Pediatric Infectious Disease Newsletter

February 2010  

Take Part in Our Vaccine Survey

A Message from David Berman, M.D.

Pediatric Infectious Disease Program
All Children's Specialty Physician

David Berman, D.O., FAAP
As most of you are aware, despite overwhelming scientific evidence demonstrating vaccine safety and efficacy, there remains a growing concern by the general public, media, legislators, and some health-care professionals questioning vaccine safety. I have recognized an increasing number of children that are either unimmunized or under-immunized. The effects have already been felt at the national level with recent outbreaks of measles, mumps, and pertussis in communities with low rates of immunization. It is difficult for the public to comprehend the seriousness of vaccine-preventable diseases if they have never seen the disease. Instead, the focus becomes the vaccine. Additional anti-vaccine sentiment runs high with some of our legislators in Tallahassee. There have been recent bills with an anti-vaccine message.

As an infectious disease specialist and more importantly as a pediatrician and parent, I know the seriousness of vaccine-preventable diseases. However, I remain very concerned about the growing number of physicians in the community that have hesitancies regarding immunizations. In order for me to better understand physician vaccine attitudes, I have developed a brief electronic survey. I am asking you to spend a few minutes of your time to participate in this survey. My specific goal is to ascertain individual physician beliefs surrounding current vaccine "controversies" in the 17 counties that All Children's Hospital serves. This survey will be used to help understand physician beliefs about vaccination and to determine where to focus our educational efforts. The survey was designed with yes or no type questions and can be easily completed within 5-10 minutes. The survey is anonymous and there are no identifiers. I am hoping to be able to present the preliminary data during a vaccination lecture at the Suncoast Pediatric Conference in June 2010 in Sarasota. My goal is to have 500 physicians complete the survey. If you would like the results of the survey sent to you, please let us know by checking off the appropriate box on the survey.

I greatly appreciate your time to complete this brief survey. If you have any specific questions, you can reach me through All Children's Hospital Division of Pediatric Infectious Disease, 727-767-4160.
Autism and MMR: Retraction of Wakefield's Case Series of Ileal-Lymphoid-Nodular Hyperplasia, Non-Specific Colitis, and Pervasive Developmental Disorder in Children
Twelve years after its publication in The Lancet, the journal editors retracted Andrew Wakefield's paper from the published record. In this case series, he came to the conclusion that MMR vaccine was associated with pervasive developmental disorder in children. It's hard to believe it took so long for the Lancet editors to retract this paper considering that 10 of 12 original authors had already retracted authorship on this paper. This publication had bad science written all over it from the beginning and it has irreversibly damaged vaccination programs worldwide.  Editors at the Lancet concluded that the reasons for retraction were:

-Cases were "consecutively referred" according to the paper but they were actually selected by Wakefield.

-The study did not obtain approval through an ethics committee as was stated in the paper (all studies are required to be reviewed by an institutional review board).

Editors of the Lancet Published Online February 2, 2010
Neisseria meningitidis
Cases of N.meningitidis reached a historic low in 2007 according to a recent study from the CDC (Cohn, AC et al). The Active Bacterial Core (ABC) surveillance is a population and laboratory based surveillance network overseen by the CDC and includes microbiology labs in 10 difference states. The ABC sites track bacterial isolates and epidemiological data to determine the incidence of several bacterial diseases in the US. The annual incidence of N.meningitidis was monitored from 1998 through 2007. The following trends were noted: incidence of disease dropped 64.1% in these years from 0.92 cases/100,000 in 1998 to .33 cases/100,000 in 2007. Interestingly, the effect of the conjugate quadrivalent (A,C,Y W-135) meningococcal vaccine (MCV-4, recommended in 2005 for adolescents) has not yet been seen, as rates among children in this age group have not appreciably changed. Considering that uptake of this vaccine was only 32.4% by 2007 for that age group, this may partially explain why. Also of conern is that the highest incidence of meningococcal disease continues to be in infants and toddlers less than 2 years of age (below the minimum age that the current MCV vaccine is licensed)--with two thirds of these cases occurring in those infants less than 6 months. Add to that, 50% of cases of meningitis in infancy are caused by serogroup B-which is not contained in the vaccine. Fortunately, MCV quadrivalent and bivalent vaccine is undergoing phase 3 trials in infants right now, and serogroup B vaccine is in phase 2 trials. Stay tuned! In the meantime, have a high index of suspicion for this nasty disease in your young patients. As expected each flu season, we have seen several cases of meningococcemia in the last month.

CID 2010:50 (15 January) Cohn, et al.
Can Toys Spread Disease?
Elmo may not be responsible for the next zoonosis (Elmo plague??), but a recent study suggests that toys may serve as fomites for human disease. D.E. Pappas et al recently published the results of a study conducted to see if toys in a pediatrician's waiting room harbored detectable RNA for 3 common respiratory viruses - picornavirus (parainfluenza and enteroviruses), RSV and influenza - during three separate visits to a private pediatrician's office.  Visits took place throughout the respiratory virus season in October, January and March. Researchers found viral RNA on 21% of the toys tested with picornavirus being the most common, followed by influenza B. RSV was not detected on any of the 52 toys sampled. The location of the toys didn't seem to matter much: 30% of the toys from the "new toy" bin (given out to children as prizes after visit) were positive for viral RNA, 20% of toys from the sick child waiting room and 17% of the toys from the well child waiting room also had detectable virus. Additionally, when the toys in the sick child waiting room were tested before and after cleaning with an anti-bacterial wipe the rates of viral detection were: 40% before cleaning and 26% after cleaning. As a final experiment, one of the adult investigators handled 20 toys from the sick child waiting room during the March visit. Despite the fact that 15% of the toys the investigator handled contained virus RNA, no virus RNA could be detected on the investigator's fingers after handling.

PIDJ Vol 29 (2) Feb. 2010
Fever, Chills, Sweats, Splenomegaly and Severe Anemia in a Returned Traveler
What is your diagnosis?  Before you answer this seemingly obvious question-the patient's itinerary included only a 2 week long visit to Block Island, RI.

Though we are taught to think of Lyme disease when evaluating the traveler to the Northeastern United States, this is not the only disease spread by those troublesome deer ticks (Ixodes scapularis). Anaplasma phagocytophilum (the cause of human granulocytic ehrlichiosis) and Babesia microti are also transmitted from this tick.

While Lyme disease frequently causes fever and malaise (and 80% of the time occurs with the tell tale "bull's eye" rash!) it does not typically cause severe anemia and splenomegaly. The constellation of symptoms above sound a lot like malaria, but they are also the common presentation of symptomatic babesiosis.

B.microti (much like malaria) are intraerythrocytic protozoa. The disease is endemic in the Connecticut/Massachusetts/Rhode Island area including the islands off the coast of these states (Nantucket, Martha's Vineyard, Block Island). Cases have been reported in other states too including: California, Kentucky, Minnesota, Missouri, New Jersey, New York, Washington and Wisconsin). They are spread through the bite of the deer tick and their incubation period is 1 week to several months. Most infections are asymptomatic and require no treatment. Severe disease is more likely to occur in adults over 40 years, and immunocompromised people (especially those with asplenia). Diagnosis is made via a blood smear identification of the parasite or by serology (Babesia IgG & IgM). The "Maltese Cross" pattern of the parasite on the red blood cell is pathognomonic. Treatment for symptomatic cases is clindamycin plus oral quinine for 7-10 days or, atovaquone plus azithromycin for 7-10 days.

There are scattered case reports of this organism being spread via blood transfusions and congenitally as well.

(PIDJ Omolara, A. 29(2) Feb 2010; Fox, LM et al. PIDJ 25. 2006)
Travel Medicine
We are often asked for pre-travel advice by pediatricians who are caring for patients about to go abroad. While individual recommendations vary depending on the country or region the patient will be visiting, some general guidelines to the evaluation of a traveling patient are applicable to all: 1) Advise patients that if they travel, they should seek medical consultation well before departure! Protective antibody response to active vaccines usually takes between 1 and 3 weeks. Also, many malaria prophylaxis regimens require pre-departure dosing in order to ensure a steady state level of drug by the time of arrival in an endemic area 2) Ask patients detailed questions about their itinerary: country, region, rural vs urban, altitude, time of year, length of stay. 3) Ask patients which activities they will be involved in (staying in a 5 star hotel vs. camping in the woods), will they have sustained contact with animals, insects, etc. 4) Take a full medical history, including chronic conditions as well as a medication history...making sure they have enough supply of their usual medicines before they go 5) Review immunizations and catch patients up if they are behind 6) Advise patients on mosquito/tick precautions as well as safe water precautions. 7) Visit the and click to their "travel" page for specifics on malaria prophylaxis as well as vaccination recommendations.

CID 2006:43 (15 December)

For more information on travel vaccines, see Dr. Messina's February 12th Grand Rounds Presentation titled "Vaccines for Travelers." Additional archived Grand Rounds are available on the All Children's Hospital website.
Vaccine Legislation in Florida
Two bills: HB 117 and SB 222 relate to childhood vaccinations:

Additions to these bills would require the Florida pediatrician to obtain "informed consent" for vaccines as we do for the more high-risk procedures like surgery.  As you are aware, there is a federal law requiring pediatricians to distribute VISs (vaccine information statements) to all patients receiving vaccines. Florida bills would conflict with existing federal laws and obtaining written consent is not a requirement by federal law. This consent will confuse families that vaccination is a risky procedure. In addition, children sometimes come to appointments with other caregivers who would not be able to sign consent and vaccination opportunities would be missed. This creates a different standard of care from other routine procedures we do in the office as part of normal well pediatric care (antibiotics, lab tests, etc). This is also extra paperwork for the pediatrician. There is no data to show that informed consent is better than what we currently do now for vaccination. Additionally, the senate bill includes wording that vaccination must only "commence" prior to entering school (this would suggest a child could enter school without being fully vaccinated....only starting the vaccines).

Senate Bill 222:

"Before vaccinating a child, a pediatrician or attending
physician must discuss the risks, benefits, and alternatives of
each vaccination recommended for the child by the Centers for
Disease Control and Prevention of the United States Department
of Health and Human Services. Pursuant to s. 1003.22, a child
must commence the required vaccination schedule before beginning kindergarten or initial entry into public or private school,
whichever occurs earlier."

Please take the time and review these bills online and contact your local Florida representative to advocate for the children of Florida.
Refrain from Antibiotics when you can... it's only a Cold!
There have been published studies dating back to the 1960's detailing the natural progression of the common cold. However, in our "modern" day medicine we have forgotten about the common cold. Frequently, patients will present to the doctor with less than 1 week of symptoms and are prescribed antibiotics for their pharyngitis (non-Group A Streptococcus), nasal congestion (diagnosed with sinusitis), and cough.  

In 1967, a paper was published in the Journal of American Medical Association detailing the duration of cold symptoms. By day 9 of the illness, patients no longer felt feverish or had a sore throat. However, 25-30% still had cough and nasal discharge. By day 14, 10% still had nasal discharge and 20% still had cough.  So the next time you prescribe antibiotics, think "virus"......and reassess your patient.  Remember, there are over 100 different rhinoviruses (that does not include other respiratory viruses) and high levels of antibody are needed for protection.  So what does this mean? Your patients will have many colds!

Gwaltney, JAMA 1967;202:158

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In This Issue
Take Part in Our Vaccine Survey
Autism and MMR: Retraction of Wakefield's Case Series of Ileal-Lymphoid-Nodular Hyperplasia, Non-Specific Colitis, and Pervasive Developmental Disorder in Children
Neisseria meningitidis
Can Toys Spread Disease?
Fever, Chills, Sweats, Splenomegaly and Severe Anemia in a Returned Traveler
Travel Medicine
Vaccine Legislation in Florida
Refrain from Antibiotics when you can... it's only a Cold!
Infectious Disease Newsletter Feedback
Moraxella catarrhalis Otitis Media
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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Moraxella catarrhalis Otitis Media
A few pathogens cause most cases of bacterial otitis media: S. pneumoniae, H. influenzae, M. catarrhalis and group A streptococcus (GAS). It is well know that of these, S.pneumoniae more frequently causes high fever, otalgia, and generally more severe disease. Moraxella is typically considered a less virulent pathogen than the other three. A recent study from Beer-Sheva, Israel compared characteristics of patients with Moraxella otitis to those with other pathogens. They found that AOM caused by Moraxella occurred as a mixed infection with other pathogens in 67% of cases (in contrast. S. pneumoniae, H. influenzae and GAS occurred as mixed infections 42%, 38% and 32% of the time). Also, there were significantly fewer cases of tympanic membrane rupture among the patients with Moraxella disease, and no cases of mastoiditis. Children with Moraxella also tender to be younger with a mean age of 9 months as compared to S. pneumoniae (11.5 mo), H. influenzae (11.2 months) and GAS (19.3 mo).

Broides, et al. CID 2009:49 (1 Dec)