.

Almost all employees who had children less than 10 years of age reported that their children were up to date on routine childhood immunizations. However, far fewer had their children immunized against influenza in the prior year.

At our institution, there is an extensive campaign launched every fall to provide education about influenza and vaccine to all employees. We also provide around-the-clock vaccine availability free of charge. Although immunization is not yet mandatory at our hospital, we ask all employees who decline vaccine to fill out and sign a declination form. Typically, a high number of our health care workers are immunized against the seasonal flu; last year, 85% were immunized with 11% signing declinations. We would like to reach 100%.

Our study found that many myths and misconceptions remain regarding influenza immunization. These myths and misconceptions make it likely that many people will refuse influenza immunization even if it is offered free of charge in a program that includes education. Eighty-five percent coverage may be as good as it gets with voluntary programs.

In this unprecedented year of pandemic H1N1 influenza activity, the success of efforts to control the spread of disease and the resulting morbidity and mortality will depend on achieving good immunization coverage. Based on our national numbers, this is unlikely through voluntary programs. Firm mandates may be necessary.

[email protected]

We are facing an unprecedented influenza season with the confluence of seasonal influenza and pandemic influenza A(H1N1).

Health care workers are morally and ethically—if not legally—bound to be immunized against influenza, especially this year.

The scenario is still unfolding, and there are many things we do not know about how it will play out. But we do know one thing: Health care workers (HCWs) are a high-risk group. Not only do they have a greater chance than ordinary citizens of becoming infected, they can also transmit the virus to patients even if they themselves aren't exhibiting symptoms. Yet, despite the wide availability of free and convenient immunization for influenza at many hospitals and other health institutions, health care workers traditionally have been one of the least well immunized of all high-risk groups.

Part of the problem may be that health care workers don't perceive themselves at high risk—after all, we're the healers, not the sick. But in a survey conducted at my hospital—led by my colleagues, Dr. Angela L. Myers and Dr. John Lantos—we found that health care providers, even in a large freestanding children's hospital, harbor some of the same misconceptions about the flu vaccine as does the general public: that you can get the flu from the vaccine, that it doesn't work, or that it isn't important. Many nurses and allied health professionals are young women of childbearing age and are fearful of receiving the flu vaccine while pregnant, even though the risk to them from the pandemic H1N1 influenza appears particularly high and the risk of getting the flu is much higher than the risk of getting the flu shot. And of course, even health care workers can have a fear of needles.

Some states, including Alabama, Arkansas, California, and Kentucky, have passed laws mandating influenza immunizations. These laws have resulted in increased participation by health care workers, but there still isn't 100% compliance. In many places, the mandate has been extended to include vaccination against the pandemic H1N1 influenza when that vaccine becomes available. However, these state laws all allow exemptions for employees who sign a special written declination, with or without a physician's note providing a medical reason for the refusal.

These requirements may soon become even stricter. Recently, there has been discussion by some health departments that a more stringent regulation be adopted. They recommend that all health care workers in inpatient, outpatient, and home health care settings be required to be vaccinated against both the seasonal and pandemic H1N1 strains of influenza or face dismissal from their jobs. The only exemption would be for a defined medical reason. There would be no religious or philosophical exemptions.

To evaluate health care worker attitudes regarding influenza vaccine, we surveyed about 1,000 employees at our 317-bed children's hospital. We got responses from 62 physicians, 177 nurses, and 346 other employees, a group that included nonclinical staff such as researchers, maintenance, security, and cafeteria workers, as well as care assistants and phlebotomists. The study was initiated in the spring of 2009, and the last surveys were completed 2 weeks after the onset of the pandemic H1N1 flu outbreak.

Physicians and nurses were significantly more likely to receive influenza vaccine than other employees. The physicians were more knowledgeable than other groups regarding immunization recommendations, communicability, high-risk groups, effectiveness, and vaccine safety. Physicians and nurses were more likely than other employees to understand the risk of severe influenza illness in patients with comorbidities.

No group scored well on questions about disease communicability prior to symptom onset. One-third of physicians and two-thirds of other employees did not know that the disease could be spread before the onset of symptoms. If these people are not immunized, and think that they could protect patients by simply not coming in to work if they are sick, they could spread influenza to patients during the presymptomatic phase of their illness. Fewer than two-thirds of physician and nurse respondents and fewer than half of other employee respondents answered this question correctly.

Physicians were more likely than nurses or other employees to agree that a hospital should mandate influenza vaccine for all employees. Overall, 2% of employee respondents reported that they would rather quit their job than comply with a policy that mandated yearly influenza vaccine. There were no physicians in this group.

Attitudes about influenza vaccine were correlated with attitudes about childhood vaccines. Physicians were more likely than nurses and others to agree with the statement: “Children should be required to get all currently recommended childhood vaccines, unless they have a medical reason not to.” When asked to agree or disagree with the statement, “I think parents should be free to decide which vaccines, if any, their children receive,” other employees and nurses were much more likely than physicians to agree or strongly agree.

Almost all employees who had children less than 10 years of age reported that their children were up to date on routine childhood immunizations. However, far fewer had their children immunized against influenza in the prior year.

At our institution, there is an extensive campaign launched every fall to provide education about influenza and vaccine to all employees. We also provide around-the-clock vaccine availability free of charge. Although immunization is not yet mandatory at our hospital, we ask all employees who decline vaccine to fill out and sign a declination form. Typically, a high number of our health care workers are immunized against the seasonal flu; last year, 85% were immunized with 11% signing declinations. We would like to reach 100%.

Our study found that many myths and misconceptions remain regarding influenza immunization. These myths and misconceptions make it likely that many people will refuse influenza immunization even if it is offered free of charge in a program that includes education. Eighty-five percent coverage may be as good as it gets with voluntary programs.

In this unprecedented year of pandemic H1N1 influenza activity, the success of efforts to control the spread of disease and the resulting morbidity and mortality will depend on achieving good immunization coverage. Based on our national numbers, this is unlikely through voluntary programs. Firm mandates may be necessary.

[email protected]

We are facing an unprecedented influenza season with the confluence of seasonal influenza and pandemic influenza A(H1N1).

Health care workers are morally and ethically—if not legally—bound to be immunized against influenza, especially this year.

The scenario is still unfolding, and there are many things we do not know about how it will play out. But we do know one thing: Health care workers (HCWs) are a high-risk group. Not only do they have a greater chance than ordinary citizens of becoming infected, they can also transmit the virus to patients even if they themselves aren't exhibiting symptoms. Yet, despite the wide availability of free and convenient immunization for influenza at many hospitals and other health institutions, health care workers traditionally have been one of the least well immunized of all high-risk groups.

Part of the problem may be that health care workers don't perceive themselves at high risk—after all, we're the healers, not the sick. But in a survey conducted at my hospital—led by my colleagues, Dr. Angela L. Myers and Dr. John Lantos—we found that health care providers, even in a large freestanding children's hospital, harbor some of the same misconceptions about the flu vaccine as does the general public: that you can get the flu from the vaccine, that it doesn't work, or that it isn't important. Many nurses and allied health professionals are young women of childbearing age and are fearful of receiving the flu vaccine while pregnant, even though the risk to them from the pandemic H1N1 influenza appears particularly high and the risk of getting the flu is much higher than the risk of getting the flu shot. And of course, even health care workers can have a fear of needles.

Some states, including Alabama, Arkansas, California, and Kentucky, have passed laws mandating influenza immunizations. These laws have resulted in increased participation by health care workers, but there still isn't 100% compliance. In many places, the mandate has been extended to include vaccination against the pandemic H1N1 influenza when that vaccine becomes available. However, these state laws all allow exemptions for employees who sign a special written declination, with or without a physician's note providing a medical reason for the refusal.

These requirements may soon become even stricter. Recently, there has been discussion by some health departments that a more stringent regulation be adopted. They recommend that all health care workers in inpatient, outpatient, and home health care settings be required to be vaccinated against both the seasonal and pandemic H1N1 strains of influenza or face dismissal from their jobs. The only exemption would be for a defined medical reason. There would be no religious or philosophical exemptions.

To evaluate health care worker attitudes regarding influenza vaccine, we surveyed about 1,000 employees at our 317-bed children's hospital. We got responses from 62 physicians, 177 nurses, and 346 other employees, a group that included nonclinical staff such as researchers, maintenance, security, and cafeteria workers, as well as care assistants and phlebotomists. The study was initiated in the spring of 2009, and the last surveys were completed 2 weeks after the onset of the pandemic H1N1 flu outbreak.

Physicians and nurses were significantly more likely to receive influenza vaccine than other employees. The physicians were more knowledgeable than other groups regarding immunization recommendations, communicability, high-risk groups, effectiveness, and vaccine safety. Physicians and nurses were more likely than other employees to understand the risk of severe influenza illness in patients with comorbidities.

No group scored well on questions about disease communicability prior to symptom onset. One-third of physicians and two-thirds of other employees did not know that the disease could be spread before the onset of symptoms. If these people are not immunized, and think that they could protect patients by simply not coming in to work if they are sick, they could spread influenza to patients during the presymptomatic phase of their illness. Fewer than two-thirds of physician and nurse respondents and fewer than half of other employee respondents answered this question correctly.

Physicians were more likely than nurses or other employees to agree that a hospital should mandate influenza vaccine for all employees. Overall, 2% of employee respondents reported that they would rather quit their job than comply with a policy that mandated yearly influenza vaccine. There were no physicians in this group.

Attitudes about influenza vaccine were correlated with attitudes about childhood vaccines. Physicians were more likely than nurses and others to agree with the statement: “Children should be required to get all currently recommended childhood vaccines, unless they have a medical reason not to.” When asked to agree or disagree with the statement, “I think parents should be free to decide which vaccines, if any, their children receive,” other employees and nurses were much more likely than physicians to agree or strongly agree.

Almost all employees who had children less than 10 years of age reported that their children were up to date on routine childhood immunizations. However, far fewer had their children immunized against influenza in the prior year.

At our institution, there is an extensive campaign launched every fall to provide education about influenza and vaccine to all employees. We also provide around-the-clock vaccine availability free of charge. Although immunization is not yet mandatory at our hospital, we ask all employees who decline vaccine to fill out and sign a declination form. Typically, a high number of our health care workers are immunized against the seasonal flu; last year, 85% were immunized with 11% signing declinations. We would like to reach 100%.

Our study found that many myths and misconceptions remain regarding influenza immunization. These myths and misconceptions make it likely that many people will refuse influenza immunization even if it is offered free of charge in a program that includes education. Eighty-five percent coverage may be as good as it gets with voluntary programs.

In this unprecedented year of pandemic H1N1 influenza activity, the success of efforts to control the spread of disease and the resulting morbidity and mortality will depend on achieving good immunization coverage. Based on our national numbers, this is unlikely through voluntary programs. Firm mandates may be necessary.

[email protected]

We are learning more daily about the 2009-H1N1 influenza, now also called the novel H1N1 flu, as the outbreak unfolds. It will be critical for us as clinicians to stay on top of developments so that we can tailor our patient care accordingly. Although disease activity seems to be decreasing, taking what we know today and preparing for fall is imperative.

As the name suggests, this strain of the virus has never circulated in the population before, but there has been some speculation that the low rate of disease in persons older than age 50 years may relate to circulation of a closely related strain decades ago.

Public health officials' main concern has been that with a large susceptible population, the outbreak will evolve into a major global pandemic with high morbidity and mortality, as occurred in 1918. Estimates from the Centers for Disease Control and Prevention suggest that even if this outbreak is a moderate one, up to 35% of the U.S. population could be infected and up to 207,000 people could die.

What is important to us as pediatricians is that in times of pandemic flu, mortality has been highest among the young and healthy. Some investigators propose as an explanation that the virus provokes a cytokine storm in people with a robust immune system, resulting in a kind of immunologic paralysis. Indeed, initial reports from Mexico suggested that most flu deaths were occurring in otherwise healthy individuals; authorities there are now reviewing their data to better assess who may be at greatest risk.

The clinical picture of influenza is usually easy to recognize: an abrupt onset of fever, cough, sore throat, and rhinitis. In a recent study from Finland, myalgia and headache were less common in children than they were in adults. At our institution, in the recent outbreak, we have gotten more selective about which children we test for influenza because we found that using the CDC criteria of a fever of at least 37.8° C and a runny nose, we picked up a lot of common colds and croup. In our first 15 pediatric cases of this flu, the mean fever was much higher at 39.8° C. So the low-grade fever used to guide testing in adults is probably not going to be reliable in children.

Another discovery has been that our rapid influenza test is not sensitive for the H1N1 virus; therefore, such testing may not aid in diagnosis. The take-home message is that it's wise to check with your local infectious disease specialists about the diagnostic performance of the rapid test used by your laboratory. In contrast, we have found that the multiplex polymerase chain reaction test that we use has reliably picked up all cases of H1N1 flu, although it identifies them as influenza A isolates that are not able to be subtyped using standard H1N1 primers.

Education will be key in responding to this outbreak. The worried well are flocking to their doctors' offices and sitting in waiting rooms next to those with mild influenza, who also don't need to be there. At our institution, we are distributing a handout to parents that explains that influenza testing and antiviral therapy are not needed for mild influenza. We instruct them in how to provide home care and about warning signs that mean they should seek care for their child.

At this point, antiviral therapy among children with influenza is mainly being restricted to those admitted to the hospital and those at high risk for complications. The latter group includes, among others, children younger than age 5 years, but particularly those younger than age 2. If more than 48 hours have elapsed since symptom onset, the therapy may have little effect, so symptomatic management alone is reasonable. Antiviral prophylaxis should be considered for exposed siblings who are at high risk for influenza complications.

Pediatricians need to be vigilant and prepared for the known possible complications of influenza, especially superinfection including bacterial pneumonia. Some of the less common complications can have tricky presentations in the pediatric population. For example, in children, influenza-related encephalopathy can manifest as aphasia, and in some children with influenza-associated myositis, parents may contact their provider with the concern that their child has an acute onset of paralysis as the child refuses to walk.

In contrast to adults with influenza, who are infectious to others for roughly 6 days, children are infectious for at least 10 days. This is going to be problematic because it may be necessary to maintain barrier protection for hospitalized children for longer than a week.

The novel H1N1 outbreak has clearly been taxing the health care system and health care providers, especially on the outpatient side. Although we have been preparing for such an event for years, several logistical problems have emerged. One is a shortage of N95 masks, a required piece of personal protective equipment when caring for hospitalized patients with pandemic influenza. Another is a shortage of staff, as personnel with suspected or confirmed infection must stay home.

We are anticipating that a vaccine against the 2009-H1N1 virus could be available by September or October. It's likely going to require two shots, in addition to the standard seasonal influenza shot. This might be a hard sell to vaccine-hesitant parents under usual circumstances, but it is too soon to tell what the reception will be like in the context of the current outbreak.

Public health officials are hoping transmission of the virus will decrease naturally with the end of the school year. However, resurgence of the 2009-H1N1 disease in the fall is a possibility that we need to be prepared for, particularly if new mutations increase its virulence.

[email protected]

We are learning more daily about the 2009-H1N1 influenza, now also called the novel H1N1 flu, as the outbreak unfolds. It will be critical for us as clinicians to stay on top of developments so that we can tailor our patient care accordingly. Although disease activity seems to be decreasing, taking what we know today and preparing for fall is imperative.

As the name suggests, this strain of the virus has never circulated in the population before, but there has been some speculation that the low rate of disease in persons older than age 50 years may relate to circulation of a closely related strain decades ago.

Public health officials' main concern has been that with a large susceptible population, the outbreak will evolve into a major global pandemic with high morbidity and mortality, as occurred in 1918. Estimates from the Centers for Disease Control and Prevention suggest that even if this outbreak is a moderate one, up to 35% of the U.S. population could be infected and up to 207,000 people could die.

What is important to us as pediatricians is that in times of pandemic flu, mortality has been highest among the young and healthy. Some investigators propose as an explanation that the virus provokes a cytokine storm in people with a robust immune system, resulting in a kind of immunologic paralysis. Indeed, initial reports from Mexico suggested that most flu deaths were occurring in otherwise healthy individuals; authorities there are now reviewing their data to better assess who may be at greatest risk.

The clinical picture of influenza is usually easy to recognize: an abrupt onset of fever, cough, sore throat, and rhinitis. In a recent study from Finland, myalgia and headache were less common in children than they were in adults. At our institution, in the recent outbreak, we have gotten more selective about which children we test for influenza because we found that using the CDC criteria of a fever of at least 37.8° C and a runny nose, we picked up a lot of common colds and croup. In our first 15 pediatric cases of this flu, the mean fever was much higher at 39.8° C. So the low-grade fever used to guide testing in adults is probably not going to be reliable in children.

Another discovery has been that our rapid influenza test is not sensitive for the H1N1 virus; therefore, such testing may not aid in diagnosis. The take-home message is that it's wise to check with your local infectious disease specialists about the diagnostic performance of the rapid test used by your laboratory. In contrast, we have found that the multiplex polymerase chain reaction test that we use has reliably picked up all cases of H1N1 flu, although it identifies them as influenza A isolates that are not able to be subtyped using standard H1N1 primers.

Education will be key in responding to this outbreak. The worried well are flocking to their doctors' offices and sitting in waiting rooms next to those with mild influenza, who also don't need to be there. At our institution, we are distributing a handout to parents that explains that influenza testing and antiviral therapy are not needed for mild influenza. We instruct them in how to provide home care and about warning signs that mean they should seek care for their child.

At this point, antiviral therapy among children with influenza is mainly being restricted to those admitted to the hospital and those at high risk for complications. The latter group includes, among others, children younger than age 5 years, but particularly those younger than age 2. If more than 48 hours have elapsed since symptom onset, the therapy may have little effect, so symptomatic management alone is reasonable. Antiviral prophylaxis should be considered for exposed siblings who are at high risk for influenza complications.

Pediatricians need to be vigilant and prepared for the known possible complications of influenza, especially superinfection including bacterial pneumonia. Some of the less common complications can have tricky presentations in the pediatric population. For example, in children, influenza-related encephalopathy can manifest as aphasia, and in some children with influenza-associated myositis, parents may contact their provider with the concern that their child has an acute onset of paralysis as the child refuses to walk.

In contrast to adults with influenza, who are infectious to others for roughly 6 days, children are infectious for at least 10 days. This is going to be problematic because it may be necessary to maintain barrier protection for hospitalized children for longer than a week.

The novel H1N1 outbreak has clearly been taxing the health care system and health care providers, especially on the outpatient side. Although we have been preparing for such an event for years, several logistical problems have emerged. One is a shortage of N95 masks, a required piece of personal protective equipment when caring for hospitalized patients with pandemic influenza. Another is a shortage of staff, as personnel with suspected or confirmed infection must stay home.

We are anticipating that a vaccine against the 2009-H1N1 virus could be available by September or October. It's likely going to require two shots, in addition to the standard seasonal influenza shot. This might be a hard sell to vaccine-hesitant parents under usual circumstances, but it is too soon to tell what the reception will be like in the context of the current outbreak.

Public health officials are hoping transmission of the virus will decrease naturally with the end of the school year. However, resurgence of the 2009-H1N1 disease in the fall is a possibility that we need to be prepared for, particularly if new mutations increase its virulence.

[email protected]

We are learning more daily about the 2009-H1N1 influenza, now also called the novel H1N1 flu, as the outbreak unfolds. It will be critical for us as clinicians to stay on top of developments so that we can tailor our patient care accordingly. Although disease activity seems to be decreasing, taking what we know today and preparing for fall is imperative.

As the name suggests, this strain of the virus has never circulated in the population before, but there has been some speculation that the low rate of disease in persons older than age 50 years may relate to circulation of a closely related strain decades ago.

Public health officials' main concern has been that with a large susceptible population, the outbreak will evolve into a major global pandemic with high morbidity and mortality, as occurred in 1918. Estimates from the Centers for Disease Control and Prevention suggest that even if this outbreak is a moderate one, up to 35% of the U.S. population could be infected and up to 207,000 people could die.

What is important to us as pediatricians is that in times of pandemic flu, mortality has been highest among the young and healthy. Some investigators propose as an explanation that the virus provokes a cytokine storm in people with a robust immune system, resulting in a kind of immunologic paralysis. Indeed, initial reports from Mexico suggested that most flu deaths were occurring in otherwise healthy individuals; authorities there are now reviewing their data to better assess who may be at greatest risk.

The clinical picture of influenza is usually easy to recognize: an abrupt onset of fever, cough, sore throat, and rhinitis. In a recent study from Finland, myalgia and headache were less common in children than they were in adults. At our institution, in the recent outbreak, we have gotten more selective about which children we test for influenza because we found that using the CDC criteria of a fever of at least 37.8° C and a runny nose, we picked up a lot of common colds and croup. In our first 15 pediatric cases of this flu, the mean fever was much higher at 39.8° C. So the low-grade fever used to guide testing in adults is probably not going to be reliable in children.

Another discovery has been that our rapid influenza test is not sensitive for the H1N1 virus; therefore, such testing may not aid in diagnosis. The take-home message is that it's wise to check with your local infectious disease specialists about the diagnostic performance of the rapid test used by your laboratory. In contrast, we have found that the multiplex polymerase chain reaction test that we use has reliably picked up all cases of H1N1 flu, although it identifies them as influenza A isolates that are not able to be subtyped using standard H1N1 primers.

Education will be key in responding to this outbreak. The worried well are flocking to their doctors' offices and sitting in waiting rooms next to those with mild influenza, who also don't need to be there. At our institution, we are distributing a handout to parents that explains that influenza testing and antiviral therapy are not needed for mild influenza. We instruct them in how to provide home care and about warning signs that mean they should seek care for their child.

At this point, antiviral therapy among children with influenza is mainly being restricted to those admitted to the hospital and those at high risk for complications. The latter group includes, among others, children younger than age 5 years, but particularly those younger than age 2. If more than 48 hours have elapsed since symptom onset, the therapy may have little effect, so symptomatic management alone is reasonable. Antiviral prophylaxis should be considered for exposed siblings who are at high risk for influenza complications.

Pediatricians need to be vigilant and prepared for the known possible complications of influenza, especially superinfection including bacterial pneumonia. Some of the less common complications can have tricky presentations in the pediatric population. For example, in children, influenza-related encephalopathy can manifest as aphasia, and in some children with influenza-associated myositis, parents may contact their provider with the concern that their child has an acute onset of paralysis as the child refuses to walk.

In contrast to adults with influenza, who are infectious to others for roughly 6 days, children are infectious for at least 10 days. This is going to be problematic because it may be necessary to maintain barrier protection for hospitalized children for longer than a week.

The novel H1N1 outbreak has clearly been taxing the health care system and health care providers, especially on the outpatient side. Although we have been preparing for such an event for years, several logistical problems have emerged. One is a shortage of N95 masks, a required piece of personal protective equipment when caring for hospitalized patients with pandemic influenza. Another is a shortage of staff, as personnel with suspected or confirmed infection must stay home.

We are anticipating that a vaccine against the 2009-H1N1 virus could be available by September or October. It's likely going to require two shots, in addition to the standard seasonal influenza shot. This might be a hard sell to vaccine-hesitant parents under usual circumstances, but it is too soon to tell what the reception will be like in the context of the current outbreak.

Public health officials are hoping transmission of the virus will decrease naturally with the end of the school year. However, resurgence of the 2009-H1N1 disease in the fall is a possibility that we need to be prepared for, particularly if new mutations increase its virulence.

[email protected]

In this era of increased hesitancy about immunization, it's important for us to be as educated as possible about the vaccines we're giving—including their true possible adverse effects—and to be willing to share that information with our patients and their families.

There's been a lot of press lately about adverse effects associated with the four-valent human papillomavirus vaccine (HPV4, Gardasil). Some of these reports are accurate, but many are not. Practitioners are better prepared to talk to families about this and other vaccines if they are well informed themselves.

To date, more than 20 million doses of HPV4 vaccine have been administered. Between June 30, 2006, and August 31, 2008, a total of 10,346 adverse events following receipt of HPV4 vaccine were reported to the Vaccine Adverse Events Reporting System (VAERS). The number sounds high, but if you do the math, this is much less than 1% and the vast majority are nonserious events.

There have been 27 reported deaths from a variety of causes including acute myocarditis, influenza B, pulmonary embolism, drug overdose, and diabetic ketoacidosis. To date, no clustering by age group, onset interval, dose number, or clinical conditions has been noted that preceded or caused death.

Dizziness and syncopal events associated with HPV4 immunization are among the events that practitioners should be aware of. The fact that fainting is associated with a medical event is not surprising because most vasovagal events follow some type of trigger, such as the sight of blood or some other type of emotionally stressful event.

Fainting events are most often noted in adolescents and young adults. One study that looked at a medical student population found that 3% of men and 3.5% of women had experienced a vasovagal event in the past. It would not be surprising then that fainting following vaccination occurs, particularly among adolescents and young adults.

There is no clear evidence that fainting is more common following HPV4 vaccine than any other vaccine.

Indeed, an increase in syncope reported to VAERS between 2005 and 2007 coincided with the licensure and recommendation of other vaccines often given during adolescence, including meningococcal conjugate vaccine (MCV4) and the adolescent/adult version of the tetanus/diphtheria/acellular pertussis vaccine (Tdap), in addition to the HPV4 vaccine.

Although HPV4 vaccine was the most frequently reported vaccine associated with syncope when only one vaccine was given (52%), that is likely due to the fact that three doses of this vaccine are given (as opposed to one each for MCV4 and Tdap), as well as to the increased publicity and media attention surrounding HPV4 vaccine.

A subsequent active surveillance evaluation done by the Centers for Disease Control and Prevention using the Vaccine Safety Datalink (VSD) derived from managed care data for 3% of the U.S. population did not detect a “safety signal” for syncope among 377,960 administered doses of HPV4 vaccine.

How should practitioners use this information? Ask your patients before immunization or blood draw if they have ever fainted. If they have, ask if they experienced a particular prodrome. Individuals who have had syncopal episodes usually have an excellent idea of what prodromal symptoms to expect. Most can articulate the warning signs pretty well, describing visual disturbances, buzzing in the ears, lightheadedness, sweating, and nausea.

Importantly, one can prevent virtually 100% of these episodes by having patients lie down and elevate their legs while they receive the injection.

Emergency departments have learned these lessons well and routinely advise against letting parents stand while watching their children being sutured, or letting patients stand for venipunctures.

Even for patients who have never had a syncopal event, having them sit or lie down in your office for 15 minutes after receiving the vaccine is recommended.

The CDC's Advisory Committee on Immunization Practices in 2006 recommended that all recipients of all vaccines be observed for 15 minutes after vaccination (MMWR 2006;55[RR15]:1–48), although HPV4 vaccine is the only one to also contain the 15-minute wait recommendation in its package label, per the Food and Drug Administration.

The timing recommendation comes from analysis of 41 syncope reports following immunization during January 2005-July 2007 where secondary injuries occurred. The time from vaccination to syncope onset was less than 5 minutes in 49% and less than 15 minutes in 80% of the reports.

The 15-minute waiting period is intended to prevent serious injury associated with falling due to the vasovagal event, which has been linked to at least one documented death.

The CDC is now beginning a survey of providers to assess their attitudes about and adherence to this recommendation.

The bottom line: HPV4 appears safe and effective. Fainting can occur with any vaccine, but be particularly alert to this in the teenage population. It can be averted in those who are known to be prone to vasovagal events by having the patient lie down for blood draws and shots. It is expected that most injuries can be avoided with the use of a waiting period following vaccine receipt.

[email protected]

In this era of increased hesitancy about immunization, it's important for us to be as educated as possible about the vaccines we're giving—including their true possible adverse effects—and to be willing to share that information with our patients and their families.

There's been a lot of press lately about adverse effects associated with the four-valent human papillomavirus vaccine (HPV4, Gardasil). Some of these reports are accurate, but many are not. Practitioners are better prepared to talk to families about this and other vaccines if they are well informed themselves.

To date, more than 20 million doses of HPV4 vaccine have been administered. Between June 30, 2006, and August 31, 2008, a total of 10,346 adverse events following receipt of HPV4 vaccine were reported to the Vaccine Adverse Events Reporting System (VAERS). The number sounds high, but if you do the math, this is much less than 1% and the vast majority are nonserious events.

There have been 27 reported deaths from a variety of causes including acute myocarditis, influenza B, pulmonary embolism, drug overdose, and diabetic ketoacidosis. To date, no clustering by age group, onset interval, dose number, or clinical conditions has been noted that preceded or caused death.

Dizziness and syncopal events associated with HPV4 immunization are among the events that practitioners should be aware of. The fact that fainting is associated with a medical event is not surprising because most vasovagal events follow some type of trigger, such as the sight of blood or some other type of emotionally stressful event.

Fainting events are most often noted in adolescents and young adults. One study that looked at a medical student population found that 3% of men and 3.5% of women had experienced a vasovagal event in the past. It would not be surprising then that fainting following vaccination occurs, particularly among adolescents and young adults.

There is no clear evidence that fainting is more common following HPV4 vaccine than any other vaccine.

Indeed, an increase in syncope reported to VAERS between 2005 and 2007 coincided with the licensure and recommendation of other vaccines often given during adolescence, including meningococcal conjugate vaccine (MCV4) and the adolescent/adult version of the tetanus/diphtheria/acellular pertussis vaccine (Tdap), in addition to the HPV4 vaccine.

Although HPV4 vaccine was the most frequently reported vaccine associated with syncope when only one vaccine was given (52%), that is likely due to the fact that three doses of this vaccine are given (as opposed to one each for MCV4 and Tdap), as well as to the increased publicity and media attention surrounding HPV4 vaccine.

A subsequent active surveillance evaluation done by the Centers for Disease Control and Prevention using the Vaccine Safety Datalink (VSD) derived from managed care data for 3% of the U.S. population did not detect a “safety signal” for syncope among 377,960 administered doses of HPV4 vaccine.

How should practitioners use this information? Ask your patients before immunization or blood draw if they have ever fainted. If they have, ask if they experienced a particular prodrome. Individuals who have had syncopal episodes usually have an excellent idea of what prodromal symptoms to expect. Most can articulate the warning signs pretty well, describing visual disturbances, buzzing in the ears, lightheadedness, sweating, and nausea.

Importantly, one can prevent virtually 100% of these episodes by having patients lie down and elevate their legs while they receive the injection.

Emergency departments have learned these lessons well and routinely advise against letting parents stand while watching their children being sutured, or letting patients stand for venipunctures.

Even for patients who have never had a syncopal event, having them sit or lie down in your office for 15 minutes after receiving the vaccine is recommended.

The CDC's Advisory Committee on Immunization Practices in 2006 recommended that all recipients of all vaccines be observed for 15 minutes after vaccination (MMWR 2006;55[RR15]:1–48), although HPV4 vaccine is the only one to also contain the 15-minute wait recommendation in its package label, per the Food and Drug Administration.

The timing recommendation comes from analysis of 41 syncope reports following immunization during January 2005-July 2007 where secondary injuries occurred. The time from vaccination to syncope onset was less than 5 minutes in 49% and less than 15 minutes in 80% of the reports.

The 15-minute waiting period is intended to prevent serious injury associated with falling due to the vasovagal event, which has been linked to at least one documented death.

The CDC is now beginning a survey of providers to assess their attitudes about and adherence to this recommendation.

The bottom line: HPV4 appears safe and effective. Fainting can occur with any vaccine, but be particularly alert to this in the teenage population. It can be averted in those who are known to be prone to vasovagal events by having the patient lie down for blood draws and shots. It is expected that most injuries can be avoided with the use of a waiting period following vaccine receipt.

[email protected]

In this era of increased hesitancy about immunization, it's important for us to be as educated as possible about the vaccines we're giving—including their true possible adverse effects—and to be willing to share that information with our patients and their families.

There's been a lot of press lately about adverse effects associated with the four-valent human papillomavirus vaccine (HPV4, Gardasil). Some of these reports are accurate, but many are not. Practitioners are better prepared to talk to families about this and other vaccines if they are well informed themselves.

To date, more than 20 million doses of HPV4 vaccine have been administered. Between June 30, 2006, and August 31, 2008, a total of 10,346 adverse events following receipt of HPV4 vaccine were reported to the Vaccine Adverse Events Reporting System (VAERS). The number sounds high, but if you do the math, this is much less than 1% and the vast majority are nonserious events.

There have been 27 reported deaths from a variety of causes including acute myocarditis, influenza B, pulmonary embolism, drug overdose, and diabetic ketoacidosis. To date, no clustering by age group, onset interval, dose number, or clinical conditions has been noted that preceded or caused death.

Dizziness and syncopal events associated with HPV4 immunization are among the events that practitioners should be aware of. The fact that fainting is associated with a medical event is not surprising because most vasovagal events follow some type of trigger, such as the sight of blood or some other type of emotionally stressful event.

Fainting events are most often noted in adolescents and young adults. One study that looked at a medical student population found that 3% of men and 3.5% of women had experienced a vasovagal event in the past. It would not be surprising then that fainting following vaccination occurs, particularly among adolescents and young adults.

There is no clear evidence that fainting is more common following HPV4 vaccine than any other vaccine.

Indeed, an increase in syncope reported to VAERS between 2005 and 2007 coincided with the licensure and recommendation of other vaccines often given during adolescence, including meningococcal conjugate vaccine (MCV4) and the adolescent/adult version of the tetanus/diphtheria/acellular pertussis vaccine (Tdap), in addition to the HPV4 vaccine.

Although HPV4 vaccine was the most frequently reported vaccine associated with syncope when only one vaccine was given (52%), that is likely due to the fact that three doses of this vaccine are given (as opposed to one each for MCV4 and Tdap), as well as to the increased publicity and media attention surrounding HPV4 vaccine.

A subsequent active surveillance evaluation done by the Centers for Disease Control and Prevention using the Vaccine Safety Datalink (VSD) derived from managed care data for 3% of the U.S. population did not detect a “safety signal” for syncope among 377,960 administered doses of HPV4 vaccine.

How should practitioners use this information? Ask your patients before immunization or blood draw if they have ever fainted. If they have, ask if they experienced a particular prodrome. Individuals who have had syncopal episodes usually have an excellent idea of what prodromal symptoms to expect. Most can articulate the warning signs pretty well, describing visual disturbances, buzzing in the ears, lightheadedness, sweating, and nausea.

Importantly, one can prevent virtually 100% of these episodes by having patients lie down and elevate their legs while they receive the injection.

Emergency departments have learned these lessons well and routinely advise against letting parents stand while watching their children being sutured, or letting patients stand for venipunctures.

Even for patients who have never had a syncopal event, having them sit or lie down in your office for 15 minutes after receiving the vaccine is recommended.

The CDC's Advisory Committee on Immunization Practices in 2006 recommended that all recipients of all vaccines be observed for 15 minutes after vaccination (MMWR 2006;55[RR15]:1–48), although HPV4 vaccine is the only one to also contain the 15-minute wait recommendation in its package label, per the Food and Drug Administration.

The timing recommendation comes from analysis of 41 syncope reports following immunization during January 2005-July 2007 where secondary injuries occurred. The time from vaccination to syncope onset was less than 5 minutes in 49% and less than 15 minutes in 80% of the reports.

The 15-minute waiting period is intended to prevent serious injury associated with falling due to the vasovagal event, which has been linked to at least one documented death.

The CDC is now beginning a survey of providers to assess their attitudes about and adherence to this recommendation.

The bottom line: HPV4 appears safe and effective. Fainting can occur with any vaccine, but be particularly alert to this in the teenage population. It can be averted in those who are known to be prone to vasovagal events by having the patient lie down for blood draws and shots. It is expected that most injuries can be avoided with the use of a waiting period following vaccine receipt.

[email protected]

Happy 2009! It's time for the annual look into the future of infectious diseases.

Two common themes were evident last year: increasing antibiotic resistance, and changing epidemiology and vaccine-preventable infections. Last year's predictions that were on the mark included the rise in pneumococcal serotype 19A, the drop in rotavirus cases, the lack of a national solution to vaccine reimbursement, the need for new strategies to raise vaccine coverage rates, and the rise in methicillin-resistant Staphylococcus aureus (MRSA) infections. This year, some similar themes prevail and some items may surprise you:

▸ MRSA will become a more prominent pathogen in your local neonatal intensive care unit (NICU). Practicing pediatricians are well aware of the emergence of MRSA. As evidence, most have probably drained more abscesses in the last year than in their entire career to date. Sporadic phone calls have alerted us to cases of MRSA infection in community hospital nurseries, and while we have not encountered a NICU outbreak of MRSA infection, they are well reported and may be difficult to halt. Active NICU surveillance (periodic nasal screening), screening of new admissions hospitalized elsewhere, and utilization of contact precautions (until results are available) may be necessary.

▸ Multidrug-resistant gram-negative infections will emerge throughout pediatric hospitals, and no new help is on the horizon for these bad bugs, which have been coined the ESKAPE bacteria. They include two gram-positive bugs—Enterococcus faecium, Staphylococcus aureus, and gram negatives including four species of Klebsiella, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species—which together are responsible for two-thirds of all health care-associated infections. While a few new drugs are available or coming for MRSA, there are few that target gram-negative pathogens. For more information, check out the article by Dr. Helen Boucher of Tufts University (Clin. Infect. Dis. 2009;48:1-12).

▸ Parental declinations of certain vaccines will plateau. No question that pediatricians are spending an increasing amount of time addressing parental concerns regarding vaccines, but the majority of parents still trust their pediatrician to provide appropriate vaccine information. The key, though, is making sure you appropriately address their concerns and deliver a clear and positive message with high-quality information.

Check out Meg Fisher's article in the September 2008 Pediatric Infectious Disease Journal for a great discussion of vaccine safety (Pediatr. Infect. Dis J. 2008:27:827-30).

▸ Pertussis cases will hit an all time low overall but beware: Outbreaks will still occur, particularly among older children. Implementation of the adolescent/adult tetanus-diphtheria-reduced antigen acellular pertussis (Tdap) vaccine is ongoing, but we still have a large susceptible population of children aged 8-12 years, as well as adults. We recently cared for a 5-week-old infant with whooping cough who required ECMO (extracorporeal membrane oxygenation). I suspect we will continue to see such cases.

The role of postpartum Tdap is important, and pediatricians should encourage their obstetrics colleagues to use a standing order to give vaccine to mothers before hospital discharge (if they have not received a tetanus-containing vaccine in the past 2 years, or prior Tdap).

▸ The new improved pneumococcal conjugate vaccine may be closer than you think. The emergence of multidrug-resistant serotype 19A disease has challenged the management of pneumococcal infection from acute suppurative otitis media to more serious infections like pneumonia and meningitis. Last May, the Food and Drug Administration granted fast-track designation for the Wyeth 13-valent vaccine (which includes 19A) to speed the process.

▸ Cases of Clostridium difficile will increase. In 2005, the Centers for Disease Control and Prevention alerted us to the reports of an increase in incidence and severity of C. difficile-associated disease (CDAD), both community acquired and health care-facility acquired or associated. While most practitioners are aware that the major driving force in CDAD is antimicrobial use, this strain appears to be causing infection in otherwise healthy persons who haven't received antibiotics. One study confirmed that with respect to health care-associated CDAD, the availability of adequate infection control personnel was associated with lower rates.

▸ You might see Haemophilus influenzae type b (Hib) invasive infection in the coming year. A Nov. 21 CDC report detailed information regarding the continued vaccine shortage (MMWR 2008;57:1252-5). (See Policy &Practice item, p. 23.) Vaccine supplies currently are insufficient to supply the booster dose, and some studies suggest that this dose is particularly important for protection and herd immunity. In the United Kingdom, a booster dose was not initially recommended; after an initial decrease in disease, the rate of invasive infection rose again. There is concern that prolonged deferral of the Hib booster in the United States may produce similar results, so be on the look out.

▸ Most physicians are still unaware of the new guidelines for subacute bacterial prophylaxis. In 2007, the American Heart Association issued the first major revision of these guidelines and endorsed antimicrobial prophylaxis for only five circumstances: prosthetic heart valves, prior infective endocarditis, cardiac transplant with valvulopathy, unrepaired cyanotic congenital heart disease, and repaired congenital heart disease with either prosthetic patch or other device in the first 6 months after placement or beyond that if there is a residual defect at the site of patch or device. Read more about it at: www.americanheart.org/presenter.jhtml?identifier=3047051

▸ A rise in tuberculosis cases will occur in the United States. A recent study in Clinical Infectious Diseases showed a particular risk for undocumented immigrants with tuberculosis to be sicker longer than documented immigrants or U.S.-born patients. With this comes a potential for increased risk for transmission.

▸ Do you know about the CDC's Web site for students who are planning to Study Abroad (www.cdc.gov/Features/StudyAbroad

[email protected]

Happy 2009! It's time for the annual look into the future of infectious diseases.

Two common themes were evident last year: increasing antibiotic resistance, and changing epidemiology and vaccine-preventable infections. Last year's predictions that were on the mark included the rise in pneumococcal serotype 19A, the drop in rotavirus cases, the lack of a national solution to vaccine reimbursement, the need for new strategies to raise vaccine coverage rates, and the rise in methicillin-resistant Staphylococcus aureus (MRSA) infections. This year, some similar themes prevail and some items may surprise you:

▸ MRSA will become a more prominent pathogen in your local neonatal intensive care unit (NICU). Practicing pediatricians are well aware of the emergence of MRSA. As evidence, most have probably drained more abscesses in the last year than in their entire career to date. Sporadic phone calls have alerted us to cases of MRSA infection in community hospital nurseries, and while we have not encountered a NICU outbreak of MRSA infection, they are well reported and may be difficult to halt. Active NICU surveillance (periodic nasal screening), screening of new admissions hospitalized elsewhere, and utilization of contact precautions (until results are available) may be necessary.

▸ Multidrug-resistant gram-negative infections will emerge throughout pediatric hospitals, and no new help is on the horizon for these bad bugs, which have been coined the ESKAPE bacteria. They include two gram-positive bugs—Enterococcus faecium, Staphylococcus aureus, and gram negatives including four species of Klebsiella, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species—which together are responsible for two-thirds of all health care-associated infections. While a few new drugs are available or coming for MRSA, there are few that target gram-negative pathogens. For more information, check out the article by Dr. Helen Boucher of Tufts University (Clin. Infect. Dis. 2009;48:1-12).

▸ Parental declinations of certain vaccines will plateau. No question that pediatricians are spending an increasing amount of time addressing parental concerns regarding vaccines, but the majority of parents still trust their pediatrician to provide appropriate vaccine information. The key, though, is making sure you appropriately address their concerns and deliver a clear and positive message with high-quality information.

Check out Meg Fisher's article in the September 2008 Pediatric Infectious Disease Journal for a great discussion of vaccine safety (Pediatr. Infect. Dis J. 2008:27:827-30).

▸ Pertussis cases will hit an all time low overall but beware: Outbreaks will still occur, particularly among older children. Implementation of the adolescent/adult tetanus-diphtheria-reduced antigen acellular pertussis (Tdap) vaccine is ongoing, but we still have a large susceptible population of children aged 8-12 years, as well as adults. We recently cared for a 5-week-old infant with whooping cough who required ECMO (extracorporeal membrane oxygenation). I suspect we will continue to see such cases.

The role of postpartum Tdap is important, and pediatricians should encourage their obstetrics colleagues to use a standing order to give vaccine to mothers before hospital discharge (if they have not received a tetanus-containing vaccine in the past 2 years, or prior Tdap).

▸ The new improved pneumococcal conjugate vaccine may be closer than you think. The emergence of multidrug-resistant serotype 19A disease has challenged the management of pneumococcal infection from acute suppurative otitis media to more serious infections like pneumonia and meningitis. Last May, the Food and Drug Administration granted fast-track designation for the Wyeth 13-valent vaccine (which includes 19A) to speed the process.

▸ Cases of Clostridium difficile will increase. In 2005, the Centers for Disease Control and Prevention alerted us to the reports of an increase in incidence and severity of C. difficile-associated disease (CDAD), both community acquired and health care-facility acquired or associated. While most practitioners are aware that the major driving force in CDAD is antimicrobial use, this strain appears to be causing infection in otherwise healthy persons who haven't received antibiotics. One study confirmed that with respect to health care-associated CDAD, the availability of adequate infection control personnel was associated with lower rates.

▸ You might see Haemophilus influenzae type b (Hib) invasive infection in the coming year. A Nov. 21 CDC report detailed information regarding the continued vaccine shortage (MMWR 2008;57:1252-5). (See Policy &Practice item, p. 23.) Vaccine supplies currently are insufficient to supply the booster dose, and some studies suggest that this dose is particularly important for protection and herd immunity. In the United Kingdom, a booster dose was not initially recommended; after an initial decrease in disease, the rate of invasive infection rose again. There is concern that prolonged deferral of the Hib booster in the United States may produce similar results, so be on the look out.

▸ Most physicians are still unaware of the new guidelines for subacute bacterial prophylaxis. In 2007, the American Heart Association issued the first major revision of these guidelines and endorsed antimicrobial prophylaxis for only five circumstances: prosthetic heart valves, prior infective endocarditis, cardiac transplant with valvulopathy, unrepaired cyanotic congenital heart disease, and repaired congenital heart disease with either prosthetic patch or other device in the first 6 months after placement or beyond that if there is a residual defect at the site of patch or device. Read more about it at: www.americanheart.org/presenter.jhtml?identifier=3047051

▸ A rise in tuberculosis cases will occur in the United States. A recent study in Clinical Infectious Diseases showed a particular risk for undocumented immigrants with tuberculosis to be sicker longer than documented immigrants or U.S.-born patients. With this comes a potential for increased risk for transmission.

▸ Do you know about the CDC's Web site for students who are planning to Study Abroad (www.cdc.gov/Features/StudyAbroad

[email protected]

Happy 2009! It's time for the annual look into the future of infectious diseases.

Two common themes were evident last year: increasing antibiotic resistance, and changing epidemiology and vaccine-preventable infections. Last year's predictions that were on the mark included the rise in pneumococcal serotype 19A, the drop in rotavirus cases, the lack of a national solution to vaccine reimbursement, the need for new strategies to raise vaccine coverage rates, and the rise in methicillin-resistant Staphylococcus aureus (MRSA) infections. This year, some similar themes prevail and some items may surprise you:

▸ MRSA will become a more prominent pathogen in your local neonatal intensive care unit (NICU). Practicing pediatricians are well aware of the emergence of MRSA. As evidence, most have probably drained more abscesses in the last year than in their entire career to date. Sporadic phone calls have alerted us to cases of MRSA infection in community hospital nurseries, and while we have not encountered a NICU outbreak of MRSA infection, they are well reported and may be difficult to halt. Active NICU surveillance (periodic nasal screening), screening of new admissions hospitalized elsewhere, and utilization of contact precautions (until results are available) may be necessary.

▸ Multidrug-resistant gram-negative infections will emerge throughout pediatric hospitals, and no new help is on the horizon for these bad bugs, which have been coined the ESKAPE bacteria. They include two gram-positive bugs—Enterococcus faecium, Staphylococcus aureus, and gram negatives including four species of Klebsiella, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species—which together are responsible for two-thirds of all health care-associated infections. While a few new drugs are available or coming for MRSA, there are few that target gram-negative pathogens. For more information, check out the article by Dr. Helen Boucher of Tufts University (Clin. Infect. Dis. 2009;48:1-12).

▸ Parental declinations of certain vaccines will plateau. No question that pediatricians are spending an increasing amount of time addressing parental concerns regarding vaccines, but the majority of parents still trust their pediatrician to provide appropriate vaccine information. The key, though, is making sure you appropriately address their concerns and deliver a clear and positive message with high-quality information.

Check out Meg Fisher's article in the September 2008 Pediatric Infectious Disease Journal for a great discussion of vaccine safety (Pediatr. Infect. Dis J. 2008:27:827-30).

▸ Pertussis cases will hit an all time low overall but beware: Outbreaks will still occur, particularly among older children. Implementation of the adolescent/adult tetanus-diphtheria-reduced antigen acellular pertussis (Tdap) vaccine is ongoing, but we still have a large susceptible population of children aged 8-12 years, as well as adults. We recently cared for a 5-week-old infant with whooping cough who required ECMO (extracorporeal membrane oxygenation). I suspect we will continue to see such cases.

The role of postpartum Tdap is important, and pediatricians should encourage their obstetrics colleagues to use a standing order to give vaccine to mothers before hospital discharge (if they have not received a tetanus-containing vaccine in the past 2 years, or prior Tdap).

▸ The new improved pneumococcal conjugate vaccine may be closer than you think. The emergence of multidrug-resistant serotype 19A disease has challenged the management of pneumococcal infection from acute suppurative otitis media to more serious infections like pneumonia and meningitis. Last May, the Food and Drug Administration granted fast-track designation for the Wyeth 13-valent vaccine (which includes 19A) to speed the process.

▸ Cases of Clostridium difficile will increase. In 2005, the Centers for Disease Control and Prevention alerted us to the reports of an increase in incidence and severity of C. difficile-associated disease (CDAD), both community acquired and health care-facility acquired or associated. While most practitioners are aware that the major driving force in CDAD is antimicrobial use, this strain appears to be causing infection in otherwise healthy persons who haven't received antibiotics. One study confirmed that with respect to health care-associated CDAD, the availability of adequate infection control personnel was associated with lower rates.

▸ You might see Haemophilus influenzae type b (Hib) invasive infection in the coming year. A Nov. 21 CDC report detailed information regarding the continued vaccine shortage (MMWR 2008;57:1252-5). (See Policy &Practice item, p. 23.) Vaccine supplies currently are insufficient to supply the booster dose, and some studies suggest that this dose is particularly important for protection and herd immunity. In the United Kingdom, a booster dose was not initially recommended; after an initial decrease in disease, the rate of invasive infection rose again. There is concern that prolonged deferral of the Hib booster in the United States may produce similar results, so be on the look out.

▸ Most physicians are still unaware of the new guidelines for subacute bacterial prophylaxis. In 2007, the American Heart Association issued the first major revision of these guidelines and endorsed antimicrobial prophylaxis for only five circumstances: prosthetic heart valves, prior infective endocarditis, cardiac transplant with valvulopathy, unrepaired cyanotic congenital heart disease, and repaired congenital heart disease with either prosthetic patch or other device in the first 6 months after placement or beyond that if there is a residual defect at the site of patch or device. Read more about it at: www.americanheart.org/presenter.jhtml?identifier=3047051

▸ A rise in tuberculosis cases will occur in the United States. A recent study in Clinical Infectious Diseases showed a particular risk for undocumented immigrants with tuberculosis to be sicker longer than documented immigrants or U.S.-born patients. With this comes a potential for increased risk for transmission.

▸ Do you know about the CDC's Web site for students who are planning to Study Abroad (www.cdc.gov/Features/StudyAbroad