Pediatric Infectious Disease Newsletter

December 2009  

H1N1 Flu Vaccine Age Indications
The injectable, monovalent, FDA-approved vaccines for 2009 H1N1 influenza have different age indications. Until now, only the Sanofi Pasteur product (Fluzone) was approved for children 6-47 months of age. The Novartis product (Fluzone) is approved for children 4 years and older. The other vaccines from CSL and ID Biomedical were approved for persons 18 and older. On 11/12/09, the FDA approved the CSL H1N1 vaccine (Afluria) for administration to children as young as 6 months old. This extension of the age indication also applies to the seasonal, trivalent version of the Afluria vaccine.

View the FDA Press Announcement

Additional information on H1N1 is available by viewing Dr. Juan Dumois' presentation titled "2009 H1N1 Influenza: Part 2". This webcast was recorded at All Children's Pediatric Ground Rounds on December 4, 2009.
Mumps Outbreak on East Coast
The largest U.S. outbreak of mumps in three years is occurring in New York and New Jersey. About 180 cases were identified in those two states from the time an investigation began in August through the end of October. Another 15 cases tied to the same outbreak have been reported in Canada. Three people have been hospitalized but no deaths reported. This outbreak was first reported at a boys camp in Sullivan County, NY and may have been triggered by an 11-year-old boy from the United Kingdom, where an ongoing mumps outbreak has sickened about 4,000. When possible, persons with suspected mumps should be isolated for 5 days after onset of parotitis and, if they visit a health-care setting, droplet precautions should be initiated immediately. Clinical specimens (both serum and buccal swabs) should be collected from persons with suspected mumps as soon as possible after symptom onset. Although vaccination is not considered effective post-exposure prophylaxis for mumps, nonimmune contacts should be vaccinated with measles, mumps, rubella (MMR) vaccine to prevent risk from subsequent exposures. Any suspected mumps case should be reported to the health department in the area where the patient resides.

MMWR Nov 12, 2009
Remember Pneumococcal Vaccines
On November 16, 2009, the CDC issued a health advisory recommending the administration of pneumococcal polysaccharide vaccine (Pneumovax) to all persons over 65 years old and to anyone 2-64 years old with certain underlying medical conditions, including chronic cardiovascular disease (congestive heart failure and cardiomyopathies), chronic pulmonary disease (including chronic obstructive pulmonary disease and emphysema), diabetes mellitus, alcoholism, chronic liver disease (including cirrhosis), cerebrospinal fluid leaks, cochlear implant, functional or anatomic asplenia including sickle cell disease and splenectomy, immunocompromising conditions including HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome; those receiving immunosuppressive chemotherapy (including corticosteroids) and those who have received an organ or bone marrow transplant; and residents of nursing homes or long-term care facilities. These are not new recommendations, but they were re-issued as a health advisory in an attempt to prevent some of the pneumococcal superinfections occurring in some patients infected with 2009 H1N1 influenza A virus.

Additional information is available on the CDC website.
What Would You Do?
A pediatrician called with a question about a healthy term baby born to a mother diagnosed with her first episode of genital herpes 10 days before delivery. Serologic testing had not been performed in the mother to confirm whether this was a primary or recurrent infection. She was given oral acyclovir that was continued until delivery, when there were no lesions remaining. The baby was delivered by Cesarean section, with artificial rupture of membranes during surgery. How much of a workup does this baby need, and should you start acyclovir? For first-episode, maternal, genital herpes infections at the time of delivery (unknown serostatus), the rate of neonatal infection is about 41% after vaginal delivery and 11% after C-section. Since oral acyclovir decreases the incidence of recurrence at delivery by 72% and viral shedding by about 85%, we might predict that this baby's risk of infection is less than 3%. With such a low rate, the appropriate plan of management would be to send herpes cultures of conjunctival, oral, nasal, and rectal swabs, and to monitor the baby for development of any clinical signs of herpes infection. Such signs would include skin vesicles, pneumonia, sepsis, or seizures.

Additional information is available on the JAMA website.
Surgical Masks vs. N95 Respirators: Which are the best protection against Influenza ?
Based in part on the findings of a study done in Australia (University of New South Wales) indicating that N95 respirators were superior to surgical masks in the reduction of spread of H1N1 influenza, the CDC and IOM recommended the use of N95 masks over surgical masks in the care of patients with novel H1N1 virus this season. However, peer reviewers questioned their statistical analysis, and the Australian group re-looked at their findings. After doing so, the authors of that study retracted their initial conclusions. "After a re-analysis prompted from questions by peer reviewers, the findings no longer demonstrated a significant benefit of the N95 respirator," said Holly Seale, PhD, one of the investigators.

A recent publication in JAMA by Loeb, M et al describes their randomized-controlled trial including 446 nurses in 8 tertiary care hospitals in Ontario, Canada. In this study, 221 nurses were randomly assigned N95 respirators for use in the care of their patients and 225 were assigned to wear surgical masks. Influenza infection (confirmed) occurred in 23.6% in the surgical mask group and in 22.9% of the group wearing N95 respirators. The difference was not statistically significant. Of note, this study was performed in the 2008 influenza season, and so no inferences can be made specifically about 2009 novel H1N1.

Loeb, M et al. JAMA. Nov. 4, 2009. Vol 320 (17) 1865-71.
What in the World Is Acanthocephaliasis?
Funny you should ask! We were recently consulted on a young toddler who was asymptomatic other than the presence of visible worms in the stool. Upon visual inspection, these worms had an odd appearance: segmented, but not in the typical appearance of a tape worm. Its eggs, too, easily identified on O+P examination, did not look like typical tape worm eggs. Our pathologist's and clinical microbiologist's extensive evaluation of these creatures determined that they were Acanthocephala, or "thorny-headed worms." Rats are the definitive hosts for thorny-headed worms and cockroaches are intermediary hosts. There are scattered case reports in the literature on human infection with these helminthes. Most all cases involve toddlers, who typically become infected after ingesting cockroaches or cockroach parts. (Yes, we cringed at that thought, too.) Reported symptoms included diarrhea, weight loss, anorexia and weakness, but some cases (like our patient's) can be asymptomatic as well. Over-the-counter medicine, pyrantel pamoate ("Reese's Pin Worm Medicine" or "Pin-X") has been used successfully for treatment.
Update from the Infectious Diseases Society America Meeting (Philadelphia, October 29 -November 1, 2009)
Direct Salivary PCR for Newborn CMV screening

Dried blood spot PCR has very low sensitivity for detecting CMV. Investigators wanted to determine the validity of PCR on saliva obtained from newborn infants. PCR was compared to rapid viral culture. The study involved 7 medical centers from 6/08-2/09. 17,737 infants were enrolled. 49.5% were female and 66% of the patients had private insurance. The mean age of the mothers was 27 years. 93 children had a positive CMV PCR from the saliva. 85 of these children also had a positive viral culture. However, 8 children had a positive PCR with a negative viral culture. The sensitivity of the PCR was 100% (95% CI 95.8-100) and specificity 99.0% (95% CI 99.8-99.9). The PCR had excellent negative and positive predictive values.

HSV Encephalitis and Prophylactic Acyclovir

Do not forget about HSV encephalitis in infants older than 4 weeks of age. During the session on clinical pediatric cases, a scenario of a 2 month old with an URI and seizure was presented. The infant was diagnosed with HSV encephalitis and recovered after 21 days of IV acyclovir. One of the questions brought up was the use of prophylactic oral acyclovir following the 21-day course.  There were no formal recommendations provided by the panel regarding the use of oral acyclovir following congenital HSV infection.  There has been some disagreement among "experts" about the use of oral acyclovir following IV treatment of congenital HSV. However, according to the panel at the session, we may have an answer to this question sometime in February 2010.

Vaccine Advocacy Update

This session stressed the importance of vaccine advocacy in a time of anti-vaccine movements. Vaccine advocacy can be carried out in various ways. The physician, other professionals, and families can be involved in the educational process. Formats including group meetings and town meetings may be helpful to educate. The internet plays a large role through social chat websites such as Facebook and Twitter (education through blogs may be careful and keep it brief!). Other forms of communication include prenatal classes and providing educational forms and websites to families earlier in the childhood vaccination process. Educational opportunities exist for young children through magazines such as Time for Kids and Scholastic Weekly Reader that you can have in your waiting rooms. Areas in the waiting room can be designated to post information about the risk of vaccine preventable diseases.

As a physician advocate, you should be ready to address any issue raised by the media (aluminum, thimerosal and discussing studies). We need to educate ourselves better to address parental vaccine concerns, so that we can unequivocally explain the safety of vaccines. Hopefully, in the future, more medical schools will develop curricula to teach the scientific method, vaccine education, and media training.

The Vaccine Education Center website from the Children's Hospital of Philadelphia provides reliable information for healthcare professionals and families.

Mandatory  Influenza Vaccination Policies for Healthcare Workers

Twenty one hospitals and hospital systems across the United States are now requiring yearly influenza vaccine for all health care workers. These include pediatric hospitals such as: Children's Hospital of Philadelphia (CHOP); Johns Hopkins Heath System, Baltimore, MD; Children's Hospital of Orange County, CA, Miller Children's Hospital, Long Beach, CA, Barnes Jewish Healthcare, MO, Creighton University, Omaha, NE.

Vaccine Safety in Children with Inborn Errors of Metabolism

Routine vaccination is recommended in this population of children but immunization rates are lacking. Investigators evaluated vaccination in Northern California among 3.2 million children ages 0-18 from 1990-2007. They described patterns and looked for serious adverse events. Patients with metabolic disorders were matched with healthy controls (1:20). Patients with metabolic disorders were characterized as "sickest" (ex. urea cycle, mitochondrial disorder, organic academia), "chronic" (ex. lysosomal storage disease), and "stable" (ex. PKU).

There were 76 children identified.  Among the three groups, there was no difference in the number of vaccines received by age 2 as compared to the healthy controls.  There was no difference in timing of vaccines (including MMR) as compared to the controls. When evaluating for ER visits and hospitalizations, investigators looked at serious adverse events occurring in the first 15 days, 15-30 and 31-70 days. Comparing the three metabolic groups to the controls there was no increase in ER visits or hospitalizations following vaccination.

Stay tuned! Prevnar v2.0 is on the way....

The 13-valent version of the current 7-valent pneumococcal vaccine is on its way soon. The current pneumococcal conjugate vaccine protects against the following pneumococcal serotypes: 4, 6B, 9V, 14, 18C, 19F and 23F. The new version of the pneumococcal conjugate vaccine would contain 6 additional serotypes including: 1, 3, 5, 6A, 7F and 19A. Once the new vaccine hits the market, the "old" 7 valent vaccine will be withdrawn. Immunization series should continue with the new vaccine replacing the old one. ACIP will likely recommend one additional 13-valent pneumococcal vaccine for young children (under 5) who have completed their 7-valent pneumococcal series. More to come on this topic in 2010...
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In This Issue
H1N1 Flu Vaccine Age Indications
Mumps Outbreak on East Coast
Remember Pneumococcal Vaccines
What Would You Do?
Surgical Masks vs. N95 Respirators: Which are the best protection against Influenza ?
What in the World Is Acanthocephaliasis?
Update from the Infectious Disease Society America Meeting (Philadelphia, Oct 29-Nov 1, 2009)
Infectious Disease Newsletter Feedback
Gardasil for Boys, too!
What ISN'T good about exercise?
David M. Berman, D.O.
Juan Dumois III, M.D.
Shirley Jankelevich, M.D.
Allison Messina, M.D.
Dale Bergamo, M.D.
Patricia Emmanuel, M.D.
Jorge Lujan-Zilbermann, M.D.
Carina A. Rodriguez, M.D.
Katie Namtu, Pharm.D.

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Gardasil for Boys, too!
The FDA recently approved the use of the quadrivalent HPV vaccine (Gardasil) for boys ages 9-26 for the prevention of genital warts (HPV 6, 11). It will also prevent infection with HPV 16 and 18, the viruses which cause the majority of cervical, anal and penile cancers. The ACIP fell short of making it a mandatory recommendation for boys, but instead made the vaccine "permissible" for patients who wish protection against these diseases. The ruling by the ACIP now includes Gardasil for boys in the federal Vaccines for Children program.

NOT included in this recommendation for boys is the Cervarix vaccine. Cervarix is the bivalent HPV vaccine containing HPV 16 and 18 alone, intended for the prevention of cervical cancer. This vaccine was recently approved for use in girls only. It can be substituted for the Gardasil vaccine in girls. This vaccine does NOT provide immunity to HPV 6 and 11.

Full details of the provisional recommendations are available on the CDC Website.
What ISN'T good about exercise?
Need yet another good reason to dust off the ol' sneakers? A study done by Kohut, ML et al. at Iowa State University demonstrated that mice that were made to exercise 5 days a week, 45 minutes/day for 14 weeks on a treadmill fared better than their couch potato counterparts when infected with influenza virus. The well-conditioned mice handled their illness better with fewer symptoms (less weight loss, greater food intake), a trend toward decreased viral load, and statistically significant decreased levels of respiratory inflammatory cytokines. Mice who ran for 45 minutes only once on the day of inoculation with influenza also did better than the non-exercised mice, but not as well as the mice who'd been training for weeks. So, get to the gym! (But, also get your flu vaccine.)

JID 2009:200 (1 November) 1434-1442