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Volume 5 | Issue 2 | February 2013
Outbreaks, Alerts & Hot Topics
Norovirus News
Mary Anne Jackson, MD | Division DIrector, Infectious Diseases
Medical Editor, The Link Newsletter | Professor of Pediatrics
Noroviruses have now become the most common cause of acute
gastroenteritis outbreaks in the United States and most cases are related
to person to person transmission. Morbidity is most common in the
youngest, older adults and those who are immunocompromised.
Noroviruses are also the leading cause of food-borne outbreaks and
have been associated with leafy vegetables, shellfish (oysters), fruits
(raspberries) contaminated at their source, and also traced to foods
contaminated by infected food handlers. More than 90 percent of
diarrheal outbreaks that occur on cruise ships are caused by norovirus,
and disease is facilitated by close living quarters, shared dining facilities
and difficulty with limiting spread once the outbreak takes off. Not
surprisingly, outbreaks have also occurred in other closely quartered
populations, including schools, nursing homes, long-term care facilities,
military encampments, colleges and prisons.
The virus is highly contagious. My colleague, Dr. Christopher Harrison
calls norovirus “the Shigella of viral diarrheal disease” as only 18 viral
particles are necessary to transmit infection (similar to Shigella, where
as few as 10 organisms can effectively transmit infection) and disease
peaks in winter (November-April). Consider that the virus, which is found
in stool for an average of two to five days following infection, contains a
viral load of approximately 100 billion (Yes, billion with a B!) viral copies
per gram of feces
and it is not hard to
see how outbreaks
happen. The virus
persists on surfaces
and is resistant to
disinfectants.
Vomiting, watery, nonbloody diarrhea and
abdominal cramping are the
most commonly reported
symptoms.
Disease
manifestations
follow a 12-24 hour
incubation period. Vomiting, watery, non-bloody diarrhea and abdominal
cramping are the most commonly reported symptoms. In most cases, the
patient recovers in one to three days. It is estimated that 10 percent come
to medical attention and longer courses have been described in those
who require hospitalization. Stool PCR assays obtained within 72 hours of
disease onset can confirm disease and are the diagnostic test of choice
for hospitalized patients.
Classification systems have identified five geno groups, GI-GV. GII
viruses are most common and 19 genotypes belonging to GII have
been described. GII.4 are most common and account for >85 percent
of outbreaks. Periodic increases in disease have been linked to the
emergence of new viral strains.
CaliciNet is a CDC surveillance system designed to classify and identify
such new strains and, when possible, to clarify the source of new clusters
of norovirus disease. This has been particularly important when outbreaks
occur in multiple states, as it allows us to define common sources (e.g.
foods), to monitor trends in disease, and to identify new, emerging
norovirus strains. Vega, et al in 2011 presented the initial data from
CaliciNet launched in March 2009 and reported 552 outbreaks in the first
year of study.1
GII.4 New Orleans strain was reported as the most common strain in the
country, emerging in October 2009. The newest data reveals that GII.4
Sydney has now replaced GII.4 New Orleans. It originated in Australia in
March 2012 and by September-December of that year had spread widely
across the United States. So far, this strain has been associated with
more hospitalizations and more deaths compared to prior strains.2
Treatment is supportive with attention to correcting fluid/electrolyte
imbalance. Meticulous hand hygiene practices, disinfection of surfaces,
and use of contact precautions for those hospitalized with diarrhea are
required. Most hospitalized patients recover in four to six days but chronic
courses of disease have been reported in the transplant population in
whom reduction of immune suppression has been required. No doubt we
are just starting to learn about this new strain and more data is sure to
come in the next several months.
References:
1. Vega E, Barclay L, Gregoricus N, Williams K, Lee D, Vinjé J. Novel surveillance network
for norovirus gastroenteritis outbreaks, United States. Emerg Infect Dis [serial on the
Internet]. 2011 Aug [date cited]. http://dx.doi.org/10.3201/eid1708.101837
2. CDC. Notes from the Field: Emergence of New Norovirus Strain GII.4 Sydney. United
States, 2012. MMWR 2013; 62(03);55-55.
Visual Diagnosis
What’s the
Diagnosis?
A 15-year-old female has a fourmonth history of recurrent fever,
fatigue, arthralgias, evanescent
rash and abdominal pain. Two
months into the course, infectious
mononucleosis was diagnosed;
however, her symptoms persisted and
she was hospitalized. Her past history included antecedent treatment with
two antibiotics for sinusitis and a daily antibiotic for acne. Transaminitis
with normal bilirubin values and pancreatitis were noted at admission.
Rheumatologic evaluation revealed elevated ANA and anti-smooth muscle
antibodies with normal creatinine phosphokinase (CPK). She had a
normal hepatic ultrasound.
Which of the following is the most likely diagnosis for this patient?
A. Ascending cholangitis D. Epstein Barr Virus (EBV) Infection
B. Autoimmune hepatitis (AIH) E. Gallstone induced hepatitis/pancreatitis
C. Dermatomyositis
February 2013
ensuring safe storage of firearms may go a long way toward decreasing the
risk of death from a firearm-related injury or death in our patients.
AAP Updates
Gun Violence and Children
Tom Tryon, MD, FAAP | Chair, AAP Committee on Membership
Division Director, Urgent Care | Associate Professor
For each of us, Dec. 14, 2012, will be a tragic day forever in our memory
as we all recall watching with horror the unfolding story of the senseless
gun violence at Sandy Hook Elementary School in Newtown, Conn. On that
day, 20 elementary students and six adults were killed.
Stories involving gun violence and loss of life in children are far too
common in our society. As pediatric professionals we know that gun
injuries cause death in children each year and the data is compelling.
According to a press release from the American Academy of Pediatrics
(AAP), “Gun injuries cause twice a many deaths as cancer, five times as
many as heart disease and 15 times as many as infections. Firearmrelated deaths are one of the top three causes of death in American
youth.”1
According to the policy
statement: “The absence
of guns from children’s
homes and communities
is the most reliable and
effective measure to
prevent firearm-related
injuries in children and
adolescents..
For many years, the AAP has
recognized the importance
of restricting gun access to
children and this was once
again reaffirmed in the most
recent AAP Policy Statement
on “Firearm Related Injuries
Affecting the Pediatric
Population,” which was
released in October, 2012,
by the Committee on
Injury, Violence and Poison
Prevention (CoIVPP).2
According to the policy
statement: “The absence of
guns from children’s homes
and communities is the
most reliable and effective measure to prevent firearm-related injuries in
children and adolescents. Adolescent suicide risk is strongly associated
with firearm availability. Safe gun storage (i.e. guns unloaded and locked,
ammunition locked separately) reduces children’s risk of injury.”2 Further,
the policy statement notes that while physician counseling of parents
regarding firearm safety may be effective in decreasing firearm-related
injuries, the same is not true of education programs aimed at children and
adolescents.
Further, evidence shows that with adolescents, even in the absence of a
psychiatric diagnosis, the presence of a gun in the home increases the
risk of suicide. According to Denise Dowd, MD, FAAP, MPH, a pediatric
emergency medicine physician at Children’s Mercy, a former executive
committee member of CoIVPP and one of the two lead authors on the
policy statement, “Adolescents often experience very strong emotions
and have difficulty seeing past a temporary setback. Their brains have not
matured fully, which makes them impulsive and relatively more likely to
attempt suicide. When those attempts are made with a gun there is little
chance for them to change their minds. The odds of suicide are particularly
high if the gun is kept loaded. It is absolutely critical that families who own
guns follow safe-storage practices.”3
How can you help? The AAP recommends that pediatricians and other
child health care professionals counsel parents and care providers about
the dangers of allowing children and adolescents to have access to guns,
either inside or outside the home. Additionally, asking about the availability
or presence of guns and recommending either eliminating access or
Website References:
1. http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-EndorsesSenator-Feinstein-Legislation-to-Ban-Assault-Weapons.aspx
2. http://pediatrics.aappublications.org/content/early/2012/10/15/peds.2012-2481.
citation
3. http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AmericanAcademy-of-Pediatrics-Renews-Committment-to-Preventing-Gun-Injuries-in-Children.aspx
E vidence-Based Strategies for Common
Clinical Questions
Cefdinir Dosing for Treatment of
Pneumococcal Infection
Ross Newman, DO | General Pediatrics | Associate Program Director, Pediatric Residency
Program | Assistant Professor of Pediatrics
Molly Krager, MD | Co-Chief Resident
Antibiotic choices for patients with acute otitis media (AOM) or community
acquired pneumonia (CAP) are based on the patient age, disease severity,
pharmacokinetics/dynamics (PK/PD) and consideration of the most
likely pathogens. The most common bacterium causing AOM or CAP is S.
pneumoniae. While penicillin had previously been the gold standard to
successfully eradicate this organism; penicillin resistance increased in
the 1980-90s prompting the implementation of 7-valent pneumococcal
conjugate vaccine (PCV7) in 2000 and PCV13 in 2010.
The PK/PD goal for beta lactam use is that drug concentrations exceed
the minimum inhibitory concentration (MIC) of penicillins for >40 percent
of the dosing interval and those of cephalosporins for 50 percent of the
interval. Another consideration is that for beta lactams, only ~10-15
percent of serum concentrations reach the middle ear while as much as
80 percent reaches the lung tissue. Amoxicillin (80-90mg/kg/day divided
in two doses) meets this PK/PD goal for AOM caused by S. pneumoniae
with adequate middle ear fluid concentrations for penicillin susceptible
and intermediately resistant S. pneumoniae as well as the one-half of
highly resistant strains with amoxicillin MIC ≤4 µg/ml. The success of highdose therapy for AOM was confirmed by double tympanocentesis studies
in which pathogen eradication occurred after 4-6 days of therapy with few
treatment failures and excellent tolerability.1
In 2004, cefdinir was recommended by the AAP and AAFP as an alternative
to amoxicillin, amoxicillin-clavulanate or ceftriaxone for AOM patients with
a non-type I hypersensitive reaction (meaning no hives or anaphylaxis) to
penicillin.2 The FDA approved dose is 14 mg/kg/day given daily or divided
BID. PK/PD and clinical evidence suggests that this dose, unfortunately,
does not effectively eradicate ~20 percent of nontypeable Haemophilus
influenzae (ntHi) or any intermediately resistant/ highly resistant strains
of S. pneumoniae.
Two articles in The Pediatric Infectious Disease Journal in March 2006
described the PK, tolerability, and effectiveness of high dose cefdinir,
specifically against penicillin nonsusceptible S. pneumoniae. Arguedas
et al reported that while high dose cefdinir had an overall 10-day clinical
success rate of 83 percent (note: 20 percent of S. pneumoniae and up
to 50 percent of ntHi spontaneously resolve by 10 days making clinical
success greater than that expected from pure antibiotic effect), it was only
43 percent microbiologically effective against penicillin resistant
S. pneumoniae strains and only 72 percent effective against H. influenzae.3
Bowlware et al, using PK analysis, determined that cefdinir at 25 mg/kg/
day would be ineffective against penicillin nonsusceptible S. pneumoniae
strains.4 Despite higher doses having a 152 percent higher peak plasma
concentration (Cmax) and a 141 percent larger area under the plasma
concentration time curve (AUC) when compared to standard dose,
time above MIC was not sufficient to recommend high dose cefdinir for
intermediately/highly penicillin resistant pneumococci. However, the
significantly higher Cmax and AUC, the safety and tolerability of the higher
dose, and the potential for greater efficacy have led many practitioners to
incorporate a higher dose into their practice.
Conclusion: While cefdinir is not a first-line drug for treatment of AOM,
sinusitis or CAP, it can be considered in the child with non-serious allergy
to penicillin. Self-reported penicillin allergy is not reliable and studies
confirm a false positive rate of 90 percent when penicillin skin testing
was used to verify. We recommend further history be obtained to validate
the authenticity of an allergic reaction. Commonly, the drug in question
was not actually taken or a recognized non-immunologic side effect (e.g.,
vomiting) was the “allergy.” For those with confirmed penicillin anaphylaxis,
remember that cross reactivity with cephalosporins occurs in 10 percent
of cases.
Based on our data review: When treating AOM or CAP with cefdinir, a
dose of 14 mg/kg/dose given BID is safe, well tolerated and likely adds
~10 percent to expected efficacy compared to standard FDA approved
cefdinir dosing. The maximum dose is 300 mg twice daily. Practitioners
should know that high dose cefdinir is not included as an option in the
Infectious Diseases Society of America CAP guideline or in the new AAP
AOM guidelines (due to be published Feb. 25). We would not generally
recommend it as an adequate step-down drug from ceftriaxone for
suspected penicillin resistant pneumococcal infection. In such cases, the
decision should be based on the specific diagnosis, severity of illness and
the child’s comorbidities. Consultation with ID may be helpful.
References:
1. Piglansky, L. MD. et al. Bacteriologic and clinical efficacy of high dose amoxicillin for
therapy of acute otitis media in children. Pediatric Infectious Disease Journal. 2003;
22:405-12.
2. American Academy of Pediatrics. Subcommittee on Management of Acute Otitis Media.
Diagnosis and management of acute otitis media. Pediatrics. 2004;113:1451-1465.
3. Arguedas, A. et al. A multicenter, open label, double tympanocentesis study of high
dose cefdinir in children with acute otitis media at high risk of persistent or recurrent
infection. Pediatric Infectious Disease Journal. 2006; 25:211-218.
4. Bowlware. KL. et al. Cefdinir pharmacokinetics and tolerability in children receiving
25mg/kg once daily. Pediatric Infectious Disease Journal. 2006; 25:208-210.
Ambulatory Approach to Common Subspecialty Problems
Gardasil: Not Just for Girls
Daryl Lynch, MD | Division Director, Adolescent Medicine
Vice Chair of Ambulatory Services, Department of Pediatrics
Professor of Pediatrics
Celeste Tarantino, MD | Column Editor | Pediatric Emergency Medicine
Chair, Medical Staff Bylaws | Associate Professor of Pediatrics
Gardasil, the quadrivalent Human Papilloma Vaccine (HPV4) from Merck,
is recommended by the Centers for Disease Control and Prevention,
the American Academy of Pediatrics and the Advisory Committee on
Immunization Practices (ACIP) for boys at age 11 or 12, with catch up
vaccination up to age 21, and may be given up to age 26.1
The vaccine is approved by the FDA for use in boys and men ages 9-26 for
the prevention of anal cancer caused by HPV types 16 and 18, genital warts
caused by HPV types 6 and 11, and for anal intraepithelial neoplasia grades
1, 2 and 3 caused by HPV types 6, 11, 16 and 18. According to the National
Immunization Survey completed by CDC, the 2011 US HPV completion of >3
doses in girls aged 13-17 for 2011 was 34.8 percent (±1.6) with a reported
HPV4 rate in boys of less than 2 percent.2 Neither of these rates is protective
of the population and needs improvement immediately.
Vaccinations are given to prevent and protect individuals as well as to
develop herd immunity for population protection. It is important that
providers follow the recommended schedule published by the ACIP.
These recommendations are made after extensive research and development
with review by scientists that devote their professional careers to the study
of vaccines. Safety and efficacy is reviewed and monitored by numerous
private and public groups and recommendations changed when needed.
Vaccination public health strategies only work when these recommendations
are followed. History and data support that vaccines have been a very
successful public health campaign for saving lives and reducing health care
costs. HPV recommendations for boys need to be supported and practiced
by providers of teens and young adults.
Protection is best provided when the vaccine is given prior to exposure.
Unfortunately, even giving the vaccine at age 11 is too late for some.
Exposure can happen with any kind of adolescent experimentation that
involves genital contact with someone who has HPV — intercourse isn’t
necessary. HPV often has no signs or symptoms, so it can be hard to detect
and males are not routinely tested. That means HPV transmission can
happen without anyone knowing it.
Vaccinating boys is important for several reasons. First of all, boys are at
least half of the equation for the spread of sexually transmitted infections.
More people getting the HPV vaccine provides better population protection.
HPV4 is protective of 90 percent of the causes of genital warts which are
devastating to the individual and adds to the health care costs from the
virus. Although the vaccine does not carry an indication for all cancers
caused by HPV, HPV has been found to be associated with several types of
cancer: cervical, vulvar, vaginal, penile, anal and oropharyngeal (back of
the throat, including the base of the tongue and tonsils). According to the
CDC, each year more than 21,000 HPV-associated cancers occur in women;
cervical cancer is the most common. More than 12,000 HPV-associated
cancers occur each year in men; oropharyngeal cancers are the most
common.
References:
1. MMWR 2010;59:626–32, available at http://www.cdc.gov/mmwr/pdf/wk/mm5920.pdf
2. http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-oct-2012/02-HPVDorell.pdf
Visual Diagnosis?
What’s the Diagnosis?
Angela L. Myers, MD, MPH | Pediatric Infectious Diseases Fellowship Program Director
Assistant Professor of Pediatrics
Answer: B: Autoimmune hepatitis (AIH)
The patient in the above vignette has drug-induced autoimmune hepatitis
(DIAIH) and the implicated medication is minocycline, which was prescribed
for her acne. Minocycline is commonly used to treat adolescent acne
vulgaris and often continued for months, even years at a time. Common
adverse events include gastrointestinal intolerance, photosensitivity,
hyperpigmentation and
hypersensitivity with rash. More severe
but less common adverse reactions
occur, including: organ dysfunction,
benign intracranial hypertension,
pneumonitis, serum sickness-like
reactions and DIAIH.
Patients with DIAIH have evidence of
active chronic hepatitis on evaluation,
features of autoimmune disease and
elevated auto-inflammatory markers.
Symptomatology may develop in as
little as two weeks after starting therapy, but typically occurs after months
or even >1 year. In a 2010 study evaluating clinical characteristics and
prognosis of autoimmune hepatitis, 9 percent of cases were found to be
drug-induced and minocycline and nitrofurantoin were most commonly
implicated. The majority of patients recovered with removal of the
offending agent, and a chronic course was less commonly noted than in
non-drug induced cases. Sugimoto et al reported on the course of seven
patients with DIAIH who had relapsing disease and speculated that druginduced liver injury may have unmasked the diagnosis of AIH. Treatment
of DIAIH includes removal of the implicated drug, and for some patients,
immune suppressive therapy with follow-up by a hepatologist.
For teens treated with minocycline, it is imperative to discontinue the drug
in any patient presenting with fever, rash and arthralgias and to evaluate
hepatic function studies. In addition, the patient should not be treated
with any tetracycline agent in the future.
Ascending cholangitis is a bacterial infection of the biliary tree and
gallstone hepatitis/pancreatitis is caused by an obstructive stone with or
without infection at the level of the common bile duct or ampulla of Vater.
Both of these etiologies were unlikely in this patient as her bilirubin levels
were normal and she had no evidence of obstruction on ultrasound. While
the patient certainly had an autoimmune diagnosis, dermatomyositis
is unlikely without significant muscle aches and in the setting of a
normal CPK. Although she had received an earlier clinical diagnosis of
mononucleosis, she never exhibited the most common features of severe
sore throat and difficulty swallowing. In addition, her symptoms continued
much longer than would be expected and an antibody profile did not
support this diagnosis.
References:
Chamberlain MC, et al. Minocycline-Induced Autoimmune Hepatitis with Subsequent
Cirrhosis. JPGN. 2006 Feb; 42(2):232-5.
Björnsson E, et al. Drug Induced Autoimmune Hepatitis: Clinical Characteristics and
Prognosis. Hepatology. 2010; 51(6):2040-8
Sugimoto et al. Seven Cases of Autoimmune Hepatitis That Developed After Drug
Induced Injury. Hepatology. 2011; 54 (5), 1892–1893.
Pediatric Bioethics
These women and their families face a complicated set of decisions. If
the evaluation takes place early enough in gestation, then termination
of pregnancy is an option. If it is later, we discuss options for obstetrical
care such as the timing, locale and mode of delivery. In rare cases, there
is also the possibility of in utero procedures. We talk about treatment
options for the baby after birth, including innovative interventions and
palliative care.
We have never before had access to such detailed information about the
fetus. Because such information is new, its meaning is often uncertain and
we don’t really know the best or appropriate way to monitor the rest of
the pregnancy. We don’t know how to accurately predict what will happen
next. We don’t know when it would be preferable to deliver the baby
prematurely or when to let the high-risk pregnancy proceed.
There are also complicated feedback loops between better diagnostic
information about the fetus, the decisions that people make based on
that information, and the outcome data.
For example, suppose that before the availability of fetal diagnosis,
disease X has a birth prevalence of 1 percent and a reported infant
mortality rate of 50 percent. Suppose further that half of the infant deaths
followed decisions by parents not to pursue aggressive life-sustaining
therapy. Thus, among 100 babies, 50 would die before their first birthday.
Twenty-five of those 50 would have died as a result of not receiving lifesustaining treatment. So, among the babies who received life-sustaining
treatment, the mortality rate would be 25/75, or 33 percent. Two-thirds
survived. What, then, would we say is the “true” mortality rate for the
condition?
If we assume the babies whose parents chose palliative care are identical
to the babies of parents who chose life-sustaining interventions, then
2/3 of those babies could have survived for a year if they were given
life-sustaining treatment and the true mortality rate would be 33 percent,
rather than the 50 percent that is accurately reported. If, on the other
hand, we assume the babies who received palliative care were sicker in
some way, and the decision to forego life-sustaining treatment reflected
an assessment that treatment would likely be futile, then most would have
died anyway.
What, then, would be the impact of the availability of prenatal diagnosis
for this condition? Some parents may choose to terminate the pregnancy.
As a result, fewer babies would be born with the condition (the birth
prevalence would fall); however, among those babies, more would likely
receive life-sustaining treatment, so the reported infant mortality rate
might fall.
Alternatively, prenatal diagnosis may allow some stratification of risk
based upon prognostic factors such as the presence or absence of other
anomalies. In this scenario, parents would be more likely to terminate
the pregnancy if the prognosis seemed worse. So, once again, the birth
prevalence of the condition would go down and the babies who were born
with the condition would likely have less severe disease than was seen
prior to prenatal diagnosis. They might have higher survival rates. So far,
this is all good.
John Lantos, MD | Director of Pediatric Bioethics | Professor of Pediatrics
But, those higher survival rates might then be used to counsel pregnant
women about prognosis after a prenatal diagnosis for a particular
condition. As a result, they may be more hopeful and more likely to
continue the pregnancy. The birth prevalence of the condition will rise,
as will the illness severity of the babies born with the condition. More
treatment might be given with less good outcomes.
Two years ago, Children’s Mercy opened a fetal medicine center. Pregnant
women are referred to us if an abnormality has shown up on screening
blood test or ultrasound. We perform additional evaluations and then sit
down with families to discuss options and make plans.
Clearly, fetal medicine is a work in progress and one that creates its own
facts as it goes. Luckily, here at Children’s Mercy, we have a phenomenal
multidisciplinary team that meets regularly, analyzes these issues, and
tried to help parents to the best decision in each case.
How Fetal Medicine Centers are
Changing Perinatal Bioethics
The World WIde of Vaccines
Vaccine Coverage Study
Barbara Pahud, MD, MPH | Associate Director, Children’s Mercy Hospital VTEU
Assistant Professor of Pediatrics
Despite established guidelines and ongoing efforts on the part of
practitioners, vaccination coverage in the United States remains
suboptimal. While screening of immunization status is recommended at
each health care encounter, this is rarely done outside of primary care
facilities.
We set out to confirm the vaccine status of a Children’s Mercy inpatient
population and to evaluate the impact of a pilot intervention that would
identify vaccine-eligible children. The study was powered to detect an
increase of 10 percent from baseline vaccination rates. For the pilot
study, 356 children were randomly selected to participate between
March and June of 2012. Immunization records were pursued from all
potential sources and vaccination status was assessed using the CDC’s
online Catch-Up Immunization Scheduler tool for health care providers. If
catch-up doses were indicated, the parents/legal guardians were informed
and the information was added to the discharge summary. One month
following hospital discharge, primary care physicians were contacted to
verify receipt of recommended vaccines.
We were able to review immunization records provided by primary care
providers (47 percent), the public health department (23 percent), the
hospital’s electronic medical record (19 percent) or a combination.
Overall, children ≥11 years were less likely to meet AAP/ACIP
recommendations than any other age group (p=<0.001).In this group of
children, HPV vaccine was the most commonly identified vaccine for which
patients were eligible; 89 percent of eligible children had not initiated the
series. Our findings are consistent with national data that confirms only
32 percent of girls aged 13 to 17 years in 2010 had completed the HPV
vaccine series.
Additionally, 70 percent of those eligible needed the second dose of
varicella vaccine. Based on data from the 2010 National Immunization
Survey, 58 percent of teens had completed the two-dose varicella vaccine
series. Kawai et al found younger age, higher maternal education level,
private health insurance, more frequent health care visits, receipt of
both MCV4 and Tdap vaccinations, and residing in a state with twodose policies for middle school entry as the key factors associated with
completion of the series. Missouri has no middle school varicella vaccine
mandate and Kansas requires two doses by the ninth grade.
We were able to increase immunization rates modestly from 73 percent
at admission to 80 percent at one month follow-up (p=<0.001). The
inpatient setting may be especially well suited to screen, administer
vaccines and educate the under-immunized population. Notifying families
of the need for vaccine(s) proved beneficial, but additional vaccine
counseling may be needed to optimize immunization rates, particularly
when it comes to HPV vaccine.
We are in the process of developing a hospital-based immunization
program as part of a quality improvement project and will keep you
updated on our progress. We welcome your thoughts and suggestions
regarding this new approach to help increase immunization rates in our
community (e-mail: [email protected]).
References:
Kawai K et al. Factors Associated with Receipt of Two Doses of Varicella Vaccine among
Adolescents in the United States.Pediatr Infect Dis J 2012 Nov 28.
Jemal A et al. Annual Report to the Nation on the Status of Cancer, 1975-2009,
Featuring the Burden and Trends in Human Papillomavirus (HPV)-Associated Cancers
and HPV Vaccination Coverage Levels. J Natl Cancer Inst 2013 Jan 7 (Epub ahead of
print).
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THE LINK
Volume 5 | Issue 2 | February 2013
Outbreaks, Alerts & Hot Topics:
Norovirus News
AAP Updates:
Gun Violence and Children
Evidence-Based Strategies:
Cefdinir Dosing for Treatment
of Pneumococcal Infection
Pediatric Bioethics:
How Fetal Medicine Centers
are Changing Perinatal Bioethics
Ambulatory Approach:
Gardasil: Not Just for Girls
The Wide World of Vaccines:
Vaccine Coverage Study
News Briefs
Parents Magazine Honors Children’s Mercy Among
the Best
The Children’s Mercy Orthopaedics Division is ranked #4 and Children’s
Mercy Hospitals and Clinics is ranked #14 overall in the Parents Magazine
survey of the Top 10 Best Children’s Hospitals in the U.S. The #14 Children’s
Mercy ranking is up eight spots from our last Parents ranking four years ago.
The list appears in the March 2013 issue of Parents.
Individualized Pediatric Therapeutics Consults
Genome Center Honors
The rapid whole genome sequencing approach developed by the Center for
Pediatric Genomic Medicine at Children’s Mercy was named one of TIME
magazine’s Top 10 Medical Breakthroughs of 2012. In addition, Stephen
Kingsmore, MB, ChB, DSc, FRCPath, Director of the Center for Pediatric
Genome Medicine at Children’s Mercy Hospital, has been named one the
best physicians of the year by Medscape. Medscape highlights his “lifesaving discovery,” which allows babies with genetic diseases to be diagnosed
in a couple of days, instead of weeks or months.
The Individualized Pediatric Therapeutics (IPT) Inpatient Consult Service has
replaced the Clinical Pharmacology Consult in Cerner effective immediately.
The change in our name is intended to promote consistency between
inpatient and outpatient services provided by the Division of Clinical
Pharmacology and Therapeutic Innovation. These include our IPT Clinic and
our IPT Drug Safety Service, an adverse drug reaction clinical program in
conjunction with the Department of Pharmacy.
This consult service is available to assist providers with diagnosis and
evaluation of patients with adverse drug reactions (including lack of
therapeutic effects with drug treatments), drug-drug interactions, drugdisease interactions, issues related to pharmacokinetics of medications,
and pharmacogenetic/pharmacodynamic variations resulting in unexpected
drug responses.
For more information, call 816-234-3059.
Contact Information
The Link is produced monthly by Communications and Marketing with editorial guidance
from Mary Anne Jackson, MD, the Associate Chair of Community and Regional Physician
Collaborations at Children’s Mercy. The columns and topics are provided by members of
the Children’s Mercy faculty and medical staff.
For more information contact: Shawn Arni (816) 346-1371; [email protected]
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