ID Consult

The conventional wisdom about urinary tract infections has changed over the years, but we still don't have consensus regarding many of its management issues.

When I was an intern in 1972, it was relatively simple. We would admit a child with a UTI to the hospital, start antimicrobial therapy, do an intravenous pyelogram after a negative urine culture, and keep the child on antibiotics for a month until the follow-up vesicoureterogram (VCUG). But in the 1980s, people began to question the evidence for spending resources on imaging and for promoting antimicrobial resistance when it may not be necessary.

Today we know that UTIs are common in children of all ages, but the main concern is for those in the under-2-year age group, where there is the greatest risk for renal damage that can result from treatment delayed beyond 72 hours of fever. Vesicoureteral reflux is far more common in this age group and tends to remit with increasing age. There is also agreement that evaluation for UTI is essential for any child in that age range who has had unexplained fever for more than 24 hours. Approximately 5% will be positive.

We have data to guide our decisions regarding who is at greatest risk for UTI. It is higher in females than males, with a 2-to-1 ratio in the first year of life and 4:1 in the second. But among boys, those who are uncircumcised have a 15- to 20-fold higher UTI rate than among those who are circumcised.

Since the advent of the 7-valent pneumococcal conjugate vaccine (PCV7), we have seen Escherichia coli increase proportionally as a cause of bacteremia as a result of the decline in pneumococcal disease (Arch. Dis. Child. 2009;94:144-7). However, the overall rate of positive urine culture among children aged 3-36 months presenting to the emergency room with fever has not changed with PCV7, remaining at approximately 7%.

There's controversy regarding UTI screening. Urine culture is the standard, with identification of 10 white blood cells per high-powered field in unspun urine on gram stain. However, this is time consuming and requires an expertise that many practitioners have lost since their training.

The presence of leukocyte esterase and nitrites on dipstick has become a widely used screen for children at risk for UTI. They are highly specific for gram-negative UTIs, but not as good for detecting gram-positive organisms.

Dipstick testing works best in ruling out a UTI: If both leukocyte esterase and nitrite tests are negative, the likelihood of a UTI is extremely low. If both are positive in a symptomatic at-risk child, it's an indication to initiate therapy and obtain a culture to confirm the infection, identify the pathogen, and determine its antimicrobial susceptibility.

While use of the two measures is considered an acceptable, rapid way to screen for UTI, there is a tradeoff. For every 1,000 children with compatible UTI signs and symptoms, these tests will identify greater than 90% of the children with culture-confirmed infection. However, as many as 20% of the children will be treated unnecessarily with antibiotics.

Collecting the urine specimen is another area that lacks consensus. Urine collected in a bag is unreliable in children less than 2 years of age, and it's not certain whether bag collection can be used in older children. Three culture collection strategies are recommended by the American Academy of Pediatrics (AAP) guideline committee report: suprapubic aspiration, catheterized specimen for girls/midstream stream in circumcised boys, or midstream clean void in girls or uncircumcised boys.

Suprapubic aspiration is the standard, but it's more time consuming, difficult, and is associated with more discomfort. It is typically reserved for children less than 6 months of age. On the other hand, a single midstream clean void is just 80%-90% reproducible so some recommend a second specimen to achieve greater (95%) reproducibility.

One area in which I do think the data are clear concerns the duration of therapy. Since approximately 50%-60% of children aged 2 months to 2 years with UTIs also have upper tract infection, there is a far better chance of cure and less chance of recurrence with 7-10 days of antibiotics vs. 3 days or fewer (Pediatr. Infect. Dis. J. 1988;7:316-9).

The most controversial areas in UTI management concern imaging and antimicrobial prophylaxis. Imaging, via sonogram plus either VCUG or radionuclide scan, accomplishes four goals: It localizes the infection (upper vs. lower tract), identifies the presence of reflux, identifies structural abnormalities, and detects renal scarring. But most structural abnormalities are already identified with prenatal ultrasound, and it's not clear whether progression of renal scarring can be prevented with prophylactic antibiotics in children with reflux.

There is recent conflicting evidence regarding the benefit of antimicrobial prophylaxis. In a meta-analysis of eight randomized controlled trials that included 677 children who had recovered from a symptomatic UTI and in whom vesicoureteral reflux had been identified independent of acute infection, there was no difference between those who did and did not receive antimicrobial prophylaxis in recurrence of symptomatic UTI or in the incidence of new or progressive renal scarring (Acta Paediatr. 2009;98:1781-6).

But the 20-center Swedish Reflux Trial did find benefit. In that study, reflux status was compared in 203 children (128 girls/75 boys) with grade III-IV dilating vesicoureteral reflux who were treated in one of three groups, either with low- dose antibiotic prophylaxis, endoscopic therapy, or with surveillance and antibiotic treatment only for febrile UTI. At 2 years, reflux had improved in all treatment arms, with reflux resolution or downgrading to grades I or II occurring in 39% of the prophylaxis group, 71% with endoscopic treatment, and 47% with surveillance (J. Urol. 2010;184:280-5).

Of concern, however, dilating reflux reappeared after initially being downgraded in 20% of the children who had received endoscopic treatment.

Both antimicrobial treatment and endoscopic therapy reduced the infection recurrence rate among the girls, occurring in 8 of 43 (19%) on prophylaxis and 10 of 43 (23%) with endoscopic therapy, compared with 24 of 42 (57%) on surveillance. In girls, the recurrence rate was associated with persistent reflux after 2 years. However, reflux severity (grade III or IV) at study entry did not predict recurrence (J. Urol. 2010;184:286-91).

Given the conflicting data, it's no surprise that guidelines also differ. The AAP advises ultrasound and VCUG for all children aged 2 months to 2 years, and antimicrobial prophylaxis for all in whom reflux is identified (Pediatrics 103;1999:843-52). In contrast, guidelines from the United Kingdom advise ultrasound only for recurrent or “atypical” UTI, and do not recommend prophylaxis after a first UTI, but only after a recurrence.

Also not surprising, practitioners differ in what they do. In an analysis of Washington State Medicaid data for 780 children diagnosed with UTI during their first year of life, less than half received either timely anatomic imaging (44%) or imaging for reflux (39.5%). Of those who had imaging for reflux, only 51% had adequate antibiotics to maintain antimicrobial prophylaxis between diagnosis and imaging for reflux (Pediatrics 2005;115:1474-8).

I believe there is certainly a role for prophylaxis in a child with recurrent UTI, especially recurrent symptomatic/febrile UTI. But whether there's a role after the first UTI remains uncertain, with conflicting evidence. We might get some answers from an ongoing randomized, placebo-controlled intervention sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (clinicaltrials.gov

The conventional wisdom about urinary tract infections has changed over the years, but we still don't have consensus regarding many of its management issues.

When I was an intern in 1972, it was relatively simple. We would admit a child with a UTI to the hospital, start antimicrobial therapy, do an intravenous pyelogram after a negative urine culture, and keep the child on antibiotics for a month until the follow-up vesicoureterogram (VCUG). But in the 1980s, people began to question the evidence for spending resources on imaging and for promoting antimicrobial resistance when it may not be necessary.

Today we know that UTIs are common in children of all ages, but the main concern is for those in the under-2-year age group, where there is the greatest risk for renal damage that can result from treatment delayed beyond 72 hours of fever. Vesicoureteral reflux is far more common in this age group and tends to remit with increasing age. There is also agreement that evaluation for UTI is essential for any child in that age range who has had unexplained fever for more than 24 hours. Approximately 5% will be positive.

We have data to guide our decisions regarding who is at greatest risk for UTI. It is higher in females than males, with a 2-to-1 ratio in the first year of life and 4:1 in the second. But among boys, those who are uncircumcised have a 15- to 20-fold higher UTI rate than among those who are circumcised.

Since the advent of the 7-valent pneumococcal conjugate vaccine (PCV7), we have seen Escherichia coli increase proportionally as a cause of bacteremia as a result of the decline in pneumococcal disease (Arch. Dis. Child. 2009;94:144-7). However, the overall rate of positive urine culture among children aged 3-36 months presenting to the emergency room with fever has not changed with PCV7, remaining at approximately 7%.

There's controversy regarding UTI screening. Urine culture is the standard, with identification of 10 white blood cells per high-powered field in unspun urine on gram stain. However, this is time consuming and requires an expertise that many practitioners have lost since their training.

The presence of leukocyte esterase and nitrites on dipstick has become a widely used screen for children at risk for UTI. They are highly specific for gram-negative UTIs, but not as good for detecting gram-positive organisms.

Dipstick testing works best in ruling out a UTI: If both leukocyte esterase and nitrite tests are negative, the likelihood of a UTI is extremely low. If both are positive in a symptomatic at-risk child, it's an indication to initiate therapy and obtain a culture to confirm the infection, identify the pathogen, and determine its antimicrobial susceptibility.

While use of the two measures is considered an acceptable, rapid way to screen for UTI, there is a tradeoff. For every 1,000 children with compatible UTI signs and symptoms, these tests will identify greater than 90% of the children with culture-confirmed infection. However, as many as 20% of the children will be treated unnecessarily with antibiotics.

Collecting the urine specimen is another area that lacks consensus. Urine collected in a bag is unreliable in children less than 2 years of age, and it's not certain whether bag collection can be used in older children. Three culture collection strategies are recommended by the American Academy of Pediatrics (AAP) guideline committee report: suprapubic aspiration, catheterized specimen for girls/midstream stream in circumcised boys, or midstream clean void in girls or uncircumcised boys.

Suprapubic aspiration is the standard, but it's more time consuming, difficult, and is associated with more discomfort. It is typically reserved for children less than 6 months of age. On the other hand, a single midstream clean void is just 80%-90% reproducible so some recommend a second specimen to achieve greater (95%) reproducibility.

One area in which I do think the data are clear concerns the duration of therapy. Since approximately 50%-60% of children aged 2 months to 2 years with UTIs also have upper tract infection, there is a far better chance of cure and less chance of recurrence with 7-10 days of antibiotics vs. 3 days or fewer (Pediatr. Infect. Dis. J. 1988;7:316-9).

The most controversial areas in UTI management concern imaging and antimicrobial prophylaxis. Imaging, via sonogram plus either VCUG or radionuclide scan, accomplishes four goals: It localizes the infection (upper vs. lower tract), identifies the presence of reflux, identifies structural abnormalities, and detects renal scarring. But most structural abnormalities are already identified with prenatal ultrasound, and it's not clear whether progression of renal scarring can be prevented with prophylactic antibiotics in children with reflux.

There is recent conflicting evidence regarding the benefit of antimicrobial prophylaxis. In a meta-analysis of eight randomized controlled trials that included 677 children who had recovered from a symptomatic UTI and in whom vesicoureteral reflux had been identified independent of acute infection, there was no difference between those who did and did not receive antimicrobial prophylaxis in recurrence of symptomatic UTI or in the incidence of new or progressive renal scarring (Acta Paediatr. 2009;98:1781-6).

But the 20-center Swedish Reflux Trial did find benefit. In that study, reflux status was compared in 203 children (128 girls/75 boys) with grade III-IV dilating vesicoureteral reflux who were treated in one of three groups, either with low- dose antibiotic prophylaxis, endoscopic therapy, or with surveillance and antibiotic treatment only for febrile UTI. At 2 years, reflux had improved in all treatment arms, with reflux resolution or downgrading to grades I or II occurring in 39% of the prophylaxis group, 71% with endoscopic treatment, and 47% with surveillance (J. Urol. 2010;184:280-5).

Of concern, however, dilating reflux reappeared after initially being downgraded in 20% of the children who had received endoscopic treatment.

Both antimicrobial treatment and endoscopic therapy reduced the infection recurrence rate among the girls, occurring in 8 of 43 (19%) on prophylaxis and 10 of 43 (23%) with endoscopic therapy, compared with 24 of 42 (57%) on surveillance. In girls, the recurrence rate was associated with persistent reflux after 2 years. However, reflux severity (grade III or IV) at study entry did not predict recurrence (J. Urol. 2010;184:286-91).

Given the conflicting data, it's no surprise that guidelines also differ. The AAP advises ultrasound and VCUG for all children aged 2 months to 2 years, and antimicrobial prophylaxis for all in whom reflux is identified (Pediatrics 103;1999:843-52). In contrast, guidelines from the United Kingdom advise ultrasound only for recurrent or “atypical” UTI, and do not recommend prophylaxis after a first UTI, but only after a recurrence.

Also not surprising, practitioners differ in what they do. In an analysis of Washington State Medicaid data for 780 children diagnosed with UTI during their first year of life, less than half received either timely anatomic imaging (44%) or imaging for reflux (39.5%). Of those who had imaging for reflux, only 51% had adequate antibiotics to maintain antimicrobial prophylaxis between diagnosis and imaging for reflux (Pediatrics 2005;115:1474-8).

I believe there is certainly a role for prophylaxis in a child with recurrent UTI, especially recurrent symptomatic/febrile UTI. But whether there's a role after the first UTI remains uncertain, with conflicting evidence. We might get some answers from an ongoing randomized, placebo-controlled intervention sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (clinicaltrials.gov

The conventional wisdom about urinary tract infections has changed over the years, but we still don't have consensus regarding many of its management issues.

When I was an intern in 1972, it was relatively simple. We would admit a child with a UTI to the hospital, start antimicrobial therapy, do an intravenous pyelogram after a negative urine culture, and keep the child on antibiotics for a month until the follow-up vesicoureterogram (VCUG). But in the 1980s, people began to question the evidence for spending resources on imaging and for promoting antimicrobial resistance when it may not be necessary.

Today we know that UTIs are common in children of all ages, but the main concern is for those in the under-2-year age group, where there is the greatest risk for renal damage that can result from treatment delayed beyond 72 hours of fever. Vesicoureteral reflux is far more common in this age group and tends to remit with increasing age. There is also agreement that evaluation for UTI is essential for any child in that age range who has had unexplained fever for more than 24 hours. Approximately 5% will be positive.

We have data to guide our decisions regarding who is at greatest risk for UTI. It is higher in females than males, with a 2-to-1 ratio in the first year of life and 4:1 in the second. But among boys, those who are uncircumcised have a 15- to 20-fold higher UTI rate than among those who are circumcised.

Since the advent of the 7-valent pneumococcal conjugate vaccine (PCV7), we have seen Escherichia coli increase proportionally as a cause of bacteremia as a result of the decline in pneumococcal disease (Arch. Dis. Child. 2009;94:144-7). However, the overall rate of positive urine culture among children aged 3-36 months presenting to the emergency room with fever has not changed with PCV7, remaining at approximately 7%.

There's controversy regarding UTI screening. Urine culture is the standard, with identification of 10 white blood cells per high-powered field in unspun urine on gram stain. However, this is time consuming and requires an expertise that many practitioners have lost since their training.

The presence of leukocyte esterase and nitrites on dipstick has become a widely used screen for children at risk for UTI. They are highly specific for gram-negative UTIs, but not as good for detecting gram-positive organisms.

Dipstick testing works best in ruling out a UTI: If both leukocyte esterase and nitrite tests are negative, the likelihood of a UTI is extremely low. If both are positive in a symptomatic at-risk child, it's an indication to initiate therapy and obtain a culture to confirm the infection, identify the pathogen, and determine its antimicrobial susceptibility.

While use of the two measures is considered an acceptable, rapid way to screen for UTI, there is a tradeoff. For every 1,000 children with compatible UTI signs and symptoms, these tests will identify greater than 90% of the children with culture-confirmed infection. However, as many as 20% of the children will be treated unnecessarily with antibiotics.

Collecting the urine specimen is another area that lacks consensus. Urine collected in a bag is unreliable in children less than 2 years of age, and it's not certain whether bag collection can be used in older children. Three culture collection strategies are recommended by the American Academy of Pediatrics (AAP) guideline committee report: suprapubic aspiration, catheterized specimen for girls/midstream stream in circumcised boys, or midstream clean void in girls or uncircumcised boys.

Suprapubic aspiration is the standard, but it's more time consuming, difficult, and is associated with more discomfort. It is typically reserved for children less than 6 months of age. On the other hand, a single midstream clean void is just 80%-90% reproducible so some recommend a second specimen to achieve greater (95%) reproducibility.

One area in which I do think the data are clear concerns the duration of therapy. Since approximately 50%-60% of children aged 2 months to 2 years with UTIs also have upper tract infection, there is a far better chance of cure and less chance of recurrence with 7-10 days of antibiotics vs. 3 days or fewer (Pediatr. Infect. Dis. J. 1988;7:316-9).

The most controversial areas in UTI management concern imaging and antimicrobial prophylaxis. Imaging, via sonogram plus either VCUG or radionuclide scan, accomplishes four goals: It localizes the infection (upper vs. lower tract), identifies the presence of reflux, identifies structural abnormalities, and detects renal scarring. But most structural abnormalities are already identified with prenatal ultrasound, and it's not clear whether progression of renal scarring can be prevented with prophylactic antibiotics in children with reflux.

There is recent conflicting evidence regarding the benefit of antimicrobial prophylaxis. In a meta-analysis of eight randomized controlled trials that included 677 children who had recovered from a symptomatic UTI and in whom vesicoureteral reflux had been identified independent of acute infection, there was no difference between those who did and did not receive antimicrobial prophylaxis in recurrence of symptomatic UTI or in the incidence of new or progressive renal scarring (Acta Paediatr. 2009;98:1781-6).

But the 20-center Swedish Reflux Trial did find benefit. In that study, reflux status was compared in 203 children (128 girls/75 boys) with grade III-IV dilating vesicoureteral reflux who were treated in one of three groups, either with low- dose antibiotic prophylaxis, endoscopic therapy, or with surveillance and antibiotic treatment only for febrile UTI. At 2 years, reflux had improved in all treatment arms, with reflux resolution or downgrading to grades I or II occurring in 39% of the prophylaxis group, 71% with endoscopic treatment, and 47% with surveillance (J. Urol. 2010;184:280-5).

Of concern, however, dilating reflux reappeared after initially being downgraded in 20% of the children who had received endoscopic treatment.

Both antimicrobial treatment and endoscopic therapy reduced the infection recurrence rate among the girls, occurring in 8 of 43 (19%) on prophylaxis and 10 of 43 (23%) with endoscopic therapy, compared with 24 of 42 (57%) on surveillance. In girls, the recurrence rate was associated with persistent reflux after 2 years. However, reflux severity (grade III or IV) at study entry did not predict recurrence (J. Urol. 2010;184:286-91).

Given the conflicting data, it's no surprise that guidelines also differ. The AAP advises ultrasound and VCUG for all children aged 2 months to 2 years, and antimicrobial prophylaxis for all in whom reflux is identified (Pediatrics 103;1999:843-52). In contrast, guidelines from the United Kingdom advise ultrasound only for recurrent or “atypical” UTI, and do not recommend prophylaxis after a first UTI, but only after a recurrence.

Also not surprising, practitioners differ in what they do. In an analysis of Washington State Medicaid data for 780 children diagnosed with UTI during their first year of life, less than half received either timely anatomic imaging (44%) or imaging for reflux (39.5%). Of those who had imaging for reflux, only 51% had adequate antibiotics to maintain antimicrobial prophylaxis between diagnosis and imaging for reflux (Pediatrics 2005;115:1474-8).

I believe there is certainly a role for prophylaxis in a child with recurrent UTI, especially recurrent symptomatic/febrile UTI. But whether there's a role after the first UTI remains uncertain, with conflicting evidence. We might get some answers from an ongoing randomized, placebo-controlled intervention sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (clinicaltrials.gov

The new 13-valent pneumococcal conjugate vaccine (Prevnar 13) is picking up right where the 7-valent version left off.

It has been 10 years since the introduction of the 7-valent pneumococcal conjugate vaccine (Prevnar). Overall in the United States, the program has had significant success, with an approximate 65%-70% reduction in invasive disease due to Streptococcus pneumoniae. We've also seen substantial reductions in acute otitis media (AOM) and community-acquired pneumonia (CAP).

Nonetheless, in the last few years we've started to see a small but real increase in invasive disease due to nonvaccine serotypes, documented by the Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs) system.

At the same time, there has also been documentation of an increase in AOM and a presumption of increases in CAP due to nonvaccine serotypes. These are harder to document, because data are typically obtained from hospital admissions or insurance claims and not from microbiological testing as is done with the ABCs. However, small studies using tympanocentesis have shown high proportions of nonvaccine S. pneumoniae serotypes in children with middle ear disease (Pediatr. Infect. Dis. J. 2007;26:S12–6).

Although we can't determine exactly what proportion of CAP and AOM is due to S. pneumoniae at any given time – and the longitudinal data are complicated by the secular changes in AOM definition – we do know that for every 1 case of invasive disease there are about 10 cases of CAP and 100 of AOM. So, we're looking at very clinically significant numbers.

In addition to the shift in serotypes, we've seen the emergence of multidrug-resistant pneumococci, particularly strain 19A. While these strains are usually sensitive to vancomycin, linezolid, and fluoroquinolones, they are resistant to the usual first-line antimicrobials, including amoxicillin, clindamycin, and trimethoprim-sulfamethoxazole, as well as ceftriaxone and other cephalosporins. Thus, both CAP and AOM have become more difficult to treat in children who don't respond to initial therapy.

Licensed earlier this year, PCV13 (Prevnar 13) contains all seven of the PCV7 strains (4, 6B, 9V, 14, 18C, 19F, and 23F), plus six more (1, 3, 5, 6A, 7F, and 19A). The serotypes represent either those that have been increasing in some countries using PCV7 (19A, 7F, 3) or that are globally important (1 and 5).

The vaccine was licensed on the basis of immunogenicity for the new serotypes as well as comparability to PCV7 for the seven “old” serotypes and a comparable safety profile.

The 13-valent vaccine is being introduced somewhat differently than was PCV7. The recommendation from the CDC Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians is to administer PCV13 routinely to all children aged 2, 4, 6, and 12–15 months.

For children who previously received one or more doses of PCV7, the series should be completed with PCV13. And for children 15 months through 5 years of age who received only PCV7 (or no vaccine), a single dose of PCV13 is recommended.

In contrast, when PCV7 was licensed, the recommended catchup immunization was through 2 years of age and only high-risk children aged 2–5 years. That's because, in general, the risk for invasive pneumococcal disease begins to decline after 3 years of age.

However, the data on multidrug-resistant strain 19A suggest that it has been producing substantial disease in previously healthy children up through 5 years of age.

In addition, nasopharyngeal carriage of 19A has been seen frequently in children up to age 5. It is hoped that preventing that carriage will reduce the spread to unvaccinated children less than 4–5 months of age, immunocompromised children who don't respond sufficiently to the vaccine, and adults.

Adding indirect protection to a large part of the population should help to reduce the incidence of disease due to the new vaccine serotypes.

Finally, I'd like to address a question that often arises. With new conjugate pneumococcal vaccines, are we simply shifting the serotypes that produce disease and not actually preventing it? I would say no. With each new expansion of the vaccine, not only do we add broader coverage, but we expect to see a further reduction in disease.

It is anticipated that the six new strains of PCV13 will add another 10%-15% reduction in pneumococcal disease beyond the 65%-70% we've already seen with PCV7, so that we will now achieve an approximate 80%-90% disease reduction compared with rates in 1998–1999.

However, I don't think we will entirely eliminate pneumococcal disease. A few other important nonvaccine serotypes, including 22F, 33F, and 15B/C, are likely to continue and possibly increase slightly following the introduction of PCV13. Nonetheless, it will help us to reduce the burden of pneumococcal disease on child health.

The new 13-valent pneumococcal conjugate vaccine (Prevnar 13) is picking up right where the 7-valent version left off.

It has been 10 years since the introduction of the 7-valent pneumococcal conjugate vaccine (Prevnar). Overall in the United States, the program has had significant success, with an approximate 65%-70% reduction in invasive disease due to Streptococcus pneumoniae. We've also seen substantial reductions in acute otitis media (AOM) and community-acquired pneumonia (CAP).

Nonetheless, in the last few years we've started to see a small but real increase in invasive disease due to nonvaccine serotypes, documented by the Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs) system.

At the same time, there has also been documentation of an increase in AOM and a presumption of increases in CAP due to nonvaccine serotypes. These are harder to document, because data are typically obtained from hospital admissions or insurance claims and not from microbiological testing as is done with the ABCs. However, small studies using tympanocentesis have shown high proportions of nonvaccine S. pneumoniae serotypes in children with middle ear disease (Pediatr. Infect. Dis. J. 2007;26:S12–6).

Although we can't determine exactly what proportion of CAP and AOM is due to S. pneumoniae at any given time – and the longitudinal data are complicated by the secular changes in AOM definition – we do know that for every 1 case of invasive disease there are about 10 cases of CAP and 100 of AOM. So, we're looking at very clinically significant numbers.

In addition to the shift in serotypes, we've seen the emergence of multidrug-resistant pneumococci, particularly strain 19A. While these strains are usually sensitive to vancomycin, linezolid, and fluoroquinolones, they are resistant to the usual first-line antimicrobials, including amoxicillin, clindamycin, and trimethoprim-sulfamethoxazole, as well as ceftriaxone and other cephalosporins. Thus, both CAP and AOM have become more difficult to treat in children who don't respond to initial therapy.

Licensed earlier this year, PCV13 (Prevnar 13) contains all seven of the PCV7 strains (4, 6B, 9V, 14, 18C, 19F, and 23F), plus six more (1, 3, 5, 6A, 7F, and 19A). The serotypes represent either those that have been increasing in some countries using PCV7 (19A, 7F, 3) or that are globally important (1 and 5).

The vaccine was licensed on the basis of immunogenicity for the new serotypes as well as comparability to PCV7 for the seven “old” serotypes and a comparable safety profile.

The 13-valent vaccine is being introduced somewhat differently than was PCV7. The recommendation from the CDC Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians is to administer PCV13 routinely to all children aged 2, 4, 6, and 12–15 months.

For children who previously received one or more doses of PCV7, the series should be completed with PCV13. And for children 15 months through 5 years of age who received only PCV7 (or no vaccine), a single dose of PCV13 is recommended.

In contrast, when PCV7 was licensed, the recommended catchup immunization was through 2 years of age and only high-risk children aged 2–5 years. That's because, in general, the risk for invasive pneumococcal disease begins to decline after 3 years of age.

However, the data on multidrug-resistant strain 19A suggest that it has been producing substantial disease in previously healthy children up through 5 years of age.

In addition, nasopharyngeal carriage of 19A has been seen frequently in children up to age 5. It is hoped that preventing that carriage will reduce the spread to unvaccinated children less than 4–5 months of age, immunocompromised children who don't respond sufficiently to the vaccine, and adults.

Adding indirect protection to a large part of the population should help to reduce the incidence of disease due to the new vaccine serotypes.

Finally, I'd like to address a question that often arises. With new conjugate pneumococcal vaccines, are we simply shifting the serotypes that produce disease and not actually preventing it? I would say no. With each new expansion of the vaccine, not only do we add broader coverage, but we expect to see a further reduction in disease.

It is anticipated that the six new strains of PCV13 will add another 10%-15% reduction in pneumococcal disease beyond the 65%-70% we've already seen with PCV7, so that we will now achieve an approximate 80%-90% disease reduction compared with rates in 1998–1999.

However, I don't think we will entirely eliminate pneumococcal disease. A few other important nonvaccine serotypes, including 22F, 33F, and 15B/C, are likely to continue and possibly increase slightly following the introduction of PCV13. Nonetheless, it will help us to reduce the burden of pneumococcal disease on child health.

The new 13-valent pneumococcal conjugate vaccine (Prevnar 13) is picking up right where the 7-valent version left off.

It has been 10 years since the introduction of the 7-valent pneumococcal conjugate vaccine (Prevnar). Overall in the United States, the program has had significant success, with an approximate 65%-70% reduction in invasive disease due to Streptococcus pneumoniae. We've also seen substantial reductions in acute otitis media (AOM) and community-acquired pneumonia (CAP).

Nonetheless, in the last few years we've started to see a small but real increase in invasive disease due to nonvaccine serotypes, documented by the Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs) system.

At the same time, there has also been documentation of an increase in AOM and a presumption of increases in CAP due to nonvaccine serotypes. These are harder to document, because data are typically obtained from hospital admissions or insurance claims and not from microbiological testing as is done with the ABCs. However, small studies using tympanocentesis have shown high proportions of nonvaccine S. pneumoniae serotypes in children with middle ear disease (Pediatr. Infect. Dis. J. 2007;26:S12–6).

Although we can't determine exactly what proportion of CAP and AOM is due to S. pneumoniae at any given time – and the longitudinal data are complicated by the secular changes in AOM definition – we do know that for every 1 case of invasive disease there are about 10 cases of CAP and 100 of AOM. So, we're looking at very clinically significant numbers.

In addition to the shift in serotypes, we've seen the emergence of multidrug-resistant pneumococci, particularly strain 19A. While these strains are usually sensitive to vancomycin, linezolid, and fluoroquinolones, they are resistant to the usual first-line antimicrobials, including amoxicillin, clindamycin, and trimethoprim-sulfamethoxazole, as well as ceftriaxone and other cephalosporins. Thus, both CAP and AOM have become more difficult to treat in children who don't respond to initial therapy.

Licensed earlier this year, PCV13 (Prevnar 13) contains all seven of the PCV7 strains (4, 6B, 9V, 14, 18C, 19F, and 23F), plus six more (1, 3, 5, 6A, 7F, and 19A). The serotypes represent either those that have been increasing in some countries using PCV7 (19A, 7F, 3) or that are globally important (1 and 5).

The vaccine was licensed on the basis of immunogenicity for the new serotypes as well as comparability to PCV7 for the seven “old” serotypes and a comparable safety profile.

The 13-valent vaccine is being introduced somewhat differently than was PCV7. The recommendation from the CDC Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians is to administer PCV13 routinely to all children aged 2, 4, 6, and 12–15 months.

For children who previously received one or more doses of PCV7, the series should be completed with PCV13. And for children 15 months through 5 years of age who received only PCV7 (or no vaccine), a single dose of PCV13 is recommended.

In contrast, when PCV7 was licensed, the recommended catchup immunization was through 2 years of age and only high-risk children aged 2–5 years. That's because, in general, the risk for invasive pneumococcal disease begins to decline after 3 years of age.

However, the data on multidrug-resistant strain 19A suggest that it has been producing substantial disease in previously healthy children up through 5 years of age.

In addition, nasopharyngeal carriage of 19A has been seen frequently in children up to age 5. It is hoped that preventing that carriage will reduce the spread to unvaccinated children less than 4–5 months of age, immunocompromised children who don't respond sufficiently to the vaccine, and adults.

Adding indirect protection to a large part of the population should help to reduce the incidence of disease due to the new vaccine serotypes.

Finally, I'd like to address a question that often arises. With new conjugate pneumococcal vaccines, are we simply shifting the serotypes that produce disease and not actually preventing it? I would say no. With each new expansion of the vaccine, not only do we add broader coverage, but we expect to see a further reduction in disease.

It is anticipated that the six new strains of PCV13 will add another 10%-15% reduction in pneumococcal disease beyond the 65%-70% we've already seen with PCV7, so that we will now achieve an approximate 80%-90% disease reduction compared with rates in 1998–1999.

However, I don't think we will entirely eliminate pneumococcal disease. A few other important nonvaccine serotypes, including 22F, 33F, and 15B/C, are likely to continue and possibly increase slightly following the introduction of PCV13. Nonetheless, it will help us to reduce the burden of pneumococcal disease on child health.

[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]

The current pertussis outbreak occurring in California clearly demonstrates that we need to make a greater effort to vaccinate adults in order to protect infants too young to be completely vaccinated.

To quote the 2010 editorial by Dr. Alfred DeMaria Jr. and Dr. Susan Lett (Clin. Infect. Dis. 2010;50:1346-8), “If it does take a village to raise a child, then that village should be fully immunized against pertussis.”

Between January and July of this year, the California Department of Public Health received reports of a total 1,337 confirmed or probable cases of pertussis, which represents a fourfold increase from the 258 cases reported during the first half of 2009. If these rates persist throughout 2010, California will have its highest annual rate of pertussis since 1963 and the most cases reported since 1958, according the Centers for Disease Control and Prevention (MMWR 2010; 59:817).

During this outbreak, the CDPH expanded recommendations to off-label situations, including vaccination of those who are pregnant, older than 65 years, and aged 7-10 years.

As we've seen in the past, infants younger than 6 months of age—too young to have received the recommended three protective diphtheria-tetanus-acellular pertussis (DTaP) doses yet—are bearing the brunt of the illness, accounting for 89% of all the California cases. Disease incidence in children younger than 1 year of age was 38.5 cases per 100,000 population vs. 3.4 per 100,000 for all ages.

Of 634 case reports with available data, 105 (17%) were hospitalized, with 63% being younger than 3 months old. And, sadly, all six of the pertussis deaths reported as of July 13, 2010, were in previously healthy infants aged younger than 2 months at disease onset.

These deaths could have been prevented. A 2006-2008 study in the Netherlands demonstrated why the so-called “cocooning” effect really works. Of 560 not recently immunized household contacts of 164 hospitalized infants who were tested for Bordetella pertussis infection, 53% were infected and 14% had no symptoms. Among 96 households for which the most likely source of infection was established, 41% were siblings, 38% were mothers, and 17% were fathers.

The authors concluded that maintaining or boosting immunity to pertussis in parents and relatives could prevent 35%-55% of infant cases (Clin. Infect. Dis. 2010;50:1339-45).

The adolescent/adult tetanus-diphtheria-acellular pertussis vaccine (Tdap) has now been recommended for all adults as a replacement for the old Td vaccine. In practice, however, beyond the adolescent years, most adults receive it only if both they require tetanus prevention and the provider is aware of recent changes in the immunization recommendations.

As clinicians caring for children, we routinely vaccinate children as old as 6 years of age with DTaP and 10- to 18-year-olds with Tdap. But I believe we also have a role in helping to ensure that our youngest patients are protected by encouraging their adult contacts to be immunized with Tdap.

Certainly, most family physicians and med-ped (combined internal medicine and pediatrics) physicians are already doing this. Pediatricians who feel comfortable vaccinating parents/adult caregivers in their offices have a great opportunity, but others could still recommend that parents get the booster from their personal physician or a local health department clinic. And don't forget to suggest pertussis immunization for other adults who come into regular contact with the young infant, including grandparents and babysitters. Some health departments offer a price reduction if they're told that the Tdap is to protect a new infant in your family.

Pregnant women are a special situation. The U.S. Advisory Committee on Immunization Practices (ACIP) recommends pertussis immunization for women prior to conception and after birth if they have not received it within the past 2 years. The ACIP did not recommend Tdap for routine use during pregnancy because there is too little safety and efficacy data (MMWR 2008; 57[RR-4]:1-51).

However, the American College of Obstetricians and Gynecologists suggests vaccinating pregnant women if the risk is felt to be higher than the undefined risks of vaccine (Obstet. Gynecol. 2009;114:398-400). The American Academy of Pediatrics, for its part, recommends Tdap for pregnant adolescents in the same way as for nonpregnant adolescents (Pediatrics 2006; 117:965-78).

Dr. DeMaria and Dr. Lett also went on to write in their editorial that—when Tdap is given to pregnant women in the second or third trimester—counseling and administration is recommended.

Pediatricians might consider suggesting pertussis immunization to pregnant women who come in to “pediatrician shop,” and to those who have their older children accompanying them.

By the time this column is published, I will have a new grandchild. During talks with my son, it became clear to me that the cocooning concept has not reached enough health care professionals. I advised him that he, my daughter-in-law, and other in-laws receive Tdap before the baby's birth to maximize the chance of protection. My wife made sure she got hers.

In my view, Tdap for adult contacts is just as important as making sure the crib and car seat you buy for your baby are safe. Here's a potentially lethal disease that's resurgent in parts of the country, and we have a tool to protect our newborns against it. Shouldn't we make every effort to do so?

[email protected]

The current pertussis outbreak occurring in California clearly demonstrates that we need to make a greater effort to vaccinate adults in order to protect infants too young to be completely vaccinated.

To quote the 2010 editorial by Dr. Alfred DeMaria Jr. and Dr. Susan Lett (Clin. Infect. Dis. 2010;50:1346-8), “If it does take a village to raise a child, then that village should be fully immunized against pertussis.”

Between January and July of this year, the California Department of Public Health received reports of a total 1,337 confirmed or probable cases of pertussis, which represents a fourfold increase from the 258 cases reported during the first half of 2009. If these rates persist throughout 2010, California will have its highest annual rate of pertussis since 1963 and the most cases reported since 1958, according the Centers for Disease Control and Prevention (MMWR 2010; 59:817).

During this outbreak, the CDPH expanded recommendations to off-label situations, including vaccination of those who are pregnant, older than 65 years, and aged 7-10 years.

As we've seen in the past, infants younger than 6 months of age—too young to have received the recommended three protective diphtheria-tetanus-acellular pertussis (DTaP) doses yet—are bearing the brunt of the illness, accounting for 89% of all the California cases. Disease incidence in children younger than 1 year of age was 38.5 cases per 100,000 population vs. 3.4 per 100,000 for all ages.

Of 634 case reports with available data, 105 (17%) were hospitalized, with 63% being younger than 3 months old. And, sadly, all six of the pertussis deaths reported as of July 13, 2010, were in previously healthy infants aged younger than 2 months at disease onset.

These deaths could have been prevented. A 2006-2008 study in the Netherlands demonstrated why the so-called “cocooning” effect really works. Of 560 not recently immunized household contacts of 164 hospitalized infants who were tested for Bordetella pertussis infection, 53% were infected and 14% had no symptoms. Among 96 households for which the most likely source of infection was established, 41% were siblings, 38% were mothers, and 17% were fathers.

The authors concluded that maintaining or boosting immunity to pertussis in parents and relatives could prevent 35%-55% of infant cases (Clin. Infect. Dis. 2010;50:1339-45).

The adolescent/adult tetanus-diphtheria-acellular pertussis vaccine (Tdap) has now been recommended for all adults as a replacement for the old Td vaccine. In practice, however, beyond the adolescent years, most adults receive it only if both they require tetanus prevention and the provider is aware of recent changes in the immunization recommendations.

As clinicians caring for children, we routinely vaccinate children as old as 6 years of age with DTaP and 10- to 18-year-olds with Tdap. But I believe we also have a role in helping to ensure that our youngest patients are protected by encouraging their adult contacts to be immunized with Tdap.

Certainly, most family physicians and med-ped (combined internal medicine and pediatrics) physicians are already doing this. Pediatricians who feel comfortable vaccinating parents/adult caregivers in their offices have a great opportunity, but others could still recommend that parents get the booster from their personal physician or a local health department clinic. And don't forget to suggest pertussis immunization for other adults who come into regular contact with the young infant, including grandparents and babysitters. Some health departments offer a price reduction if they're told that the Tdap is to protect a new infant in your family.

Pregnant women are a special situation. The U.S. Advisory Committee on Immunization Practices (ACIP) recommends pertussis immunization for women prior to conception and after birth if they have not received it within the past 2 years. The ACIP did not recommend Tdap for routine use during pregnancy because there is too little safety and efficacy data (MMWR 2008; 57[RR-4]:1-51).

However, the American College of Obstetricians and Gynecologists suggests vaccinating pregnant women if the risk is felt to be higher than the undefined risks of vaccine (Obstet. Gynecol. 2009;114:398-400). The American Academy of Pediatrics, for its part, recommends Tdap for pregnant adolescents in the same way as for nonpregnant adolescents (Pediatrics 2006; 117:965-78).

Dr. DeMaria and Dr. Lett also went on to write in their editorial that—when Tdap is given to pregnant women in the second or third trimester—counseling and administration is recommended.

Pediatricians might consider suggesting pertussis immunization to pregnant women who come in to “pediatrician shop,” and to those who have their older children accompanying them.

By the time this column is published, I will have a new grandchild. During talks with my son, it became clear to me that the cocooning concept has not reached enough health care professionals. I advised him that he, my daughter-in-law, and other in-laws receive Tdap before the baby's birth to maximize the chance of protection. My wife made sure she got hers.

In my view, Tdap for adult contacts is just as important as making sure the crib and car seat you buy for your baby are safe. Here's a potentially lethal disease that's resurgent in parts of the country, and we have a tool to protect our newborns against it. Shouldn't we make every effort to do so?

[email protected]

The current pertussis outbreak occurring in California clearly demonstrates that we need to make a greater effort to vaccinate adults in order to protect infants too young to be completely vaccinated.

To quote the 2010 editorial by Dr. Alfred DeMaria Jr. and Dr. Susan Lett (Clin. Infect. Dis. 2010;50:1346-8), “If it does take a village to raise a child, then that village should be fully immunized against pertussis.”

Between January and July of this year, the California Department of Public Health received reports of a total 1,337 confirmed or probable cases of pertussis, which represents a fourfold increase from the 258 cases reported during the first half of 2009. If these rates persist throughout 2010, California will have its highest annual rate of pertussis since 1963 and the most cases reported since 1958, according the Centers for Disease Control and Prevention (MMWR 2010; 59:817).

During this outbreak, the CDPH expanded recommendations to off-label situations, including vaccination of those who are pregnant, older than 65 years, and aged 7-10 years.

As we've seen in the past, infants younger than 6 months of age—too young to have received the recommended three protective diphtheria-tetanus-acellular pertussis (DTaP) doses yet—are bearing the brunt of the illness, accounting for 89% of all the California cases. Disease incidence in children younger than 1 year of age was 38.5 cases per 100,000 population vs. 3.4 per 100,000 for all ages.

Of 634 case reports with available data, 105 (17%) were hospitalized, with 63% being younger than 3 months old. And, sadly, all six of the pertussis deaths reported as of July 13, 2010, were in previously healthy infants aged younger than 2 months at disease onset.

These deaths could have been prevented. A 2006-2008 study in the Netherlands demonstrated why the so-called “cocooning” effect really works. Of 560 not recently immunized household contacts of 164 hospitalized infants who were tested for Bordetella pertussis infection, 53% were infected and 14% had no symptoms. Among 96 households for which the most likely source of infection was established, 41% were siblings, 38% were mothers, and 17% were fathers.

The authors concluded that maintaining or boosting immunity to pertussis in parents and relatives could prevent 35%-55% of infant cases (Clin. Infect. Dis. 2010;50:1339-45).

The adolescent/adult tetanus-diphtheria-acellular pertussis vaccine (Tdap) has now been recommended for all adults as a replacement for the old Td vaccine. In practice, however, beyond the adolescent years, most adults receive it only if both they require tetanus prevention and the provider is aware of recent changes in the immunization recommendations.

As clinicians caring for children, we routinely vaccinate children as old as 6 years of age with DTaP and 10- to 18-year-olds with Tdap. But I believe we also have a role in helping to ensure that our youngest patients are protected by encouraging their adult contacts to be immunized with Tdap.

Certainly, most family physicians and med-ped (combined internal medicine and pediatrics) physicians are already doing this. Pediatricians who feel comfortable vaccinating parents/adult caregivers in their offices have a great opportunity, but others could still recommend that parents get the booster from their personal physician or a local health department clinic. And don't forget to suggest pertussis immunization for other adults who come into regular contact with the young infant, including grandparents and babysitters. Some health departments offer a price reduction if they're told that the Tdap is to protect a new infant in your family.

Pregnant women are a special situation. The U.S. Advisory Committee on Immunization Practices (ACIP) recommends pertussis immunization for women prior to conception and after birth if they have not received it within the past 2 years. The ACIP did not recommend Tdap for routine use during pregnancy because there is too little safety and efficacy data (MMWR 2008; 57[RR-4]:1-51).

However, the American College of Obstetricians and Gynecologists suggests vaccinating pregnant women if the risk is felt to be higher than the undefined risks of vaccine (Obstet. Gynecol. 2009;114:398-400). The American Academy of Pediatrics, for its part, recommends Tdap for pregnant adolescents in the same way as for nonpregnant adolescents (Pediatrics 2006; 117:965-78).

Dr. DeMaria and Dr. Lett also went on to write in their editorial that—when Tdap is given to pregnant women in the second or third trimester—counseling and administration is recommended.

Pediatricians might consider suggesting pertussis immunization to pregnant women who come in to “pediatrician shop,” and to those who have their older children accompanying them.

By the time this column is published, I will have a new grandchild. During talks with my son, it became clear to me that the cocooning concept has not reached enough health care professionals. I advised him that he, my daughter-in-law, and other in-laws receive Tdap before the baby's birth to maximize the chance of protection. My wife made sure she got hers.

In my view, Tdap for adult contacts is just as important as making sure the crib and car seat you buy for your baby are safe. Here's a potentially lethal disease that's resurgent in parts of the country, and we have a tool to protect our newborns against it. Shouldn't we make every effort to do so?

[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]

Parents' concern that children receive too many vaccines too soon can result in delay or avoidance of vaccination, with the measles-mumps-rubella vaccine often being delayed. However, a recent study showed no neurologic harm from on-time receipt of all the recommended vaccines—including MMR—from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and children with on-time receipt of vaccines performed better on select neurologic testing than those delaying vaccine. Another study showed that children lose maternally derived measles antibody protection as early as 1 month of age.

The study by Dr. Michael J. Smith and Dr. Charles R. Woods of the University of Louisville (Ky.) addressed the “too many vaccines too close together” issue. Using publicly available Vaccine Safety Datalink data from a previous study on thimerosal exposure and neuropsychological outcomes, the authors found that getting all recommended vaccines per the ACIP recommended schedule was associated with better—not worse—performance on selected neurologic outcomes at age 7-10 years, even when such factors as socioeconomic status were controlled for (Pediatrics 2010;125:1134-41). Importantly, there were no statistically significant differences favoring the less-vaccinated children. The authors concluded—and, I agree—that these data add reassurance for parents who are concerned that children receive too many vaccines too soon.

In the other study, Belgian investigators measured measles antibodies in mothers and persistence of the maternal antibody transferred to infants (BMJ 2010;340:c1626[doi:10.1136/bmj.c1626]). They found that the 86 women with antibody from measles vaccine had significantly lower, yet still protective, measles IgG titers, being one-quarter as high as in 120 mothers with antibody from previous measles infection, and that cord blood and initial infant titers correlated with maternal titers.

Of concern is that maternally endowed measles antibody disappeared at a median of 3.8 months in infants of previously measles-infected mothers (only a few infants had antibody at 6 months of age), and at nearly 1 month of age in infants of vaccinated women (none had antibody at 6 months). Thus infants became vulnerable to measles even earlier than previously reported. If maternal antibody is from vaccine, their infants are susceptible for the 9-14 months just prior to the MMR if it is administered at 12-15 months of age.

While waning maternally endowed antibody by 6 months of age is expected for most infections, measles had seemed different. In the 1970s-1980s, MMR was given at 15 months of age. This was because maternal antibody reportedly persisted up to 12 months and prevented a vaccine “take” if the mothers' antibody came from measles infection (J. Pediatr 1977; 91:715-8).hA later report showed waning antibody sooner when mothers' immunity came from measles vaccine: no antibody in 71% of 9-month-olds and 95% of 12-month-olds Maediatrics 1995;96:447-50).httis set the stage for the earlier 12-month MMR option. Now we have increasing evidence of even younger age for disappearance of the vaccine-interfering yet protective antibody to measles.

These data also have implications for the infant traveler. Although MMR isn't currently licensed for infants less than 1 year of age, data like these are the rationale for the Redbook recommendation that MMR be given to infants at 6 months of age or older who will be traveling to measles-endemic countries or during measles outbreaks. Of note, this is considered an “invalid” dose and the 12- to 15-month dose is still needed to attend school.

It might surprise some that Switzerland is now a measles-endemic country apparently due to its low 71% measles immunization rate. In fact, the per capita Swiss measles attack rate is similar to Somalia's. This shows that developed countries will have reemergent measles if herd immunity is lost.

I think we can make a case for studying earlier MMR dosing, particularly with measles outbreaks occurring in the United States, and imported cases potentially now coming from developed countries. If herd immunity (greater than 90% immunized) is in place, the infants' gap in measles protection may not be so worrisome. But as MMR immunization rates decline and become particularly low in some pockets in our country, concern increases over potential larger outbreaks. Studies to evaluate MMR at age 9 months could be the first step. If the vaccine were effective, we could narrow the measles-vulnerable window and vaccinate at the 9-month wellness visit.

[email protected]

Parents' concern that children receive too many vaccines too soon can result in delay or avoidance of vaccination, with the measles-mumps-rubella vaccine often being delayed. However, a recent study showed no neurologic harm from on-time receipt of all the recommended vaccines—including MMR—from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and children with on-time receipt of vaccines performed better on select neurologic testing than those delaying vaccine. Another study showed that children lose maternally derived measles antibody protection as early as 1 month of age.

The study by Dr. Michael J. Smith and Dr. Charles R. Woods of the University of Louisville (Ky.) addressed the “too many vaccines too close together” issue. Using publicly available Vaccine Safety Datalink data from a previous study on thimerosal exposure and neuropsychological outcomes, the authors found that getting all recommended vaccines per the ACIP recommended schedule was associated with better—not worse—performance on selected neurologic outcomes at age 7-10 years, even when such factors as socioeconomic status were controlled for (Pediatrics 2010;125:1134-41). Importantly, there were no statistically significant differences favoring the less-vaccinated children. The authors concluded—and, I agree—that these data add reassurance for parents who are concerned that children receive too many vaccines too soon.

In the other study, Belgian investigators measured measles antibodies in mothers and persistence of the maternal antibody transferred to infants (BMJ 2010;340:c1626[doi:10.1136/bmj.c1626]). They found that the 86 women with antibody from measles vaccine had significantly lower, yet still protective, measles IgG titers, being one-quarter as high as in 120 mothers with antibody from previous measles infection, and that cord blood and initial infant titers correlated with maternal titers.

Of concern is that maternally endowed measles antibody disappeared at a median of 3.8 months in infants of previously measles-infected mothers (only a few infants had antibody at 6 months of age), and at nearly 1 month of age in infants of vaccinated women (none had antibody at 6 months). Thus infants became vulnerable to measles even earlier than previously reported. If maternal antibody is from vaccine, their infants are susceptible for the 9-14 months just prior to the MMR if it is administered at 12-15 months of age.

While waning maternally endowed antibody by 6 months of age is expected for most infections, measles had seemed different. In the 1970s-1980s, MMR was given at 15 months of age. This was because maternal antibody reportedly persisted up to 12 months and prevented a vaccine “take” if the mothers' antibody came from measles infection (J. Pediatr 1977; 91:715-8).hA later report showed waning antibody sooner when mothers' immunity came from measles vaccine: no antibody in 71% of 9-month-olds and 95% of 12-month-olds Maediatrics 1995;96:447-50).httis set the stage for the earlier 12-month MMR option. Now we have increasing evidence of even younger age for disappearance of the vaccine-interfering yet protective antibody to measles.

These data also have implications for the infant traveler. Although MMR isn't currently licensed for infants less than 1 year of age, data like these are the rationale for the Redbook recommendation that MMR be given to infants at 6 months of age or older who will be traveling to measles-endemic countries or during measles outbreaks. Of note, this is considered an “invalid” dose and the 12- to 15-month dose is still needed to attend school.

It might surprise some that Switzerland is now a measles-endemic country apparently due to its low 71% measles immunization rate. In fact, the per capita Swiss measles attack rate is similar to Somalia's. This shows that developed countries will have reemergent measles if herd immunity is lost.

I think we can make a case for studying earlier MMR dosing, particularly with measles outbreaks occurring in the United States, and imported cases potentially now coming from developed countries. If herd immunity (greater than 90% immunized) is in place, the infants' gap in measles protection may not be so worrisome. But as MMR immunization rates decline and become particularly low in some pockets in our country, concern increases over potential larger outbreaks. Studies to evaluate MMR at age 9 months could be the first step. If the vaccine were effective, we could narrow the measles-vulnerable window and vaccinate at the 9-month wellness visit.

[email protected]

Parents' concern that children receive too many vaccines too soon can result in delay or avoidance of vaccination, with the measles-mumps-rubella vaccine often being delayed. However, a recent study showed no neurologic harm from on-time receipt of all the recommended vaccines—including MMR—from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and children with on-time receipt of vaccines performed better on select neurologic testing than those delaying vaccine. Another study showed that children lose maternally derived measles antibody protection as early as 1 month of age.

The study by Dr. Michael J. Smith and Dr. Charles R. Woods of the University of Louisville (Ky.) addressed the “too many vaccines too close together” issue. Using publicly available Vaccine Safety Datalink data from a previous study on thimerosal exposure and neuropsychological outcomes, the authors found that getting all recommended vaccines per the ACIP recommended schedule was associated with better—not worse—performance on selected neurologic outcomes at age 7-10 years, even when such factors as socioeconomic status were controlled for (Pediatrics 2010;125:1134-41). Importantly, there were no statistically significant differences favoring the less-vaccinated children. The authors concluded—and, I agree—that these data add reassurance for parents who are concerned that children receive too many vaccines too soon.

In the other study, Belgian investigators measured measles antibodies in mothers and persistence of the maternal antibody transferred to infants (BMJ 2010;340:c1626[doi:10.1136/bmj.c1626]). They found that the 86 women with antibody from measles vaccine had significantly lower, yet still protective, measles IgG titers, being one-quarter as high as in 120 mothers with antibody from previous measles infection, and that cord blood and initial infant titers correlated with maternal titers.

Of concern is that maternally endowed measles antibody disappeared at a median of 3.8 months in infants of previously measles-infected mothers (only a few infants had antibody at 6 months of age), and at nearly 1 month of age in infants of vaccinated women (none had antibody at 6 months). Thus infants became vulnerable to measles even earlier than previously reported. If maternal antibody is from vaccine, their infants are susceptible for the 9-14 months just prior to the MMR if it is administered at 12-15 months of age.

While waning maternally endowed antibody by 6 months of age is expected for most infections, measles had seemed different. In the 1970s-1980s, MMR was given at 15 months of age. This was because maternal antibody reportedly persisted up to 12 months and prevented a vaccine “take” if the mothers' antibody came from measles infection (J. Pediatr 1977; 91:715-8).hA later report showed waning antibody sooner when mothers' immunity came from measles vaccine: no antibody in 71% of 9-month-olds and 95% of 12-month-olds Maediatrics 1995;96:447-50).httis set the stage for the earlier 12-month MMR option. Now we have increasing evidence of even younger age for disappearance of the vaccine-interfering yet protective antibody to measles.

These data also have implications for the infant traveler. Although MMR isn't currently licensed for infants less than 1 year of age, data like these are the rationale for the Redbook recommendation that MMR be given to infants at 6 months of age or older who will be traveling to measles-endemic countries or during measles outbreaks. Of note, this is considered an “invalid” dose and the 12- to 15-month dose is still needed to attend school.

It might surprise some that Switzerland is now a measles-endemic country apparently due to its low 71% measles immunization rate. In fact, the per capita Swiss measles attack rate is similar to Somalia's. This shows that developed countries will have reemergent measles if herd immunity is lost.

I think we can make a case for studying earlier MMR dosing, particularly with measles outbreaks occurring in the United States, and imported cases potentially now coming from developed countries. If herd immunity (greater than 90% immunized) is in place, the infants' gap in measles protection may not be so worrisome. But as MMR immunization rates decline and become particularly low in some pockets in our country, concern increases over potential larger outbreaks. Studies to evaluate MMR at age 9 months could be the first step. If the vaccine were effective, we could narrow the measles-vulnerable window and vaccinate at the 9-month wellness visit.

[email protected]

The treatment of bacterial conjunctivitis has become more challenging in this era of increasing antimicrobial resistance.

Conjunctivitis in children is extremely common, accounting for an estimated 1%–4% of all pediatric office visits. Yet, with so much focus on otitis media, the impact of antimicrobial resistance on conjunctivitis treatment has been widely overlooked. This is despite that approximately one-third of children with bacterial conjunctivitis have concurrent otitis media, most commonly caused by Haemophilus influenzae. In fact, my interest in conjunctivitis stems from its connection with otitis media.

Many of the traditional topical ocular agents we've used in the past to treat bacterial conjunctivitis—including those of the aminoglycoside, polymixin B combination, and macrolide classes—are less effective than they once were, thanks to increasing resistance. At the same time, many of these agents have tolerability issues, which render them even less effective. After all, if a child won't allow the medicine to be placed in her eyes, it most certainly won't work.

Fluoroquinolones, while remaining highly effective with far less resistance, are about 10 times as expensive as older agents available generically. Is it worth the cost to speed up the cure and reduce the contagion of a self-limited disease by a day or two at the most? The answer to that depends on a variety of factors, including the degree of the child's discomfort, the potential burden to the parent of missing days from work, and whether the child attends day care. It's not a simple decision.

Of course, it's important to determine whether the conjunctivitis is bacterial. Acute bacterial conjunctivitis begins abruptly with early symptoms of irritation or foreign body sensation and tearing. Mucopurulent or purulent discharge, morning crusting, swelling, and comorbid otitis media are common indicators. In contrast, viral conjunctivitis is characterized by watery discharge and conjunctival injection, while allergic conjunctivitis is more likely to involve itching, stringy or ropy discharge, lid edema, red/hyperemic conjunctiva, and comorbid allergic rhinitis.

The age of the child is also predictive. Conjunctivitis in preschool children is most likely bacterial, usually either H. influenzae or Streptococcus pneumoniae. In a newborn, the cause is most likely chemical irritation (from silver nitrate), while in older children the conjunctivitis is usually viral or allergic.

Oral antibiotics are recommended for any child who has concurrent otitis media. But for uncomplicated bacterial conjunctivitis, topical ophthalmic agents are recommended over systemic agents because they achieve a greater concentration of antibiotic to the eye while avoiding systemic side effects. Most of the topicals discussed below are approved for children 1 year of age and older.

Aminoglycosides, including gentamicin, tobramycin, and neomycin, are most active against gram-negative bacteria such as Pseudomonas aeruginosa (except neomycin) and methicillin-sensitive Staphylococcus aureus (MSSA). However, they do not cover streptococci or methicillin-resistant Staph. aureus (MRSA), and studies have shown increasing resistance of Streptococcus pneumoniae to these agents, reaching 65% by 2006 in the Ocular TRUST (Tracking Resistance in U.S. Today) 1 survey (Am. J. Ophthalmol. 2008;145:951–8).

Polymixin B is active only against gram-negative bacteria and therefore is given in combination with other antibiotics, including trimethoprim, bacitracin, and neomycin/bacitracin, which broaden the coverage to include staphylococci, streptococci, and some gram-negative bacteria including H. influenzae. While most H. influenzae strains remain susceptible to polymixin B alone or in combination, there is high resistance among Strep. pneumoniae and MSSA isolates.

The macrolide erythromycin—used as a 0.5% ointment—is one of the oldest ocular antibiotics, but now is rarely effective in bacterial conjunctivitis because of the high resistance among Staphylococcus species and poor activity against H. influenzae. The newer topical macrolide azithromycin is also hampered by high levels of resistance. In the TRUST survey, resistance to azithromycin was 22% for Strep. pneumoniae isolates, 46% among MSSA bacteria, and 91% among MRSA isolates. Other studies have shown significant resistance among H. influenzae as well.

Fluoroquinolones offer broad-spectrum coverage against both gram-positive and gram-negative organisms. The older topical agents ofloxacin and ciprofloxacin have largely been replaced by the newer agents levofloxacin, moxifloxacin, gatifloxacin, and now besifloxacin, which was approved by the U.S. Food and Drug Administration in May 2009. Numerous randomized, double-masked, controlled clinical trials in children and adults with bacterial conjunctivitis have demonstrated clinical cure rates of approximately 66%–96% and microbial eradication rates ranging from 84% to 96% for the newer fluoroquinolones.

There has been almost no resistance to fluoroquinolones among Strep. pneumoniae or H. influenzae organisms, but there is some fluoroquinolone resistance among MSSA isolates and a high level for MRSA, reaching 85% in Ocular TRUST 1.

Although most topical ophthalmic antibiotics used for the treatment of bacterial conjunctivitis are generally safe and well tolerated, ocular adverse events can cause discomfort that leads to noncompliance. Topical aminoglycosides have been associated with corneal and conjunctival toxicity, especially when used frequently, as well as ocular allergic reactions. Bacitracin has been associated with cases of contact dermatitis in the conjunctival area, and the polymixin B combinations can also cause local irritation. Macrolides, too, can cause minor ocular irritation, redness, and hypersensitivity.

In contrast, the fluoroquinolones have been well tolerated and associated with less toxicity than the other ophthalmic antibacterial classes, although crystalline precipitates have been seen with ciprofloxacin when it is administered frequently.

The ideal treatment for acute bacterial conjunctivitis should be a well-tolerated, broad-spectrum, highly potent, and bactericidal agent with a high concentration on the ocular surface and a rapid kill time. Convenience in dosing is also an important consideration. The newer fluoroquinolones, with potent efficacy against H. influenzae and Strep. pneumoniae, may best fulfill those requirements. But of course, cost remains a problem for many.

[email protected]

The treatment of bacterial conjunctivitis has become more challenging in this era of increasing antimicrobial resistance.

Conjunctivitis in children is extremely common, accounting for an estimated 1%–4% of all pediatric office visits. Yet, with so much focus on otitis media, the impact of antimicrobial resistance on conjunctivitis treatment has been widely overlooked. This is despite that approximately one-third of children with bacterial conjunctivitis have concurrent otitis media, most commonly caused by Haemophilus influenzae. In fact, my interest in conjunctivitis stems from its connection with otitis media.

Many of the traditional topical ocular agents we've used in the past to treat bacterial conjunctivitis—including those of the aminoglycoside, polymixin B combination, and macrolide classes—are less effective than they once were, thanks to increasing resistance. At the same time, many of these agents have tolerability issues, which render them even less effective. After all, if a child won't allow the medicine to be placed in her eyes, it most certainly won't work.

Fluoroquinolones, while remaining highly effective with far less resistance, are about 10 times as expensive as older agents available generically. Is it worth the cost to speed up the cure and reduce the contagion of a self-limited disease by a day or two at the most? The answer to that depends on a variety of factors, including the degree of the child's discomfort, the potential burden to the parent of missing days from work, and whether the child attends day care. It's not a simple decision.

Of course, it's important to determine whether the conjunctivitis is bacterial. Acute bacterial conjunctivitis begins abruptly with early symptoms of irritation or foreign body sensation and tearing. Mucopurulent or purulent discharge, morning crusting, swelling, and comorbid otitis media are common indicators. In contrast, viral conjunctivitis is characterized by watery discharge and conjunctival injection, while allergic conjunctivitis is more likely to involve itching, stringy or ropy discharge, lid edema, red/hyperemic conjunctiva, and comorbid allergic rhinitis.

The age of the child is also predictive. Conjunctivitis in preschool children is most likely bacterial, usually either H. influenzae or Streptococcus pneumoniae. In a newborn, the cause is most likely chemical irritation (from silver nitrate), while in older children the conjunctivitis is usually viral or allergic.

Oral antibiotics are recommended for any child who has concurrent otitis media. But for uncomplicated bacterial conjunctivitis, topical ophthalmic agents are recommended over systemic agents because they achieve a greater concentration of antibiotic to the eye while avoiding systemic side effects. Most of the topicals discussed below are approved for children 1 year of age and older.

Aminoglycosides, including gentamicin, tobramycin, and neomycin, are most active against gram-negative bacteria such as Pseudomonas aeruginosa (except neomycin) and methicillin-sensitive Staphylococcus aureus (MSSA). However, they do not cover streptococci or methicillin-resistant Staph. aureus (MRSA), and studies have shown increasing resistance of Streptococcus pneumoniae to these agents, reaching 65% by 2006 in the Ocular TRUST (Tracking Resistance in U.S. Today) 1 survey (Am. J. Ophthalmol. 2008;145:951–8).

Polymixin B is active only against gram-negative bacteria and therefore is given in combination with other antibiotics, including trimethoprim, bacitracin, and neomycin/bacitracin, which broaden the coverage to include staphylococci, streptococci, and some gram-negative bacteria including H. influenzae. While most H. influenzae strains remain susceptible to polymixin B alone or in combination, there is high resistance among Strep. pneumoniae and MSSA isolates.

The macrolide erythromycin—used as a 0.5% ointment—is one of the oldest ocular antibiotics, but now is rarely effective in bacterial conjunctivitis because of the high resistance among Staphylococcus species and poor activity against H. influenzae. The newer topical macrolide azithromycin is also hampered by high levels of resistance. In the TRUST survey, resistance to azithromycin was 22% for Strep. pneumoniae isolates, 46% among MSSA bacteria, and 91% among MRSA isolates. Other studies have shown significant resistance among H. influenzae as well.

Fluoroquinolones offer broad-spectrum coverage against both gram-positive and gram-negative organisms. The older topical agents ofloxacin and ciprofloxacin have largely been replaced by the newer agents levofloxacin, moxifloxacin, gatifloxacin, and now besifloxacin, which was approved by the U.S. Food and Drug Administration in May 2009. Numerous randomized, double-masked, controlled clinical trials in children and adults with bacterial conjunctivitis have demonstrated clinical cure rates of approximately 66%–96% and microbial eradication rates ranging from 84% to 96% for the newer fluoroquinolones.

There has been almost no resistance to fluoroquinolones among Strep. pneumoniae or H. influenzae organisms, but there is some fluoroquinolone resistance among MSSA isolates and a high level for MRSA, reaching 85% in Ocular TRUST 1.

Although most topical ophthalmic antibiotics used for the treatment of bacterial conjunctivitis are generally safe and well tolerated, ocular adverse events can cause discomfort that leads to noncompliance. Topical aminoglycosides have been associated with corneal and conjunctival toxicity, especially when used frequently, as well as ocular allergic reactions. Bacitracin has been associated with cases of contact dermatitis in the conjunctival area, and the polymixin B combinations can also cause local irritation. Macrolides, too, can cause minor ocular irritation, redness, and hypersensitivity.

In contrast, the fluoroquinolones have been well tolerated and associated with less toxicity than the other ophthalmic antibacterial classes, although crystalline precipitates have been seen with ciprofloxacin when it is administered frequently.

The ideal treatment for acute bacterial conjunctivitis should be a well-tolerated, broad-spectrum, highly potent, and bactericidal agent with a high concentration on the ocular surface and a rapid kill time. Convenience in dosing is also an important consideration. The newer fluoroquinolones, with potent efficacy against H. influenzae and Strep. pneumoniae, may best fulfill those requirements. But of course, cost remains a problem for many.

[email protected]

The treatment of bacterial conjunctivitis has become more challenging in this era of increasing antimicrobial resistance.

Conjunctivitis in children is extremely common, accounting for an estimated 1%–4% of all pediatric office visits. Yet, with so much focus on otitis media, the impact of antimicrobial resistance on conjunctivitis treatment has been widely overlooked. This is despite that approximately one-third of children with bacterial conjunctivitis have concurrent otitis media, most commonly caused by Haemophilus influenzae. In fact, my interest in conjunctivitis stems from its connection with otitis media.

Many of the traditional topical ocular agents we've used in the past to treat bacterial conjunctivitis—including those of the aminoglycoside, polymixin B combination, and macrolide classes—are less effective than they once were, thanks to increasing resistance. At the same time, many of these agents have tolerability issues, which render them even less effective. After all, if a child won't allow the medicine to be placed in her eyes, it most certainly won't work.

Fluoroquinolones, while remaining highly effective with far less resistance, are about 10 times as expensive as older agents available generically. Is it worth the cost to speed up the cure and reduce the contagion of a self-limited disease by a day or two at the most? The answer to that depends on a variety of factors, including the degree of the child's discomfort, the potential burden to the parent of missing days from work, and whether the child attends day care. It's not a simple decision.

Of course, it's important to determine whether the conjunctivitis is bacterial. Acute bacterial conjunctivitis begins abruptly with early symptoms of irritation or foreign body sensation and tearing. Mucopurulent or purulent discharge, morning crusting, swelling, and comorbid otitis media are common indicators. In contrast, viral conjunctivitis is characterized by watery discharge and conjunctival injection, while allergic conjunctivitis is more likely to involve itching, stringy or ropy discharge, lid edema, red/hyperemic conjunctiva, and comorbid allergic rhinitis.

The age of the child is also predictive. Conjunctivitis in preschool children is most likely bacterial, usually either H. influenzae or Streptococcus pneumoniae. In a newborn, the cause is most likely chemical irritation (from silver nitrate), while in older children the conjunctivitis is usually viral or allergic.

Oral antibiotics are recommended for any child who has concurrent otitis media. But for uncomplicated bacterial conjunctivitis, topical ophthalmic agents are recommended over systemic agents because they achieve a greater concentration of antibiotic to the eye while avoiding systemic side effects. Most of the topicals discussed below are approved for children 1 year of age and older.

Aminoglycosides, including gentamicin, tobramycin, and neomycin, are most active against gram-negative bacteria such as Pseudomonas aeruginosa (except neomycin) and methicillin-sensitive Staphylococcus aureus (MSSA). However, they do not cover streptococci or methicillin-resistant Staph. aureus (MRSA), and studies have shown increasing resistance of Streptococcus pneumoniae to these agents, reaching 65% by 2006 in the Ocular TRUST (Tracking Resistance in U.S. Today) 1 survey (Am. J. Ophthalmol. 2008;145:951–8).

Polymixin B is active only against gram-negative bacteria and therefore is given in combination with other antibiotics, including trimethoprim, bacitracin, and neomycin/bacitracin, which broaden the coverage to include staphylococci, streptococci, and some gram-negative bacteria including H. influenzae. While most H. influenzae strains remain susceptible to polymixin B alone or in combination, there is high resistance among Strep. pneumoniae and MSSA isolates.

The macrolide erythromycin—used as a 0.5% ointment—is one of the oldest ocular antibiotics, but now is rarely effective in bacterial conjunctivitis because of the high resistance among Staphylococcus species and poor activity against H. influenzae. The newer topical macrolide azithromycin is also hampered by high levels of resistance. In the TRUST survey, resistance to azithromycin was 22% for Strep. pneumoniae isolates, 46% among MSSA bacteria, and 91% among MRSA isolates. Other studies have shown significant resistance among H. influenzae as well.

Fluoroquinolones offer broad-spectrum coverage against both gram-positive and gram-negative organisms. The older topical agents ofloxacin and ciprofloxacin have largely been replaced by the newer agents levofloxacin, moxifloxacin, gatifloxacin, and now besifloxacin, which was approved by the U.S. Food and Drug Administration in May 2009. Numerous randomized, double-masked, controlled clinical trials in children and adults with bacterial conjunctivitis have demonstrated clinical cure rates of approximately 66%–96% and microbial eradication rates ranging from 84% to 96% for the newer fluoroquinolones.

There has been almost no resistance to fluoroquinolones among Strep. pneumoniae or H. influenzae organisms, but there is some fluoroquinolone resistance among MSSA isolates and a high level for MRSA, reaching 85% in Ocular TRUST 1.

Although most topical ophthalmic antibiotics used for the treatment of bacterial conjunctivitis are generally safe and well tolerated, ocular adverse events can cause discomfort that leads to noncompliance. Topical aminoglycosides have been associated with corneal and conjunctival toxicity, especially when used frequently, as well as ocular allergic reactions. Bacitracin has been associated with cases of contact dermatitis in the conjunctival area, and the polymixin B combinations can also cause local irritation. Macrolides, too, can cause minor ocular irritation, redness, and hypersensitivity.

In contrast, the fluoroquinolones have been well tolerated and associated with less toxicity than the other ophthalmic antibacterial classes, although crystalline precipitates have been seen with ciprofloxacin when it is administered frequently.

The ideal treatment for acute bacterial conjunctivitis should be a well-tolerated, broad-spectrum, highly potent, and bactericidal agent with a high concentration on the ocular surface and a rapid kill time. Convenience in dosing is also an important consideration. The newer fluoroquinolones, with potent efficacy against H. influenzae and Strep. pneumoniae, may best fulfill those requirements. But of course, cost remains a problem for many.

[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.

I'm very glad that the Lancet finally retracted the 1998 paper by Andrew J. Wakefield et al. that incorrectly suggested a link between the measles-mumps-rubella combined vaccine and autism. In my opinion, as well as others, the data did not warrant publication in 1998.

Following the judgment of the U.K. General Medical Council's Fitness to Practise Panel on Jan. 28, 2010, the Lancet editors said in a Feb. 2 statement, “it has become clear that several elements of the 1998 paper by Wakefield et al. are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were 'consecutively referred' and that investigations were 'approved' by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record” (Lancet 2010 Feb. 2 [doi: 10.1016/S0140-6736(10)60175-4

Indeed, the authors never established what they claimed to demonstrate: a link between the MMR vaccine and a phenomenon they called “autistic enterocolitis.” The study was small—just 12 children—there was no control group, and the children had been specifically selected from among those referred to a pediatric gastroenterology clinic with both bowel symptoms and pervasive developmental disorder (Lancet 1998;351:637-41).

The study relied on parental report—8 of the 12 said that the onset of developmental delay symptoms was within 2 weeks of MMR receipt and the authors made no apparent attempt to confirm the reports. The study also relied on very sophisticated technology (in-situ hybridization, in-cell reverse transcriptase, and real-time quantitative TaqMan PCR) to demonstrate measles virus in the gut but failed to include a basic concept—a control population. Research by other investigators including a recent study of children with gastrointestinal syndromes with and without “autistic behavior” have failed to confirm Wakefield's findings.

At most, Wakefield and his colleagues showed a potential association. However, their final paragraph emphasizes the potential linkage (“In most cases, onset of symptoms was after measles, mumps, and rubella immunization”) and in subsequent statements warned against the use of combined MMR vaccines. As a result, use of MMR vaccine plummeted in the United Kingdom, measles cases rose, and overall public confidence in immunization was severely damaged.

Unfortunately the fallout continues today, despite the accumulation of a vast literature contradicting Wakefield's conclusions, including an Institute of Medicine report (“Immunization Safety Review: Vaccines and Autism 2004”) rejecting a causal relationship. One study particularly relevant to Wakefield's advocacy for using single dosing of measles vaccine is the unique situation in Japan, where, due to a problem with the mumps component, use of the MMR vaccine ceased completely in April 1993 and only monovalent vaccines were used thereafter (which, as it happens, is what Wakefield's group had recommended as a solution).

Despite the removal of the combination MMR vaccine from Japan's immunization program, the cumulative incidence of autism spectrum disorder (ASD) increased significantly up to age 7 among children born in Kohoku Ward (population approximately 300,000) in the years 1988-1996, with the most notable rise beginning with the birth cohort of 1993 (J. Child Psychol. Psychiatry 2005;46:572-9). “The significance of this finding is that MMR vaccination is most unlikely to be a cause of ASD, that it cannot explain the rise over time in the incidence of ASD, and that withdrawal of MMR in countries where it is still being used cannot be expected to lead to a reduction in the incidence of ASD,” Dr. Hideo Honda and associates concluded.

Numerous additional studies from the United States, Scandinavia, and elsewhere have also conclusively shown a lack of any link between the vaccine, autism, and/or this supposed gastrointestinal syndrome. There's a good summary of all these data in Wikipedia, under “MMR Vaccine Controversy” (http://en.wikipedia.org/wiki/MMR_vaccine_controversywww.briandeer.com/mmr/lancet-greenhalgh.htm

What are the lessons we learn from this 20-year episode? We all have biases that have the potential to color our view of scientific data. Recently, concern about undue influence from the pharmaceutical industry has become a hot topic, hopefully addressed by full transparency of potential conflicts of interest by authors. It is equally imperative for journal editors to be aware of their biases and to advocate for scientific rigor as the criterion for publication and not a political agenda.

I do not have the insight to claim knowledge of what went awry in the case of the Wakefield paper. I do know that I have heard colleagues say, “How could you believe the results of such and such study; it was sponsored by industry.” This episode should remind us that scientific rigor should be the gold standard that investigators, reviewers, and editors rely on.

The Lancet and this newspaper are both published by Elsevier.

I'm very glad that the Lancet finally retracted the 1998 paper by Andrew J. Wakefield et al. that incorrectly suggested a link between the measles-mumps-rubella combined vaccine and autism. In my opinion, as well as others, the data did not warrant publication in 1998.

Following the judgment of the U.K. General Medical Council's Fitness to Practise Panel on Jan. 28, 2010, the Lancet editors said in a Feb. 2 statement, “it has become clear that several elements of the 1998 paper by Wakefield et al. are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were 'consecutively referred' and that investigations were 'approved' by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record” (Lancet 2010 Feb. 2 [doi: 10.1016/S0140-6736(10)60175-4

Indeed, the authors never established what they claimed to demonstrate: a link between the MMR vaccine and a phenomenon they called “autistic enterocolitis.” The study was small—just 12 children—there was no control group, and the children had been specifically selected from among those referred to a pediatric gastroenterology clinic with both bowel symptoms and pervasive developmental disorder (Lancet 1998;351:637-41).

The study relied on parental report—8 of the 12 said that the onset of developmental delay symptoms was within 2 weeks of MMR receipt and the authors made no apparent attempt to confirm the reports. The study also relied on very sophisticated technology (in-situ hybridization, in-cell reverse transcriptase, and real-time quantitative TaqMan PCR) to demonstrate measles virus in the gut but failed to include a basic concept—a control population. Research by other investigators including a recent study of children with gastrointestinal syndromes with and without “autistic behavior” have failed to confirm Wakefield's findings.

At most, Wakefield and his colleagues showed a potential association. However, their final paragraph emphasizes the potential linkage (“In most cases, onset of symptoms was after measles, mumps, and rubella immunization”) and in subsequent statements warned against the use of combined MMR vaccines. As a result, use of MMR vaccine plummeted in the United Kingdom, measles cases rose, and overall public confidence in immunization was severely damaged.

Unfortunately the fallout continues today, despite the accumulation of a vast literature contradicting Wakefield's conclusions, including an Institute of Medicine report (“Immunization Safety Review: Vaccines and Autism 2004”) rejecting a causal relationship. One study particularly relevant to Wakefield's advocacy for using single dosing of measles vaccine is the unique situation in Japan, where, due to a problem with the mumps component, use of the MMR vaccine ceased completely in April 1993 and only monovalent vaccines were used thereafter (which, as it happens, is what Wakefield's group had recommended as a solution).

Despite the removal of the combination MMR vaccine from Japan's immunization program, the cumulative incidence of autism spectrum disorder (ASD) increased significantly up to age 7 among children born in Kohoku Ward (population approximately 300,000) in the years 1988-1996, with the most notable rise beginning with the birth cohort of 1993 (J. Child Psychol. Psychiatry 2005;46:572-9). “The significance of this finding is that MMR vaccination is most unlikely to be a cause of ASD, that it cannot explain the rise over time in the incidence of ASD, and that withdrawal of MMR in countries where it is still being used cannot be expected to lead to a reduction in the incidence of ASD,” Dr. Hideo Honda and associates concluded.

Numerous additional studies from the United States, Scandinavia, and elsewhere have also conclusively shown a lack of any link between the vaccine, autism, and/or this supposed gastrointestinal syndrome. There's a good summary of all these data in Wikipedia, under “MMR Vaccine Controversy” (http://en.wikipedia.org/wiki/MMR_vaccine_controversywww.briandeer.com/mmr/lancet-greenhalgh.htm

What are the lessons we learn from this 20-year episode? We all have biases that have the potential to color our view of scientific data. Recently, concern about undue influence from the pharmaceutical industry has become a hot topic, hopefully addressed by full transparency of potential conflicts of interest by authors. It is equally imperative for journal editors to be aware of their biases and to advocate for scientific rigor as the criterion for publication and not a political agenda.

I do not have the insight to claim knowledge of what went awry in the case of the Wakefield paper. I do know that I have heard colleagues say, “How could you believe the results of such and such study; it was sponsored by industry.” This episode should remind us that scientific rigor should be the gold standard that investigators, reviewers, and editors rely on.

The Lancet and this newspaper are both published by Elsevier.

I'm very glad that the Lancet finally retracted the 1998 paper by Andrew J. Wakefield et al. that incorrectly suggested a link between the measles-mumps-rubella combined vaccine and autism. In my opinion, as well as others, the data did not warrant publication in 1998.

Following the judgment of the U.K. General Medical Council's Fitness to Practise Panel on Jan. 28, 2010, the Lancet editors said in a Feb. 2 statement, “it has become clear that several elements of the 1998 paper by Wakefield et al. are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were 'consecutively referred' and that investigations were 'approved' by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record” (Lancet 2010 Feb. 2 [doi: 10.1016/S0140-6736(10)60175-4

Indeed, the authors never established what they claimed to demonstrate: a link between the MMR vaccine and a phenomenon they called “autistic enterocolitis.” The study was small—just 12 children—there was no control group, and the children had been specifically selected from among those referred to a pediatric gastroenterology clinic with both bowel symptoms and pervasive developmental disorder (Lancet 1998;351:637-41).

The study relied on parental report—8 of the 12 said that the onset of developmental delay symptoms was within 2 weeks of MMR receipt and the authors made no apparent attempt to confirm the reports. The study also relied on very sophisticated technology (in-situ hybridization, in-cell reverse transcriptase, and real-time quantitative TaqMan PCR) to demonstrate measles virus in the gut but failed to include a basic concept—a control population. Research by other investigators including a recent study of children with gastrointestinal syndromes with and without “autistic behavior” have failed to confirm Wakefield's findings.

At most, Wakefield and his colleagues showed a potential association. However, their final paragraph emphasizes the potential linkage (“In most cases, onset of symptoms was after measles, mumps, and rubella immunization”) and in subsequent statements warned against the use of combined MMR vaccines. As a result, use of MMR vaccine plummeted in the United Kingdom, measles cases rose, and overall public confidence in immunization was severely damaged.

Unfortunately the fallout continues today, despite the accumulation of a vast literature contradicting Wakefield's conclusions, including an Institute of Medicine report (“Immunization Safety Review: Vaccines and Autism 2004”) rejecting a causal relationship. One study particularly relevant to Wakefield's advocacy for using single dosing of measles vaccine is the unique situation in Japan, where, due to a problem with the mumps component, use of the MMR vaccine ceased completely in April 1993 and only monovalent vaccines were used thereafter (which, as it happens, is what Wakefield's group had recommended as a solution).

Despite the removal of the combination MMR vaccine from Japan's immunization program, the cumulative incidence of autism spectrum disorder (ASD) increased significantly up to age 7 among children born in Kohoku Ward (population approximately 300,000) in the years 1988-1996, with the most notable rise beginning with the birth cohort of 1993 (J. Child Psychol. Psychiatry 2005;46:572-9). “The significance of this finding is that MMR vaccination is most unlikely to be a cause of ASD, that it cannot explain the rise over time in the incidence of ASD, and that withdrawal of MMR in countries where it is still being used cannot be expected to lead to a reduction in the incidence of ASD,” Dr. Hideo Honda and associates concluded.

Numerous additional studies from the United States, Scandinavia, and elsewhere have also conclusively shown a lack of any link between the vaccine, autism, and/or this supposed gastrointestinal syndrome. There's a good summary of all these data in Wikipedia, under “MMR Vaccine Controversy” (http://en.wikipedia.org/wiki/MMR_vaccine_controversywww.briandeer.com/mmr/lancet-greenhalgh.htm

What are the lessons we learn from this 20-year episode? We all have biases that have the potential to color our view of scientific data. Recently, concern about undue influence from the pharmaceutical industry has become a hot topic, hopefully addressed by full transparency of potential conflicts of interest by authors. It is equally imperative for journal editors to be aware of their biases and to advocate for scientific rigor as the criterion for publication and not a political agenda.

I do not have the insight to claim knowledge of what went awry in the case of the Wakefield paper. I do know that I have heard colleagues say, “How could you believe the results of such and such study; it was sponsored by industry.” This episode should remind us that scientific rigor should be the gold standard that investigators, reviewers, and editors rely on.

The Lancet and this newspaper are both published by Elsevier.

[email protected]

Could it be that our own cultural affiliations and beliefs might affect our patients' willingness to accept the human papillomavirus vaccine? A fascinating new study suggests just that.

To me, HPV vaccine should be a no-brainer. It protects against 60%-70% of cervical cancers, and is as safe as any other available vaccine. Yet, only about 40% of young females recommended to receive the vaccine have done so thus far. Why?

It may be in part because it is one of the most expensive vaccines in our repertoire, but it's covered by the Vaccines for Children program and now by most third-party payers. And it's not just a matter of 11- to 12-year-olds not getting vaccinated overall. In my area, only about two-thirds of adolescents who get the tetanus-diphtheria-acellular pertussis booster are concurrently receiving the HPV vaccine. It seems that they are refusing it specifically.

The HPV vaccine has been the object of misinformation and is controversial. Some people argue that it is unsafe or that it encourages young females to be more sexually active.

But a recent study actually suggests that girls getting HPV vaccine may be more cautious about sexual activity (Br. J. Cancer 2009;101:1502-4), yet the incorrect beliefs persist.

We hope that families will accept our advice on matters when they have concerns, but another new study sheds light on why families might not.

Yale University law professor Dan M. Kahan and his associates randomly surveyed 1,538 U.S. adults from a database of 40,000 scholarly public opinion poll respondents regarding their views on the HPV vaccine.

Individuals with cultural values favoring “authority” and/or “individualism” perceived the vaccine as risky, in part because they believed it would lead girls to engage in unsafe sex. But those favoring gender equality and/or community/government involvement in basic health care were more likely to see the vaccine as low risk and high benefit (Law Hum. Behav. 2010 Jan. 14 [doi:10.1007/s10979-009-9201-0

We all have suspected this to be the case, but now there are data to support that suspicion. Now here's the really interesting part: The researchers designed fictional “experts” who appeared to either share or oppose the respondents' cultural values. When views about HPV vaccines came from experts who respondents believed shared their values, they were more willing to accept the information. But when the views came from experts whom they perceived held values different from theirs, the subjects did not accept the experts' information.

So, when proauthority/individualism experts asserted the vaccine was risky, proauthority/individualism respondents agreed with them. When the egalitarian/procommunity experts argued that it was safe, egalitarian/procommunity respondents also agreed with them, solidifying overall disagreement about use of the vaccine.

However, when proauthority/individualism experts asserted that the vaccine was safe, proauthority/individualism respondents (who originally thought the vaccine was risky) moderated their original viewpoints, because the information came from experts who they perceived shared their values.

This held true for the opposite scenario, too: If egalitarian/procommunity experts argued the vaccine was risky, egalitarian/procommunity respondents shifted their belief toward its being risky.

As clinicians, we'd like to believe that our patients respect and trust us. But it's possible that when it comes to controversial recommendations, they may resist what we say if they don't identify enough with us based on our apparent values. If it is clear that our patient's family holds values widely disparate from ours, it might be helpful to utilize another more culturally congruent health professional in our practice to counsel about vaccination. This would vary by practice and from case to case, but could include people of similar race, religion, political viewpoint, or even regional accent.

Studies suggest that patients sometimes choose physicians to match their values. But with Medicaid and managed care, that may not always be possible. Using this type of approach may have more impact.

Surveys and discussion groups by the CDC suggest that scare tactics and scientific data may not successfully modify the opinion of parents who are disinclined toward vaccination (and I think most of us have the same experience). However, I did want to briefly mention recent data regarding HPV transmission in young adults that took me by surprise and may be persuasive for some patients.

Dr. Ann N. Burchell and her associates at McGill University, Montreal, evaluated female college/university students (aged 18-24 years) in self-described “stable” relationships exclusively with one male partner. The 263 couples had engaged in vaginal sex for a median of 3.9 months. HPV was detected in 64% of the couples. In 41% of the couples, both partners had the same HPV type. This risk of having the same strain was nearly four times more than what would be found by testing two random individuals. Also, oncogenic HPV-16 was the most common type, detected in 22% of couples (Epidemiology 2010;21:31-7).

In other words, one partner frequently came into the relationship with HPV and quickly transmitted it to the other. I was startled by the transmission frequency in these young adult females, who considered themselves in stable relationships. It suggests that acquisition is not just in early adolescence (although the risk of persistence is higher in that age group) and that catch-up immunization may be more important than some have thought. Perhaps these data won't convince all of your patients to get the HPV vaccine, but it may be helpful in some who are in their late teens or precollege age.

[email protected]

Could it be that our own cultural affiliations and beliefs might affect our patients' willingness to accept the human papillomavirus vaccine? A fascinating new study suggests just that.

To me, HPV vaccine should be a no-brainer. It protects against 60%-70% of cervical cancers, and is as safe as any other available vaccine. Yet, only about 40% of young females recommended to receive the vaccine have done so thus far. Why?

It may be in part because it is one of the most expensive vaccines in our repertoire, but it's covered by the Vaccines for Children program and now by most third-party payers. And it's not just a matter of 11- to 12-year-olds not getting vaccinated overall. In my area, only about two-thirds of adolescents who get the tetanus-diphtheria-acellular pertussis booster are concurrently receiving the HPV vaccine. It seems that they are refusing it specifically.

The HPV vaccine has been the object of misinformation and is controversial. Some people argue that it is unsafe or that it encourages young females to be more sexually active.

But a recent study actually suggests that girls getting HPV vaccine may be more cautious about sexual activity (Br. J. Cancer 2009;101:1502-4), yet the incorrect beliefs persist.

We hope that families will accept our advice on matters when they have concerns, but another new study sheds light on why families might not.

Yale University law professor Dan M. Kahan and his associates randomly surveyed 1,538 U.S. adults from a database of 40,000 scholarly public opinion poll respondents regarding their views on the HPV vaccine.

Individuals with cultural values favoring “authority” and/or “individualism” perceived the vaccine as risky, in part because they believed it would lead girls to engage in unsafe sex. But those favoring gender equality and/or community/government involvement in basic health care were more likely to see the vaccine as low risk and high benefit (Law Hum. Behav. 2010 Jan. 14 [doi:10.1007/s10979-009-9201-0

We all have suspected this to be the case, but now there are data to support that suspicion. Now here's the really interesting part: The researchers designed fictional “experts” who appeared to either share or oppose the respondents' cultural values. When views about HPV vaccines came from experts who respondents believed shared their values, they were more willing to accept the information. But when the views came from experts whom they perceived held values different from theirs, the subjects did not accept the experts' information.

So, when proauthority/individualism experts asserted the vaccine was risky, proauthority/individualism respondents agreed with them. When the egalitarian/procommunity experts argued that it was safe, egalitarian/procommunity respondents also agreed with them, solidifying overall disagreement about use of the vaccine.

However, when proauthority/individualism experts asserted that the vaccine was safe, proauthority/individualism respondents (who originally thought the vaccine was risky) moderated their original viewpoints, because the information came from experts who they perceived shared their values.

This held true for the opposite scenario, too: If egalitarian/procommunity experts argued the vaccine was risky, egalitarian/procommunity respondents shifted their belief toward its being risky.

As clinicians, we'd like to believe that our patients respect and trust us. But it's possible that when it comes to controversial recommendations, they may resist what we say if they don't identify enough with us based on our apparent values. If it is clear that our patient's family holds values widely disparate from ours, it might be helpful to utilize another more culturally congruent health professional in our practice to counsel about vaccination. This would vary by practice and from case to case, but could include people of similar race, religion, political viewpoint, or even regional accent.

Studies suggest that patients sometimes choose physicians to match their values. But with Medicaid and managed care, that may not always be possible. Using this type of approach may have more impact.

Surveys and discussion groups by the CDC suggest that scare tactics and scientific data may not successfully modify the opinion of parents who are disinclined toward vaccination (and I think most of us have the same experience). However, I did want to briefly mention recent data regarding HPV transmission in young adults that took me by surprise and may be persuasive for some patients.

Dr. Ann N. Burchell and her associates at McGill University, Montreal, evaluated female college/university students (aged 18-24 years) in self-described “stable” relationships exclusively with one male partner. The 263 couples had engaged in vaginal sex for a median of 3.9 months. HPV was detected in 64% of the couples. In 41% of the couples, both partners had the same HPV type. This risk of having the same strain was nearly four times more than what would be found by testing two random individuals. Also, oncogenic HPV-16 was the most common type, detected in 22% of couples (Epidemiology 2010;21:31-7).

In other words, one partner frequently came into the relationship with HPV and quickly transmitted it to the other. I was startled by the transmission frequency in these young adult females, who considered themselves in stable relationships. It suggests that acquisition is not just in early adolescence (although the risk of persistence is higher in that age group) and that catch-up immunization may be more important than some have thought. Perhaps these data won't convince all of your patients to get the HPV vaccine, but it may be helpful in some who are in their late teens or precollege age.

[email protected]

Could it be that our own cultural affiliations and beliefs might affect our patients' willingness to accept the human papillomavirus vaccine? A fascinating new study suggests just that.

To me, HPV vaccine should be a no-brainer. It protects against 60%-70% of cervical cancers, and is as safe as any other available vaccine. Yet, only about 40% of young females recommended to receive the vaccine have done so thus far. Why?

It may be in part because it is one of the most expensive vaccines in our repertoire, but it's covered by the Vaccines for Children program and now by most third-party payers. And it's not just a matter of 11- to 12-year-olds not getting vaccinated overall. In my area, only about two-thirds of adolescents who get the tetanus-diphtheria-acellular pertussis booster are concurrently receiving the HPV vaccine. It seems that they are refusing it specifically.

The HPV vaccine has been the object of misinformation and is controversial. Some people argue that it is unsafe or that it encourages young females to be more sexually active.

But a recent study actually suggests that girls getting HPV vaccine may be more cautious about sexual activity (Br. J. Cancer 2009;101:1502-4), yet the incorrect beliefs persist.

We hope that families will accept our advice on matters when they have concerns, but another new study sheds light on why families might not.

Yale University law professor Dan M. Kahan and his associates randomly surveyed 1,538 U.S. adults from a database of 40,000 scholarly public opinion poll respondents regarding their views on the HPV vaccine.

Individuals with cultural values favoring “authority” and/or “individualism” perceived the vaccine as risky, in part because they believed it would lead girls to engage in unsafe sex. But those favoring gender equality and/or community/government involvement in basic health care were more likely to see the vaccine as low risk and high benefit (Law Hum. Behav. 2010 Jan. 14 [doi:10.1007/s10979-009-9201-0

We all have suspected this to be the case, but now there are data to support that suspicion. Now here's the really interesting part: The researchers designed fictional “experts” who appeared to either share or oppose the respondents' cultural values. When views about HPV vaccines came from experts who respondents believed shared their values, they were more willing to accept the information. But when the views came from experts whom they perceived held values different from theirs, the subjects did not accept the experts' information.

So, when proauthority/individualism experts asserted the vaccine was risky, proauthority/individualism respondents agreed with them. When the egalitarian/procommunity experts argued that it was safe, egalitarian/procommunity respondents also agreed with them, solidifying overall disagreement about use of the vaccine.

However, when proauthority/individualism experts asserted that the vaccine was safe, proauthority/individualism respondents (who originally thought the vaccine was risky) moderated their original viewpoints, because the information came from experts who they perceived shared their values.

This held true for the opposite scenario, too: If egalitarian/procommunity experts argued the vaccine was risky, egalitarian/procommunity respondents shifted their belief toward its being risky.

As clinicians, we'd like to believe that our patients respect and trust us. But it's possible that when it comes to controversial recommendations, they may resist what we say if they don't identify enough with us based on our apparent values. If it is clear that our patient's family holds values widely disparate from ours, it might be helpful to utilize another more culturally congruent health professional in our practice to counsel about vaccination. This would vary by practice and from case to case, but could include people of similar race, religion, political viewpoint, or even regional accent.

Studies suggest that patients sometimes choose physicians to match their values. But with Medicaid and managed care, that may not always be possible. Using this type of approach may have more impact.

Surveys and discussion groups by the CDC suggest that scare tactics and scientific data may not successfully modify the opinion of parents who are disinclined toward vaccination (and I think most of us have the same experience). However, I did want to briefly mention recent data regarding HPV transmission in young adults that took me by surprise and may be persuasive for some patients.

Dr. Ann N. Burchell and her associates at McGill University, Montreal, evaluated female college/university students (aged 18-24 years) in self-described “stable” relationships exclusively with one male partner. The 263 couples had engaged in vaginal sex for a median of 3.9 months. HPV was detected in 64% of the couples. In 41% of the couples, both partners had the same HPV type. This risk of having the same strain was nearly four times more than what would be found by testing two random individuals. Also, oncogenic HPV-16 was the most common type, detected in 22% of couples (Epidemiology 2010;21:31-7).

In other words, one partner frequently came into the relationship with HPV and quickly transmitted it to the other. I was startled by the transmission frequency in these young adult females, who considered themselves in stable relationships. It suggests that acquisition is not just in early adolescence (although the risk of persistence is higher in that age group) and that catch-up immunization may be more important than some have thought. Perhaps these data won't convince all of your patients to get the HPV vaccine, but it may be helpful in some who are in their late teens or precollege age.